BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 31st of January 2011
PRESENT
SMT. ASHA SHETTY : PRESIDENT
SMT.LAVANYA M. RAI : MEMBER
SRI. ARUN KUMAR K. : MEMBER
COMPLAINT NO.183/2010
(Admitted on 03.07.2010)
Mr.V.M. Manuvel,
So. V.M. Devasya,
Aged about 45 years,
RA. Veluthedath,
Parambil House,
Konalu Post & Village,
Puttur Taluk, Dakshina Kannada. …….. COMPLAINANT
(Advocate for the Complainant: Sri.Sanjay D).
VERSUS
Manager,
Oriental Insurance Co. Ltd.,
Krishna Prasad Building,
Main Road, Puttur
Dakshina Kannada. ……. OPPOSITE PARTY
(Advocate for the Opposite Party: Mrs.Hemalatha Mallya).
***************
ORDER DELIVERED BY PRESIDENT SMT. ASHA SHETTY:
1. 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 is the holder of Universal Health Insurance Policy of the Opposite Party along with his three family members under the policy No.422207/47/2010/282. The sum assured under the policy was Rs.30,000/-. It is stated that, the Complainant was admitted to KMC hospital Mangalore on 24.11.2009 for left renal calculi and hence, left bulb ureterogram was done, with DJ stent was indwelled with the intention of relieving obstruction in the stone bearing left kidney and to drain infected contents in the PLS and the Complainant was suggested an elective destoning of the left kidney by PCNL after one month and discharged on 2.12.2009 and spent Rs.14,642/-. Thereafter, again admitted to the KMC hospital on 18.1.2010 and the Complainant was operated and DJ stent fixed was removed. Thereafter the Complainant was discharged on 21.1.2010 and spent Rs.12,576/- for the operation. The Complainant has preferred claim on both occasion but the Opposite Party has paid Rs.7,500/- for the 1st claim and Rs.2,850/- for the 2nd claim. Hence, the Complainant issued a lawyer’s notice to comply the entire claim but the Opposite Party issued a reply stating that as per S-III Clause 5 the Opposite Party is not liable. The repudiation of the Opposite Party is arbitrary and amounts to deficiency and hence the above complaint filed under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Party to pay Rs.16,868/- with interest at 12% p.a. from 21.01.2010 till payment and also claimed Rs.35,000/- as compensation and cost of the proceedings.
2. Version notice served to the Opposite Party by RPAD. Opposite Party appeared through their counsel filed version, admitted the policy but it is stated that, as per Section III clause 5, any one illness will be deemed to mean continuous period of illness and it includes relapse within 60 days from the date of discharge from the hospital from where treatment was taken. Occurrence of the same illness after 60 days will be treated as fresh illness. Hence the Complainant is not entitled for benefit under the policy and contended that there is no deficiency and prayed for dismissal of the complaint.
3. In view of the above said facts, the points now that arise for our consideration in this case are as under:
- Whether the Complainant proves that the Opposite Party has committed deficiency in service?
- If so, whether the Complainant is entitled for the reliefs claimed?
- What order?
4. In support of the complaint, Mr.V.M. Manuvel (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him. Ex C1 to C7 were marked for the Complainant as listed in the annexure. One Mr.Sudhakara (RW1), Senior Divisional Manager of the Opposite Party filed counter affidavit and answered the interrogatories served on him. Ex R1 to R6 were marked for the Opposite Party as listed in the annexure. The Complainant produced notes of arguments.
We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No.(i): Negative.
Point No.(ii) & (iii): As per the final order.
Reasons
5. Point No. (i) to (iii):
It is admitted that, the Complainant is the holder of Universal Health Insurance Policy bearing policy No.422207/47/2010/282 and the same was valid from 10.07.2009 to 09.07.2010, the sum assured under the policy was Rs.30,000/- (as per Ex C1). Even the date of admission to the hospital by the Complainant and the date of discharge and the amount spent for the above treatment also admitted.
Now the point in dispute between the parties are that, according to the Complainant, he had admitted to the hospital on 24.11.2009 for Left Renal Calculi and discharged on 02.12.2009 and spent Rs.14,642/-. The Complainant was suggested an elective destoning of the left kidney after a month from the date of discharge. Thereafter the Complainant once again admitted on 18.1.2010 and was operated and the DJ stent was removed and thereby spent Rs.12,576/- but the Opposite Party paid Rs.7,500/- for the 1st claim and Rs.2,850/- for the 2nd claim to the Complainant which is not correct, hence came up with this complaint.
