DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                  .…. PRESIDENT

                 THIRU.P.MURUGAN,M.Com.,ICWA (Inter), B.L.,                                     ....MEMBER-II

 

CC. No.81/2022

THIS TUESDAY, THE 14th DAY OF FEBRUARY 2023

 

Saroj Ramakrishnan,

Plot No.2111, New No.14, 13th Main Road,

Anna Nagar, Chennai – 600 040.                                                      ……Complainant.

                                                                     //Vs//

1.National Insurance Company Limited,

   Anna Nagar Branch,

   Rep.by its Branch Manager,

   Division V, 1st Floor,

   AG3/1, Shanthi Colony,

   Anna Nagar, Chennai -600 040. 

 

2.National Insurance Company Limited,

    Rep.by its Managing Director,

    No.3, Middleton Street,

    Kolkata 700 071                                                               ..........Opposite parties. 

 

Counsel for the complainant                                 :   M/s.B.Mohan, Advocate.

Counsel for the opposite parties                          :   Mr.R.Ravichandran,Advocate. 

                         

This complaint is coming before us on various dates and finally on 30.01.2023 in the presence of M/s.B.Mohan Advocate, counsel for the complainant and Mr.R.Ravichandran  Advocate, counsel for the opposite parties and upon perusing the documents and evidences of both sides, this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI,   PRESIDENT.

 

This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service by the repudiation of insurance claim along with a prayer to direct the opposite parties to pay a sum of Rs.1,41,526/- towards hospitalization expenses incurred by the complainant covered under the insurance policy and to pay a sum of Rs.5,000/-being the cost incurred by her in pursuing the insurance claim with the insurance ombudsman and to pay  a sum of Rs.3,00,000/- towards deficiency in service along with 12% interest per annum till realization and to pay a sum of Rs.5,000/- towards cost of the proceedings to the complainant.

Summary of the facts culminating into complaint:-

 

The complainant being a senior citizen insured with the opposite party vide NATIONAL MEDICLAIM POLICY valid from 14.02.2016 to 13.02.2017 for Rs.5,00,000/- under the policy No. No.500500501510000513. One of the main reason for the complainant’s choice of the policy was that it covered medical expenses incurred under alternative medicine like Auyrvedic Treatment. The complainant underwent Ayurvedic treatment from 31.10.2016 till 06.12.2016 and submitted the claim papers to the Third Party Administrator of the opposite party on 26.12.2016.  But the claim was rejected by the opposite party vide letter dated 21.02.2017 and the reason for rejection was mentioned as “Diagnostic and evaluation purpose – where such diagnosis and evaluation can be carried out as outpatient procedure and the condition of the patient does not require Hospitalisation.  No active line of treatment was given to the patient.  Line of Treatment does not need support for hospitalisation”. After obtaining opinion, again submitted to the opposite party, however the same was also rejected by a letter dated 23.03.2017.  On a complaint to the Insurance Ombudsman the same was also rejected vide award dated 06.06.2018 in IO/CHN/A/G1/0003/20192019.  On a scrutiny of the award of the Insurance Ombudsman it refers to an “SCN dated 21.04.2017 of opposite party and an “opinion of panel of Doctors”. However, the complainant was not provided with these documents during processing of the claim. Insurance Ombudsman directed the complainant to obtain copies from the opposite party.  On several efforts taken the SCN dated 21.04.2017 was provided however “Opinion of panel of Doctors” alleged to have been filed by the opposite party was not furnished to the complainant. Further it was also found that no opinion of Doctor was furnished by the opposite party before Ombudsman but Ombudsman had casually accepted the oral representation of the opposite party about the opinion of panel of doctors.  The opposite party had thus misled the Ombudsman by falsely representing that the opinion from penal of Doctors was obtained.  The Ombudsman failed to take note of clause 2.3, 3.2, and 4.15 of the policy.  Clause 4.15 was not considered in proper manner and had rejected the claim of the complainant. The treating Doctor informed the complainant that no one from the opposite party or its TPA had contacted him regarding the insurance claim of the complainant. The treating Doctor has given a detailed opinion quoting from the Ayurvedic scriptures about the need for bed rest after detoxification and abhyangam etc., as being essential and indispensible in the kind of aliment the complainant was treated for in the present case which warranted hospitalisation.  This was also in turn supplied to the opposite party by the complainant along with a letter dated 17.03.2017 requesting review of the rejection of the claim but the opposite party as well as the Learned Ombudsman have failed to consider the merits of the claim. Thus aggrieved by the act of the opposite party the present complaint was filed by the complainant alleging deficiency in service on the part of the opposite party in not honouring the claim of the complainant for the following reliefs as mentioned below;

