By Sri. A.A. Vijayan, President.
The complaint is in respect of Medi-claim policy. A brief account of the case of complainant is as follows.
Complainant had availed Medi-claim policy in 2007 from opposite party and it was being renewed till August 2017. The present insurance coverage is Rs. 1,00,000/- (Rupees One lakh only) and the policy period was from 11-08-2016 to 10-08-2017. The policy covers all sorts of treatment and hospitalization for more than 24 hours. On one day the complainant collapsed at work place and he was taken to MIMS hospital , Kozhikode and the reason for the break down was diagnosed as posterior circulation stroke. Then he was admitted and treated in various hospital including CMC Vellore . Since there was valid policy during that period he was granted insurance benefit. On 30-12-2016 he was readmitted at CMC Vellore for further treatment and rehabilitation since his limbs were not functioning properly . At the time of hospitalization he was not in a position even to speak. The treatment continued till 24-02-2017. Though he got much relief in the treatment he remained bed ridden and he is meeting his daily primary needs with the help of a male- nurse. To meet the expenses incurred for the present treatment at CMC Vellore, complainant preferred a claim for Rs. 1,00,000/-(Rupees One lakh only). Then the opposite party required the bank details and those details were also furnished. On 05-04 2017, he got a letter from the opposite party repudiating the claim on the basis of exclusion clause No. 4:22 of the policy. The rejection of the claim is baseless and that was done without evaluating the real facts. The rejection of the claim of complainant is violation of the assurance given to him by the opposite party at the time of taking the policy .This shows gross deficiency in service of opposite party. The repudiation of the claim of the complainant caused much hardship and mental agony to complainant. Thus complainant claimed the insurance amount of Rs. 1,00,000/-(Rupees One lakh only ) with interest at the rate of 12% per annum and Rs.50000/-(Rupees Fifty thousand only) as compensation for mental agony. Complainant claimed cost of proceedings also.
The opposite party filed version disputing the claim as follows. The admission of complainant regarding payment of Rs. 1,00,000/-(Rupees One lakh only ) as insurance coverage reveals that the present rejection of the claim is on valid ground. Therefore there is no deficiency in service on the part of opposite party. The medical records reveals that the complainant was a victim of posterior circulation stroke on 0 5-06-2016 and was rehabilitated at CMC Vellore, 3 months back. That indicates that the present claim is a follow up treatment of the previous admission on 05-06-2016 for which this opposite party has already paid the hospital expenses. As per General Exclusions No. 4:22 mentioned in the policy the insurance company shall not be liable to make any payment under this policy in respect of any expense incurred by the insured in connection with or in respect of any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist. The medical records reveal that the present hospitalization was for the purpose of the rehabilitation of the complainant and therefore it is beyond the scope of the policy conditions. There is no deficiency in service on the part of this opposite party closing the claim of complainant without settling the claim and thus complaint is to be dismissed.
The complainant and opposite party filed affidavits and Ext. A1 to A6 and Ext B1 to B3 and Ext.X1 are marked. Points arise for consideration.
- Whether complainant is entitled to get the insurance amount.
- Whether there was any deficiency in service on the part of opposite party.
- Reliefs and cost.
