DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE

PRESENT: Sri. P.C. PAULACHEN, M.Com, LLB    : PRESIDENT

Smt. PRIYA.S, BAL, LLB, MBA (HRM) :  MEMBER

Thursday the 30^th day of May 2024

CC.174/2015

Complainant

V.K. Jayaraman,

S/o. Chathukkutty Nair,

Aswathy (HO), P.O. Melur,

Chengottukave, Koyilandy,

Kozhikode – 673306

(By Adv. Sri. Rammanohar)

Opposite Parties

1.               M/s. United India Insurance Co. Ltd,

City Complex, Near Bus Stand,

Main Road, Vatakara - 673101

2.               Managing Director,

Baby Memorial Hospital Ltd,

Kozhikode - 673004

3.               Mohanan. A,

Assistant General Manager,

Baby Memorial ­Hospital Ltd,

Kozhikode – 673004

(OP1 By Adv. Sri. T. V. Hari,

OP2 and OP3 By Adv. Sri. Z. P. Zachariah)

ORDER

By Sri. P.C. PAULACHEN  – PRESIDENT.             

            This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.

2. The case of the complainant, in brief, is as follows:

The complainant’s son Rajesh.J.S was an employee of Baby Memorial Hospital Ltd, Kozhikode. The complainant and his wife are members of the group insurance policy of the first and second opposite parties under the care of his son. Being a group insurance policy, he was not served with a separate policy. Nobody has explained the terms and conditions of the policy to him.

3. On 31/07/2014 he was admitted in the Baby Memorial Hospital with acute calculous cholecystitis. It was informed by the hospital authorities that the treatment expenses would be reimbursed by the insurance company. Cholecystectomy was done and he was discharged on 7/08/2014. The medical and treatment expenses amounting to Rs. 1,27,705/- was paid by the complainant. Thereafter, the medical bills and the relevant documents were entrusted to the concerned section in the hospital for preferring the claim. But the claim was repudiated by the insurance company and the complainant collected the bills with covering letter from the hospital.  
4. On going through the documents, the complainant came to know that the hospital authorities had not forwarded the relevant documents to the insurance company. On 1/1/2015 the complainant issued  notice to the opposite parties calling up on them to make available the insurance amount. Though the notice was received by the opposite parties, the same evoked no response.
5. On 27/01/2015 the third opposite party informed him over phone to submit all the bills to the Vatakara branch of the first opposite party. Accordingly, on 28/01/2015 the complainant entrusted all the bills to that office. But after one week when he contacted the branch manager to enquire about the status of the claim and for renewing the policy,  the response of the branch manager was not good.
6. On 05/02/2015 the complainant again issued a notice to the first opposite party either to allow the claim or to return the bills. But the bills were not returned. However, they had sent a letter stating that the claim could not be considered. Hence the complaint for getting the claim amount of Rs. 1,27,705/- with interest along with compensation of Rs. 2,00,000/-  and cost of the proceedings.
7. The opposite parties have resisted the complaint by filing written version. According to the first opposite party, the policy is issued to the second opposite party hospital and no amount is collected from the complainant as premium. The terms and conditions are negotiated and known to the second opposite party. The son of the complainant, who was an employee of the hospital, is well aware of his employment conditions and policy is the part of employee-employer relationship. It is a tailor made group policy covering the staff and family members of the second opposite party hospital on family floater basis as per the terms and conditions of the family medicare policy. This is not a consumer dispute.
8. The averment that the second opposite party had not forwarded the claim papers is not correct. In fact, they had lodged the claim. The claim is coming under exclusion 4.3 of the policy and hence repudiated. The treatment for Cholecystitis was done during 31/07/2014  to 01/08/2014 i.e. within 24 months from the inception date of coverage under the policy and as per exclusion 4.3 this illness comes under 2 year exclusion clause.
9. The present complaint is an experimental one. The floated policy is issued to the second opposite party hospital and had nothing to do with the complainant in person. The premium amount of the policy is not collected from the complainant in person.
10. The complainant had submitted claim form after the repudiation and intimation to the second opposite party. Thereafter the returned records were taken back by the complainant from the hospital and then resubmitted. The complainant was informed as per letter dated 18/02/2015 of the repudiation of the claim and also the reason for the same. The complainant is not entitled to the reliefs prayed for. There is no deficiency of service or unfair trade practice on the part of the first opposite party. It is, therefore, prayed to dismiss the complaint with costs.
11. In the joint written version filed by the second and third opposite parties, it is stated that they are unnecessary parties to the proceedings as the complainant can seek remedy only from the insurance company. There is no contract between the second opposite party and the complainant. The contract is in between the son of the complainant and the insurance company as per the group policy and the complainant is the beneficiary to the insurance policy issued by the first opposite party. The son of the complainant was an employee of the hospital. The second opposite party had made an arrangement with the first opposite party to extend medical benefits to the employees and their dependents, family members etc.
12. The complainant was treated in the second opposite party hospital and the treatment records were submitted to the insurance company as requested by the complainant. The complainant was subjected to gall bladder removal surgery and he had paid the treatment expenses at the time of discharge. The second opposite party had given all the treatment records to the complainant for submitting before the insurance company for settling the claim. The allegation that the second opposite party had not submitted the claim before the insurance company in time is absolutely incorrect. Equally, the allegation that the second and third opposite parties had not forwarded the documents is false and hence denied. 
13. The second and third opposite parties have no role in the matter of settling the claim. There was no unfair trade practice or deficiency of service on their part. The complaint is bereft of bonafides. It is, therefore, prayed to dismiss the complaint.
14. The points that arise for determination in this complaint are;

