Date of Filing: 27/05/2011

        Date of Order: 14/07/2011

BEFORE THE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE -  20

Dated:  14^th DAY OF JULY 2011

PRESENT

SRI.H.V.RAMACHANDRA RAO,B.SC.,B.L., PRESIDENT

SRI.KESHAV RAO PATIL, B.COM., M.A., LL.B., PGDPR, MEMBER

SMT.NIVEDITHA .J, B.SC.,LLB., MEMBER

COMPLAINT NO. 993 OF 2011

Sri. I.C. Roopa, major,

W/o. Sri. I.P. Chandrakumar,

S/o. late I. Pattabhiramaiah Setty,

Vasavi Nilaya, V.G. Temple Street,

Chikkaballapur-562 101.

(Rep. by Advocate S. Vema Reddy)                                             Complainant.

-V/s-

1) M/s. Medi Assist India TPA Pvt., Ltd.,

Annapurna, No.797, 10^th Main Road,

4^th Block, Jayanagar,

BANGALORE-560 011.

Rep. by its Chief Manager.

(Rep. by Advocate V. Subramani)

2) New India Assurance Company Limited,

Brigade Plaza, N-202, North Wing,

2^nd Floor, S.C. Road, Ananda Rao Circle,

Bangalore-560 009.

Rep. by its Manager.            

(Rep. by Advocate V. Subramani)                                           Opposite parties.

BY SRI. H.V.RAMACHANDRA RAO, PRESIDENT

ORDER

            The brief antecedents that lead to the filing of the complainant made under section 12 of the Consumer Protection Act, seeking direction to the opposite parties to pay a sum of Rs.43,500/-, are necessary:-

            The husband of the complainant had taken medi-claim policy from the opposite party which covers his risk and also of the complainant and it was in force.  The complainant suffered the ailment of Fissure in Ano with Haemorrhoids and got admitted to the Apoorva Diagnostic Centre, CMH Road, Indiranagar, Bangalore, and took treatment as an inpatient between 21.11.2009 to 22.11.2009 incurring the expenses of Rs.18,500/-.  Accordingly the complainant submitted the medical claim with the opposite parties, but the opposite parties on 14.12.2009 by invoking Clause-3(2) of the Insurance Policy alleging that the Hospital had no 15 beds repudiated the claim.  The said M/s. Apoorva Diagnostic Centre has issued a Certificate dated: 27.07.2010 stating that it has been registered vide No.43358, dated: 18.02.1991 by Government Of Karnataka and it has got all the facilities to treat 10 patients on day care basis, it has got full fledged OT to undertake minor OT procedures, it has got qualified doctors and nursing staff to take care of the patients and also the BBMP has issued Trade License Certificate to run medical and diagnostic centre on 26.07.2004.  The complainant furnished these details to the opposite parties even then the opposite party No.1 has repudiated the claim on 27.10.2010.  The number of inpatient beds could not be a major criteria to repudiate the claim.  The repudiation amounts to unfair trade practice.  Hence the complainant has to be reimbursed with Rs.18,500/- and Rs,.25,000/- as compensation.

2.        In this case the opposite parties engaged the services of the same advocate, but only opposite party No.2 has filed the version.  In brief the version of opposite party No.2 are:-

            Obtaining of the medi-claim policy by the husband of the complainant for himself, complainant and their child are all admitted.  The complainant is put to strict proof of allegation that she was admitted to the Apoorva Diagnostic Centre on 21.11.2009 and discharged on 22.11.2009 and spent Rs.18,500/-.  The opposite party admits the claim made by the complainant and its repudiation on 14.12.2009.  The opposite party admits that the complainant had sent certificates issued by the Apoorva Diagnostic Centre and the other certificates issued by the BBMP.  The opposite party considered the same and repudiated the claim which is perfectly justified.  According to the certificate the Apoorva Diagnostic Centre is permitted to treat 10 patients only on day care basis and not as a inpatients basis.  Hence the Apoorva Diagnostic Centre does not fulfill the policy conditions.   According to the policy conditions the medical reimbursement shall be restricted to Rs.13,500/- only since Rs.5,000/- is disallowed.  The said Apoorva Diagnostic Centre is not suffixed or prefixed with the nursing home.  It is clearly establishes that the said diagnostic center will not come within the definition of Hospital/Nursing Home as per Clause-3(2) and 3.2(a) of Clause Mediclaim 2007.

3.        In this case subsequent to filing of the complaint the complainant and her counsel did not turn up.  Only opposite party No.2 has filed his affidavit.  The complainant has filed his documents along with the complaint.  Hence the arguments were heard by opposite party No.2. 

4.        The points that arise for our consideration are:-

1. Whether there is unfair trade practice as contended in the complaint?
2. What order?

5.        Our findings on the above points are:-

            Point (A) & (B)        :           As per the final order

For the following:-

REASONS

POINT (A) to (D):-

6.        Reading the pleadings in conjunction with the affidavit of the opposite party No.2 and documents of both the parties on record, it is an admitted fact that the husband of the complainant has obtained medi-claim policy for the benefit of himself, the complainant and their baby; bearing policy No.670200/34/08/11/00000928 i.e., Hospitalization Benefit Policy/Medi-claim Policy 2007 and it was valid between the period 05.12.2008 and 04.12.2009 and collected a premium of Rs.4,865/-.

