By Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite Party to pay Rs.31,950/- towards medical expense and to pay Rs.50,000/- as compensation and Rs.2,500/- as cost of the proceedings.
2. Brief of the complaint:- The Complainant took a mediclaim insurance policy from the Opposite Party through its agent at Kalpetta in the year 1998 and renewed the same from year to year. The current policy number during 2012 is 101601/48/12/97/00000811. The validity of the present policy is for the period from 25.10.2012 to 24.10.2013. While so on 07.08.2013 the petitioner developed severe back pain and stomach pain and consulted Dr. Mohandas at Kalpetta and he was taken to MIMS Hospital Kozhikode. On 10.08.2013, the Complainant was admitted again for treatment. The Complainant informed the Opposite Party about the admission on the very same day of admission. The Opposite Party then informed the Complainant that the expenses will be met by them. The Doctor diagnosed the disease as right lower ureteric calculus and right URS. DJ Stunting was done on 12.08.2013. The Complainant was discharged on 13.08.2013. Though the Complainant submitted the hospital bill for treatment, the Opposite Party asked the complainant to pay the entire amount and informed that the reimbursement would be done only after confirmation from the Head of Office. The Opposite Party kept the complainant to wait from morning till night for passing this information and forced the Complainant to pay the entire bill amount of Rs.33,000/- towards medical expenses, operation theatre charges, drugs, Medicines, room rent, consulting charges etc. After One week, a sum of Rs.11,000/- was sanctioned by the Opposite Party. As per terms , the Opposite Party is bound to pay the entire expenses to the Complainant. As continuation of treatment, the petitioner was again admitted at MIMS Calicut on 08.09.2013 and discharged on 19.09.2013. Though the Hospital bill was Rs.10,924/-, the Opposite Party paid only 9,000/-. The Complainant had spent an amount of Rs.52,850/- but reimbursed only Rs.20,900/-. The balance to be reimbursed is Rs.31,950/-. Aggrieved by them, the Complainant filed this complaint.
3. On receipt of complaint, notice was issued to Opposite Party and Opposite Party appeared before the Forum and filed version. In the version of Opposite Party, the Opposite Party pleaded that on receipt of details of treatment, the Opposite Party informed the TPA for taking steps to process the claim. After making proper assessment as per terms, the TPA sanctioned an amount of Rs.11,900/- to the Complainant. The sum assured is Rs.75,000/- as per policy. The Complainant is not entitled to get any amount in excess than what is mentioned by TPA. As per condition 1.2(A) of policy, the amount of expense payable under room boarding and nursing expenses head is restricted to 1% of the sum insured or the actual amount whichever is less. This also includes nursing care, RMV charges, IVFluids/Blood transfusion /injection administration and similar expense. In this case, the Complainant is entitled to Rs.750/- per day as Room rent . As per note 1 of conditions 1.2, it is expressly stated for expense payable under head 1.2 C & D ie doctor fees, operation theatre charges, surgical appliances, anesthetic, dialysis, Chemotheraphy etc. shall be at the rate applicable to the entitled room category. In case the insured opts for room with rent higher than the entitled category as in 1.2 A above, the charges payable under 1.2 C & D shall be limited to the charges application to the entitled category. This will not be applicable in respect of medicines, drugs, and implants. In this case, all other expense other than medicines and implants were proportionately reduced to the entitled category as per 1.2 A. Hence the Opposite Party contends that Complainant is not entitled to the claimed amount.
4. On going through the complaint, affidavit, version the Forum raised the following
points for consideration.
1. Whether there is deficiency of service from the part of Opposite Party?
2. What order as to cost and compensation?
5. Point No.1:- In addition to complaint, the Complainant produced proof affidavit and is examined as PW1. The document produced by Complainant are marked as Ext.A1. Ext.A1 is the policy. The Opposite Party's Branch Manager is examined as OPW1 and Marked Exts.B1 and B2. Ext.B1 is the policy and Ext.B2 is the work sheet of assessment made by the Opposite Party. OPW1 deposed before the Forum that the claim of the Complainant is processed by the TPA ie Paramount Health Services at Cochin. Ext.B2 is the work sheet. On perusal Ext.B2 it did not contain the signature of TPA, address of TPA and seal of TPA. Ext.B2 is seen prepared at Kalpetta. No calculation of TPA is produced in this case. According to the complainant, since the assessment is made by the TPA, the best person to give evidence in favour of Opposite Party is the TPA and TPA's evidence will be the best evidence. But in this case, TPA is not examined and their original calculation statement is also not produced by Opposite Party. According to the Complainant, Ext.B2 have no authenticity. On perusal it is seen that the doctor fees is claimed as Rs.12,430/-. But the Opposite Party allowed only Rs.4,116/-. On going through the policy, it is found that there is no mention regarding the quantum of Doctor fees. So when there is no mention regarding doctor fees, the Complainant is entitled to get the whole doctor fees paid by the Complainant. The Opposite Party have to prove the ratio used in calculating the quantum to be payable to the Complainant. But on perusal, the Forum found that no such assessment work sheet is produced by the Opposite Party. Ext.B2 did not contain all such details. If the assessment is made by the Opposite Party itself, the evidence of Opposite party can be fully accepted. But here in this case, the calculation is made by TPA but not produced the calculation statement of TPA signed by TPA. Ext. B2 is prepared by the Opposite Party. So the Forum found that the best evidence will be the evidence of TPA, at least the calculation statement of TPA would have been sufficient. Therefore, analysing the entire evidence, the Forum found that there is deficiency of service from the part of Opposite Party is dealing the matter. Point No.1 is found accordingly.
6. Point No.2:- Since the point No.1 is found in favour of Complainant, the Opposite Party is liable to pay the cost and compensation.
In the result, the complaint is partly allowed and the Opposite party is directed to pay Rs.31,950/- (Rupees Thirty One thousand Nine hundred and Fifty) only towards medical expense and Rs.2,500/- (Rupees Two thousand Five hundred) only towards compensation and Rs.2,000/- (Rupees Two thousand) only towards the cost of the proceedings. The Opposite Party shall pay the amount within one month from the date of receipt of this order failing which the Complainant is entitled to get 12% interest from the whole amount.
Dictated to the C.A transcribed by him and corrected by me and pronounced in the Open Forum on this the 19th day of August 2014.
Date of filing: 17.12.2013
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
A P P E N D I X
Witness for the Complainant:
PW1. Alavi. Complainant.
Witness for the Opposite Party:
OPW1. Naveen Palliath. Branch Manager, United India Insurance Co.
Kalpetta.
Exhibits for the Complainant:
A1. Policy
Exhibit for the Opposite Party:
B1. Policy.
B2. Work Sheet.
