IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Saturday the 30th day of July, 2016
Filed on 20.05.2015
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt.Jasmine.D. (Member)
in
C.C.No.153/2015
between
Complainant:- Opposite Parties:-
Sri. Syamlal Sasi 1. Nimish Ramnik Parekh
Malayiltharayil House Additional Director
Puthiyavila P.O. United Health Care Parekh TPA
Kayamkulam – 690 531 Private Ltd., 3B/1, GundechaOnclave
Kherani Road, Sakinaka
Andheri (East), Mumbai
Maharashtra – 400 072
2. Sri. Gopalan Sreenivasan
Managing Director
New India Assurance Company
Building 87 M.G. Road, Fort Mumbai
Maharashtra – 400 001
(By Adv. C. Muraleedharan – for
Opposite parties)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant was admitted at KIMS hospital, Kochi on 24th June following an accident. After investigation and observation he was transferred from casualty to the Surgery Department for further treatment at 7.30 p.m. on the same day. Later he was discharged from surgery IP on 25th June 5.56 p.m. his claim was rejected by the opposite parties on the ground that his surgery IP being less than the minimum time period of 24 hours by one hour 30 minutes. He had the policy coverage since 28th October, 2010 till date. But he was not provided with justice, hence the complaint.
2. The version of the opposite parties is as follows:-
Complaint is not maintainable. Since the hospitalization period was less then 24 hours the claim is not payable as per Section 3-4 of the policy condition. Thus the claim was repudiated. There is no deficiency in service on the part of the opposite parties. The opposite parties acted fairly reasonable unjustifiably and as per law.
3. Complainant was examined as PW1. The documents produced and marked as Exts.A1 to A9. Opposite parties filed proof affidavit and produced one document marked as Ext.B1.
4. The points came up for considerations are:-
- Whether there is any deficiency in service on the part of the opposite parties?
- Whether the complainant is entitled to get relief and cost?
5. It is an admitted fact that the opposite parties issued a policy under United Health Care in favour of the complainant for the period from 1.11.2013 to 31.10.2014. According to the complainant, he was admitted at KIMS Hospital, Kochi on 24th June 2014 at 2.30 p.m. and was discharged on 25th June, 2014 at 5.56 p.m. In order to substantiate the allegation, the complainant produced Ext.A6 discharge summary issued from the KIMS hospital. On verifying Ext.A6 we came to see that the complainant was admitted on 24th June 2014 and discharged on 25th June 2014. The contention of the opposite party is that since the hospitalization period less than 24 hours, the claim of the complainant is not payable as per Section 3.17.1 of the policy conditions. The policy conditions produced and marked as Ext.B1. As per Section 3.17.1 – “Hospitalization: means admission in a Hospital for a minimum period of 24 in patient Care consecutive hours except for specified procedures /treatments listed in Annexure 1, where such admission could be for a period of less than 24 consecutive hours.” In this case Ext.A8 certificate issued from the KIMS hospital shows that complainant came to the hospital casualty at 2.35 on 24.6.2014 and after the investigation and observation in emergency department, the patient got admitted at 7.32 p.m. on the same day. Hence it is clear that he was admitted at 7.32 p.m. on 24.6.2014. The complainant himself admitted that he was discharged from the surgery IP on 25th June at 5.56 p.m. The allegation of the complainant is that the total time between the time of admittance and discharge is 27 hours 30 minutes. But from the evidence on record it is clear that he admitted at 7.32 p.m. on 24.6.2014 and discharged on 25.6.2014 at 5.56 p.m. Since the period of admission in the hospital was less than 24 hours, the claim is not payable as per Section 3.17.1 of the policy conditions of the opposite parties. There is no deficiency in service on the part of the opposite parties in repudiating the claim of the complainant.
In the result, complaint is dismissed.
Dictated to the Confidential Assistant transcribed by her corrected by me and
pronounced in open Forum on this the 30th day of July, 2016.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Shyamlal Sasi (Witness)
Ext.A1 - Copy of the United Health Care Id
Ext.A2 - Copy of the email details
Ext.A3 - Copy of the claim form
Ext.A4 - Copy of the letter dated 16.7.14
Ext.A5 - Copy of the claim details
Ext.A6 - Copy of the discharge summary
Ext.A7 - Copy of the scanning photos
Ext.A8 - Copy of the certificate dated 10.10.2014
Ext.A9 series - Copy of the bills (11 Nos.)
Ext.A10 - Copy of the doctor’s report of KIMS hospital, Kochi
Evidence of the opposite parties:-
Ext.B1 - Certified copy of policy
. // True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
