DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

[Complaint Case No.558 of 2011]

Ravi Wadhwa age 36 years son of Shri D.P. Wadhwa r/o House No.1201, Phase V, Mohali.

                                                                   ---Complainant.

Versus

1.                 ICICI Lombard General Insurance Company Limited, Health Care Insurance, TGV Mansion, 6^th Floor, Plot No.6-2-1-12, Khairatabad, Hyderabad, Andhra Pardesh – 500004 through its Managing Director/CMD.

2.                 ICICI Lombard General Insurance Company Limited, Health Care Insurance, SCO 24-25, First Floor, Sector 8-C, Madhya Marg, Chandigarh through its Manager/Authorised signatory.

---Opposite Parties.

BEFORE:  SHRI LAKSHMAN SHARMA                 PRESIDENT

                   SMT. MADHU MUTNEJA                       MEMBER

                   SHRI JASWINDER SINGH SIDHU       MEMBER

Argued by: Sh. R.M. Dutta, Adv. for the complainant

                        None for the OPs.    

PER LAKSHMAN SHARMA, PRESIDENT

1.                           Sh. Ravi Wadhwa has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act only) praying for the following relief :

a)       To pay amount of Rs.14,538/- with interest @ 12% p.a. from the date of payment till its actual and physical realization;

b)                 To pay amount of compensation for causing mental and physical torture to the complainant by the respondents/OPs.

c)                 To pay amount on account of damages caused to the complainant caused by the respondents/OPs.

d)                To pay costs of this complaint, counsel’s fee and litigation expenses incurred by the complainant

e)                 Any other relief which so ever this Hon’ble Court may deem fit and just be also granted to the complainant against the respondents/OPs. This complaint be allowed with costs and interest.

2.                           In brief, the case of the complainant is that he took a Health Insurance Policy from the opposite party in the year 2009, which was renewed regularly including for the year 2011-12.  It has further been pleaded by the complainant that on 19.1.2011, he developed acute pain in the lower abdomen.  So, he went to the Ivy Hospital, Mohali where he was admitted. The Hospital Authorities wrote letter to the opposite parties regarding the cashless facility.  In reply to the said letter, the opposite parties authorised the hospital to treat the complainant and guaranteed the payment of the bill to the extent of Rs.49,500/-.  It has further been pleaded by the complainant that thereafter several tests were conducted on the complainant and ultimately it was found that there was a calculus measuring approx.7mm at the right ureterovesical junction.  However, instead of operating immediately, the doctors treating the complainant thought it proper to dissolve the said stone through medicines.  So, they started treatment of the complainant conservatively.  The complainant was discharged on 20.4.2011 and advised to take the medicines.  According to the complainant, he took the medicines and ultimately the stone was dissolved.  The complainant spent a sum of Rs.14,538/- on his treatment.

                   According to the complainant, the opposite parties did not honour the commitment made in their letter dated 19.4.2011 and did not pay the billed amount, despite the fact that the policy was cashless.  Ultimately, the complainant had to pay the bills.  It has further been pleaded by the complainant that thereafter the complainant lodged a claim alongwith all the required documents but, to his surprise, he was not reimbursed for the amount spent by him.  In these circumstances the present complaint has been filed seeking the reliefs mentioned above.

3.                           In the written statement filed by opposite parties, it has been averred that in view of the admission of the complainant in the hospital because of severe pain in the abdomen, and in view of the letter written by the hospital, the hospital was authorised to go on with the treatment and payment of Rs.49,500/- was guaranteed.  However, later on, it was found that no operation was required nor any procedure was done.  It has further been pleaded that the complainant was admitted only for observation and evaluation and was managed only with oral antibiotics and analgesics.  In such circumstances, according to the opposite parties, the complainant is not entitled to any indemnification in view of clause 3.4 of the policy.  So, there is no deficiency in service on the part of the opposite parties.  Hence, according to the opposite parties, this complaint deserves dismissal. 

4.                           On 26.7.2012, when the case was fixed for arguments, none appeared for the opposite parties.  Therefore, we proceeded to dispose of this complaint on merits under Rule 4 (8) of the Chandigarh Consumer Protection Rules, 1987 read with Section 13(2) of the Act even in the absence of the opposite parties. 

