Date of Filling     : 11.06.2014.

                                                                                         Date of Disposal :  25.02.2016.

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, THIRUVALLUR - 1.

PRESENT: THIRU. S.  PANDIAN, B.Sc., L.L.M.,            …    PRESIDENT

                 TMT. S.  SUJATHA,B.Sc.,                            …    MEMBER-I

C.C. No.36/2014

(Thursday the 25^th February 2016)

Mr. P.S. Srihari,

S/o. P.R. Sriramalu,

No.23, Nammalvar Street,

Gandhi Nagar,

Avadi,

Thiruvallur District - 600 054.                                                 … Complainant.

                                                          / Versus /

1. The Branch Manager,

    M/s. United India Insurance Company Limited,

    B.O:012004, No.235, I Floor, AMK Plaza, Near IOB Bank,

    N.M. Road, Avadi,

    Chennai - 600 054.

2. The General Manager,

    M/s. United India Insurance Company Limited,

    Regd. and Head Office,

    No.24, Whites Road,

   Chennai - 600 116.

3. The Regional Manager,

    M/s. United India Insurance Company Limited,

    No.134, Silingi Building,

    2^nd, 3^rd and 4^th Floor, Behind IDBI Bank,

   Greams Road,

   Chennai - 600 006.

4. The Management of

    Sri Ramachandra Medical College and

    Research Institute and Hospital,

    Rep. by its Authourised Signatory,

    No.1 Ramachandra Nagar,

    Porur,

    Chennai - 600 116.                                                             … Opposite Parties.        

This complaint is coming upon before us finally on 16.02.2016 in the presence of M/s. S. Kannan, Counsel for the complainant, M/s. Nageswaran, Counsel for the 1 to 3 opposite parties and Thiru. A.R. Poovannan, Counsel for  the 4^th opposite party and upon hearing arguments of the 4^th opposite party’s side, and  having  perused the documents and evidences and written arguments of both sides, this Forum delivered the following,

                                                ORDER

PRONOUNCED BY THIRU. S.  PANDIAN, PRESIDENT

          This complaint is filed by the complainant U/S 12 of Consumer Protection Act, 1986 against the opposite parties seeking direction to refund the entire hospital charges of Rs.8,124/-, to pay the medicine and other expenses amounting to Rs.20,000/-, to pay Rs.2,00,000/- towards mental agony and stress suffered by the complainant and to pay Rs.10,000/- towards cost.

1. The brief averments of the complaint are as follows:-

The complainant’s son P.A. Riswanth had accidently consumed ‘ALA’ a whitening agent of detergent about 10ml at about 11:00 A.M. on 14.06.2012.  So, the complainant took in emergently to the Sri Ramachandra Medical College Hospital and admitted as in-patient in the ICU, as it was a ‘Sodium Hydrochloride Poisoning’.  The complainant informed the hospital that he has Medi-claim Policy for payment of Hospital fees, but the Hospital management told the complainant to pay the amount and to get reimbursed from the insurer.  So, the complainant admitted his son in the hospital by paying Rs.4,000/- as an advance. The complainant’s son was admitted in ward C3 bed 20 and the charge is Rs.1,500/- per day.  The complainant informed immediately the insurer about the admission of his son in the hospital.  The complainant’s son was discharged at 05-26-59 p.m. on 15^th June 2012 after paying Rs.8,124/- towards the inpatient bill in total, as he had paid Rs.4,000/- as advance and Rs.4,124/- at 05-24-43 p.m. on 15^th June 2012.

2.       That on 10.11.2012 to his surprise, the 1^st opposite party has sent a letter that the claim was repudiated, that the reason for such repudiation is “remarked: as Admission for Sodium Hypo chloride Poisoning, date of admission - 15.06.2012 1:35 p.m. and the date of discharge  15.06.2012 11:45 a.m.  There is no 24 hrs. hospitalization.  As per the policy T & C  WHICH IS NOT PAYABLE.  HENCE THIS CLAIM GETS REPUDATED under the clause 2, 3”.  Further the 1^st opposite party has repudiated the claim stating that the 4^th opposite party has given a statement that the hospitalization is only for one day.  But the complainant states that the hospitalization is for 2 days.  Then the complainant preferred legal notice to all the opposite parties call upon them to make reimbursement of money.  All of them received the notice and only the 4^th opposite party replied through their counsel and clearly stated that the patient stayed in the C3 Pediatric ICU for approximately 28 hours i.e. 13:35 hrs. on 14.06.2012 until 17:30 hrs. on 15.06.2012, for medical treatment.  Hence, this complaint.