7.        It is also an admitted fact that the complainant laid a claim with the opposite party on 30.11.2009 for Rs.18,500/- by filing the claim petition with the original receipts dated: 21.11.2009, discharge bill of 22.11.2009, discharge summery, and diagnostic bill i.e., Exhibit-R1 to R10 produced by the opposite party himself.  This clearly goes to show that the complainant was admitted in M/s. Apoorva Diagnostics Center on 21.11.2009 at 8.00 am and was discharged on 22.11.2009 at 9.00 am.  She was diagnosed as “IInd Hemorrhoids Fissure in Ano” and she was treated with Cryo-Hemorrhoidectomy + Sphiretentomy and in that regard the said Apoorva Diagnostics Center has collected Rs.18,500/-.

8.        The opposite parties repudiated the claim on 14.12.2009 by invoking Clause.3(2) of the Insurance Policy.  It is also an admitted that the Apoorva Diagnostics Center has issued a certificate on 22.11.2009 to the complainant and this has been submitted to the opposite parties and the opposite parties has produced it at Exhibit R.9.  The Exhibit R.9 reads thus:-

Even after this certificate the opposite parties has repudiated the claim on 14.12.2009.

9.        Even after this the complainant approached the Apoorva Diagnostics Center which has clarified and issued a certificate which has been forwarded to the opposite parties on 17.07.2010 and produced by the opposite parties at Exhibit-R.11.  Even after this the opposite parties has repudiated the claim.  Hence we have to see whether the repudiation is justified.

10.      Clause-3.2 of the Insurance Policy reads thus:-

“3.2      HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as a hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner, or

Complies with minimum criteria as under:

1. Must have a minimum of:

10 in-patient beds if located in towns having population of less than 10 Lacs

Or

15 in-patient beds if located in other towns.

2. Fully equipped operation theatre of its own wherever surgical operations are carried out.
3. Fully qualified Nursing Staff under its employment round the clock.
4. Fully qualified Medical Practitioner should be in-charge round the clock.
5. Maintains a daily medical record for each of its patients.

Note: In case of Ayurvedic/Homeopathic/Unani Treatment (b) is not applicable.

In case of Day Care Centre, (a) is not applicable

For the purpose of this definition the term Hospital/Nursing Home/Day Care Center shall not include an establishment, which is a place of rest, a place for the aged, a place for drug addicts or place for alcoholics, a hotel or any other like place.”

That is to say here in this case the first portion of Clause-3.2 is not applicable since the Apoorva Diagnostics Center has not been registered as a hospital or nursing home by the concerned authorities admittedly.  First part of Clause-3.2 (a) is not applicable to this case.  The second part of Clause.3(2)(a) say in any other places having 15 in-patient beds; it must be fully equipped with operation theatre of its own where surgical operations are carried out, qualified nursing staff, a medical Practitioner be there, then it will be a Nursing Home/Hospital.  Accordingly certificate was issued by the competent authority which establishes it has an operation theater, it has a nursing staff, it has qualified doctors and according to the certificate it can treat as day care patient 10 persons.  It does not say that the hospital has not admitted the complainant at any point of time, it does not state that the complainant was not treated as in-patient in the hospital.  The permission to the Apoorva Diagnostics Center might be for day care patients, but it has treated patients as in-patient.  The opposite party has not gone to the Apoorva Diagnostics Center conducted any investigation to know whether the Diagnostic Center had any facilities to treat any person as an in-patient or not or not treated the complainant as an in-patient when that is the case there is no question of disputing or disbelieving the certificate issued by the Apoorva Diagnostics Center which has admitted the complainant as an in-patient and treated her does not arise.  Hence the act of the opposite party is nothing but unfair trade practice.

11.      Medi-claim is made so that the people can get a relief at the time of necessity.  In large number of cases the premium paid is a profit and an asset to the insurance companies.  Only in a meager cases the claim will be made one such is a case of the complainant. Number of beds is immetierial for consideration of mediclaim.   However as policy as admitted by the opposite party their claim will be restricted to only Rs.13,500/- on Rs.5,000/- is dis-allowed.  There is no per-contra evidence.

12.      Hence under these circumstances denying the whole claim is nothing but an unfair trade practice.  Hence the complainant is entitled to Rs.13,500/-.  Hence we hold the above points accordingly and proceed to pass the following:-

ORDER

1.        The complaint is Allowed-in-part.

2.        The opposite parties are directed to pay to the complainant a sum of Rs.13,500/- within 30 days from the date of this order.

3. The opposite parties are also directed to pay Rs.2,000/- to the complainant towards cost of this litigation.

4.       If for any reason the opposite parties does not pay the aforesaid amounts as ordered at serial Nos. 2 and 3 above then it shall pay the said amounts along with interest on Rs.13,500/- at a rate of 12% per annum from 21.11.2009 until payment within 60 days from the date of this order.

5.       The opposite parties are directed to send the amounts as ordered at Serial Nos.2 & 3 above through DD by registered post acknowledgment due to the complainant and submit the compliance report to this Forum with necessary documents within 45 days.

6.       Return the extra sets filed by the parties to the concerned as under Regulation 20(3) of the Consumer’s Protection Regulation 2005.

7.       Send a copy of this order to both parties free of costs, immediately.

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this the 14^th  Day of July 2011)

MEMBER                                                 MEMBER                                       PRESIDENT