 To direct the opposite parties to pay a sum of Rs.1,41,526/- towards hospitalization expenses incurred to the complainant covered under the insurance policy;

 To pay a sum of Rs.5,000/-being the cost incurred by her in pursuing the insurance claim with the insurance ombudsman;

 To pay  a sum of Rs.3,00,000/- towards deficiency in service along with 12% interest per annum till realization;

Defence of the opposite parties:-

The opposite parties filed version stating that the complainant had made the claim for the expenses incurred by her for the Ayurvedic treatment of Migraine and sandhigatavatam (Osteoarthritis).   On going through the Discharge Summary and other documents submitted by the complainant and after taking opinion from their panel Doctors, the opposite party found that no active line of treatment was given to the complainant and that the line of treatment did not support need for hospitalisation and hence the claim fell under exclusion clause viz. Clause No.4.15, clause No.4.19 and clause No.4.22 of the insurance policy. Clause 4.19 of the policy reads that the company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or in respect of diagnosis and evaluation purpose when it can be carried out as out-patient procedure and the condition of the patient does not require hospitalization.  Hence the line of treatment undergone by the complainant was conservative Ayurvedic treatment/application of oils and massaging which did not require any hospitalisation at all and hence stood excluded under policy clause 4.22 of the which reads as “The company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or in respect of stay in hospital which is not medically necessary”.  So only after due consideration of all the facts and circumstances and after taking proper medical opinion, the claim of the complainant was rejected by the opposite party.  The complainant thereupon took the matter to Ombudsman but the same was dismissed.  Thus the opposite parties sought for the dismissal of the complaint.

On the side of complainant proof affidavit was filed and documents Ex.A1 to Ex.A15 were marked.  On the side of opposite parties proof affidavit was filed but no documents were marked.

 

Point for consideration:-

Whether the rejection of Medical Insurance Claim by the opposite parties with respect to the policy No.500500501510000513 submitted via claim dated 26.12.2016 for a total amount of Rs.1,41,526/- amounted to deficiency in service and whether the deficiency in service has been successfully proved by the complainant?

If so to what reliefs the complainant is entitled?

 Point:1

On the side of complainant the following documents were filed in proof of complaint allegations;

Claim for submitted by the complainant to the opposite party was marked as Ex.A1;

Claim rejection letter issued by the opposite party dated 21.02.2017 was marked as Ex.A2;

Certificate for hospitalisation dated 16.03.2017 was marked as Ex.A3;

Representation to the Higher Officers of the opposite parties by complainant requesting to consider the claim rejection dated 17.03.2017 was marked as Ex.A4;

2nd rejection letter issued by the opposite party dated 23.03.2017 was marked as Ex.A5;

Letter of the opposite party reiterating the rejection of the claim dated 20.04.2017 was marked as Ex.A6;

Award of the insurance Ombudsman upholding the rejection of the claim of the complainant dated 06.06.2018 was marked as Ex.A7;

Letter from complainant to opposite party requesting copies of certain documents relied on by the opposite party before the Insurance Ombudsman dated 19.11.2018 was marked as Ex.A8;

Reply letter by the Insurance Ombudsman to the complainant dated 30.11.2018 was marked as Ex.A9;

Letter from opposite party attaching the SCN dated 21.04.2017 and its panel Doctor’s opinion dated 05.12.2018 was marked as Ex.A10;

Qualification certificate of the Ayurveda Doctor who treated the complainant was marked as Ex.A11;

Registration certificates/Licenses issued by the Statutory Authorities to the hospital was marked as Ex.A12;

Mediclaim Insurance Policy document issued by the opposite party was marked as Ex.A13;

Mediclaim Insurance Policy issued by the opposite party to complainant for the period 14.02.2016 to 13.02.2017 was marked as Ex.A14;

In patient receipt issued by the Hospital dated 06.12.2016 was marked as Ex.A15;

Heard the oral arguments submitted by the complainant and perused the written arguments and material evidences produced by him.  On the side of opposite parties the endorsement was made to that effect that the written arguments filed by them may be treated as oral arguments and no documents was filed by the opposite parties though they have filed proof affidavit.