1. Whether there was any unfair trade practice or deficiency of service on the part of the opposite parties, as alleged?
2. Reliefs and costs.

15.  Evidence consists of the oral evidence of PW1 and Exts A1 to A7 and A7(a)on the side of the complainant. No oral evidence was let in by the first opposite party. Exts B1 to B5 were marked on the side of the first opposite party. RW1 was examined and Ext B6 was marked on the side of the second and third opposite parties.    
16.        Heard.
17. Point No.1:-   The complainant, who is a senior citizen and the beneficiary in the group mediclaim Policy, has approached this Commission with a grievance that there was neglect on the part of the opposite parties to pay the promised amount as per the policy for his medical treatment. The complainant has also a grievance that the second and third opposite parties failed to forward the documents submitted by him in connection with the claim to the insurance company.
18. The son of the complainant was an employee of the second opposite party hospital. The second opposite party had made an arrangement with the first opposite party insurance company to extend medical benefits to their employees, dependents and family members etc. The complainant is a beneficiary under the policy. The period of the policy is from 01/02/2014 to 31/01/2015. The sum assured is Rs. 2,00,000/-. Ext B5 is the list showing the name of the persons included in the policy and also the sum assured. Ext B1 is the policy schedule with terms and conditions. On 31/07/2014 the complainant was admitted in the second opposite party hospital for treatment of acute calculous cholecystitis, systemic hyper tension and diabetes mellitus. Cholecystectomy was done. The post-operative findings were that gall bladder inflamed, oedematous and covered by omentum  with pericholecystic fluid, gall bladder partly intra hepatic. Adhesions at Calot’s triangle. Gall bladder filled with multiple stones. He was discharged on 07/08/2014. Ext A1 is the copy of the discharge summary. The medical and treatment bill amounted to Rs. 1,27,705/-. Ext A2 is the copy of the consolidated bill. Thereafter, he preferred the claim before the insurer through the second opposite party with necessary documents. The claim was repudiated by the insurer as per Ext B2 letter stating the reason that as per family medi care policy condition 4.3 treatment for gall bladder stone removal  is an exclusion unless the insured has 24 months of continuous  coverage. There is no serious dispute on the above aspects.
19. In order to substantiate his case, the complainant got himself examined as PW1, who has filed proof affidavit and deposed in terms of the averments in the complaint and in support of the claim. Ext A1 is the  copy of the discharge summary, Ext A2 is the copy of the consolidated bill, Ext A3 series are the copies of the receipts, Ext A4 is the copy of the covering letter dated 15/08/2014, Ext A5 series are the copies of the complaints and the acknowledgment card,  Ext A6 is the copy of the covering letter dated 28/01/2015, Ext A7 is the copy of the letter dated 05/02/2015 and Ext A7(a) is the copy of the acknowledgment card.
20. The first opposite party did not adduce any evidence. Ext B1 is the Policy with terms and conditions, Ext B2 is the copy of the letter dated 18/02/2015, Ext B3 is the copy of the letter dated 15/08/2014, Ext B4 is the copy of the postal acknowledgment card and Ext B5 is the copy of the list of persons included in the policy.   The Assistant Manager of Baby Memorial hospital was examined as RW1. Ext B6 is the copy of the discharge summary, consolidated bill and payment receipts.  
21. The cardinal point to be considered in this case is as to whether the disease of the complainant and the treatment undergone by him in the second opposite party hospital is hit by the exclusion clause 4.3 of the policy. Exclusion 4.3 of Ext B1 reads as follows; 

