BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE URBAN

 02^nd DAY OF JULY 2016

O R D E R

SRI. P.V SINGRI, PRESIDENT

The complainant has filed this complaint U/s.12 of the Consumer Protection Act, 1986 against the Opposite Party (herein after referred as OP) with a prayer to direct the OP to pay him a sum of Rs.21,110/- being hospital charges together with interest, compensation of Rs.15,000/- and cost of the proceedings.

2. The brief averments made in the complaint are as under:

The complainant is a policy holder of OP Insurance Company and has obtained a health insurance policy which covers both the complainant and his wife Smt.Lakshmi Devi for all the benefits as stated by the OP at the time of issuing the said policy.  The policy is also a cashless benefit policy.  That on 10.12.2012 the wife of the complainant Smt.Lakshmi Devi complained of severe giddiness and immediately the complainant took her to Vegus Super Speciality Hospital, Malleshwaram, Bangalore for check-up and treatment.  That in the hospital the doctors after examining the said Mrs.Lakshmi Devi, admitted in hospital as inpatient.  That the complainant intimated the OP about the admission of his wife in terms of policy and he was asked by the Medi Assist to furnish the name and ID of the doctor as well as the policy details.  Accordingly, the complainant submitted all the necessary information to the TPA.  Mrs.Lakshmi Devi was submitted to various tests on the same day and on the basis of the test results she was given necessary treatment and on the next day i.e., on 11.12.2012 she was discharged by the doctors as she was feeling comfortable.  That the OP by their letter dated 24.06.2013 informed the complainant about their inability to settle the claim.  That the complainant paid a sum of Rs.21,110/- towards hospital charges at the time of discharge of his wife.  Though his claim was genuine OP repudiated the claim without there being any valid grounds.

OP committed breach of terms and conditions of the policy.  OP refused to entertain the claim on the basis of exclusions.  The reasons assigned by the OP for refusing to pay the claim amount is done with a malafide and malicious intention and the same amounts to deficiency of service.  Therefore, the complainant prays for an order directing the OP to pay him a sum of Rs.21,110/- which he has paid towards the treatment of his wife Mrs.Lakshmi Devi together with interest @ 21% p.a and compensation of Rs.50,000/- for causing physical and mental agony together with cost of the proceedings.

3. In response to the notice issued, OP entered their appearance through their advocate and filed their version contending in brief as under:

It is true that the complainant and his wife were beneficiary under the group policy obtained by the complainant valid from 01.01.2012 to 30.12.2012.  The subject policy is governed by the terms and conditions as stipulated in the policy.  That the complainant made cashless claim in the group policy stating that his wife was admitted to M/s.Vagus Super Specialty hospital for Anemia and disc prolapsed from 10.12.2012 to 13.12.2012 and in furtherance to the said hospitalization a cashless claim for Rs.21,110/- was made with TPA i.e., M/s.Medi Assist India Pvt. Ltd.  However the TPA disallowed the cashless claim as the hospitalization was primarily for the purpose of evaluation and investigation purpose only, as the complainant did not take any active treatment during the period of hospitalization and therefore the claim of the complainant was disallowed by the TPA as terms of the policy excluded such claims which were for investigative purpose.  That the TPA had opined that the claim is inadmissible as the treatment papers apparently showed that the complainant was admitted for investigation and evaluation only which could have been done on outpatient basis and therefore the same did not required any inpatient hospitalization.  Thereafter, the complainant made a claim with OP for reimbursement of the amount then the OP scrutinized the claim documents as submitted by the complainant and the documents clearly showed that Mrs.Lakshmi Devi was admitted for investigation and evaluation purpose only and was managed with various investigations like hematology, bio-chemistry, urine test, MRI, Abdomen Ultrasound Scan, X-ray, Iron test and Microbiology report which clearly showed that she was admitted for the purpose of investigation and evaluation only and the same could have been done as out-patient without hospitalization.  That the policy issued to the complainant provided for reimbursement of the medical expenses which necessitated hospitalization and not for investigative procedures which could have been managed on out-patient basis.  That all the procedures and investigations revealed normal study as the patient was normal.  That the said Lakshmi Devi deliberately got admitted in order to make claim from OP as the policy term-19 specifically excludes all out-patient treatment charges.  That the policy conditions clearly excludes all such hospitalizations intended for investigations and evaluation purpose as the same is apparent from the claim documents and overwhelming opinion of third party doctors.  Therefore, the claim is not admissible under the terms issued as same did not required any hospitalization.  The relevant exclusion clause is reproduced for kind reference.

“Charges incurred at Hospital or nursing home primarily for diagnostic, X-ray of laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any aliment, sickness or injury, for which confinement is required at a Hospital/nursing home as defined.”

There was no negligence or deficiency in service that can be attributed to the OP in dealing with the claim.  Therefore, the complainant is not entitled to any relief sought for in the complaint.  For the reasons stated above, the OP prays for dismissal of the complaint with costs.

4. Subsequent to filing of the version, the complainant was called upon to submit his evidence by way of affidavit.  Accordingly, he submitted his affidavit evidence reiterating the allegations made in the complaint.  Thereafter, the OP got filed the affidavit evidence in support of the averments made in the version.  The complainant as well as the OP produced several documents in support of their respective contentions.  The complainant also filed written arguments.   