Records perused. The crux of the oral arguments adduced by the complainant’s side is that as per clause 4.15 of the policy as the said treatment was done in Ayurveda it is not excluded under the policy and quoted the specific clause.  Further the learned counsel relied upon clause 4.19 wherein it has been stated that the diagnostic and evaluation purpose is not covered and he submitted that no claim was made by the complainant with respect to the diagnostic and evaluation purpose and hence rejection of policy based on the said clause is not proper.  Further with respect to the clause 4.22 it was argued that staying in hospital which is not medically necessary, however the Doctor of the complainant opined and suggested for hospitalisation and hence the complainant got admitted in the hospital.  Further he also cited the rejection letter dated 21.02.2017 and pointed out the reason for rejection as illusive and imaginary as the ground for the rejection was mentioned as clause 4.19 and 4.22. He also relied upon the letter issued by the Doctor wherein he had given his opinion that it is a must and compulsory to admit the patient and that bed rest recommended especially in old age people.  He also submitted that when requested the opposite party did not provide the SCN of panel of Doctors relied by the opposite party before the Ombudsman and thus he sought for the complaint to be allowed.

In the written arguments submitted by the opposite parties it was mentioned that as per the clause 4.15, 4.19 and 4.22 the treatment underwent by the complainant was not covered under the policy and hence it was contended that the rejection of claim made only as per the terms and conditions of the policy and he sought for the dismissal of the complaint.

On appreciation of the evidence produced by the parties, this commission is of the view that the complaint has to be allowed for the following reasons;

The clause 4.15 relied upon by the parties reads as follows;

Massages, spa, steam bath, naturopathy, experimental treatment.

“Massages, spa, steam bath, shirodhara, udhwarthanam, abhyangam, kayasekham and similar treatment.

Expenses for naturopathy. Experimental medicine/treatment, unproven procedure/treatment, alternative medicine/treatment (other than Ayurvada and Homeopathy), acupuncture, acupressure, magneto-therapy and similar treatment”. 

In the said clause it has been specifically mentioned that other than Ayurvada and Homeopathy and hence when it is specifically proved that the complainant had taken only Ayurvada treatment,  the rejection based on clause 4.15 is not proper when Ayurvada &Homeopathy is not excluded.

Rejection of claim based on 4.19 stating that the claim could not be honoured for the expenses covering diagnostic and evaluation purpose is also not proper as in the present case the claim by the complainant was not sought for any reimbursement with regard to diagnostic and evaluation purpose.

Rejection made on the basis of clause 4.22 is also not proper as the said clause provides that “Stay in hospital which is not medically necessary”.  However in the present case the complainant has produced material evidence (Ex.A3), the letter issued by the treating Authority (AYER KSHETRA) whereby the Doctor has opined that “so it is a must to admit the patient and bed rest recommended especially in old age people. After the loosening process from the hospital we give exercise to strengthen the muscular system.  After that only patient is advice to walk Even after treatment we ask the patient to take rest for three more weeks to prepare themselves for travel. Many manage centres are giving same such treatments for young people.  Those things should not be correlated with aged diseased persons.  So in this case after considering age, severity of pain and weakness of body, we advice the patient to be hospitalised and take complete bed rest so as to facilitate in recovery of health”.  The opposite parties has not provided any contra evidence to prove that hospitalisation is not necessitated for the treatment of the complainant;

Further the complainant when sought for the opinion of Doctor relied upon by the opposite party before Ombudsman the same was not provided by them and still worse the same has not been produced before this commission by the opposite party to show that they rejected the claim only based upon the opinion of panel of Doctors;

