PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief consumer dispute is as under –
On 04/02/2002 the Complainant obtained Mediclaim Policy for himself and for his wife from the Opposite Party and the said policy was renewed from time to time till 04/02/2011 without any break. The Complainant had produced copy of the relevant Mediclaim Policy for the period from 05/02/09 to 04/02/2010. It appears that sum assured under the policy to the Complainant is Rs.2 Lacs and his wife is Rs1 Lac.
2) It is submitted that in the month of November, 2009, the Complainant fail ill and have taken medicines from his family doctor Chetan A. Sejapal for having continuous fever since 3-4 days. But there was no recovery so far as the fever was concerned. Therefore, the Complainant was advised by his family doctor to investigate the matter. With the result the Complainant was admitted in Hurkisandas Hospital on 22/11/09 to 25/11/09 in Economic Class, Ward No.18, Cot No.6 under the Incharge of Dr. Suresh R. Agrawal and Dr. Riti Shah. He was diagnosed FALCIPARUM MALARIA. The Complainant remained in the hospital from 22/11/09 to 25/11/09 for medical treatment. During the aforesaid period the Complainant incurred hospital expenses of Rs.13,795/- and Rs.3,205/- on medicines, investigations and other miscellaneous expenses.
3) After discharge from the hospital the Complainant submitted his claim for the reimbursement of Rs.17,000/- from the Opposite Party and alongwith claim form he submitted necessary medical case papers, medical bills, etc. Then the TPA of Opposite Party No.1 (Raksha TPA) by letter dtd.02/01/2010 asked the Complainant to submit certain documents for processing his claim and accordingly he submitted said documents to Raksha TPA. Then by letter dtd.29/01/2010, Opposite Party through their TPA conveyed Complainant that the claim of the Complainant stands non-payable under Exclusion Clause 4.11.
4) Thereafter the Complainant submitted explanation for his emergency hospitalization and requested to reconsider his claim. Inspite of Complainant’s three visits to Raksha TPA, Opposite Party has not considered grievance of the Complainant and so on 26/05/2010 the Complainant sent legal notice to the Opposite Party and demanded claim together with sum of Rs.10,000/- as compensation for mental agony. Opposite Party did not comply with the notice and therefore, the Complainant has filed this complaint.
5) The Complainant has requested to direct Opposite Party to pay to the Complainant an amount of Rs.27,000/- (Rs.17,000/- towards medical expenses + Rs.10,000/- as compensation for mental agony) and cost of this proceeding. Alongwith compliant, the Complainant has produced copies of documents at Annexure ‘A’ to ‘F’. On 24/08/2010 the Complainant produced photo copy of mediclaim policy for period 05/02/09 to 04/02/2010 alongwith receipt of payment of premium and terms and conditions of mediclaim policy.
6) Opposite Party has filed written statement and thereby resisted claim of the Complainant contending that allegations made in the complaint are false and deserves to be dismissed with cost.
7) According to the Opposite Party, the Complainant had availed services of Opposite Party by taking mediclaim policy for himself and for his wife. The Complainant was admitted for MALARIA FALCIPARUM and was treated for the said ailment. As per available documents the line of treatment given during hospitalization included only oral medication and undergone only investigation. For the aforesaid treatment hospitalization was not necessary.
8) It is admitted by Opposite Party that the Complainant had lodged his claim for Rs.16,123/- with Opposite Party and after scrutiny of the document submitted by the Complainant and as per terms and conditions of the policy, Complainant’s claim was repudiated under Exclusion Clause 4.4.11. Opposite Party has recited in the written statement Exclusion Clause 4.4.11 which is as under –
“Diagnostic, X-ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. MALARIA FALCIPARUM + MED MGT.”
