BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
ERNAKULAM.
Date of filing : 03/11/2011
Date of Order : 31/05/2012
Present :-
Shri. A. Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member.
C.C. No. 615/2011
Between
1. Febin Rafi, | :: | Complainant |
Malieckal House, Azhakam. P.O., Kuruppinkadu, Ernakulam. 2. Remya Febin, W/o. Febin Rafi, Malieckal House, Azhakam. P.O., Kuruppinkadu, Ernakulam. |
| (By Adv. P.U. Ziyad, Kalabhavan Road, Kochi - 18) |
And
National Insurance Co. Ltd., | :: | Opposite Party |
2nd Floor, Mallappally Building, A.M. Road, Prumbavoor – 683 542. |
| (By Adv. C.M. Rasheed, Rex Building, Railway Station Road, Alwaye) |
O R D E R
C.K. Lekhamma, Member.
1. The brief facts of the complainant's case are as follows :-
The complainants are the mediclaim policy holders of the opposite party with effect from 18-08-2010. The 2nd complainant was admitted in Little Flower Hospital and Research Centre on 10-02-2011 due to her illness. At the hospital, various tests were conducted and was discharged on 14-07-2011. The opposite party is duty bound to pay the hospital expenses incurred by the 2nd complainant. The MRI scan of the complainant's brain was done by spending Rs. 3,500/-. All the other expenses incurred for the diagnosis of the 2nd complainant, except the MRI scan charge was paid by the opposite party. The complainants are entitled to get the said charges incurred along with compensation and costs. Hence this complaint.
2. The version of the opposite party is as follows :
The illness of the 2nd complainant is Upper Respiratory Infection. The expenses alleged to have been incurred was for MRI scan of her brain. After the said scanning, no active treatment was given to the 2nd complainant. It is therefore evident that the expenses incurred are primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalisation and therefore the claim of the complainants are not payable by the opposite party, as per Exclusion Clause No. 4.10 of the terms and conditions of the policy. The opposite party is not liable to pay any amount to the complainants. Hence the complaint is to be dismissed with costs.
3. The complainants and the opposite party represented through counsel. The 1st complainant was examined as PW1 and Exts. A1 to A7 were marked. No oral evidence for the opposite party. Ext. B1 was marked on their side. Heard both sides.
4.The points that arose for determination are as follows :-
Whether the complainants are entitled to get the amount incurred for MRI scan from the opposite party?
Compensation and costs, if any?
5. Point Nos. i. and ii. :- No dispute with regard to the policy and hospitalization. Admittedly, the opposite party had paid all the expenses incurred by the 2nd complainant for the treatment except the charges of MRI scan. The opposite party contended that the scanning was done for evaluation purpose and not followed by active treatment during hospitalisation.
6. It is pertinent to note that the 2nd complainant was hospitalised for 4 days. The scan was taken on the first day itself. In Ext. A2 requisition form, the clinical history of the 2nd complainant is noted as giddiness, weakness and difficulty to speak. It is evident from Ext. A5 case summary that the scanning was advised by the doctor as the part of relevant investigation. It is also mentioned in the said document that during the period of hospitalisation, the patient was 'treated with antibiotics analgesics.' In the said document under the heading 'Advice' the following medicines were prescribed :
“1. TAB GRENIL 1-1-1 }
2. TAB. TRIKA 0.25 MG. 0-0-1 } X 3 DAYS
3. CAP. BLIEU 1 OD X 1 MONTH
Follow up in Neurology OPD”
Seemingly, after the scanning, the doctor who treated the patient had prescribed medicines. On the contrary, nothing is before us to substantiate the contentions of the opposite party that the MRI scan is not related to the diagnosis. In the aforementioned reasons, we are of the considered view that the rejection of charges incurred for MRI scan is not justifiable. Therefore, the complainants are entitled to get the MRI scanning charges as per Ext. A3 bill together with interest from the opposite party. In the facts and circumstances of the case, we are not ordering any compensation and costs. Since, we have already ordered interest.
7. In view of the above, we direct the opposite party to pay Rs. 3,500/- towards the scanning charges to the complainants with interest @ 12% p.a. from the date of complaint till realisation.
The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.
Pronounced in open Forum on this the 31st day of May 2012
Sd/- C.K. Lekhamma, Member. Sd/- A. Rajesh, President.
Sd/- Paul Gomez, Member.
Forwarded/By order,
Senior Superintendent.
A P P E N D I X
Complainant's Exhibits :-
Exhibit A1 | :: | Copy of the policy schedule |
“ A2 | :: | Copy of the requisition form |
“ A3 | :: | Copy of the receipt dt. 10-07-2011 |
“ A4 | :: | Copy of the MRI Brain (screening) |
“ A5 | :: | Copy of case summary & discharge record |
“ A6 | :: | Copy of the hospital bill dt. 14-07-2011 |
“ A7 | :: | Copy of the letter dt. 28-09-2011 |
Opposite party's Exhibits :-
Exhibit B1 | :: | Copy of the policy schedule |
Depositions :- |
|
|
PW1 | :: | Febin Rafi - complainant |
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