5. The points that arise for our determination in this case are as under:

        6. Perused the allegations made in the complaint, averments made in the version, sworn testimony of both parties, written arguments submitted by the complainant, various documents produced by both sides and other materials placed on record.

7. Our answer to the above points are as under:

REASONS

8.  The OP admits that the complainant and his wife were the beneficiary under a group policy bearing No.HG00001124000102 taken by M/s.Metro Cash and Carry India Pvt. Ltd., and the said policy was valid from 01.01.2012 to 31.12.2012.  The complainant has also produced the copy of the policy obtained by him.  It is also not in dispute that, the wife of the complainant Mrs.Lakshmi Devi was admitted to M/s. Vagus Super Specialty Hospital, Malleshwaram, Bangalore with certain complaints and was subjected to various investigations and examination after being admitted in-patient from 10.12.2012 to 13.12.2012.  During the course of her admission to the hospital, the complainant as per the terms of the policy intimated the same to the OP explaining the circumstances under which Mrs.Lakshmi Devi was admitted to the hospital.

9. It is also not in dispute that, the TPA by its letter dated 10.12.2012 called upon the complainant to furnish certain information which were furnished by the complainant together with necessary report of the doctors.  M/s.Medi Assist India Pvt Ltd., (TPA) after examining the documents and reports submitted by the complainant disallowed the cashless claim on the ground that the hospitalization of Mrs.Lakshmi Devi was primarily for the purpose of evaluation and investigation purpose only and she did not take any active treatment during the period of hospitalization.  The TPA in their letter dated 31.12.2012 addressed to complainant quoted the following exclusion which reads as under:

“Charges incurred at Hospital or nursing home primarily for diagnostic, X-ray of laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any aliment, sickness or injury, for which confinement is required at a Hospital/nursing home as defined.”

10. The complainant was not satisfied with the reply furnished by TPA and he paid the hospital charges of Rs.21,110/- to the hospital and thereafter submitted a claim to the OP for reimbursement of the amount paid to the hospital for the investigation and treatment of his wife Mrs.Lakshmi Devi.  After examining all the investigation reports and other documents furnished by the complainant along with his claim, OP repudiated the claim of the complainant citing the exclusion clause referred supra.  It is contended by the OP that, the policy issued to the complainant provided for reimbursement of the medical expenses which necessitated hospitalization and not for investigative procedures which could be managed on out-patient basis.  It is further contended by the OP that all the procedures and investigations undergone by Mrs.Lakshmi Devi revealed normal as she was normal.  It is further contended by the OP that the complainant deliberately got his wife admitted to the hospital in order to make claim from the OP as the policy term-19 specifically excludes all out-patient treatment charges.

11. Admittedly, the close perusal of the terms and conditions of the policy clearly excludes all such hospitalization intended for investigation and evaluation purpose.  Third party doctors from whom the opinion was sought by the OP overwhelmingly opined that the procedures under the investigation under gone by the Mrs.Lakshmi Devi could have been managed on out-patient basis.  In the face of the terms and conditions of the exclusion clause as stated above, the complainant failed to convince us as to whether the hospitalization of his wife was necessary for the purpose of investigation and the examinations conducted on her between 10.12.2012 to 13.12.2012.  The careful perusal of the various medical records pertaining to Mrs.Lakshmi Devi does not disclose that she was admitted for any treatment for any of the ailments.  Moreover all her investigation and tests did not disclose any abnormality or deficiency.  Therefore, we find force in the contention of the OP that, the complainant deliberately got his wife admitted to hospital in order to make claim from the OP.  OP has produced the group health insurance policy schedule which contains each and every terms and conditions governing the policy obtained by the OP.  The exclusion clause finds place at serial No.15 of the exclusions in the policy.  In view of the exclusion policy explained supra, the complainant is not entitled for the expenses incurred for the diagnostic and other laboratory examinations etc., undergone by his wife.  Absolutely there is no material on record to believe that, the hospitalization of Mrs.Lakshmi Devi was essential or necessary for the purpose of conducting the various investigations and tests.  It appears to us that the said test and investigation could have been managed on out-patient basis.  Therefore, we don’t find any deficiency of service on the part of the OP.  The OP is justified in repudiating the claim of the complainant in view of the terms and conditions of the policy as well as the exclusion clause.

12. In view of the discussions made above, we are of the opinion that, there is no merit in the complaint and therefore the same is liable to be dismissed.

13. The order could not be passed within the stipulated time due to heavy pendency. 

14. In the result, we proceed to pass the following:   

  O R D E R

The complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is dismissed.  Parties to bear their own costs.

Furnish free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this 02^nd day of July 2016)

MEMBER                            MEMBER                    PRESIDENT

Vln* 

Witnesses examined on behalf of the complainant dated 12.02.2014.

1. Sri.K.Ravi.

Documents produced by the complainant:

Witnesses examined on behalf of the Opposite party-1 dated 03.03.2014.

1. Sri.G. Vinay Prakash.  

Documents produced by the Opposite Party:

  MEMBER                           MEMBER                     PRESIDENT

   Vln*