The award of the ombudsman was also not proper as they also relied upon clause 4.15, 4.19 and the opinion of Doctor which was not produced at all;

In the letter from the opposite party dated 05.12.2018 attaching the SCN dated 21.04.2017 and its panel Doctor’s opinion dt.10.04.2017 the opposite party had admitted that “the diagnoses of osteoarthritis have been confirmed by the Ayurvadist”.  Though it is stated that opinion of panel Doctor was also attached, the same was not issued to the complainant even after several request.  For the above cited reasons thus this commission is of the view that the complaint has to be allowed and we hold that the repudiation of the insurance claim by the opposite party was not on any valid reason and without basis which amounted to clear deficiency in service on their part.

Thus we hold that deficiency in service was clearly proved by the complainant.  This point is answered accordingly in favour of the complainant and as against the opposite party.

Point No.2:

As we have held above that the opposite party has evaded its liability without any reason to honour the claim of the complainant which amounted to deficiency in service, we feel that the proper relief would be to direct them to reimburse the medical expenses made by the complainant based on the medical bills amounting to Rs.1,41,526/-.  With respect to the expenses incurred before Insurance Ombudsman no document was produced and hence we are unable to award any amount against the said head.  Further for the mental agony and physical suffering caused to the complainant by the deficit act of opposite party we award a compensation of Rs.50,000/- to be paid by the opposite party to the complainant.  We also award Rs.5,000/- towards cost of litigation expenses to the complainant. 

In the result, the complaint is partly allowed against the opposite party directing them 

a) to pay a sum of Rs.1,41,526/- (Rupees one lakh forty one thousand five hundred and twenty six only) being the claim amount within six weeks from the date of receipt of copy of this order; 

b) to pay a sum of Rs.50,000/- (Rupees fifty thousand only) towards compensation for the mental agony and hardship caused to the complainant;

c)  to pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant. 

d) Amount in clause (a) if not paid within six weeks from the date of receipt of copy of this order, interest at the rate of 6% will be levied on the said amount from the date of complaint till realization. 

  Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 14th day of February 2023.

 

         -Sd-                                                                                                                 -Sd-                                                                                                  

MEMBER-II                                                                                                     PRESIDENT

 

List of document filed by the complainant:-

 

Ex.A1 ............... Claim for submitted by the complainant to the opposite party Xerox

Ex.A2 21.02.2017 Claim rejection letter issued by the opposite party. Xerox

Ex.A3 16.03.2017 Certificate for hospitalisation. Xerox

Ex.A4 17.03.2017 Representation to the Higher Officers of the opposite parties by complainant requesting to consider the claim rejection. Xerox

Ex.A5 23.03.2017 2nd rejection letter issued by the opposite party. Xerox

Ex.A6 20.04.2017 Letter of the opposite party reiterating the rejection of the claim Xerox

Ex.A7 06.06.2018 Award of the insurance Ombudsman upholding the rejection of the claim of the complainant. Xerox

Ex.A8 19.11.2018 Letter from complainant to opposite party requesting copies of certain documents relied on by the opposite party before the Insurance Ombudsman. Xerox

Ex.A9 30.11.2018 Reply letter by the Insurance Ombudsman to the complainant. Xerox

Ex.A10 05.12.2018 Letter from opposite party attaching the SCN dated 21.04.2017 and its panel Doctor’s opinion. Xerox

Ex.A11 .............. Qualification certificate of the Ayurveda Doctor who treated the complainant Xerox

Ex.A12 ............. Registration certificates/Licenses issued by the Statutory Authorities to the hospital. Xerox

Ex.A13 ................ Mediclaim Insurance Policy document issued by the opposite party. Xerox

Ex.A14 .............. Mediclaim Insurance Policy issued by the opposite party to complainant for the period 14.02.2016 to 13.02.2017. Xerox

Ex.A15 06.12.2016 In patient receipt issued by the Hospital. Xerox

 

                                                                                                                       

 

       -Sd-                                                                                                                 -Sd-

MEMBER-II                                                                                                    PRESIDENT