IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday the 31st day of May, 2016
Filed on 21.07.2015
Present
1.Smt. Elizabeth George (President)
2.Sri. Antony Xavier (Member)
3.Smt.Jasmine.D. (Member)
in
C.C.No.225/2015
between
Complainants:- Opposite Parties:-
- Sri. Unnikrishnan 1. Medi. Assist India Pvt. Ltd.
Krishnajali 3rd Floor, No.49, Shilpa Vidya
Ponnadu P.O. Sarakki Industrial Layout
Alappuzha – 688 538 1st Main J.P. Nagar 3rd Phase
Bangalore – 560 078
- Smt. Bhadradeviamma
W/o Unnikrishnan 2. The Manager, (Health Insurance)
-do- LIC of India Divisional Office
(By Adv. R. Rajendraprasad) Ernakulam
3. LIC’s Health Protection Plus
Branch Office IV 0-1 Vellakkinar
P.B. No.444, Alappuzha
(By Adv. P.K. Mathew – for opposite
parties 2 and 3)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The first complainant had taken a Health Protection Plus policy from the 2nd opposite party. The 2nd complainant was admitted to the Taluk Hospital, Cherthala on 21.4.2014 to 28.4.2014 for the surgery of Hernia. She was again admitted to Amritha Hospital, Ernakulam on 16.5.2014 and was discharged on 26.5.2014. The total expenses incurred for the treatment at Cherthala Taluk Hospital and Amritha Hospital amounts to Rs.2,35,972.74/-. As per the policy the opposite party is bound to meet the expenses incurred by the 2nd complainant and the children. But the opposite party repudiated the claim for the treatment expenses of the second complainant. Alleging deficiency in service on the part of the opposite parties, the complaint is filed.
2. Notice issued against the first opposite party was served, but did not turn up, hence the first opposite party is set ex-parte.
3. The version of the opposite parties 2 and 3 is as follows:-
It is admitted that the first complainant had taken a Health Protection Plus policy (Table 902) from the opposite party with date of commencement 10.10.2012 numbered 779160050. The 2nd complainant was admitted to Taluk Hospital, Cherthala on 21.4.2014 to 28.4.2014 for Umbilical Hernia with Appendicitis and Appendisectomy operation was done with Umbilical Hernia repair on 23.4.2014. Thereafter she was admitted for the period from 30.4.2014 to 3.5.2014 for sub acute intestinal obstruction with adhesion. She was again admitted to AIMS and Research Center on 3.5.2014 for sub acute intestinal obstruction with adhesion and discharged on 9.5.2014. On 16.5.2014 she was admitted to AIMS again for intestinal obstruction. Small Bowel resection and Anastomosis was done on 17.5.2014 and she was discharged on 26.5.2014. The claim forms were submitted, TPA processed the claim and called for additional requirements. The claim was rejected for the lawful reason that the surgeries underwent are not covered under the policy. The plan provides Health Insurance cover against specified health risks alone and since complainant’s case is not covered under the conditions and privileges the claim is rightly rejected. There is no deficiency in service on the part of the opposite parties 2 and 3.
3. The complainant was examined as PW1. One witness was examined as PW2. The documents produced were marked as Exts.A1 to A17. The opposite party produced 2 documents marked as Exts.B1 and B2.
4. The points that arose for consideration are as follows:-
1) Whether there is any deficiency in service on the side of the opposite parties?
2) If so the reliefs and costs?
5. It is an admitted fact that the first complainant and his family have taken Health Protection Plus policy from the second opposite party. It is also an admitted fact that the 2nd complainant was admitted to Taluk Hospital, Cherthala on 21.4.014 and discharged 28.4.2014, and again admitted to Amritha Hospital on 16.5.2014 and discharged on 26.5.2014. According to the complainant the total expenses incurred for the treatment is Rs.2,35,972.74/-. The claim for the medical expenses was repudiated by the opposite party vide letter dated 20.2.2015 for the reason that the surgery underwent by the 2nd complainant are not covered under the policy. In order to substantiate the contention raised by the opposite parties they produced the copy of the conditions and privileges of the Health Protection Plus policy which marked as Ext.B1. On verifying the surgical benefit annexure under the Head List of surgical procedure under digestive system it is stated that, “Resection and Anastomosis of any part of digestive Tract – 60% of the sum assured can be claimed. Ext.A9 is the discharge summary issued from the Amritha Hospital. In Ext.A9 under the title procedure done it is clearly stated that, “Small Bowel Resection + Anastomosis on 17.5.2014”. Hence as per the terms and conditions in Ext.B1 policy, since the complainant undergone surgery Resection and Anastomosis on 17.5.2014 the 2nd complainant is entitled to get 60% of the insured amount. As per Ext.A1 policy the sum assured for major surgical benefit is Rs.2 lakhs. The denial on the part of the 2nd opposite party in providing the insured amount as per the policy amounts to deficiency in service.
In the result, complaint is partly allowed. The opposite parties 2 and 3 are directed to pay Rs.1,20,000/- (Rupees one lakh and twenty thousand only) [60% of Rs.2 lakhs] with 9% interest per annum from 20.2.2015 till realization to the 2nd complainant. The opposite parties 2 and 3 are further directed to pay Rs.2,000/- (Rupees two thousand only) towards costs of this proceedings to the 2nd complainant. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the day 31st day of May, 2016.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Unnikrishnan. S. (Witness)
PW2 - Rejimon Joseph. K. (Witness)
Ext.A1 - Health Protection Plus policy schedule
Ext.A2 - Claim rejection letter dated 8.11.2014
Ext.A3 - Claim Rejection letter dated 20.02.2015
Ext.A4 - Claim rejection letter dated 17.10.2014
Ext.A5 - Information reminder 1 dated 27.9.2014
Ext.A6 - Information reminder 2 dated 5.2.2015
Ext.A7 - Copy of the claim rejection letter dated 8.11.2014
Ext.A8 - Prescription and Scanning report
Ext.A9 - Copy of the discharge summary dated 26.5.2014
Ext.A10 - Copy of the in-patient summary Annexure – 1
Ext.A11 - Copy of the in-patient collection and appropriation
Ext.A12 - Pharmacy cash bill for Rs.529/-
Ext.A13 - Pharmacy cash bill for Rs.105/-
Ext.A14 - Discharge Clearance
Ext.A15 - Copy of the discharge summary dated 9.5.2014
Ext.A16 - Copy of the in-patient collection and appropriation
Ext.A17 - Copy of the medical reports
Evidence of the opposite parties:-
Ext.B1 - Copy of the LIC’s Health Protection Plus conditions and privileges
Ext.B2 - Copy of the details of Health Protection Plus policy
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
