Kerala

StateCommission

A/13/413

THE BRANCH MANAGER, STAR HEALTH & ALLIED INSURANCE COMPANY AND ANOTHER - Complainant(s)

Versus

NELIKUTH HANEEFA - Opp.Party(s)

LAKSHMANAN T.J

24 Dec 2014

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM

 

APPEAL NO.413/2013

JUDGMENT DATED 24/12/2014

 (Appeal filed against the order in CC No.141/2011 on the file of CDRF, Malappuram dated, 06/02/2013)

 

 

PRESENT:

 

SMT. A. RADHA                                      :         MEMBER

SHRI. K. CHANDRADAS NADAR           :        JUDICIAL MEMBER

SMT. SANTHAMMA THOMAS              :        MEMBER

 

APPELLANTS:

 

1. The Branch Manager,

Star Health & Allied Insurance Company,

Branch Office Silsila Sankar Nagar,

Residency Road, Chinnakad, Kollam, Pin-691001.

 

1. Star Health & Allied Insurance Company,

New Tank Street, Valluvarkottam High Road,

Nungampackam, Chennai-600 034.

 

(By Adv:   T.J. Lakshmanan)                   

 

                   Vs

 

RESPONDENT:

 

Nelikuth Haneefa, S/o. Kutty Ali Haji,

Pularibhavan, Nelikuth, Payyanade,

Manjeri-671 122.

 

(By Advs:  M. Hashim Babu & Baby.M.M.)                    

JUDGMENT

 

SMT. A. RADHA  :  MEMBER

 

          This appeal is preferred against the order in C.C.No.141/11 on the file of CDRF, Malappuram by the opposite parties.  The Forum Below allowed the complaint with compensation of Rs.5,000/- and cost of Rs.2,000/-.

          2.  The case of the complainant is that he joined the Medi Claim Policy offered by the Kerala Sabdham Management for their staff members for a period from on 04/03/2010 to 03/03/2011.  As per the insurance policy the complainant is entitled for an amount of Rs.30,000/- in case of treatment or hospitalization.  The complainant was admitted in Korambayil Hospital, Manjeri, following the swelling in his legs and general tiredness.  On 04/01/2011 as part of treatment the complainant was advised for scanning, blood and urine test.  On investigation it was revealed that the complainant is having kidney problem and referring the patient to Nephrologist discharged from the hospital and the complainant consulted the Nephrologist at MIMS Hospital on 15/01/2011 and he was again admitted in the Hospital.         It was revealed that the complainant was having Nephrotic Syndrome and prescribed medicines for 3 months and discharged him             on 18/01/2011.  It is stated in the complaint that on admission in the Korambayil Hospital he informed the opposite party regarding his admission in the hospital.  The opposite party informed their inability to entertain the claim.  The same act was repeated on the part of opposite parties in refusing the claim of the complainant on admission to the MIMS Hospital.  The complainant had to spend Rs.12,000/- at Korambayil Hospital for treatment charges and Rs.10,000/- towards hospital charges at the MIMS Hospital. All the bills were sent to the opposite parties.  Thereafter a few months later, the repudiation of the claim was received by the complainant.  The complainant belongs to the Kerala Union of working Journalists and had never been to any hospital earlier.  The complainant submitted all the bills with documents on 04/05/2011 by registered post and so far the claim was not entertained by the opposite parties. The complaint is filed for the claim amount of Rs.12,000/- + Rs.10,000/- and also for the future treatment of Rs.2,373/- along with compensation and cost.

          3.  In the version filed by the opposite party the Star True Value Policy was admitted covering the employees and the family members for a sum of Rs.30,000/- for the period from 04/03/2010 to 03/03/2011.  The premium was paid by M/s. Kerala Sabdham on the basis of the contract of insurance entered into between the Kerala Sabdham and Star Health and Allied Insurance Company.  It is contended that the contract is between the M/s. Kerala Sabdham and the opposite party where as the Kerala Sabdham was not made a party to the case.  Hence the complaint is bad for non-joinder of necessary party.  It is also contended that the cashless treatment is an additional facility extended by the insurance company and not a contractual obligation as per the policy.  It is admitted that the complainant submitted two claims for hospitalization from 04/01/2011 to 07/01/2011 and from 15/01/2011.  The first hospitalization in which the clinical findings shows history of generalised tiredness.  As per exclusion clause the treatment for generalised tiredness falls outside the scope of policy.  The complainant had not submitted any case sheet copy.  The claim repudiation later was sent to the proposer on 28/03/2011 as the claim placed was without mentioning anything about the claim under KUWJ policy.  At the MIMS Hospital on 15/01/2011 he was admitted for conducting renal biopsy. On admission it was ascertained that the complainant was hospitalized for a diagnostic procedure.  As per the discharge summary it is recorded he was subjected to renal biopsy and he “tolerated the procedure well, he was being discharged with advise to review in OP 4 days with renal biopsy report”.  During the stay in the hospital no medicines were prescribed. The medicines seen administered for Rs.111/- were for the purpose of conducting the test of renal biopsy and not for treatment.  There had no confinement in the hospital for the treatment of illness and the treatment had to be decided during OP consultation on a later date based on the biopsy report.  The claim cannot be entertained under the insurance contract condition No.7 between the parties.  The claim was repudiated on the exclusion clause No.14 of the insurance policy.  The expenses for diagnostic procedures are excluded and the complainant is not entitled for the claim submitted by him.

