CONSUMER DISPUTES REDRESSAL FORUM
PALAKKAD, KERALA
Dated this the 28th day of January, 2013.
Present: Smt. Seena. H, President
: Smt. Preetha. G. Nair, Member
: Smt. Bhanumathi. A.K, Member Date of filing: 07/09/2012
CC/166/2012
1. Subhash. M.V.
S/o. Late Vasudevan
Melebhagath house, Mankara,
Vellaroad, Palakkad – 678 613 - Complainants
(By Adv. V. Krishnadas)
2. Prameela.M,
W/o. Subhash M.V.,
Melebhagath house, Mankara,
Vellaroad, Palakkad – 678 613
(By Adv. V. Krishnadas)
Vs
1. Managing Director,
India Health Care Services Pvt. Ltd.,
EL 63/521, Opp. Karuna Printers, - Opposite parties
Kasim Lane, Near Augustin Sched ,
Kaloor , Kochin – 682 017
2. Manager,
Oriental Insurance Co. Ltd.,
Kings Way Buildings,
1st Floor, Mavoor Road, Junction,
Calicut 673 001, Kerala.
(By Adv. P. Ramachandran)
O R D ER
BY SMT. BHANUMATHI. A.K, MEMBER
Complaint in brief :-
The 1st Complainant has taken a Policy No. 441003/48/2012/33 as PNB Oriental Royal Mediclaim Policy. Complainants and their daughter are covered under the policy for the period from 12/04/2011 to 11/04/2012. On 09/06/2011 the 2nd complainant was admitted in the District Ayurveda Hospital, Palakkad and spent a huge amount for treatment. The complainants have submitted original medical certificate, the originals of bills given for medicines, hospital expenditure bill, discharge summary and mediclaim policy along with claim form claiming an amount of Rs. 21,388.50 by courier on 27/06/2011. The documents were received by them. But they have not disbursed the amount. On 02/01/2012 the complainant sent a lawyer notice to the opposite parties but no reply was received.
The act of opposite parties amounts to deficiency of service and unfair trade practice on their part.
So the complainants seeking an order directing the opposite parties to pay an amount of Rs. 56,388/- in the following heads.
Mediclaim amount - 21,388.50
Bystander's expense - 5,000/-
Travelling expense - 5,000/-
Compensation for mental agony - 25,000/-
2nd opposite party entered appearance and filed version. 1st opposite party remained exparte.
2nd opposite party admits that the 1st complainant had taken PNB – Oriental Royal Mediclaim Policy. But they denies the liability on the ground that hospitalization is not required for the treatment of the current illness of the 2nd complainant, head ache and neck pain. It can be treated as out patient diagnostic basis. The claim of the complainants is not maintainable as it comes under the exclusion clause 4.21 in the policy. All the treatments which can be done as ' out patient diagnostic ' basis are excluded under clause No. 4.21 of the policy. The clause 4.22 of the policy specifically excluded massages, steam bathing and alike treatment under Ayurveda. The medical certificate dated 25/06/2011 reveals that the 2nd complainant was given oil massages, steam bathing and internal medication during the period of treatment. 1st opposite party was of the opinion that the claim of the complainants is not payable under exclusion clause No. 4.21 in the policy. So the 2nd opposite party has repudiated the claim made by the complainants. There is no deficiency of service on the part of opposite party and complaint is liable to be dismissed.
Complainant and 2nd opposite party filed chief affidavit. Ext. A1 to A12 except A8 were marked on the side of the complainant. Ext. A8 was marked as subject to proof. The doctor, who treated the 2nd complainant was cross examined as PW1.
Issues to be considered are:-
1. Whether there is any deficiency of service on the part of opposite parties ?
2. If so what is the relief and cost ?
Issues I & II
We have gone throgh the entire documents on record and heard the matter.
The grievance of the complainants is that the opposite parties did not pay the amount claimed by them as per the policy. The 1st complainant had taken PNB – Oriental Royal Mediclaim policy subsequently his wife, the 2nd complainant was admitted in the District Ayurveda Hospital from 09/06/2011 to 17/06/2011. There after the complainants have submitted the claim form to the opposite parties for getting the medical expenses reimbursed. The opposite parties repudiated the claim on the ground that the treatment of the 2nd complainant as in patient was unnecessary.
