Kerala

Idukki

CC/138/2018

Doey Augustine - Complainant(s)

Versus

Manager National Insurance co Ltd - Opp.Party(s)

29 Nov 2019

ORDER

DATE OF FILING :12/07/2018

IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 29^th day of November 2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

SMT.ASAMOL P. MEMBER

CC NO. 138/2018

Between

Complainant :1 . Doy Augustine,

Valiyakunnel House,

Thudanganadu P.O., Thodupuzha.

2 . Jessy Antony, W/o Doy Augustine,

Valiyakunnel House,

Thudanganadu P.O., Thodupuzha.

(Both by Adv: K.M.Sanu)

And

Opposite Party : The Manager,

National Insurance Co.Ltd.,

Thodupuzha Branch, Thodupuzha P.O.

(By Adv: Thomas Sebastian)

 

O R D E R

SRI. S. GOPAKUMAR (PRESIDENT)

 

The case of the complainant is that,

 

Complainants are husband and wife. The first complainant availed a mediclaim policy of opposite party for a period from 14/01/16 to 13/01/17 by paying Rs.11,000/- as premium. This policy covers the medical expenses of both the complainants to a tune of Rs.2 Lakhs each. While so, the second complainant treated for Malignant Neoplasm of Thyroid Gland in Kolenchery Medical College Hospital and underwent a surgery in the end of the year 2016. On a biopsy test the primary gland of cancer was ruled out and the hospital authority referred the matter to Ernakulam Medical Trust Hospital for further treatment on 22/11/16. The expenses incurred in the MCH, Kolenchery was allowed by the opposite party company. Thereafter the second complainant continued her treatment in Model Medi Diagnostic Centre, which is a part of Medical Trust Hospital, Ernakulam at

(Cont.....2)

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there various tests done on 17/12/16 and 19/12/16. After that she was admitted there on 03/01/17 and on 04/01/17 she was discharge after radiation treatment. For this purpose, the second complainant was incurred an expenses of Rs.8,000/- for various lab tests and Rs.30,000/- as treatment expenses.

 

After the discharge complainant lodged a mediclaim with relevant treatment records and the opposite party rejected the claim on 29/06/18. Complainant further averred that the treatment given to the Medical Trust Hospital is the continuation treatment of MCH, Kolenchery, since the MCH Kolenchery is lacking in the treatment of cancer. She was referred to Medical Trust Hospital, Ernakulam. Hence the act of the opposite party in rejecting the legally entitled claim of the complainants is a gross deficiency in their service. Against this the complainants filed this petition seeking relief such as to direct the opposite pry to pay the medi-claim amount of Rs.38,000/- along with interest, compensation and cost.

 

Upon notice, opposite party entered appearance and filed detailed reply version admitting the issuance of Parivar Mediclaim policy having No.570801/48/15/8500001176 for the period from 14/01/16 to 13/01/17. Opposite party further contented that the complainant has submitted a claim form for claiming medical expenses for radioiodine ablation to Jessy Antony on 03/01/17. Initially the patient was admitted MOSC, Kolenchery on 11/11/16 with complaint of swelling of front neck. She was treated there and undergone Thyroidectomy on 22/11/16. On 22/11/16 she was referred to Medical Trust Hospital, Kochi for radioiodine ablation. At there, the patient was orally ablated with 2590 MBq of 1-131 on 03/01/17. The admission is only for ablation. The treatment given was not part of inpatient treatment during hospitalization. As per circular, the terms and conditions of Mediclaim policy, the Radio Active treatment payable only if it forms apart of inpatient treatment in case of hospitalization or part of discharge advice up to the limits for post hospitalization. The clause 3.2 of the policy condition stated that “ Relevant medical expenses incurred during the period up to 30 days post to hospitalization on decease/illness/injury sustained will be considered as part of claim mentioned under hospitalization expenses”. In this case the patient was discharged on 15/11/16. Thereafter the patient was orally ablated on 03/01/17. That is after

(Cont.....3)

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30 days from the discharge of earlier hospitalization. Hence the claim is not covered under clause 3.2. of the policy. Since the treatment is given not during inpatient treatment in case of hospitalization, the claim is not covered by this policy. So the opposite party is not liable to pay any amount against the claim of the complainant.

 

Opposite party averred that Rs.8,000/- claimed towards lab expenses is not payable since lab test are conducted 30 days from the discharge of earlier hospitalization and those bills are not produced along with claim form. Rs.30,000/- claimed towards the High dose Iodine charge is not payable since claim is not covered under clause 3.2 of the policy. Hence there is no deficiency in service on the part of the opposite party in this matter.

 

Evidence adduced by the complainant by way of proof affidavit and document. Complainant was examined as PW1 and Ext.P1 to Ext.P7 were marked. Ext.P1 is the claim repudiation letter dated 29/06/18, Ext.P2 is the discharge summary of MOSC Medical College Hospital, Kolenchery, Ext.P3 is the refer latter dated 22/11/16, Ext.P4 is the Histopathologiy Report of MOSC, Medical College, Kolenchery dated 21/11/16, Ext.P5 is the treatment records of Model Medi Diagnostic Center dated 17/12/16, Ext.P6 is the discharge summary of Model Medi Diagnostic Centre dated 04/01/17, Ext.P7(s) are the bills of Rs.30,000/- dated 04/01/17 and Rs.8000/- dated 17/12/16.