9) It is submitted that at the time of admission of the Complainant in the hospital all the vital parameters were within normal limits. The hospitalization of the Complainant was primarily for investigation. These investigations could have been carried out at the Outstation Patient Department (OPD) and did not justify confinement at hospital. During the entire period of hospitalization no active line of management was adopted requiring confinement at hospital and therefore, Complainant’s claim was repudiated under Exclusion Clause 4.4.11. It is submitted that the Complainant had accepted mediclaim policy alongwith its terms and conditions and exclusions. It is admitted by the Opposite Party was admitted to Hurkisandas Hospital. The Complainant was suffering from fever for last 7 days i.e. form 22/11/09. Hospitalization of the Complainant was not necessary and claim was repudiated as per the terms and conditions of the mediclaim policy therefore, there is no deficiency in service on the part of Opposite Party and the complaint deserves to be dismissed with cost.
10) The Complainant has filed affidavit of evidence and written argument. Opposite Party has also filed affidavit of evidence and written argument. Heard oral submission of the Complainant. As the written argument submitted by the Opposite Party, the Opposite Party has not made oral submission.
11) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Party ?
Findings : Yes.
Point No.2 : Whether the Complainant is entitled to recover amount of claim as prayed in the complaint from the Opposite
Party ?
Findings : As per final order.
Reasons :-
Point No.1 :- It is undisputed fact that the Complainant obtained mediclaim policy for himself and for his wife from the Opposite Party on 04/02/2002 and the said policy was renewed from time to time till 04/02/2011 without any break. The Complainant had produced copy of the relevant Mediclaim Policy No.111700/34/08/11/00012601 for the period from 05/02/09 to 04/02/2010. In the aforesaid policy the Opposite Party has given sum assured of Rs.2 Lacs to the Complainant and Rs.1 Lac to his wife. None of the disease of the Insured is excluded from the policy. The Opposite Party has admitted that fact that the aforesaid policy was issued to the Complainant
It is case of the Complainant that in the month of November, 2009, the Complainant fail ill and he had taken medicines from his family Dr. Chetan Sejapal but the Complainant had continuous fever since 3-4 days. Inspite of medicines taken from his family doctor the Complainant’s fever was continuous and therefore, his family doctor advised him to investigate the matter and advised to hospitalization for ascertaining the disease. With the result the Complainant got admitted in Hurkisandas Hospital on 22/11/09 in Economic Class, Ward No.18, Cot No.6 under the Incharge of Dr. Suresh Agrawal and Dr. Riti Shah. The Complainant was diagnosed Falciparum Malaria. The Complainant was discharged form Hurkisandas Hospital on 25/11/09. For medical treatment in the Hurkisandas Hospital, the Complainant incurred hospital expenses of Rs.13,795/- and Rs.3,205/- towards medicines, investigation and other miscellaneous expenses. After discharge from the hospital the Complainant submitted his claim form for an amount of Rs.17,000/- to the Opposite Party. Alongwith claim form the Complainant has submitted necessary medical case papers, medical bills, etc. The Opposite Party in the written statement has admitted the fact that, 3-4 days before admission in the Hurkisandas Hospital the Complainant was suffering from fever. As per the Opposite Party, claim submitted by the Complainant was scrutinized by their TPA. Opposite Party has submitted that during the hospitalization only oral medicines were given to the Complainant and the Complainant had undergone only investigation. For this purpose hospitalization was not necessary. Therefore, Opposite Party as per Exclusion Clause 4.4.11 repudiated the claim of the Complainant vide letter dtd.29/01/2010. It is observed by the Opposite Party that as per the available documents patient was admitted for Malaria Falciparum and was treated for the said ailment. Line of treatment given to the Complainant during the hospitalization included only the oral medicines and undergone only investigation. Hence, claim is not payable under Exclusion Clause 4.4.11. Exclusion Clause 4.4.11 is recited in the repudiation letter which is reproduced by the Opposite Party in their written statement.
The Complainant has produced the terms and conditions of the mediclaim policy and Exclusion Clause 4.4.11. The said terms and conditions of policy stated is as under –
“Diagnostic, X-ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.”