“During the first two years of the operation of the policy, the expenses on treatment of diseases such as cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout and Rheumatism, Calculus Diseases, Joint Replacement due to Degenerative condition and age-related Osteoarthritis and Osteoporosis are not payable.”

22. Here the complainant was treated for acute calculous cholecystitis. Acute calculous cholecystitis is inflammation of the gall bladder that occurs due to occlusion of cystic duct. Acute calculous cholecystitis develops when the main opening to the gall bladder called cystic duct gets blocked by a gall bladder stone or by substance known as biliary sludge. Ext. A1reveals that the gall bladder of the complainant was filled with multiple small stones. Therefore, it is evident that  acute calculous cholecystitis developed to the complainant due to the reason that the cystic duct was blocked by the stones. The treating doctor found that the best treatment option for the gall bladder stone is surgical removal of gall bladder of the complainant. It is often better to remove the entire gall bladder rather than just targeting the gall stones. This is because gall stones tend to recur over time and removing the gall bladder eliminates the risk of gall stones formation and associated complications. So because of the gall stones and associated complications, the gall bladder of the complainant which was filled with multiple small stones was removed by surgery.  The gall bladder of the complainant was removed along with stones and this is evident from Ext A1. The case of the complainant that gall bladder stone has nothing to do with acute calculous cholecystitis and cholecystectomy, cannot be accepted. The expenditure of Rs. 1,27,705/- has resulted from the removal of gall bladder with stones.
23. A similar question came up for consideration before the Hon’ble National Consumer Disputes Redressal Commission in Dr. Biharilal Singhania Vs Branch Manager United India Insurance Co. Ltd & Ors.  reported in 2016 (4) CPR 179 (NC)  which was a revision petition filed against the order passed by the Bihar State Consumer Disputes Redressal Commission in Appeal No. 112/2014 preferred against the order passed by the District Forum, in Muzaffarpur in CC No. 06/2012. The District Forum held that the exclusion clause 4.3 was not applicable since the gall bladder of the complainant in that case had been removed ‘without stone’ and hence the claim was allowed. In appeal, the Hon’ble State Commission held that the claim was not allowable because the expenditure had resulted from the removal of gall bladder ‘with stone’. The revision petition filed against the order of the Hon’ble State Commission was dismissed by the Hon’ble National Consumer Disputes Redressal Commission upholding the order passed by the Hon’ble State Commission. It was held in paragraph 11 of the order as follows;

“Based on the reports stated above and the documentary evidence, the State Commission concluded that the claim was not admissible as during removal of gall bladder, stones were also extracted and hence, the exclusion clause was applicable. I do not find any irregularity, infirmity or jurisdictional error in the order passed by the State Commission, which may merit any interference at the revisional stage. This revision petition is, therefore, ordered to be dismissed and the impugned order passed by the State Commission is upheld.”