3.         The contention of the written version of the 1 to 3 opposite parties are briefly as follows:-

The various allegations found in the complaint are denied as they are contrary to facts and terms of contract of insurance and based on misinformed and misunderstood appreciation of the Policy.  That the complainant’s son was admitted in the Hospital for 2 days is specifically denied and as much as it is contrary to the Certificate issued by the Hospital to the Investigator of the opposite parties.   According to the Hospital Certificate issued, the complainant’s son was admitted on 14.06.2012 at 13:35 hrs. and discharged on 15.06.2012 at 11:45 hrs. being the total period of hospitalization as per this certificate issued by the District Superintendent Group Head, Non Billing Department.  Hence, total number of hrs. for which the complainant’s son was hospitalized is less than 24 hrs.

4.         The relevant terms and conditions, as set out in the Policy, under the Head “ Definition and in 2-3 which reads as follows: “Hospitalization means admission in Hospital Nursing Home in India upon the written advise of the Medical Practitioner for a  minimum period of 24 consecutive hours”.  The claim of the complainant for hospitalization of his son is rightly repudiated after due application of mind and after thorough investigation coupled with the Certificate issued by the concerned Hospital.  The contention of the complaint to the effect that he had paid the hospital charges for 2 days is irrelevant for the purpose of considering the claim in accordance with the Terms and conditions of the Policies.  In as much as there is no proof of Hospitalization beyond 24 hours, as certified by the concerned Hospital, it is submitted that the repudiation of liability is in accordance with the terms and conditions of the Policy.   Hence, there was no deficiency in service as alleged and the 1 to 3 opposite parties are not liable to pay any amount.  Hence, this complaint is liable to be dismissed.

5.         The contention of the written version of the 4^th opposite party as briefly as below:-

The 4^th opposite party denies all the allegations made in the complaint except which are all specifically admitted herein and the complainant is put to very strict proof of the same.  The 4^th opposite party submits that they are not aware of the statements made in paragraphs 3 to 5 of the complaint.   The allegations made in the paragraphs 9, 11 to 14 of the complaint are not known to the 4^th opposite party and it is between the complainant and the 1 to 3 opposite parties.  The 4^th opposite party strongly denies the allegation made in paragraph 15 of the complaint as the complainant never approached the 4^th opposite party in this regard.  The 4^th opposite party submits that it has satisfactorily restored the health condition of the complainant’s son and has thereby duly fulfilled its professional obligations towards the complainant.   Whether or not United India Insurance Company Limited repays the amount is entirely a matter between the complainant and the Insurance Company and is entirely beyond the liability of the 4^th opposite party.

6.         The patient’s condition was stable on the next day i.e. on 15.06.2012 and hence, was advised discharge by the doctor.  The total bill amount for the treatment and facilities provided  by the hospital amounted to Rs.8,124/- and the bill was settled by the attender after which the patient was discharged.  According to the 4^th opposite party records, the date and time of admission is recorded as 14.06.2012 at 13:04 hrs. and the date and time of discharge is recorded as 15.06.2012 at 17:30 hrs.  The copy of the invoice as given to the patient’s attender at the time of discharge is attached herewith.  The 4^th opposite party submits that the patients attender had paid bed charges for 2 days for the C3 Paediatric ICU amounting to a total of Rs.3,000/- (Rs.1,500/- per day for 14.06.2012 and 15.06.2012 respectively) since the patient stayed in the C3 paediatric ICU for approximately 28 hrs. (i.e., from 13:35 hrs. on 14.06.2012 to 17:30 hrs. on 15.06.2012) for medical treatment.  The 4^th opposite party has clearly informed all those things in their reply to the legal notice by the complainant.