It appears that in the repudiation letter dtd.29/01/2010 and in the written statement, the Opposite Party has deliberately added following words Malaria Falciparum + MED MGT in the Clause No.4.4.11 deliberately to mislead this Forum.
It is submitted by the Complainant that in the month of November, 09, he fall ill and so he approached his family doctor Sejapal. Inspite of treatment given by his family Dr. Sejapal for 3-4 days, his fever continued and then his family doctor advised him for investigation and hospitalization. In support of his contention, the Complainant has produced copy of letter dtd.05/02/2010 of Dr. Suresh Agrawal. It appears that Dr. Suresh Agrawal, M.S.(Bom.) Hon. Surgeon, H.N. Hospital. Dr.Agrawal in his letter dtd.05/02/2010 has stated that Mr. Sohanraj Chopda was admitted in his hospital as an emergency as fever was not coming under control and further management was required. Patient was not admitted for diagnose. Even the Opposite Party has admitted that prior to admission of the Complainant in Hurkisandas Hospital the Complainant was suffering from fever. It appears from the letter of Dr. Suresh Agrawal, the Complainant’s fever was not under control and so as an emergency he was admitted in the Hurkisandas Hospital. In view of aforesaid evidence on record, we do not find substance in the allegations made by the Opposite Party that the Complainant was admitted in the Hurkisandas Hospital only for investigation. It is admitted by the Opposite Party that investigation were carried out in Hurkisandas Hospital and medicines were given to the Complainant. In such circumstances provisions of Exclusion Clause 4.4.11 are not applicable to the present case. Therefore, we hold that the Opposite Party has repudiated genuine claim of the Complainant by misinterpreting Exclusion Clause 4.4.11 of the Mediclaim Policy. Repudiation of genuine claim of the Complainant by the Opposite Party amounts to deficiency in their services. Therefore, we answer point no.1 in the affirmative.
Point No.2 :- The Complainants was admitted in the Hurkisandas Hospital on 22/11/09 and discharged on 25/11/09. During aforesaid period according to the Complainant, he incurred total expenses of Rs.17,000/- and preferred claim to the Opposite Party for reimbursement. In support of his claim the Complainant has produced bills of Hurkisandas Hospital and bills of Diagnostic Centre. The Complainant’s genuine claim is wrongly repudiated by the Opposite Party. So we think it just to direct Opposite Party to pay to the Complainant an amount of Rs.17,000/-.
The Complainant has claimed interest on Rs.17,000/- from the date of this complaint till realization of entire amount. We think it just to direct Opposite Party to pay to the Complainant interest @ 10% p.a. on Rs.17,000/- from the date of complaint i.e. from 13/07/2010 till realization of entire amount to the Complainant.
The Complainant has claimed Rs.10,000/- as compensation for mental agony. The Complainant is a senior citizen aged about 70 years. The Opposite Party has wrongly rejected genuine claim of the Complainant. We think it just to direct Opposite Party to the Complainant an amount of Rs.5,000/- as compensation for mental agony and Rs.2,000/- towards cost of this proceeding. Hence, we answer point no.2 accordingly.
For the reasons discussed above, we pass following order –
O R D E R
i.Complaint No.207/2010 is partly allowed.
ii.Opposite Party shall pay an amount of Rs.17,000/- (Rs. Seventeen Thousand Only) to the Complainant with
interest @10% p.a. on aforesaid amount from 13/07//2010 till realization of entire amount to the
Complainant.
iii.Opposite Party shall pay an amount of Rs.5,000/-(Rs. Five Thousand Only) as compensation for mental
agony and Rs.2,000/- (Rs. Two Thousand Only) as cost of this complaint to the Complainant.
iv.Opposite Party shall comply with the aforesaid order within period of one month from the date of receipt
of this order.
v.Certified copies of this order be furnished to the parties.
