R.Vijayakumar, Member
This is a complaint filed Under Section 12 of Consumer Protection Act.
The complaint is filed for getting compensation for deficiency in service Rs.50,000/- compensation for mental agony Rs.5000 and cost Rs.2000/- and other reliefs from the opposite party.
The complainant’s case is that the complainant had availed an accident and health care policy from the opposite party’s office at Changanasseri for covering
(2)
the complainant and his entire family members under a Medical Benefit Scheme from 17/12/08 to 16/12/08 under which the insured persons are eligible to get accident medi claim to a sum of Rs.1,00,000/- per person. The complainant’s wife met with an accident on 12/03/09 at 7.45 PM near Kottarakulangara Temple, at Chavara. She had taken treatment in AM Hospital, Karunagappally and referred to SP Fort Hospital, Thiruvananthapuram for the expert management of fracture and other injuries. The complainant filed claim application along with records. But the opposite party repudiated the claim. The act of opposite party is against the terms and conditions of policy and it amounts to deficiency in service which resulted in much pain and mental agony. Hence the complainant filed this complaint seeking releifs.
The contentions raised by the opposite parties were that the complaint is not maintainable either in law or on facts.
The opposite party had issued an accidental and Health Care Policy to the complainant ensuring medical benefits to the complainant and his family members for a sum insured of Rs.1, 00,000/- each a period commencing from 17/12/2008 to 16/12/2009. The complainant had submitted a claim stating that the complainant’s wife Sheeja met with a traffic accident on 12/03/09 at 7.45 PM for which she had taken treatment in AM Hospital, Karunagappally and afterwards SP Fort Hospital, Thiruvananthapuram.
As requested to submit the treatment records, original bills and hospital bills, the complainant submitted total bills for an amount of Rs.13,184/- incurred by the complainant. But on verification it was found that majority of the bills were submitted by the complainant for the evaluation and diagnostic purpose which was not followed by active treatment during hospitalization and which were not payable by the opposite parties under the policy. The complainant has not
(3)
produced any documents showing that his wife had undergone active treatment as a follow up to the evaluation and diagnosis made as claimed in the complaint. The admissible claim is only for Rs.219/- and the remaining expenses were out of coverage of the policy. The opposite party communicated the matter to the complainant by registered letter dated: 08/07/09 itself. There is no jurisdiction in attributing deficiency in service against the opposite parties.
The complainant filed affidavit. PW1 was examined. Exts.P1 to P3 marked. The opposite party had no oral evidence. Ext.D1 marked.
The points that would arise for consideration are :
- Whether there is any deficiency in service from the part of opposite party ?
- Compensation and cost
Points (1) and (2)
Admittedly the complainant had availed an accident and Health Care Policy from the opposite party covering risk of the complainant and his family members from 17/12/08 to 16/12/09. It is also admitted that the complainant’s wife met with an accident on 12/03/09. No contention was raised by the opposite parties regarding the fact that the complainant’s wife was hospitalized and treated in AM Hospital and referred to SP Fort Hospital, Thiruvananthapuram .
The main contention raised by the opposite party is that majority of the bills produced by the complainant contains the expenditure incurred for evaluation and diagnostic purpose which was not followed by active treatment during hospitalization and which were not payable by the opposite parties as per policy conditions. The complainant had not produced any document to prove that
(4)
his wife had undergone active treatment following the evaluation and diagnosis. The admissible part of claim is only for Rs.219/-.
The Learned Counsel for the opposite party argued that as per exclusion clause 4.10 of the said Insurance Policy issued by the opposite parties the expenses incurred primarily for evaluation / diagnostic purposes which has not followed by active treatment during hospitalization are not payable. In support of the argument the opposite party had produced the terms and conditions of the policy and marked as Ext.D1.We have perused the documents in detail. It is clearly stated in Ext.D1 as Exclusion Clause 4.10 that “expenses incurred primarily for evaluation / diagnostic purposes not followed by active treatment during hospitalization.
On a careful verification of Ext.D1 we have noticed that it is stated in Ext.D1 prospectus clause 1.1. that the policy covers reimbursement of hospitalization expenses for illness / diseases or injury sustained.
The schedule and different heads under which the claim is payable as per the scheme is clearly stated in clauses 1.2.A, 1.2.B and 1.2.C.
Clause 1.2.A. Room, Boarding, Nursing expenses as provided by the hospital / nursing home. Room rent limit 1% of sum insured per day subject to the maximum of Rs.5000/-. If admitted in IC Unit 2% of sum insured per day subject to maximum of Rs.10000/- overall limit under the head: 25% sum insured per illness.
Clause 1.2.B Surgeon, Anesthetist, Medical Practitioner consultant special fees- maximum limit per illness 25% of the sum insured.
(5)
Clause 1.2.C Anesthesia, Blood oxygen, OT Charges, surgical appliances, Medicines, drugs, diagnostic Medical and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, artificial limbs and cost of stent and implant – maximum limit per illness.
It is clear from clauses 1.2.A 1.2.B and 1.2.C that reimbursement of the bill amount for which the complainant applied are covered by the policy except registration for Rs.20/- which is not included in the schedule of benefits under the policy .After offering attractive benefits as per clauses 1.2.A, 1.2.B and 1.2.C the opposite party had repudiated the claim interpreting 4.10. Exclusion clause. The act of opposite party is nothing but unfair practice. We are of the opinion that the opposite party wrongly and intentionally interpreted clause 4.10.to evade from their liability. Even a common man knows that, the process of diagonis and evaluation is inevitable for the treatment of injury, pain, fracture etc caused by an accident and to rule out future complications. Here in this case we feel that the opposite party cleverly played a trick to repudiate the genuine claim of the complainant wrongly and intentionally interpreting 4.10 exclusion clause. The complainant is entitled to get reimbursement as he had claimed, except the bill amounting Rs.20/- which was received by the Fort SP Hospital as registration fee.
It is further argued by the learned counsel for opposite party that even though the opposite party had requested, the complainant had not produced any discharge certificate or treatment certificate issued by the doctors and not produced the original records.
The opposite party has not produced any document to prove that they have made request to the complainant as argued by the learned counsel. No such contention was raised in the version also. Ext.P3 also shows that the repudiation is based only up on exclusion clause 4.10. Hence the argument
(6)
regarding non-production of discharge certificate and treatment certificate will not sustain.
Considering the relevant facts and circumstances we came to the conclusion that there is deficiency in service from the part of opposite party. The points found accordingly.
In the result, the complaint is allowed in part. The opposite party is directed to pay Rs.13,164/- to the complainant as the claim amount. The opposite party is further directed to pay compensation Rs.5000/- and cost Rs.1000/- to the complainant.
The order is to be complied with within one month of the date of receipt of the order.
Dated this the 9th day of March 2012.
G.Vasanthakumari :Sd/-
Adv.Ravi Susha :Sd/-
R.Vijayakumar :Sd/
INDEX
List of witness for the complainant
PW1 - Abbas
List of documents for the complainant
P1 - FIR Report
P2 - Bill
P3 - Repudiation letter
List of documents for the opposite party
D1 - National and health care policy
// Forwarded by Order //
Senior Superintendent