 

From the opposite party's side the Senior Branch Manager of opposite party was examined as DW1. Ext.R1 to Ext.R5 were marked. Ext.R1 is the policy copy, Ext.R2 is the copy of reimbursement claim form, Ext.R3 is the document index sheet, Ext.R4 is the treatment history of MOSC Medical College Hospital, Kolenchery, Ext.R5 is the copy of repudiation letter.

 

Heard both sides,

 

The point that arose 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 ?

 

(Cont.....4)

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The Point:- We have heard the counsels for both sides and had perused the documents. It is an admitted fact that the treatment availed by the second complainant from the MOSC Medical College Hospital as well as the Model Medi Diagnostic Centre, Ernakulam within the validity period of the mediclaim policy issued by the opposite party, which covers the complainants 1 and 2 to the maximum of Rs.2 Lakhs each.

 

The pertinent question arises here is whether the complainants are entitled to get the benefits of the policy, for the treatment under gone by her in Model Medi Diagnostic Centre, Kochi on 03/01/17 to 04/01/17.

 

The learned counsel for the complainants argued that this treatment is a continuation of the treatment where the second complainant undergone in MOSC, Medical College Hospital, Kolenchery from 12/11/16 to 21/11/16. The treatment expenses incurred to her in this treatment was reimbursed by the first opposite party, in the light of the policy in question.

 

The learned counsel further stated that the doctors of the MOSC, Medical College was found that after histopathological examination of the resected specimen is reported as papillary carcinoma, classical variant (Rt) lobe of thyroid with nodular hyperplasia and Lymphocytic thyroiditis, Focal Angioinvasion, the patient was referred to department of Nuclear Medicines Medical Trust Hospital, Kochi for radioiodine scan + ablation, since there is no such facility in MOSC Medical College, Kolenchery. This is a continuation of the treatment which was given by MOSC, Medical College. Hence repudiation of claim on some baseless ground is utter deficiency in service and unfair trade practice.

 

On the other hand the learned counsel for the opposite party vehementaly argued that the parties was referred to Medical Trust Hospital, Kochi only for radioiodine ablation. The admission is only for ablation and the Radio- Active treatment is payable only of it form apart of inpatient treatment in case of hospitalization or part of discharge advice up to the limits for post hospitalization, as per the circular terms and condition of this policy.

 

(Cont.....5)

 

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The complainants further argued that as per clause 3.2 of the policy condition claim after 30 days from discharge of earlier hospitalization cannot be considered. In the present case complainant is discharged on 15/11/16 and the patient was orally ablated radioiodine was on 03/01/17 ie, after 30 days of discharge.

 

Hence on perusing the evidence on record and the deposition of witness, it is seen that, the patient was referred from MOSC, Medical College, Kolenchery as per Ext.P3 refer letter on 22/11/16 and on 17/12/16 the Model Medi Diagnostic Centre, conducted various tests including iodine (1) whole body scientegraphy and thereafter she was admitted there on 03/01/17 for high dose radioiodine ablation and she was discharged on 04/01/17. This test was done on 17/12/16 within 30 days of discharging from MOSC, Medical College and thereafter the patient was admitted to undergo Radioiodine ablation. These tests given to the second complainant is a continuation of former treatment and the rival contention of the opposite party is only to reject the claim of the complainant, which she is legally entitled, and it cannot be admissible.

 

Then regarding the lab test expenses of Rs.8,000/-. On perusing the Ext.R2 and Ext.R3 records it is seen that the second claim application was lodged for Rs.30,000/-. But as per the policy condition, the complainant is not entitled to claim the lab test expenses.

 

On the basis of above discussion we have a considered view that, the rejection of the treatment expense, which the complainant was incurred in the Model Medi Diagnostic Centre, Kochi by the opposite party is a gross deficiency in their service where the complainant is legally entitled to.

 

Hence under the above circumstance, the complaint allowed in part, opposite party is directed to pay Rs.30,000/- as per Ext.P7 medical bill dated 04/01/17 along with 12% interest from 26/01/17 the date of claim till its

 

(Cont.....6)

 

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realization. Opposite party further directed to pay cost of Rs.2000/- to the complainant. The order shall be complied within 30 days from the date of receipt of the copy of this order.

 

Pronounced in the Open Forum on this the 29^th day of November, 2019.

 

Sd/-

SRI. S. GOPAKUMAR (PRESIDENT)

Sd/-

SMT. ASAMOL P. (MEMBER)

APPENDIX

Depositions :

On the side of the Complainant :

PW1 - Doy Augustine

On the side of the Opposite Party :

DW1 - Ratheesh K.K.

Exhibits :

On the side of the Complainant :

Ext.P1 - The claim repudiation letter dated 29/06/18

Ext.P2 - The discharge summary of MOSC Medical College Hospital, Kolenchery

Ext.P3 -The refer latter dated 22/11/16

Ext.P4 -The Histopathologiy Report of MOSC, Medical College,

Kolenchery dated 21/11/16

Ext.P5 -The treatment records of Model Medi Diagnostic Center dated 17/12/16 Ext.P6-The discharge summary of Model Medi Diagnostic Centre dated 04/01/17 Ext.P7(s) -The bills of Rs.30,000/- dated 04/01/17 and Rs.8000/- dated 17/12/16.

On the side of the Opposite Party :

Ext.R1 -The policy copy

Ext.R2-The copy of reimbursement claim form

Ext.R3-The document index sheet

Ext.R4-The treatment history of MOSC Medical College Hospital, Kolenchery, Ext.R5-The copy of repudiation letter.

 

Forwarded by Order,

 

SENIOR SUPERINTENDENT