PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of July 2012
Filed on : 22/03/2012
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 183/2012
Between
Reju K. Mathew, : Complainant
S/o. Mathai, Kuttichira house, (By Adv. Johnson Thomas,
Pallikkara, Kumarapuram P.O., Thayil buildings, KCM Mather
Ernakulam-683 565. road, Opp. Specialist’s Hospital
Ernakulam North, Kochi-682 018.
And
Met Life Insurance Co. Ltd., : Opposite party
Rep. by its Manager Palarivattom (By Adv. Nelson J Manayil, Edathil
Branch, Ernakulam, Building, Market road, Premkumar
Kochi-682 025. Singh, Kochi-682 035.)
O R D E R
A Rajesh, President.
The case of the complainant is as follows:
The complainant was a holder of medical insurance policy for the period from 11-01-2011 to 23-10-2011 which was of reinstatement of the existing insurance policy from 23-10-2009. On 09-04-2011 the complainant was admitted to Carmel Hospital, Aluva, consequent to an injury sustained to the right shoulder due to accidental fall while playing volley ball. The disease was diagnosed as traumatic subluxation right shoulder. He was discharged from the hospital on 18-04-2011. Thereafter the complainant submitted claim application before the opposite party for Rs. 65,000/-. The opposite party repudiated the claim vide letter dated 05-12-2011. The complainant is entitled to get the insurance amount with interest together with compensation and costs of the proceedings.
2. The version of the opposite party is as follows:
The complainant has failed to furnish the day wise medical treatment undergone by him and as such in the absence of receipt of the required document from the complainant, the opposite party could not process the claim. The opposite party received hospital certificate on 06-05-2011. After verification the opposite party sent a letter dated 22-06-2011 to the complainant requesting submission of documents from treating doctor with complete day to day treatment details for processing the claim. However the complainant failed to do so. So on 26-09-2011 the opposite party sent a claim closure letter to the complainant. Subsequently the opposite party received a grievance e-mail from the complainant for reconsidering the claim. The discharge summary stated that only physiotherapy treatment was given to the complainant which is excluded from payment as per clause 5 of the policy. Accordingly the claim was dismissed. There is no deficiency in service on the part of the opposite party.
3. The complainant was examined as PW1 and Exts. A1 to A7 were marked on his side. No oral evidence was adduced by the opposite party. Exts. B1 to B4 were marked on their side. Heard the counsel for the parties.
4. The question that arises for consideration is whether the complainant is entitled to get insurance claim from the opposite party together with compensation and costs of the proceedings to the complainant.
5. . Admittedly the complainant was holding valid mediclaim insurance policy of the opposite party from 23-10-2009 to 23-10-2011. It is not in dispute that during the currency of the insurance policy the complainant underwent treatment at Carmel Hospital, Aluva from 09-04-2011 to 18-04-2011 and his disease was diagnosed as Traumatic subluxation Right Shoulder evidenced by Ext. A5 Medical certificate.
6. The opposite party repudiated the claim of the complainant vide Ext. B4 letter dated 05-12-2011 which reads as follows:
“ During the course of assessment we found that you were hospitalized for traumatic subluxation at Carmel Hospital, Aluva, from 09/04/2011 to 18/04/2011. As per discharge summary dated 18/04/2011 signed by the treating consultant we found that only physiotherapy treatment was given to you. As per clause 5.0 of the terms and conditions of the policy, hospitalization for the sole purpose of physiotherapy is excluded.
In light of above mentioned evidences, and after applying the principles of equity, justice and good conscience, in line with the provisions laid down under the Insurance Act, 1938, as upheld by various Courts in their judicial pronouncements, the Claims Committee has decided to Uphold the decision as Inadmissible.”
7. The opposite party relied on exclusion clause 5(n) and (o) of Ext. B1 terms sand conditions of the policy which reads as follows:
“No claim for daily hospitalization cash benefit, daily ICU cash benefit or recuperation benefit shall be admissible on account of hospitalization, directly or indirectly caused by, based on arising out of or howsoever attributable to any of the following
x x x x
(n)Hospitalization for the sole purpose of physiotherapy or any ailment for which hospitalization is not warranted due to advancement in medical technoloty.
(o)Any treatment not performed by a physician or any treatment of a purely experimental nature”
8. As per Ext.A5 medical certificate the complainant had undergone impatient treatment at Carmel Hospital, Aluva for the per iod from 09-04-2011 to 18-04-2011. The ailment was diagnosed as “Traumatic Subluxation right shoulder”. The treatment details as per the certificate is as follows:
a. Shoulder immobilization
b. Ultra sound heat to shoulder to alleviate pain
c. Static strengthening exercise to shoulder stabilization muscles under the supervision of physiotherapist”.
9. Ext. A7 series medical bills 12 in numbers goes to show that various medicines were administered to the complainant during the stay at the hospital and he had to undergo various tests at the hospital. It is pertinent to note that no medical evidence is on record to show that admission of the patient at the hospital was not necessary for the treatment of the complainant especially of Ext. A7 speaks volumes themselves. Neither has the opposite party a bonafide claim there such a treatment could have been taken anywhere other than a hospital not to mention the timely medication (emphasis applied). Moreover the treating doctor alone is to decide whether a patient is to be admitted in the hospital or not. The opposite party has not. The opposite party has not controverted the same for the conspicious absence for an expert opinion.
10. In the above circumstances we are of the firm view that the complainant is entitled to get the insurance claim from the opposite party for his treatment at the Carmel Hospital, Aluva for the period from 09-04-2011 to 18-04-2011 especially when the complainant has produced all the relevant records pertaining to his treatment in this Forum. We unanimously ordered so.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order, failing which the amount shall carry interest @12% p.a. till payment.
Pronounced in the open Forum on this the 31st day of July 2012
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of statement
A2 series : discharge summary (two pages)
A3 : Copy of discharge memo
A4 : Copy of receipt dt. 12/04/2011
A4(a) : Copy of MRI right shoulder
A5 : Copy of certificate
A6 : Copy of claim decision letter
Opposite party’s Exhibits : :
Ext. B1 series : Copy of application form
B2 : Copies of Hospital cash benefit
claim form
B3 : copy of requirement dt. 10/05/2011
B4 : copy of claim decision letter
Depositions:
PW1 : Reju K. Mathew