5.                           We have heard the learned Counsel for the complainant and have gone through the documents on record.

6.                           Annexure C-3 is the discharge summary and the relevant portion of the same reads as under :-

“Brief history of present illness : This 36 years old male patient k/c/o HTN, non-diabetic presented with c/o acute pain lower abdomen radiating to groin region with nausea feeling since morning of day of admission.

          XXX                      XXX                      XXX

Course during hospitalization : Patient was admitted for evaluation & management of above mentioned complaints & managed conservatively with oral antibiotics, analgesics etc.  As per the study of NCCT KUB most probably stone will be removed spontaneously if did’nt than plan is for URS after 1 week of conservative treatment.  Presently he is being discharged in a stable condition on following advise.

          XXX                      XXX                      XXX

U-Bladder : is normally filled and shows normal anechoic lumen.  Wall thickness is normal.  A calculus measuring approx. 7mm is seen at the right ureterovesical junction.”

From the bare perusal of the above said discharge summary, it is apparent that the complainant was admitted because of acute pain in lower abdomen radiating to groin region with nausea feeling.  The investigations revealed that the complainant was having a calculus measuring approx. 7 mm at the right ureterovesical junction.  Ordinarily the removal of stone requires operation, however, the doctors thought it proper to treat the complainant conservatively, without operating him, and, therefore, they prescribed medicines for oral consumption.  He was discharged from the hospital and was advised to visit after 7 days for follow up.

7.                           Thus, in the present case, the complainant was admitted in the hospital on the advice of the medical practitioner.  Here we may also refer to Clause 2 of the policy, which reads as under :-

“2.     Scope of the Cover.

The Company will indemnify, subject always to the Limit of Indemnity, the insured against :

(i)      The Medical Charges incurred by the Insured, as a result of suffering illness of Bodily Injury during the period of Insurance, which on the advice of a Medical Practitioner requires Hospitalization.

XXX                      XXX                      XXX”

It is pertinent to mention here that in the written statement it has been averred that the complainant is not entitled to indemnification of the expenditure incurred by him because of clause 3.4 of the policy. The relevant part of Clause 3.4 reads as under :-

“3.4    Permanent exclusions

                    XXX                      XXX                      XXX

ii.       Routine medical, eye and ear examinations, cost of spectacles, laser surgery, contact lenses or hearing aids, vaccinations, issue of medical certificates and examinations as to suitability for employment or travel.

XXX                      XXX                      XXX”

8.                           From clause 3.4 of the policy, it is apparent that the insured is not entitled to indemnification for admission in the hospital for routine checkups and other purposes mentioned in clause (ii) reproduced above.  However, in the present case, the complainant was not admitted in the hospital for any routine check up.  In fact, he was admitted in the hospital because he was suffering from acute pain in lower abdomen radiating to groin region with nausea.  He was admitted for diagnosis and a number of tests were conducted on the complainant and, from the report of the tests, it was revealed that a calculus measuring approx. 7 mm was present at the right ureterovesical junction.  In such circumstances, to our mind, clause 3.4 reproduced above, and on which reliance is placed by the opposite parties, is not applicable to the facts and circumstances of the case as the complainant was admitted on the advice of the medical practitioner.  So, in view of clause 2, reproduced above, the complainant is entitled to indemnification of the expenditure incurred by him on his treatment.  Hence, failure to indemnify the complainant for the expenditure incurred by him, on his treatment, amounts to deficiency in service.

9.                           In view of the above discussion, the present complaint is allowed and the opposite parties are directed to pay –

i)                   Rs.14,538/- to the complainant being the amount spent by him on his treatment

ii)                Rs.10,000/- as compensation for mental harassment and agony; and

iii)              Rs.7,000/- as costs of litigation.

10.                       This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amounts at Sr. No.(i) & (ii) above, shall carry interest @18% per annum from the date of this order till actual payment besides payment of litigation costs.

11.                       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

30.7.2012.

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER