DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM

       Dated this the 25^th day of March, 2024

                          Filed on: 05/01/2016

PRESENT

Shri.D.B.Binu                                                                          President

Shri.V.Ramachandran                                                              Member

Smt.Sreevidhia.T.N                                                                  Member                                                        

CC NO. 4/2016

Between

COMPLAINANT

T.C. Xavier @ Francis, S/o. late T.L. Chakkappan, Thoippil House, Chuttupadukara, Aliyathuparambil, Edappally P.O., Ernakulam 682024.

(Rep. by Adv. P. Fazil, Jayasree Manoj, Jithin Paul Varghese, M/s. Lawyers United, 1^st Floor, St. Benedict Road, Ernakulam 682018)

VS

OPPOSITE PARTIES

National Insurance Company Ltd., Divisional Office, Mydhili Mandiram, Janatha Junction, Palarivattom, Cochin 682025. Rep. by its Divisional Manager.

(Rep. by Adv. Rajan Kaliyath, Lotus Law Chambers, Kombara Jn., Market Road, Kochi 682018)

FINAL ORDER

Sreevidhia T.N., Member:

1. A brief statement of facts of this complaint is as stated below:

The complainant and his wife and two children are insured under the National Mediclaim Scheme of the opposite party. The policy was effected from 04/02/2015 midnight to 03/02/2016 midnight. The complainant and his family members were covered by the policies of the opposite party for nearly a decade. At present the members of the complainant’s family were covered under an insurance policy for a total sum of Rs.1,50,000/-.

The complainant’s wife Lilly Francis was diagnosed with fibroid uterus and underwent hysterectomy under GA on 11/08/2015 at AIIMS. She was hospitalized on 09/08/2015 and discharged on 12/08/2015. There was no symptom of cancer. The total expenses came to Rs.1,25,015/-. Payment of an amount of Rs.60,685/- was approved by the opposite party after claim for cashless treatment and an amount of Rs.16,610/- was provided by the hospital as charitable subsidy. The balance amount of Rs.47,720/- was claimed before the opposite party, but the opposite party rejected the claim for the balance amount. Opposite party repudiated the claim in part on the ground that ailment duration was under 2008 policy. The opposite party had allowed part of the claim under 2008 policy. The opposite party had allowed part of the claim to an extent of Rs.1,937/-. The repudiation was based on the diagnosis in the discharge summary that wife of the complainant was suffering from Carcinoma of breast. The complainant states that the history in the discharge summary as well as the certificate dated 26/08/2015 clearly indicates that the wife of the complainant had underwent hysterectomy alone. The complainant also states that it is without considering the certification as well as the contents of the discharge summary that the claim was rejected. The repudiation of the claim is illegal, improper and is groundless. The repudiation of the claim amount to deficiency in service on the part of the opposite party. The complainant is entitled to get the entire claim amount. Hence the complainant approached this Commission seeking re-imbursement of Rs.45,783/- being the balance amount after re-imbursement in part by the opposite party together with interest at 12% from the date of repudiation till the date of payment along with Rs.5,000/- as cost of proceedings with such other reliefs.

2. Notice :

Notice was issued to the opposite party from this Commission. Opposite party appeared and filed their version.

3. Version of opposite party

The present complaint is filed for getting more amount than the claim settled and hence the complaint is not maintainable. The complainant had submitted the claim in respect of his wife and the claim was considered in detail by the 3^rd party administrator and the admissible amount was also paid to him. The complainant also admits the receipts of the amount.

The opposite party specifically deny the averments contained in paragraph 1 to 4 of the complaint. There was a mediclaim policy for the period from 04/02/2015 to 03/02/2016 with terms, conditions and exclusions. As per the policy the sum assured was enhanced in respect of Lilly Francis was raised from Rs.1,00,000/- to Rs.1,50,000/- making it explicitly clear that exclusions under the previous policy and the benefit of the enhanced sum assured would be subject to the exclusions for the various periods from 11/03/2014. The treatment undergone by Lilly Francis is in respect of Carcinoma breast and Fibroid Uterus as evidence from the discharge summary submitted with the claim. As stated by the complainant in paragraph 3 of the complaint that the complainant had spent Rs.1,25,000/- and the insured is entitled to get the entire amount is not correct. In fact the complainant was charged for Rs.1,08,405/- only. In addition to the application of exclusions in respect of enhanced sum assured, there are various sub limits specified in the policy and professional charges payable is only 25% of the sum assured of while the claim is for a total amount of professional charges is Rs.71,400/- this was limited to the above sum limit under this head and there is a deduction of Rs.46,400/- ended that head. The computation of admissible expenses was made by the Vidal Health and the admissible amount has already been paid to the complainant and hence there is no merit in the complaint.

The claim was examined and paid as per the terms and conditions and exclusions contained in the policy. The complainant is not entitled to get the sum of Rs.45,783/- as contemplated in the complaint.

4. Evidence:

Evidence in this complaint consists of the documentary evidence filed along with the complaint which are marked as Exbt. A1 to A5 on 29/09/2018. On 21/01/2023 complainant filed I.A. 95/2023 to re-open the evidence of the complainant. I.A. 95/2023 heard and allowed. Complainant filed 5 additional documents which were marked as Exbt. A6 to A10. On 06/03/2020. Dr. Anupama, Amritha Institute of Medical Science was examined as PW1 on the basis of the Exbt. A4 certificate issued by the said Doctor. Opposite party filed 3 documents which were marked as Exbt. B1 to B3. Opposite party has no oral evidence.

Evidence closed and heard both parties.

The complainant has not filed proof affidavit in this case.

5. Issues:

1. Whether any deficiency in service or unfair trade practice is proved from the side of opposite parties towards the complainant?
2. If so, reliefs and costs?

For the sake of convenience we have considered Issue no. (1) (2) together.

The case of the complainant is that the opposite party had repudiated the claim of the complainant on the ground that the ailment duration falls under 2008 policy period. Exbt. A1 produced by the complainant is the policy schedule of the National Insurance Policy taken by the complainant bearing No. 571600/48/14/8500007086, Exbt. A2 is the inpatient collection and appropriate bill from Amritha Hosptial, Kochi for the patient Lilly Francis dated 12/08/2015 for Rs.1,25,015/-, Exbt. A3 is the discharge summary of the complainant’s wife Lilly Francis from Amritha Institute of Medical Sciences dated 12/08/2015, Exbt. A4 is the certificate issued by Dr. Anupama R to Lilly Francis, MRD No. 753593 dated 26/08/2015 stating that the patient is having fibroid uterus and had underwent hysterectomy on 11/08/2015 under GA, Exbt. A5 is the copy of the re-imbursement claim approved letter dated 05/12/2015 regarding the hospitalization of the patient at Amritha Institute Medical Science on 09/08/2015. The complainant has claimedRs.47,725/- and the claim is settled by the opposite party for Rs.1,937/- as per Exbt. A5 letter., Exbt. A6 is the previous policy of the insured Lilly Francis for the period from 11/03/2010 to 10/03/2011. The sum insured was Rs.1,00,000/-. Exbt. A7 is the previous policy of the insured Lilly Francis for the period from 11/03/2011 to 10/03/2012. As per Exbt. A7 the sum insured was Rs.1,00,000/-, Exbt. A8 is the hospitalization benefit policy for the insured Lilly Francis period from 11/03/2012 to 10/03/2013 with sum assured for Rs.1,00,000/-, Exbt. A9 is the previous policy for the period from 11/03/2013 to 10/03/2014. The sum assured was Rs.1,50,000/-, Exbt. A10 is the previous policy for the period from 11/03/2014 to 10/03/2015. The sum assured as per Exbt. A10 is Rs.1,50,000/-.

As per Exbt. A1 the complainant had taken a National Insurance Policy from the opposite party on 21/01/2015 for the period from 04/02/2015 to 03/02/2016 midnight. Complainant’s wife Lilly Francis was also insured with the said policy. The sum insured was Rs.1,50,000/- as per renewal of policy No. 13/85008283 dated 11/03/2014. As per Exbt. A3 discharge summary, the procedure done was Hysterectomy (robotic) under GA. Exbt. A4 also proves that the patient underwent hysterectomy on 11/08/2025 under GA. As per Exbt. A2 the total bill amount comes to Rs.1,08,405/- (Rs.1,25,015/- - Rs.16,610/- Charitable subsidy)