7.         The complainant has not made out any specific complaint against the 4^th opposite party.  The 4^th opposite party even in their reply has categorically denied of their liability and the complainant only to harass the 4^th opposite party has filed this false case.  The 4^th opposite party submits that the medi claim and its reimbursement is upon the terms and conditions of the complainant and the other opposite parties.  The 4^th opposite party is an unnecessary party to this case.  The complaint is for MIS JOINDER of parties.  Further, the reliefs claimed by the complainant mismatch his own pleadings.  The complainant is not entitled for the refund of the fees paid to the 4^th opposite party towards hospitalization, medicine, other expenses and compensation.  The complainant is not bonafide and the claim is not maintainable and is liable to be dismissed.

8.         In order to prove the case on the side of the complainant, the proof affidavit submitted for his evidence and Exhibit A1 to A10 are marked. While so, on the side of the 1 to 3 opposite parties, the proof affidavit is filed along with the documents which are marked as Exhibit B1 and B2 and on the side of the 4^th opposite party the proof affidavit is filed along with the document which is marked as Exhibit B3.

9.         At this juncture, the point for the consideration before this Forum is:

1. Whether there is any deficiency of service on the part of the opposite parties as alleged in the complaint?
2. To what other reliefs, the complainant is entitled to?

10.     Written arguments submitted on the side of 1 to 3 & 4^th opposite parties and the copies of the same have been furnished to either side.  In addition to that, oral arguments also adduced on both the sides.  In spite of sufficient opportunities given to the complainant, he didn’t turn up either to file the written arguments nor for adducing oral arguments and hence the same are closed.

11.     Point no.1:-

According to the case of the complainant is  that inspite of having medi claim policy from the opposite party 1 to 3, and the amount claimed by the complainant for the treatment taken for his son in the 4^th opposite party’s hospital has been repudiated for the reason stated by 1 to 3 opposite parties that the patient was hospitalized under treatment which is less than 24 hours whereas the opposite party has collected the charges for 2 days from the complainant and thereby the opposite parties have committed deficiency of service.  While so, it is contented by the opposite parties 1 to 3 that as per the certificate given by the hospital to the investigator of 1 to 3 opposite parties clearly shown that the patient underwent treatment in the hospital of 4^th opposite party is less than 24 hours as per the relevant terms and conditions as said duly in the policy issued by them.  In such situation the 4^th opposite party has stated that the patient was admitted on 14.06.2012 at 13:04 hours and discharged on 15.06.2012 at 17:30 hours and therefore they have collected bed charges for 2 days and thereby the patient stayed in the C3 Pediatric ICU for approximately 28 hours for medical treatment and therefore the 4^th opposite party is not liable to pay any refund of fees or any compensation to the complainant.

12.     At the outset, it is the duty of the complainant to prove the allegations made in the complainant against the opposite parties regarding this.  On careful perusal of the proof affidavit of the complainant, it is seen that Ex A1 is the medi claim policy taken by the complainant from Opposite parties 1 to 3 for himself as well as for  his family members.  It is further seen that the complainant’s son Rishwanth was admitted in the ward C3 number 20 in the hospital of 4^th opposite party on 14.06.2012 as in patient as that was detected as ‘Sodium Hydrochloride Poisoning’ and discharged on 15.06.2012 and thereby the complainant’s son was taken treatment for 2 days as per the records issued by the 4^th opposite party.  The inpatient receipts, the inpatient summary and discharge summary have been marked as Ex. A2 to Ex.A4 respectively.  It is further learnt that the claiming of medical expenses incurred by the complainant for medical treatment of his son has been repudiated by the opposite parties 1 to 3 for the reason that there is no 24 hours hospitalization which is marked as Ex.A5 and therefore, the complainant issued a legal notice to the opposite parties which is marked as Ex.A6 and the acknowledgement cards as Ex.A7 & Ex.A8 for the receipt of the same by the opposite parties.  The postal receipts are marked as Ex.A9 series and for which the 4^th opposite party has replied through reply notice which is marked as Ex.A10.

