PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 29th day of March 2012
Filed on : 15/09/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No. 493/2011
Between
Dr. Paul Jacob, : Complainant
Marekattu house, (By Adv. Tom Joseph,
Pampakuda P.O., Court road, Muvattupuzha)
Muvattupuzha-686 691..
And
M/s. New India Assurance Co. Ltd : Opposite party
Aluva Divisional Office, (By Adv. P.G. Ganappan,
Kadavath Shopping Complex, Anjali, Thrikkakara p.o.
Sub Jail Road, Aluva-683 101. Ernakulam, Kochi-21)
O R D E R
Paul Gomez, Member.
The short facts leading to the complaint are the following:
The complainant and his wife are the beneficiaries of a family medi-claim policy held by them. He underwent treatment at CMC hospital Velloore on 19-07-2010 for some chronic diseases he was suffering from for a very long time. Similarly his wife also was admitted in the same hospital with some other complaints, total of Rs. 77,070/- was incurred by the couple for their treatment. When the amount was demanded to be reimbursed, the claim was repudiated by the opposite party. Hence this complainant seeking various reliefs.
2.In their version, opposite party cling on to their stand by describing the treatment as executive check up. There was no positive diagnosis of any disease and no medicine worth the name were prescribed. This was a pre-planned hospitalization. Therefore the repudiation is justified.
3. No oral evidence for complainant. Ext. A1 (series) to A3 (series) marked. No oral evidence for opposite party either. Exts. B1 to B9 marked. Both sides were heard.
4. The following points require to be resolved.
i. Whether repudiation of insurance claim is justified?
ii. What are the reliefs, if any.
5. Points No.i. The spouses visited CMC Hospital Vellore on 19-07-2010 for the purpose of conducting high level investigation on their respective ailments from which they were suffering. Both of them were having treatment at Kothamangalam and Ernakulam for some time. Since those treatments were not proved to be fruitful, they were advised to go to the famous medical centre for more authoritative investigation and diagnosis. Both of them underwent several tests and investigation and their diseases were finally diagnosed and accordingly medical experts advised them to follow certain medical prescriptions and visit them for follow-up action.
Opposite party has repudiated the claim presumably because there was no active treatment after the long investigation. The medicines prescribed were cheap. Moreover, they think that this was a pleasure trip conducted by the couple to have an investigation for investigations sake. We do not find much merit in the contention of the opposite party. They have repudiated the claim based on the Exclusion clause 4.4.11 of Exht. B9 policy, where medical expenses incurred or arising out of “Diagnosis, X-ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury for which confinement is required at Hospital/Nursing Home” are excluded from being paid. The plain meaning that can be ascribed to the clause is that the company will not pay for diagnosis done for diagnosis sake. In this context doubts may arise as to Whether different connotations are to be attributed to the same word diagnosis at different places of the same sentence? It is to be said that the clause is framed in a clumsy manner that the literal meaning that can be attributed to the clause would lead one to the absurd result that the company is ready and willing to pay if the tests and examinations are done without confinement in the hospital. In the same way, what is the implication of the expression positive existence and treatment of any ailment. Does it mean that company would be liable to pay only if, result of the diagnosis was positive. Can anybody predict the result before actual investigation is done? What is the purpose of investigation if one is sure of the existence of a disease. Many more question come to mind one after another on reading this clause. One would wish that the clause be reframed so that ordinary person can understand it without much strain by plain reading.
Even though the clause is not susceptible for easy comprehension what we make out with much difficulty from these words is that cumulatively two events must occur. There must be confinement in the hospital, what ever be its duration. Secondly, the investigation should have been done with a bonafide intention as part of diagnosis of a disease. Incidentally, it is difficult to test the bonafides behind and an act when even the devil knoweth not what is in the mind of a man. We think in this case, both these conditions have been satisfied by the couple. There is no dispute with regard to hospitalization. The only doubt is raised with regard to the bonafides of the act. Opposite party suspects that it was a pleasure trip conducted by the couple and incidentally they have visited the hospital and undergone the examinations. We cannot accept such a contention because the undisputed facts narrated by the complainant go to show that these investigations and examinations have been conducted to track the real cause of their ailments. Going by the records, both of them were suffering a lot because of their respective bodily infirmities. Opposite party has not raised any objection with regard to their long standing ailments. Moreover Exts. B2 to B4 corroborates the fact that husband was really suffering from ailments. In the same way Ext. B7 stands testimony to diseases of the wife. Hence the contention of the opposite party that the investigations have been conducted light heartedly as part of executive check-up cannot be sustained. In the light of the discussions we had, we do not think that opposite party is justified in repudiating the claim relying on clause 4.4.11 of the Exht. B9 policy.
6. Point No. ii. In view of the finding on point No. (i), we have to determine various reliefs that can be allowed to the complainant. In Ext. B1 claim form Rs. 34,315/- has been claimed and in Ext. B6 claim form Rs. 42,755/- has been claimed. Both these sums put together, will not exceed the maximum permissible amount as per Ext. B9 policy. Moreover, there is no demur regarding the quantum of claim. Interest is demanded from the date of claim @ 15% p.a. We think it is on the higher side. To meet the ends of justice, we think interest @ 9% p.a. from the date of complaint will suffice.
7. In the facts and circumstances of the case, there will be no order as to compensation but opposite party will pay costs of the proceedings.
8. To sum up, the complaint is allowed and opposite party is directed to
i. pay Rs. 77,070/- to the complainant along with interest @ 9%
from the date of complaint till payment.
ii. pay Rs. 1,000/- towards costs of litigation.
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.
Pronounced in the open Forum on this the 29th day of March 2012.
Sd/-
Forwarded/By Order, Paul Gomez, Member.
Sd/-
A Rajesh, President.
Sd/
Senior Superintendent. C.K. Lekhamma, Member
Appendix
Complainant’s exhibits :
Ext. A1 series : two letters
A2 series : two letters
A3 series : two letteres
Opposite party’s Exhibits : :
Ext. B1 ; Claim form
B2 : Discharge summary
B3 : MR Study of brain
B4 : Receipt dt. 27-07-2010
B5 : Inpatient discharge bill
B6 : Claim form
B7 : Discharge summary
B8 : In-patient discharge bill
B9 : Mediclaim policy