          4.  No oral evidence adduced by the parties. Both parties filed affidavits and documents produced as Exbt.A1 (series), A2 to A10, Exbts. B1 to B10 on the part of complainant and opposite party respectively.

          5.  It is submitted by the counsel for the appellant that the complainant is a member of Group Medi Claim Policy of Kerala Sabdham with the opposite party.  As per the terms and conditions the general tiredness does not come under the purview of the policy conditions.  The complainant was admitted twice in two hospitals and all the treatments conducted were for diagnostic purposes.  No medicines were prescribed as medicine and for the treatment of his illness.  Renal biopsy is only an investigation purpose.  It is admitted that the respondent was admitted as in-patient.  The medicines used were for the investigation purpose only.  The complainant submitted complete claim form with discharge card.  The complainant had not submitted any case sheet along with bills.  Thereafter on 15/01/2011 the complete claim form with medical certificate, lab reports and bills for Rs.7,092/- submitted.  The counsel argued to reduce the awarded amount and also prayed  to dis-allow the compensation.

          6.  It is submitted by the counsel for the respondent that the respondent is entitled for the Medi Claim Policy.  Even though the claim was not allowed on cashless facility the complainant submitted all the documents with case sheet as on 15/11/2011.  The complainant is entitled for the amount spent for the treatment and also for the future treatment.  The complainant had to be admitted in the hospital twice.  The complainant was suffering from swelling in the leg and general tiredness.  The insurance period is from 04/03/2010 to 03/03/2011. The complainant had to spend Rs.12,000/- and Rs.10,000/- and also Rs.2,373/- for the future expense.  The complainant had never been an in-patient earlier or he was not having any pre-existing diseases.  The diagnosis could not be done without the medicines.  The admission to the hospital was not due to general tiredness alone but he was also having swelling in his leg.  He was referred to Nephrologist where he was admitted initially.  The renal biopsy could be done on application of medicines and advised on discharge advised to take tablets  Nicardia 20 mg VD and tablet Lasix 40 mg VD and was advised to review after 5 days with the renal biopsy report which clearly says that the complainant is on medication on all these days.  From the various tests it came to know that the complainant was having Nephrotic Syndrome and it is to be followed with medicines and discharged from the hospital.  Hence the Medi Claim of the complainant is to be allowed in toto.

          7.  We have heard both the counsels in detail and had gone through the records.  The complainant was a member of the Group Insurance Scheme extended to the workers of the Kerala Sabdham and the opposite parties issued the Insurance Policy for the period from 04/03/2010 to 03/03/2011 to the employees and their family.      It is in evidence that the complainant was hospitalized due to swelling in his legs and general tiredness.  It is the argument that the general tiredness comes under exclusion clause.  We find that the general tiredness is one of the symptoms and the complainant was having swelling in his legs resulted in referring him to Nephrologist at the MIMS Hospital where a Nephrologist is available.  We would like to point out that even the Nephrologist could find out the disease only through lab tests and examinations. As such, the complainant had to undergo renal biopsy which is to be administered along with medicines. It is in evidence that the respondent was advised to take medicines like Nicardia and again advised by the Nephrologist to consult in OP with the biopsy report after 5 days.  From this it is very clear that the complainant was under medication and he had to continue the medicines even after discharge from the Hospital.  Thereafter the Nephrologist arrived at a conclusion that the complainant was having Nephrotic Syndrome which is to be treated with medicine for some more period.  Hence the claim by the respondent is to be allowed.  We would like to point out that the Medi Claim is intended for the welfare of the insured and the repudiation is only on some wild technical grounds by the opposite party.  However, the Forum Below allowed an amount of Rs.22,000/- towards the treatment and Rs.2,373/- for future treatment and along with compensation and cost.  We are of the considered view that the order of the Forum is only to be upheld.

          In the result, appeal is dismissed and we uphold the order passed by the Forum Below.

          The order is to comply within one month on receipt of the copy of this order.  Failure to comply this order will entitle the respond to realize the amount with interest @ 9% till realization.

The office is directed to send a copy of this order to the Forum below along with LCR.

 

 A. RADHA               :              MEMBER

 

 

 

K. CHANDRADAS NADAR  :   JUDICIAL MEMBER

 

 

 

SANTHAMMA THOMAS     :        MEMBER

 

Sa.

 

 

 

 

 

 

 

 

 

KERALA STATE CONSUMER

                                                                  DISPUTES REDRESSAL

                                                           COMMISSION

THIRUVANANTHAPURAM

 

 

 

 

 

 

 

 

APPEAL NO.413/2013

JUDGMENT DATED 24/12/2014

 

 

 

 

Sa.