DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 23rd day of February, 2023
Present : Sri.Vinay Menon V., President
: Smt.Vidya A., Member
: Sri.Krishnankutty N.K., Member Date of Filing: 05.12.2018
CC/161/2018
Jubil Yoosuf
S/o Yoosuf, JubilMandir
Kumbalakkode (P.O), Pazhayannur
Thrissur – 680 587 - Complainant
(By Adv. K.Dhananjayan)
V/s
1. M/s The Oriental Insurance Co. Ltd.
Registered & Head Office at A-25/27
Asaf Ali Road, New Delhi – 110 002
2. M/s The Oriental Insurance Co. Ltd.
Registered & Head Office at A-25/27
Asaf Ali Road, New Delhi – 110 002
Rep. by its Managing Director/
Manager/Authorised Signatory
3. The Manager
M/s The Oriental Insurance Co. Ltd.
Branch Office Code – 442 090
9/82 9 (12), K.V.M Plaza, Main Road
Ottapalam (P.O), Palakkad
(opposite parties 1 to 3 by Adv. P.Ratnavalli)
4. The Manager
M/s E-Meditek TPA Services Ltd.
577, UdyogVihar Phase V
Gurgaon, Haryana - 122 016
5. M/s E-Meditek TPA Services Ltd.
KPV Estate, 4th Floor, Civil Line Road
Opp. ING Vysya Bank, Palarivattom (P.O)
Cochin – 682 025 - Opposite parties
(4th & 5th opposite parties - Exparte)
O R D E R
By Smt. Vidya.A, Member
1. Pleadings of the complainant in brief
The complainant took a Medical Insurance Policy namely “Happy Family Floater – 2015” covering the period from 29/01/2017 to 28/01/2018. The policy covers complainant, his wife, child and parents. The sum insured to every person covered under the policy is 2 lakh rupees and the complainant had paid Rs. 18,777/- towards insurance premium. The complainant had availed an insurance policy earlier from the opposite parties covering the period from 27/01/2016 to 28/01/2017. As there is no interruptions in the renewal of the policy, the present policy can be considered as a continuation of the earlier policy.
As per the terms & condition of the policy, the opposite parties are liable to indemnify all the medical expenses incurred to the insured person in the event of any hospitalization for treatment. During the period of the policy, complainant’s mother Smt. Jameela had been affected with acute exacerbation of backache and was admitted in Amala Institute of medical science for treatment and consulted Dr. Sudheer. As per his advice, she was admitted in hospital, for the period from 07/01/2017 to 12/01/2017. Second time she was admitted from 27/03/2017 to 05/04/2017. During these periods she had undergone various tests, investigations and clinical evaluations. The total sum incurred by the complainant in the treatment amounts to Rs. 89,972/-
The complainant submitted a claim before the opposite party with all relevant details including original cash bills. But the opposite parties repudiated the claim stating that the expenses incurred in the treatment of Jameela is only as a part of investigation and evaluation or diagnostic purposes and not followed by active treatment. The complainant caused issuance of a lawyer notice dated 11/08/2017 to 3rd opposite party but instead of settling the claim, they send a reply justifying the company’s stand. The repudiation of bonafide claim of the complainant amount to deficiency in service on the part of the opposite parties.
So the complainant has approached the Commission for directing the opposite parties to pay Rs. 89,972/- being the expenses incurred in the treatment and Rs. 50,000/- as compensation for the mental agony suffered together with cost.
2. Complaint was admitted and notices were issued to the opposite parties. 1st to 3rd opposite parties appeared and filed their version. 4th and 5th opposite parties did not appear even after receiving notice and they were set ex-parte.
3. Opposite parties 1 to 3 in their version contended that the complaint is not maintainable. The complainant is a resident of Pazhayanur, Thrissur District and the treatment was done in Amala Institute of Medical Science, Thrissur. Further the beneficiary is his wife (Actual beneficiary is his mother wrongly written as wife) and she has not been made a party and the complaint is bad for non-joinder of necessary parties. Insurance policy is a contract and the parties are bound by its terms & conditions. They admit that the risk of the persons covered under the policy is Rs. 2 lakhs each subject to exclusions contained in the policy.