The above decision is squarely applicable to the facts situation in this case. The gall bladder of the complainant was removed along with multiple small stones and so the exclusion clause 4.3 is applicable in this case. The said exclusion clause makes it clear that if the gall bladder stone removal is done during the first two years of the operation of the policy, the expenses on such treatment are not payable. If that be so, the claim was repudiated by the first opposite party for valid reason and consequently no deficiency of service or unfair trade practice can be attributed against the first opposite party.

24. The complainant has a case that the terms and conditions of the policy wherein the exclusion clause etc. were included were not disclosed to him by any one. In this context, the contention of the insurance company is that the terms and conditions of the policy are known to the second opposite party and the son of the complainant. Ext B1 is a group insurance policy issued to  Baby Memorial Hospital, Kozhikode. It is a tailor made family medicare policy covering the staff, family members and the dependents of the staff of the Baby Memorial Hospital. The policy terms and conditions are negotiated and known to Baby Memorial Hospital and the policy is only a part of employee-employer relationship. The complainant is only a beneficiary being the father of Rajesh.J.S, who was an employee in the said hospital. The premium amount is not collected from the complainant in person. The second opposite party  has no case that the terms and conditions of the policy were not disclosed or furnish to them. The son of the complainant is not made a party to the proceedings. He was not examined as a witness also. The complainant has no case that his son was not aware of the terms and conditions of the group insurance policy.
25. The complainant has a further allegation that there was neglect on the part of the opposite parties 2 and 3 in forwarding the claim papers to the insurance company. But this allegation is stoutly denied by the second and third opposite parties, who have asserted that the claim papers were duly forwarded to the insurance company. It may be noted that the allegation of the complainant is not supported by any evidence. The insurance company has categorically admitted in paragraph 3 of the written version that the claim papers had been received from the second opposite party. Moreover, the second and third opposite parties have no role in the matter of sanctioning the claim.  That being so, no latches or negligence can be attributed against the second and third opposite parties.
26. From the above discussion, what emerges is that the claim was repudiated by the Insurance Company for valid reason as the same is hit by the exclusion clause 4.3 of the policy. There is no proof of any deficiency of service or unfair trade practice on the part of the opposite parties and consequently the complaint must fail.
27. Point No. 2:- In view of the finding on the above point, the complainant is not entitled to claim and get any relief.

In the result, the complaint is dismissed. However, no order as to costs.

Pronounced in open Commission on this, the 30^th day of  May,  2024.

Date of Filing:   20/03/2015

                                                        Sd/-                                                                                          Sd/-

                                                PRESIDENT                                                                             MEMBER

APPENDIX

Exhibits for the Complainant :

Ext.A1 – Copy of the discharge summary.

Ext.A2 – Copy of the consolidated bill.

Ext.A3 Series – Copies of the receipts.

Ext.A4 – Copy of the covering letter dated 15/08/2014. 

Ext.A5 Series– Copies of the complaints and the acknowledgment card.

Ext.A6 – Copy of the covering letter dated 28/01/2015.

Ext.A7 – Copy of letter dated 05/02/2015.

Ext.A7(a) – Copy of the acknowledgment card.

Exhibits for the Opposite Party

Ext.B1 – Policy with terms and conditions.

Ext.B2 – Copy of the letter dated 18/02/2015.

Ext.B3 – Copy of the letter dated 15/08/2014.

Ext. B4 - Copy of the postal acknowledgment card.

Ext. B5 – Copy of the list of persons included in the policy.

Ext. B6 - copy of the discharge summary, consolidated bill and payment receipts.  

Witnesses for the Complainant

PW1 -  V.K. Jayaraman (Complainant)

Witnesses for the opposite parties 

RW1 – Mohanan. A

                                                                  Sd/-                                                                                          Sd/-

                                                          PRESIDENT                                                                             MEMBER

True Copy,      

                                                                                                                                                                Sd/-

                                                                 Assistant Registrar.