DATE OF FILING : 6.10.2016
IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI
Dated this the 30th day of May, 2017
Present :
SRI. S. GOPAKUMAR PRESIDENT
SRI. BENNY. K. MEMBER
CC NO.277/2016
Between
Complainant : Joseph M.C.,
Choorathottiyil House,
Vannappuram P.O.,
Thodupuzha, Idukki.
(By Adv: K.M. Sanu)
And
Opposite Parties : 1. The Manager,
Indian Overseas Bank,
Thodupuzha Branch,
Pala Road, Thodupuzha,
Idukki.
(By Adv: Thomas Sebastian)
2. The Manager,
Universal Sompo General Insurance
Co. Ltd.,
Sangam Complex, 127,
Andheri – Kurla Road,
Andheri East P.O.,
Mumbai – 400 059.
(By Adv: Saji Isaac K.J.)
3. The Manager,
Vidal Health TPA Pvt. Ltd.,
GN Chetti Road,
T Nagar, Chennai – 600 017.
O R D E R
SRI. S. GOPAKUMAR, PRESIDENT
Case of the complainant is that,
Complainant had availed a health care plus policy customised for Indian Overseas Bank customers to cover health and personal accident from 1st opposite party and renewed it on 18.6.2015 by paying an amount
(cont...2)
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of Rs.3088/- as premium for a period upto 17.6.2016. While so, the complainant was admitted in Lisie hospital, Ernakulam and treated there as inpatient from 6.1.2016 to 11.1.2016 for suspected seronegative spondyloarthropathy. He spent an amount of Rs.14500/- for treatment alone. After discharge from the hospital, he lodged a claim before the opposite party with sufficient medical records. But the claim was rejected by the opposite party as per clause 9 of policy terms and conditions which reads as “expenses on diagnostic, X-ray or laboratory examinations, unless related to the treatment of disease or injury falling within”. Against this, complainant filed the petition alleging deficiency in service against opposite party and prayed for getting relief such as to direct the opposite party to allow the insurance claim of the complainant and other consequential reliefs.
Opposite parties 1 and 2 entered appearance and filed detailed version separately. In their version, 1st opposite party contended that this opposite party has only facilitated the complainant to avail medi-claim policy from the 2nd opposite party, since the complainant is an account holder. As per the medi-claim policy, there is only insurance contract between the 2nd opposite party and the complainant to indemnify the medical expense of the complainant and the 2nd opposite party alone is liable to reimburse the claim of the insured. Since there is no insurance contract between the complainant and 1st opposite party, there is no unfair trade practice and deficiency in service in repudiating the claim of the complainant.
In their version, 2nd opposite party admitted the policy and further contended that the expenses incurred by the complainant were in relation to diagnosis, X-ray or laboratory examinations and not related to any particular disease. These expenses are only for primary evaluation and hence it is not liable to be compensated by the insurer. Being an educated person, complainant had taken policy after being fully convenienced the terms and conditions of the policy. Opposite party further contended that contract of insurance is a contract based on terms and conditions of the policy and the opposite party is liable only according to the conditions, terms, limitations and exclusions of the policy. Therefore, there is no deficiency from the part of the opposite party and the complainant is liable to be dismissed. (cont...3)
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Complainant examined as PW1 and Exts.P1 to P5 marked. Ext.P1 is claim repudiation letter. Ext.P2 is renewal notice dated 27.3.2016. Ext.P3 is claim form and medical bill. Ext.P4 is letter from insurance company dated 11.2.2016. Ext.P5 is treatment certificate dated 7.3.2016. From the defence side, health policy with terms and conditions and DMS controlled copy of treatment record produced and marked as Exts.R1 and R2 respectively.
Heard both sides.
The point for consideration is whether there is any deficiency in service from the part of opposite parties, and if so for what relief the complainant is entitled to ?
The POINT :- We have heard the counsels of both the parties and carefully gone through the records. The complainant has produced the document relating to his treatment in Lisie hospital, Ernakulam and duly filled claim form, on the other hand opposite party produced Ext.R1 health policy and terms and conditions of the policy and Ext.R2 treatment record of the complainant. As per the version of the opposite party, they party denied the claim application of the complainant on the ground that the expenses incurred by the complainant was in relation to diagnosis and this is excluded in clause 9 of the terms and conditions of the policy as discussed above. At the same time, on the perusal of Ext.R2 treatment record of the complainant issued from the Lisie hospital, Ernakulam, we can see that the complainant was admitted there for the complaint of pain all over the body for 3 months, difficulty in moving neck for 3 months, associated with weight loss and anorexia. After investigation, it is found that the patient is suffering from seronegative spondylo arthropathy and given treatment for this by admitted him there for 5 days from 6.1.2016 to 11.1.2016. He was treated with bed rest, analgesics, anti inflammatory medicines and other supportives and neuromedicine consultation given. But after going through all the records, the opposite party rejected his claim on the ground that expenses are incurred by the complainant for diagnosis only.
(cont...4)
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Here it is pertinent to note that after thorough diagnosis and check up, the doctor find out that the patient is suffering from seronegative spondylo arthropathy and given treatment for this ailment. Without having sufficient laboratory tests, a doctor cannot find out the actual ailment or disease. Here the x-ray and laboratory tests are done only to find out the disease and disease was diagnosed and proper treatment was given.
Clause 9 of the policy condition excludes claim relating to laboratory tests. The case in hand is different and through laboratory test the ailment was find out and properly treated. The treatment pointed out in this case is wilfully suppressed by the opposite party and denied the claim petition of the complainant. It is against the actual facts and is not justifiable. Clinical examinations and laboratory tests are part and parcel of a diagnosis and it cannot be denied on flimsy ground. Moreover, in this case, the complainant had not served the terms and conditions along with the insurance policy, which is a usual practice and it amounts to unfair trade practice.
At the same time, eventhough the complainant demanded an amount of Rs.14,450/- as medical expenses, no evidence is produced by the complainant to corroborate this except Ext.P3 medical bill and it shows only an amount of Rs.10,953/- was incurred to him as medical expenses.
Hence the Forum directs the opposite party to pay an amount of Rs.10,953/- as per Ext.P3 bill along with Rs.3000/- as compensation and Rs.2000/- as litigation cost.
Pronounced in the Open Forum on this the 30th day of May, 2017
Sd/-
SRI. S. GOPAKUMAR, PRESIDENT
Sd/-
SRI. BENNY. K., MEMBER (cont...5)
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APPENDIX
Depositions :
On the side of the Complainant :
PW1 - Joseph C.C.
On the side of the Opposite Party :
Nil.
Exhibits :
On the side of the Complainant :
Ext.P1 - Repudiation letter.
Ext.P2 - renewal notice dated 27.3.2016.
Ext.P3 - claim form and medical bill.
Ext.P4 - letter from insurance company dated 11.2.2016.
Ext.P5 - treatment certificate dated 7.3.2016.
On the side of the Opposite Party :
Ext.R1 - health policy with terms and conditions.
Ext.R2 - DMS controlled copy of treatment record.
Forwarded by Order,
SENIOR SUPERINTENDENT