As per the terms & conditions in 4.10 of the policy, it is agreed and admitted the exclusion to say “Expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period”. In this case the beneficiary Smt. Jameela was admitted in Amala Institute of Medical Science in the department of Orthopaedics on 07/01/2017 in connection with analysis related to Intervertebral disc prolapse; no active treatment was given to the patient. The second admission on 29/02/2017 was also for diagnostic purpose. The complainant was not cooperating with the hospital to undergo any treatment and the beneficiary left the hospital at her request. It is clear that the intension of the complainant was to diagnose the illness and it comes under the exclusion clause of the policy. Mere admission without treatment also a bar for clause 4.10; hence diagnostic admission will not give cause of action.
The 4th opposite party is service provider and they are unnecessary party to the proceedings. There is no deficiency in service on the part of the opposite parties and the complainant is not entitled to get any amount from the opposite parties. Hence the complaint has to be dismissed with cost of the opposite parties.
4. From the pleadings of both parties, the following points arise for consideration
- Whether the complaint is maintainable before this Commission?
- Whether the claim made by the complainant comes under exclusion clause of the policy?
- Whether there is any deficiency in service on the part of the opposite parties in repudiating the claim?
- Whether the complainant is entitled to the reliefs claimed?
- Reliefs as cost and compensation.
5. Complainant filed proof affidavit and Exhibits A1 to A5 marked. Opposite parties 1 to 3 filed proof affidavit without any documents. Later they filed documents; but did not mark the documents. Opposite parties filed IA 343/22 seeking to issue summons to the treating doctor and it was allowed. The doctor was examined as DW1. Exhibits X1 series [X1(a) to (i)] marked. Evidence closed. Heard.
6. Point No: 1
The opposite parties 1 to 3 in their version contended that the complainant is a resident of Pazhayanoor, Thrissur District and his mother was treated in Amala Institute of Medical Science, Thrissur; so this Commission has no jurisdiction to entertain the claim.
But it is seen that the policy is issued to the complainant by 3rd opposite party, The Branch office of opposite party at Ottapalam. So the opposite party has a Branch office at Ottapalam, Palakkad and part of cause of action also took place in Palakkad. So the complaint can be entertained before this Commission. Point No:1 is decided accordingly.
7. Point No: 2
Complaint averment is that the complainant took an insurance policy namely “Happy Family Floater – 2015” from 3rd opposite party, the opposite party’s branch office at Ottapalam covering a period from 29/01/2017 to 28/01/2018. The policy covered the following person –
- Jubil Yousaf, Complainant
- Sufiya
- Amal Yousaf
- Yoosaf
- Jameela
The sum insured to every person covered under the policy is Rs. 2 lakhs and he paid Rs. 18,779/- towards insurance premium. During the coverage of the policy, the complainant’s mother Jameela had been affected with acute exacerbation of backache and was admitted in Amala Institute of Medical Science. As per the advice of the treating doctor Dr. Sudheer, Orthopaedican, she was admitted in the hospital from 07/01/2017 to 12/01/2017 and second time from 27/03/2017 to 05/04/2017. During this period she had undergone various tests, investigations and clinical evaluations. Complainant filed a claim before the opposite parties for getting Rs. 89,972/- being the medical expenses incurred by him in the treatment of his mother.
8. The opposite parties admitted the existence of the policy during the period. The opposite parties contention is that the complainant’s mother was admitted in the hospital only for investigation/diagnosis purposes and no active treatments were given to consider the claim under the provisions of the policy. As per conditions 4.10 of the policy under the general exclusions, mere admissions for diagnosis purposes and incurring expenses for that purposes are not covered by the policy.
9. Further they contended that the complainant has not produced any bills for the claim for Rs. 45,122/- alleged to have been paid by him on 17/04/2017 and Rs. 20,000/- for whole body scan. So it is clear that these amounts are spent for diagnosis purpose. The present claim and bills produced is only with regard to the claim for Rs. 24,850/- paid by him on 12/01/2017. The second admission from 27/03/2017 to 05/04/2017 was again for diagnosis purpose and no treatments were given as per the discharge summary.
10. The opposite party produced copy of Policy with conditions and the discharge summaries dated 07/01/2017 and 27/03/2017. But these documents were not marked from their side. The doctor who treated the patient Dr. Sudheer, Orthopaedician, Amala Institute of Medical Science was examined as DW1. The medical reports from the said hospital is marked as Ext. X1 (series1) [X1 (a) to X1 (i)].