The opposite party in their version contents that the treatment undergone by Lilly Francis is in respect of the Carcinomas breast and fibroid uterus as evidenced from the discharge summary. The opposite party had repudiated the balance amount of Rs.45,783/- stating that the ailment duration falls under  2008 policy period. As per the discharge summary the complainant’s wife underwent hysterectomy alone and was not undergoing treatment for cancer in August, 2015. PW1 Dr. Anupama on 06/03/2020 also deposed that no treatment for breast cancer was given to the complainant’s wife on 12/08/2015. From Exbt. A4 discharge summary and from the deposition of the treated doctor Dr. Anupama, “in August, 2015 the complainant’s wife had underwent for hysterectomy alone and was not undergoing treatment for cancer.”

The opposite party also contented that there is an exclusion of 2 years period for hysterectomy as per the terms of the insurance contract. The opposite party had produced Exbt. B1 policy with terms, conditions and exclusions is produced. Exbt. A9 proves that the wife of the complainant Lilly Francis’ policy’s sum insured was Rs.1,50,000/-. Exbt. A9’s policy period was from 11/03/2013 to 10/03/2014. As per Exbt. A9 the 2 year exclusion period for hysterectomy ended on 10/03/2015 also. Hence the contention of the opposite party that the sum assured applicable for calculation was only Rs.1,00,000/- is false. The opposite party repudiated the balance amount on the basis that there was an exclusion of 2 years period for hysterectomy. On the date of the surgery ie. on 11/08/2015 the patient is having a valid insurance policy for the period from 04/02/2015 to 03/02/2016 with a sum assured for Rs.1,50,000/-. The terms for 2 years exclusion for hysterectomy also ended on 10/03/2015. The surgery was done in August, 2015. The rejection of the claim of the complainant for the balance amount is deficiency in service from the part of opposite party. The complainant is entitled to get the balance amount of the claim. The complainant had to suffer monetary loss, hardships and other difficulties due to the deficient service of the opposite parties. The complainant is entitled to get the balance amount of the claim (Rs.45,783/- (Rupees forty five thousand seven hundred eighty three only) (Rs.1,08,405/- - Rs.60,685/- - Rs.1,937/-) from the opposite party. The Issue No. (1) and (2) proved in favour of the complainant and the following orders are hereby passed.   

1. The opposite party shall pay Rs.45,783/- (Rupees forty five thousand seven hundred eighty three only) to the complainant being the balance amount of the hospital charges.
2. The opposite party shall pay a compensation of Rs.5,000/- (Rupees five thousand only) to the complainant for the deficiency in service from their part.
3. The opposite party shall pay an amount of Rs.5,000/- (Rupees five thousand only) as cost of proceedings to the complainant.

The above order shall be complied within 30 days from the date of receipt of a copy of this order. If the order is not complied within 30 days the amount ordered as (1) and (2) above shall attract interest at the rate of 7% per annum from the date of order till the date of realization.

Pronounced in the Open Commission this the 25^th day of March, 2024.

Sreevidhia.T.N, Member

D.B.Binu, President

Forwarded/by Order

Assistant Registrar

Appendix

Complainant’s evidence

Exhibit A1: Copy of the policy schedule

Exhibit A2:           Copy of inpatient collection and appropriate bill for the patient Exbt. A3:          Copy of discharge summary

Exbt. A4:    Copy of the certificate issued by Dr. Anupama R

Exbt. A5:    Copy of the re-imbursement claim approved letter dated 05/12/2015

Exbt. A6:    Copy of previous policy for the period from 11/03/2010 to 10/03/2011

Exbt. A7:    Copy of previous policy for the period from 11/03/2011 to 10/03/2012

Exbt. A8:    Copy of previous policy for the period from 11/03/2012 to 10/03/2013

Exbt. A9:    Copy of previous policy for the period from 11/03/2013 to 10/03/2014

Exbt. A10:  Copy of previous policy for the period from 11/03/2014 to 10/03/2015

Opposite party’s evidence

Exbt. B1:    Copy of National Mediclaim Policy

Exbt. B2:    Copy of mediclaim computation sheet

Exbt. B3:    Copy of discharge summary

Despatch date:

By hand:     By post                                                       

kp/

CC No. 4/2016

Order date:  25/03/2024

Order Date: 16/02/2024