Karnataka

Udupi

CC/32/2012

B. Ashok Kumar Shetty, - Complainant(s)

Versus

Divisional Manager,The Oriental Insurance Company Limited, - Opp.Party(s)

Sri.Sunil S.M,

07 Aug 2014

ORDER

Complaint filed on 01.08.2012 Decided on  07.08.2014

BEFORE THE UDUPI DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

AT UDUPI (KARNATAKA)

 

                        

PRESENT

 

SMT. ASHA SHETTY                 :        HON’BLE PRESIDENT

SRI T.C.RAJASHEKAR             :        HON’BLE MEMBER

 

CONSUMER COMPLAINT NO.32/2012

ORDER DATED 07.08.2014

Between:

 

B.Ashok Kumar Shetty,

Aged about 50 years,

S/o Late Ramanna Shetty,

R/A “Indrali Rice Mill House”,

Post Kunjibettu, Udupi.

 

(Sri Sunil S.M., Advocate for the Complainant)

………. Complainant

/  Vs.  /

 

Divisional Manager,

The Oriental Insurance Company Limited,

Divisional Office,Vishnu Prakash Building,

2^nd and 3^rd Floor, Court Road,

Udupi.

 

(Sri K.S.Hegde, Advocate for Opposite Party)

…………..Opposite Party

 

ORDER DELIVERED BY HON’BLE MEMBER SRI T.C.RAJASHEKAR,

 

I.       This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Party  claiming certain reliefs. 

 

The brief facts of the case are as under:

The Complainant submitted that, he had obtained mediclaim policy from the Opposite Party from the year 2007.  The said policy was renewed every year.  The Complainant has renewed policy for the year 03.01.2012 to 02.01.2013.  The Opposite Party has issued policy bearing No.472700/48/2012/1399.  The said insurance policy covered mediclaim benefit to the complainant, his wife Mrs.Mallika A.Shetty and their son Mr.Ashritha S.Shetty.  The said mediclaim policy covered domiciliary hospitalization limit upto Rs.15,000/- to each of them.

 

          It is submitted that the wife of the complainant was admitted to Adarsha Hospital, Udupi for treatment with the complaint of LUMBAGO with left sided SCIATICA.  There she was admitted as an inpatient from 04.01.2012 to 07.01.2012.  For MRI L/S SPINE she was taken to Hi-tech Medicare Hospital, Udupi on 06.01.2012.  During the said period of treatment the complainant has spent an amount of more than Rs.13,953.25.  When the complainant claimed the said amount from the Opposite Party, they refused to accept the bills or pay the amount.  The Complainant made several oral requests with the Opposite Party for the re-imbursement of the medical bill.  But they have been dodging the claim of the Complainant on one pretext or the other. The Complainant ultimately issued a lawyer’s registered notice dated 18.06.2012 on his behalf calling upon the Opposite Party to claim the below mentioned relief.  The notice was duly served on the Opposite Party.  But they have not bothered to reply to the notice.  They have acquiesced the contents of the notice.  They are estopped from raising any contentions contrary to it.  At the time of issuing the said notice due to the typing mistake it was shown the due amount is Rs.19,099/-.  It was a bonafide typing mistake and actual amount due is Rs.13,953.25.

 

          It is submitted that the Opposite Party is indulged in Unfair Trade Practice which in turn amounts to deficiency of service.  The Complainant is a “consumer” as defined under the Consumer Protection Act.  Hence this complaint.

 

II.      Version notice served to the Opposite Party by RPAD. Opposite Party appeared through their counsel and filed version stating that the complaint filed by the Complainant is wholly false, frivolous and same is not sustainable either at law or at merits.

 

          The Opposite Party generally admits the averments made in para II(4) of the complaint.  It is submitted that the policy issued is subject to terms and conditions stipulated therein.

          The Complainant while admitting the admission of the wife of the Complainant to Adharsha Hospital, Udupi and the claim made by the Complainant for Rs.13,953.25.  The other allegations made in para II(2) are not admitted.  The Opposite Party has sent a registered letter dated 24.02.2012 to the Complainant informing about the repudiation of the claim of the Complainant and the same was received by the Complainant.  The Opposite Party admits the receipt of lawyers notice dated 18.06.2012.