The Opposite Party on the other hand stated that, as per Section III clause 5 of the policy, any one illness will be deemed to mean continuous period of illness and it includes relapse within 60 days from the date of discharge from the hospital/nursing home from where treatment was taken. Occurrence of same illness after 60 days will be treated as fresh illness. In the instant case, the Complainant admitted to the hospital twice for one and the same illness within 60 days and the claim was settled by paying Rs.7,500/- and Rs.2,850/- to the Complainant which is correct.
Complainant filed oral evidence by way of affidavit and produced Ex C1 to C7. Opposite Party also filed oral evidence by way of affidavit and produced Ex R1 to R6.
On scrutiny of the oral as well as documentary evidence placed on record, we find that, the policy and the sum assured and the period of coverage are not in dispute. Even the date of admission, date of operation and discharge from KMC hospital Mangalore are also not in dispute. The contention of the Complainant is that, he has spent Rs.14,642/- for the 1st operation and for the 2nd time he has spent Rs.12,576/- but the Opposite Party reimbursed only Rs.7,500/- for the 1st claim and Rs.2,850/- for the 2nd claim. However, the Opposite Party produced the terms and conditions of the policy, wherein, the terms of the policy under Section III Clause 5.0 reads thus:
5.0: Any one illness:
“Any one illness will be deemed to mean continuous period of illness and it includes relapse within 60 days from the date of discharge from the hospital/nursing home from where treatment was taken. Occurrence of same illness after a lapse of 60 days as stated above will be considered as fresh illness for the purpose of this policy”.
From the above clause it is very clear that, any one illness will be deemed to mean continuous period of illness and it includes within 60 days from the date of discharge from the hospital. Occurrence of same illness after a lapse of 60 days will be considered as fresh illness. In the instant case, admittedly the discharge summary produced by the Complainant reveals that, the Complainant was admitted on 24.11.2009 to the KMC hospital Mangalore, on its final diagnosis it revealed that the Complainant was suffering from Radiolucent (L) Renal Calculi ? Uric Acid Lithiasis, on 30.11.2009 left bulb uterogram was done, a DJ stent was indwelled with the intention of relieving obstruction in the stone bearing left kidney and to drain infected contents in the PLS. Complainant was suggested an elective distoning of the left kidney by PCNL after one month and discharged on 02.12.2009 and thereafter within 60 days, once again admitted to the KMC hospital in continuation of very same illness on 18.1.2010 and percutaneous nephrostomy tube was removed and catheter was removed and discharged on 21.01.2010. That means, the Complainant took treatment in continuation of the earlier treatment within 60 days in the same hospital. Under that circumstances, as per the policy conditions it cannot be treated as fresh illness. Further, as per the schedule mentioned in the policy wherein, the hospitalization benefits were stated clearly. As per the schedule, the Opposite Party paid the amount and there is no deficiency whatsoever hence the Complainant is not entitled for further claim. The payment made by the Opposite Party Company in this case is correct as per the terms and conditions of the policy, hence the complaint deserves to be dismissed. No order as to costs.
6. In the result, we pass the following:
ORDER
The complaint is dismissed. No order as to costs.
The copy of this order as per the statutory requirements be forwarded to the parties free of charge and therefore the file be consigned to record.
(Page No.1 to 8 dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 31st day of January 2011.)
PRESIDENT MEMBER MEMBER
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 – Mr.V.M. Manuvel – Complainant.
Documents produced on behalf of the Complainant:
Ex C1 – 09.07.2009: Original policy issued by the Opposite Party.
Ex C2 – 24.11.2009: Copy of the Discharge Summary issued by K.M.C. Hospital.
Ex C3 – 02.12.2009: Copy of the bill issued by K.M.C. Hospital.
Ex C4 – 18.01.2010: Copy of the Discharge Summary issued by K.M.C. Hopsital.
Ex C5 – 21.01.2010: Copies of the bill.
Ex C6 – 12.03.2010: Lawyer’s notice issued to the Opposite Party on behalf of the Complainant.
Ex C7 – 22.03.2010: Reply of the Opposite Party.
Witnesses examined on behalf of the Opposite Party:
RW1 – Mr.Sudhakara, Senior Divisional Manager of the Opposite Party.
Documents produced on behalf of the Opposite Party:
Ex R1 – 04.01.2010: Discharge voucher for Rs.7,500/-.
Ex R2 – 09.02.2009: Discharge voucher for Rs.2,850/-/
Ex R3 - : Policy with prospectus.
Ex R4 - : Entire case sheets pertaining to the Complainant.
Ex R5 – 09.12.2009: Letter issued by the TTK Healthcare TPA Pvt. Ltd., to the Opposite Party.
Ex R6 - : Claim form with policy.
Dated:31.01.2011 PRESIDENT
