PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 30th day of December 2011
Filed on :25/11/2010
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No. 624/2010
Between
Rajani Satheesan, : Complainant
Melamkuzhiyil house, (By Adv. Tom Joseph,
Monippilly,Puthencruz P.O., Court road, Muvattupuzha)
Ernakulam.
And
1. M/s. National Insurance Co. Ltd., : Opposite parties
Kolencherry Branch Office, (1st O.P. party in person)
Kolencherry P.O.,
Ernakulam.
2. M/s. Medi Assist India Pvt. Ltd., (2nd O.P. by Adv. Rajan P
Shilpa Vidya, 3rd Floor, #49. Kaliyath, 42/1824, Near Masjid
1st main road, Kombara, Market road,
Srakki Industrial Layout, 3rd Phase, Kochi-682 019)
J.P. Nagar,
Bangalore-560 078.
O R D E R
Paul Gomez, Member.
The short facts behind the complaint are as follows:
The complainant was admitted in MOSC Medical College Hospital, Kolenchery during the currency of mediclaim insurance policy. She was holding with the 1st opposite party company. The disease was diagnosed as intervertebral disc bulge with mild protrusion abutting the Thecalsac, mild cervical spondylosis. The mediclaim preferred by her before the opposite parties for reimbursement of hospital expenses was rejected on the ground that there was no active line of treatment undergone in the hospital. Hence this complaint claiming reimbursement along with compensation and costs.
2. Version was filed by the 1st opposite party controverting the arguments raised in the complaint. The hospitalization, on examination of medical records, is found to have been made for investigation and oral medicines. According to 1st opposite party, these acts can be done even as an out patient. Rs. 14,859/- was expended towards MRI scan out of the total claim of Rs. 15,865/-. The claim falls within the purview of Exclusion clause No. 4.10 of the Policy. The nature of treatment given was purely conservative management and hence repudiation is perfectly justified. Hence it is urged to dismiss the complaint with costs to the opposite parties.
3. No oral evidence to the complainant. Exts. A1 and A2 marked on her side. No oral evidence to opposite parties. Exts. B1 to B5 marked for them. Parties heard.
4. The points for determination.
i. Whether opposite parties are justified in repudiating the
claim?
ii. Reliefs, if any
5. Point Nos. i & ii. The dispute raised in the complaint pertains to repudiation of mediclaim preferred by the complainant, who is a policy holder of 1st opposite party. Even though Ext. A2 claim form is silent on the averment of the claim, Ext. B4 would tell us that amount claimed is 15,757.00 being the hospital charges. The document produced by 1st opposite party would show that the ground of repudiation is ‘no active line of treatment’ taken during hospitalization period except investigation, the claim is repudiated under clause 4.10 of the policy. In this context, it is pertinent to note that we are in the dark as to whether the claim was in fact processed by the TPA and their opinion in the instant case. Anyhow 1st opposite party feels emboldened in their repudiation relying on clause 4.10 of the Ext. B1 policy conditions. The text of clause 4.10 is extracted in toto for the sake of clarity.
“4.10 charges incurred at hospital or Nursing Home primary for diagnosis X-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing home”.
What we make out from this clause is that charges incurred for diagnosis Per se are excluded. In the same way charges in connection with diagnostic studies that have not any bearing on diagnosis and treatment of sickness are also excluded even if such procedure is carried on as inpatient. The fall out of this perception is that the insurance company has a liability to pay when laboratory or incidental examination are conducted in furtherance of diagnosis of a disease or its treatment. While the treatment was on inpatient basis. Exts. A1 and B2 would show that the claimant was admitted in hospital on 24-06-2010 in connection with her complaints regarding neck pain radiating to left upper limb and in the course of diagnosis of this symptom several investigations including MRI scan were undergone by patient for which she was medically advised to stay in hospital till 26-06-2010. We do not think it to be fair to challenge the bonafides of the doctor when he chooses one course of action in preference to others with regard to investigation diagnosis and treatment of diseases and infirmities. Sometimes stay in the hospital of the patient may be quite essential for the physician to closely monitor the investigations and treatment. Sitting judgments over such exclusive rights of the medical men at least occasionally is a disservice to the society undermining the morale of the medical profession. Obviously the hospitalization in this case has a bearing on diagnosis and treatment of the diseases which was identified as Intervertebral Disc bulge with mild protrusion Abutting the Thecal SDac Mild Cervical Spondilosis. In that view of the matter we do not find ourselves in consus with opposite parties in repudiating the claim validly made by the complainant.
We also make it clear that in our view, the opposite parties can not take shelter under clause 4.10 when claim is rejected on the ground that no active line of treatment has been followed while in hospital. At the same time 1st opposite party concede that conservative management of the condition was effected in the hospital. Conservative management, in our perception means management of the condition with medicines rather than surgical procedure. In our opinion 4.10 deals with hospitalization for the sole purpose of conducting investigations. In that view if one apprehends that 1st opposite party was not confident as to the ground on which it was dismissing the claim, one can not be found fault with.
To wind up, we are of the considered view that the opposite parties have committed deficiency in service to the complainant as they have illegally dismissed her valid claim for reimbursement of the hospital expenses. She is also entitled for costs of the proceedings in this Forum.
6. Accordingly the complaint is allowed in part and 1st opposite party is directed to pay Rs. 15,757.00 (Rupees fifteen thousand seven hundred and fifty seven only) along with interest @ 9% p.a. from the date of the complaint till payment. 1st opposite party is also directed to pay Rs. 1,000/- towards costs of proceedings in this Forum.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order.
Pronounced in the open Forum on this the 30th day of December 2011
Sd/- Paul Gomez, Member.
Sd/- A Rajesh, President.
Sd/-C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