Policy is admitted by the opposite parties. 2nd opposite pary is mostly relying on the PNB-Oriental Royal Mediclaim Policy, marked as Ext. A7. As per clause 4.21 “ all the treatments which can be done as ' out patient diagnostic' basis are excluded”. Ext. A9, the discharge certificate, shows that the treatment given to the 2nd complainant was Snehapanam and Abhyooga Swedam. Opposite parties contents that for giving these treatments hospitalization is not necessary. At the time of cross examination, PW1, the doctor who treated the 2nd complainant, stated that the treatment given to the 2nd complainant can't be given as out patient basis. Snehapanam treatment is giving medicated ghee to the patient strictly under the
supervision of the doctor”. “ Abhyooga Swedam treatment ചെയ്യുന്നത് എണ്ണ പാത്തിയില് ആണ് v. അതിനുള്ള സൗ ക ര്യം ഹോസ്പിറ്റ ലിലാന്ന് ഉള്ളത്.’’ So the hospitalization of the 2nd complainant is necessary.
As per clause 4.22 massages, steam bathing, shirodhara and alike treatments under Ayurvedic treatment are excluded. None of the said treatments is given to the 2nd complainant.
Regarding Ext. A8, the photocopy of the medical bills sent to the opposite parties, it is marked as subject to proof. The complainant filed application to call for original documents and bills from 2nd opposite party. Instead of producing the documents 2nd opposite party filed an affidavit stating they are not in a position to produce the said documents.
In the above facts and circumstances we are of the view that the opposite parties are deficient in their service.
In the result complaint allowed. Opposite parties are jointly and severally directed to pay an amount of Rs. 21,388/- ( Rupees Twentyone thousand Three hundred and Eightyeight only), the expenditure for treating the patient and Rs. 5,000/- ( Rupees Five thousand only) as compensation for mental agony along with Rs. 1000/- (Rupees One thousand only) as cost of the proceedings.
Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order till realization.
Pronounced in the open court on this the 28th day of January, 2013.
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Preetha.G.Nair
Member
Sd/-
Smt. Bhanumathi.A.K
Member
A P P E N D I X
Exhibits marked on the side of complainant
Ext. A1– Registered notice sent to the opposite parties along with postal receipt dtd. 02/01/2012.
Ext.A2 – Acknowledgement card signed by 1st opposite party dtd. 09.01.2012
Ext. A3 – Receipt issued from professional couriers dtd. 27/06/2011.
Ext.A4 – Original of the medical bills for Rs. 323/- dtd. 17/06/2011
Ext.A5 - Original of the medical bills for Rs. 213/- dtd. 23/06/2011
Ext. A6- PNB Oriental Royal Mediclaim policy schedule dtd. 20.04.2011.
Ext. A7- PNB Oriental Royal Mediclaim Policy (with family Floater for Punjab National Bank account holders and employees policy condition copy)
Ext. A8 – Photocopy of the Medical bills sent to the opposite parties.
Ext. A9 – Copy of the discharge certificate issued Dr. K.P. Jayakrishnan dtd. 17/06/11.
Ext. 10 – Copy of mediclaim policy form submitted by complainants to oppostie paties dtd. 25/06/2011.
Ext. 11- Copy of medical certificate issued by Dr. K.P. Jayakrishnan to 2nd complainant sent to opposite parties dtd. 25/06/2011.
Ext. 12 - Copy of the HDC receipt from District Ayurveda Hospital, Palakkad to
2nd complainant (original sent to opposite parties) dtd. 09/06/2011
Exhibitsmarked on the side of opposite party
Nil
Witness examined on the side of complainant
PW1 – Dr. Jayakrishnan
Witness examined on the side of opposite party
Nil
Cost allowed
Rs. 1,000/-( Rupees One thousand only) allowed as cost of the proceedings.