 

          This Opposite Party does not admit the allegations made in complaint para II(3).  It is not admitted that the Opposite Party is indulged in unfair trade practice which in terms amounts to deficiency of service.    The Opposite Party submits that as per policy conditions exclusions 4.10 the company shall not be liable to make any payment under the policy in respect of any expenses incurred at Hospital or nursing home primarily  for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period.  The amount claimed by the Complainant is towards  evaluation / diagnostic purpose which is not followed by active treatment for ailment during the hospitalized period and therefore the claim was repudiated.  It is further submitted that all the medical papers submitted by the Complainant along with the claim application was sent to Dr.N.Ravindranath for his opinion by the Opposite Party as per the letter dated 09.02.2012 and Dr.N.Ravindranath has sent his opinion dated 20.02.2012 opining that no active treatment has been given other than anlagen which would have been on the outpatient basis also.  It is submitted that on the basis of the policy exclusions and also doctor’s opinion, the claim of the Complainant was repudiated.

 

          The Opposite Party submits that as the claim made by the complainant is coming under exclusions clause the same was repudiated and there was/is no any deficiency of service on the part of the Opposite Party.

 

          The Opposite Party submits that the Complainant is having no cause of action to the file this complaint against the Opposite Party.  The cause of action alleged in the complaint is the imaginary one and Opposite Party in conclusion denies all other allegations not expressly traversed herein and prays that the complaint filed by the Complainant may be dismissed with costs.

 

III.     1.       In support of the complaint, Sri B.Ashok Kumar Shetty (CW1) – Complainant filed affidavit reiterating what has been stated in the complaint and answered the interrogatories and got marked Ex.C-1 to Ex.C-6 and one Diego Quordes S/o Leo Quordes examined as CW-2.  One Mr Sharath Kumar S/o Late Shivarama Nayak, Divisional Manager, Oriental Insurance Co. Ltd., Udupi (RW-1) filed counter affidavit and answered the interrogatories served on him and got marked Ex.R-1 to Ex.R-5.

On close perusal of the complaint and version and other available documents, evidences, and heard arguments, the following facts found. The complaint is a subsisting medical insurance policy (No. 472700/48/2012/ 1399) holder for himself and his family, and the complainant’s wife Mrs.Mallika A.Shetty admitted to hospital and spent Rs.13,953.25 as hospital expenses. The complainant submitted the claim to the opposite party. But Opposite party, insurance company repudiated the claim on the ground that, the claim is not allowed as per policy exclusion clause No. 4.10, and hence the opposite party repudiated the claim. The opposite party is not disputing the facts that, the complainant has obtained medical policy for him and his family, which is running. That, the complainant’s wife admitted to hospital from 04.01.2012 to 07.01.2012, with the complaint of LUMBAGO with left sided SCIATICA, that, from there she has been sent to Hi-Tech Medicare Hospital, Udupi for MRI scanning, that, the amount spent for medical expense of Rs.13,953.25 as treatment charges. The only point of dispute is that, the treatment expenses come under the exclusion clause of insurance policy. Hence the reimbursement is not permissible. Now the points to be decided in resolving this dispute is,

1. Whether the complainant is a consumer as per the consumer protection Act 1986?
2. Whether the opposite party proved that the treatment expenses comes under the exclusion clause in the policy and not reimbursable as per policy condition?
3. Whether the complainant entitled for the relief prayed for?
4. What order?

We have answered the above points as under.

Point No.1 : In the affirmative.

Point No.2 : In the negative.

Point No.3 : In the affirmative.

Point No.4 : As per final order.

REASONS

IV.     (1) Point No.1:

we have observed through document insurance policy No. 472700/48/2012/1399 that the complainant had obtained a medical policy from the opposite party covering himself and his family by paying premium amount of Rs.6,314/-. The opposite party is not disputing the purchase of the policy or its subsistence.  Thereby the opposite party has become service provider and the complainant has become the consumer. Hence we answered the Point No.1 in the Affirmative.

(2) Point No.2:

Opposite party contends that the hospitalisation expense paid by the complainant is comes under the exclusive clause 4.10 of the policy and not reimbursable and hence the claim of the complainant is repudiated. It is pertinent to have a detailed look of the exclusion clause 4.10,which states. “Expense incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.” Here two qualifications involved to make an expense reimbursable. 1) The expense should not be primarily for evaluation/diagnostic purpose, 2)which, is not followed by active treatment during the hospitalised period. As per qualification no.1 above the patient should have gone to hospital only for evaluation or diagnostic purpose without any ailment. But it is not a case here. The complaint’s wife admitted to hospital complaining of LUMBAGO with left sided SCIATICA, which fact is not disputed by the opposite party. So it is not primarily for evaluation purpose but due to ailment she was suffering. The qualification no. 2 above, the patient’s problem is diagnosed as stated above and she has been treated in the hospital as per case sheets like Doctors order sheet dated between 04.01.2012to 07.01.2012 and Nursing record sheet for the same period reveals, which is produced by the opposite party. It is also note worth here that the opposite party not explained or defined any where the meaning of “active treatment”. In general sense any treatment given, to get some result or improvement in the condition of the patient is termed as an active treatment. The patient admitted to hospital with some sickness and discharged after cured must be because of active treatment only. The opposite party argues that as per record no any conservative treatment is given to the patient except prescribing the medicine. We have studied the records and observed the medicines administered from time to time. There is medical practice when a patient comes with ailment of severe pain, will be admitted and kept on observation till final diagnosis. During the period of observation the required medicine will be administered whether Anlagen or Saridon as decided by the doctor treating but not YOU and I. Because anlagen is administered no one can come to conclusion that treatment not given. It is true the opposite party to prove its contention has produced the Report given by the Dr.Ravindranath an MBBS, D.ORTHO. Even though The Doctor’s letter says “not followed by active treatment but only anlagen given which would have been given by outpatient basis also. It is possible that the patient was admitted with the purpose of investigation (MRI Scan) evaluation only and hence may attract the exclusion clause mentioned by you.” But this doctor given his opinion on the base of records and as rightly stated by complainant, the doctor has not been examined, and he is the panel doctor of the opposite party.  He is not a doctor who has treated the patient. Only the doctor who treated can better decide, whether the treatment shall have been be given on outpatient or inpatient basis. It is also surprising that the opposite party states so many kind of treatments like Active treatment, Conservative treatment etc. which we have not come across in medical treatments, and the opposite party is also not explaining what does it mean. Depending wholly on the panel Doctors report the opposite party repudiated the claim of the complainant.

In this juncture we have observed some of the other exclusion clause 4.14 and 4.22. The exclusion clause 4.14 states, “Expense incurred for investigation or treatment irrelevant to the disease diagnosed during the hospitalisation or primary reason for admission.  Private nursing charges, Referral fee to family doctors, Outstation consultants, surgeons etc.” and 4.22states, “any stay in hospital for any domestic reason or where no active regular treatment is given by the specialist” In combined study of these clauses 4.10, 4.14 and 4.22 reveals that the opposite party added these clauses to avoid claims of treatment or diagnosis expenses either which is taken by false hospitalisation or the diagnosis which is not related to ailment the patient is suffering. But here the opposite party case is not that, the patient is not admitted to the hospital, or admitted without any ailment, or taken treatment and evaluated for the illness other than for which she is admitted.  The only opposite party contention is the expenses comes under the exclusion clause. But as discussed above it is not proved that“Expense incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.” as stated in clause 4.10, to bring the expenses under the exclusion clause. So in our opinion the expense will not come under exclusion clause No 4.10, and hence it is reimbursable. As such we answered the point No.2 in the Negative.

 

(3)  Point No.3 & 4:

As per forgoing discussion in point no 2 it is cleared that the opposite party’s repudiation of complaints claim on the ground of expense comes under the exclusion clause and thereby non-reimbursable is not correct. The opposite party had committed the deficiency in service. Hence the complainant is entitled to get reimbursed the expenses of hospitalisation of Rs.13,953.25 with interest at 9% per annum till the payment. Even though the amount of bill produced is not matching with the amount claimed for, but only with slight variation, since the opposite party admitted the expenses of Rs.13,953.25 towards treatment expenses the same has been awarded.  The award of interest is treated as compensation. Since the opposite party depended on the doctor opinion in repudiating the claim we do not see any kind of negligence on the part of the opposite party to fit for award of separate compensation and hence in our considered opinion no separate compensation is necessary. The complainant is also entitled to get an amount of Rs.2,000/- towards litigation expenses. Hence we answered the Point No.3 in the Affirmative.

In the result of above discussion, we deliver the following

ORDER

The complaint is allowed. The Opposite Party shall pay the complainant a sum of Rs.13,953.25 alongwith interest at 9% per annum till payment and further a sum of Rs.2,000/- towards cost of the proceedings. Opposite Party shall comply with the aforesaid order within 30 days from the date of order copy received.

(Page No.1 to 8 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 07^th August 2014.)

 

 

                            

 

 

                   PRESIDENT                                              MEMBER

 

​

 

 

 

 

Dated:07.08.2014