The Doctor during Chief examination by opposite party deposed that (page no: 2 line no: 14 and Page no: 3 lines 1 to 5) “Ext. X1 (a) പ്രകാരം evaluation diagnostic purpose ന് വേണ്ടി മാത്രമാണ് എന്ന് പറഞ്ഞാൽ ശരിയല്ല. 07/01/2017 മുതൽ 12/01/2017 വരെ patient ന് severe pain ആയിരുന്നു. OP മരുന്ന് കൊണ്ട് മാറാതെ വന്നപ്പോഴാണ് patientനെ admit ചെയ്യേണ്ടി വന്നത് evaluationന് വേണ്ടി മാത്രമല്ല admit ചെയ്തത്. ചികിത്സയ്ക്കും കൂടി വേണ്ടിയാണ്. എല്ലാ treatmentന്റെ കാര്യങ്ങളും case sheetല് പറഞ്ഞിട്ടുണ്ട്”. (Page 3 of deposition) Further in page: 4 of deposition. He added that “patientനെ admit ചെയ്യാൻ ഞാൻ instruction കൊടുത്തു എന്നു കാണിക്കുന്ന രേഖയാണ് Ext. X1(c) [Page: 4 of Ext.X1]. Ext.X1 (b) പ്രകാരം CT Guided Biopsy, IP ആയി മാത്രമേ ചെയ്യാൻ പറ്റുകയുള്ളു എന്ന കാണിക്കുന്നതിന് രേഖകളില്ല. അതെന്റെ studied reasoning ആണ്”. In page No:7 of deposition it is stated that Patientന്റെ pain കുറയ്ക്കുന്നതിന് വേണ്ടിയാണ് admit ചെയ്തത്. Initial scan reportല് cancer സംശയം ഉള്ളതു കൊണ്ടാണ് (ഇടത്തേ ഇടുപ്പെല്ലില്) ബാക്കി ടെസ്റ്റുകള് ചെയ്യേണ്ടിവന്നത്.
11. So the doctor who treated the patient has clearly stated that the patient was admitted in hospital not for evaluation only. She had severe pain and admitted in the hospital as per his instruction for treatment. Further he deposed that he had given explanation to the insurance company regarding the admission of the patient which is marked as Ext. X1 (b) (Page 92 of X1 series).
In Ext. X1(b) he had explained the procedures i.e. “Mrs. Jameela is admitted for treatment of IVDP with left sciatica for bed rest, analgesics and traction. MRI Scan was taken which was suggestive of alytic lesion with left ileum”. And finally he added that “I didn’t believe the above procedures can be done on an OP basis”.
All these shows that the admission of the patient was suggested by the doctor who treated the patient. Only doctor and not the insurance company can decide the course of treatment given to the patient. So the claim filed by the complainant do not come within the exclusion clause of the policy as per the evidence adduced. Point No.2 is decided in favour of the complainant.
12. Points 3 to 5
From the conclusion arrived at Point No.2, it is clear that the beneficiary of the insurance policy was admitted for treatment in the hospital and the doctor who treated her has given clear explanation for that. Hence the claim is admissible.
So there is clear deficiency in service on the part of the opposite parties in repudiating the claim of the complainant and they are liable to compensate the complainant for that. Opposite parties 4 and 5 are only the TPA and service providers and they don’t have a separate liability than that of the insurance company.
In the result, complaint is allowed.
We direct the opposite parties 1 to 3 jointly and severally to pay the claim amount as per the claim submitted by the complainant duly supported with bills/receipts for payment together with interest at 10% from 05/12/2018 (date of complaint) till realization. We further direct the opposite parties to pay Rs. 20,000/- for their deficiency in service, Rs.15,000/- for the mental agony suffered by the complainant and Rs.10,000/- as cost.
The opposite parties shall comply with the directions in this order within 45 days of receipt of this order, failing which opposite party shall pay to the complainant Rs. 250/- per month or part thereof until the date of payment in full and final settlement of this order.
Pronounced in open court on this the 23rd day of February, 2023.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Documents marked from the side of the complainant
Ext.A1 – Bill from Amala Institute of Medical Science dated 12/01/2017.
Ext.A2 – Insurance Policy issued by 3rd opposite party dated 23/01/2017 (Photocopy).
Ext.A3 – Discharge summary dated 12/01/2017.
Ext.A4 – Lawyer notice sent to opposite parties dated 14/08/2017.
Ext.A5 – Reply notice dated 17/11/2017.
Ext.X1 – IP case record issued by Amala Institute Of Medical Science, Thrissur.
Documents marked from the side of opposite parties – Nil
Witness examined from the complainant’s side: NIL
Witness examined from the opposite parties side:
DW1 – Dr. Sudheer – Doctor, Amala Institute of Medical Science, Thrissur.
Cost- Rs. 10,000/-
NB: Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