13.     It is further learnt that from Ex.A1 to Ex.A5, it is crystal clear that the complainant’s son have taken treatment for ‘Sodium Hydrochloride Poisoning’ for which, he was admitted on 14.06.2012 and discharged on 15.06.2012 and incurred certain medical expenses and the same were fully paid by the complainant to the 4^th opposite party.  On seeing the Ex.A4 discharge summary with naked eye that the amount collected for 2 days for bed charges at the rate of Rs.3,000/-.  The said fact was clearly admitted by the 4^th opposite party in Ex.A10.  Whereas as per Ex.B2 the report of the investigator pointed out by the  1 to 3 opposite parties reveals the fact that the complainant’s son has taken treatment is less than 24 hours i.e. the time of admission is 14.06.2012 13:35 p.m. and the time of discharge on 15.06.2012 at 11:45 a.m. and to that effect the investigator  has filed the certificate issued by the Deputy Superintendent Group Head of the 4^th opposite party.  From these documents, it goes without seeing that the treatment taken by the complainant’s son is less than 24 hours.  Such being the position, on seeing the proof affidavit filed by the 4^th opposite party, it is stated in para no.8 as follows.

14.     “That on verification it appears that when the Insurance Co., made verification of the claim application of the complainant through its investigator,  a letter has been given by the Deputy Superintendent (Insurance) of SRMC mentioning the time of discharge of the patient dated 11:45 a.m. of 15.06.2012 instead of 5:30 P.M. of 15.06.2012.  So, from the above version, it is clearly admitted by the 4^th opposite party that, the Deputy Superintendent of 4^th opposite party has been issued the certificate which was marked as Ex.B2 which is clearly shown that the treatment taken is less than 24 hours.

15.     Furthermore, there is no mentioning about the time of discharge anywhere in Ex.B3 that the patient was taken treatment approximately for 28 hours that is till 5:30 P.M. on 15.06.2012.   From the  foregoing the facts and circumstance, it is crystal clear that there is no record to show that the complainant’s son has taken treatment exceeding 24 hours. The 4^th opposite party has knowingly collected the bed charges for 2 days of Rs.3000/- as per Ex. A3.  On the other hand the Deputy Superintendent has issued certificate enclosed with Ex.B2, which shows the duration of treatment taken by the said patient is  less than 24 hours which leads complication to the complainant for not claiming the expenses actually incurred by means of medi claim Policy which was repudiated by the opposite parties 1 to 3.  It clearly shows the unfair trade practice as well as deficiency in service on the part of the 4^th opposite party.  The reasons stated by the 4^th opposite party regarding the certificate issued by the Deputy Superintendent and Group Head (Insurance Policy) cannot be accepted since it is not convinced.  Therefore, it  needless to say that the opposite parties 1 to  has rightly repudiated the claim of the complainant to the Ex. A1 medi claim Policy as per the terms and conditions of the said policy and on furnishing the Ex.B2 by the investigator.  Hence, the inability for not claiming the medical expenses by the complainant is only due to the deficiency in service and gross negligence on the part of the 4^th opposite party and the same has been proved beyond of all reasonable doubts.  Thus the point no.1 is answered accordingly. 

16.     Point no.2:-

As per the decision arrived in point no.1 this Forum concludes without any hesitation that the 4^th opposite party is only liable for the relief claimed by the complainant and the opposite parties 1 to 3 are not at all liable for any relief as prayed in the complaint against them.  Hence, the complainant is entitled for the refund of the hospital charges and reasonable compensation with cost. Thus point no.2 is answered accordingly.

17.     In the result, this complaint is allowed in part.  Accordingly, the 4^th opposite party is directed to refund the hospital charges to the tune of Rs.8,124/-, the medicine and other charges of Rs.1,352/- amounting to Rs.9,951/- rounded off Rs.10,000/- in total and to pay a compensation for a sum of Rs.10,000/- for mental agony caused due to the deficiency of service on the part of the 4^th opposite party totally of Rs.20,000/- (Rupees Twenty Thousand only) with interest at the rate of 9% p.a. from the date of filing of this complaint (11.06.2014) till the date of this order (25.02.2016) and Rs.5,000/- towards cost of litigation of this complaint.  The claim against 1 to 3 opposite parties is hereby dismissed.

The above amount shall be payable within one month from the date of receipt of the copy of the order, failing which the said amount shall carry interest at the rate of 9.5% p.a. till the date of payment.

Dictated by the president to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Forum on this 25^th February 2016.

Sd/-****                                                                                                     Sd/-****

MEMBER I                                                                                        PRESIDENT

List of documents filed by the complainant:-

List of documents filed by the 1 to 3 opposite parties-

Document filed by the 4th opposite party-

Sd/-****                                                                                                     Sd/-****

MEMBER I                                                                                        PRESIDENT