Point No.1 and 2
In this case Valid Medi-claim policy of the complainant is admitted by opposite parties. The facts that complainant had been admitted in various hospitals and given treatment when he suffered Posterior circulation stroke and for the above treatment he was given Rs. 1,00,000/- (Rupees One lakh only) as insurance amount by the opposite party and again complainant readmitted in CMC, Vellore on 30-12-2016 for further treatment and rehabilitation since his limbs were not functioning and he was not in a position even to speak and he was treated therein till 24-02-2017 are admitted by the opposite party. Now the claim of complainant is in respect of the subsequent treatment given to complainant from 30-12-2016 till 24-02-2017 . The claim for insurance amount for the above treatment was denied only on the ground of Exclusion Clause No. 4:22 which reads “any stay in the hospital for any domestic reasons or where no active regular treatment is given by the specialist”. The word domestic reason is not explained in the conditions of the policy. In the present case immediate admission of complainant in the hospital was warranted since his limbs were found not functioning properly and he was unable to speak properly. Ext.B2 discharge summary reveals the conditions of the complainant at the time of admission and at the time of discharge. The goals at admission are also noted in Ext. B2 . They are ambulation training ADLs modification and speech rehabilitation . It is clear from this discharge summary that the complainant was admitted in the hospital for follow up treatment . In the exclusion clause the follow up treatment is not excluded specifically. According to opposite party the Exclusion Clause No.4:22 is applicable to the complainant. It is significant to note that he was admitted when he was found having much difficulties in speaking and standing without the support of two persons. It is true that the above symptoms are the result of posterior circulation stroke suffered by him earlier. On admission in the hospital for the above disputed period continuous regular and active treatment had been given to complainant and that is revealed from Ext. B2 . There is nothing to show that the treatment given during this periods was not essential to the complainant. When a person takes a medi-calim policy, he will expect treatment expenses when it is done with in the period of the policy and if it does not come within Exclusion clause. Here there is nothing in Clause 4:22 to exclude, the treatment given to complainant in the hospital during this period. It can be seen from the stand taken by the opposite party that this clause can be interpreted in any way at the whims and fancies of opposite party to reject a claim. We find no much clarity for this clause and we find no ground to apply that clause to the present treatment given to the complainant. Hence we find that denial of the claim of complainant on the basis of the above clause is violation of justice and thus action taken by the opposite party in this matter cannot be supported. There is no case for opposite party that the complainant sought exorbitant amount or they fabricated documents for undue claim etc. Therefore we hold that rejection of the claim of complainant is improper, illegal and violation of terms and conditions of the insurance policy. The denial of the claim of an insured person illegally and without any valid reasons shows deficiency in service of the insurer , the opposite party and such illegal stand will definitely cause mental agony to insured. So the opposite party is liable to pay compensation for mental agony and their deficiency in their service.
The complainant has claimed Rs. 1,00,000/- (Rupees One lakh only) as insurance claim and opposite party is liable to pay that amount since there is no case for opposite party that for the above treatment the complainant has not spent Rs. 1,00,000/-(Rupees One lakh only). Complainant also claimed Rs. 50000/- (Rupees Fifty thousand only) as compensation for mental agony and hardship caused to him on account of deficiency in service of opposite party. We find no impropriety or illegality in allowing those claims. Points are decided accordingly.
Point No.3
On the basis of the findings on the above points we allow this complaintand opposite party is directed to pay Rs. 1,00,000/-(Rupees One lakh only) covered by the insurance policy and Rs. 50,000/-(Rupees Fifty thousand only) as compensation for mental agony and deficiency in service ofopposite party.The complainant is also entitled to Rs. 25000/-(Rupees Twenty five thousand only) as the cost of proceedings.
The above amount shall be paid by opposite party to complainant within 30 days from the date of receipt of copy of this order failing whichthey shall pay the amount with interest atthe rate of 12 % per annumfrom the date of complaint till realization.
Dated this 29th day of September, 2018.
A.A.VIJAYAN, PRESIDENT
R.K.MADANAVALLY , MEMBER
MINI MATHEW, MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A6
Ext.A1 : Copy of Medi –Claim Insurance Policy
Ext.A2 : Copy of Claim form with list of documents.
Ext A3 : ID copy.
Ext A4 :Copy of discharge summary.
Ext A5 : Letter dated 14-03-2017.
Ext.A6 : Copy of letter from opposite party rejecting the claim.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B3
Ext.B1 : True copy of Insurance Police with conditions.
Ext.B2 : Discharge Summary Preliminary Report dated 24-02-2017.
Ext.B3 : Letter dated 05-04-2017.
Ext.X1 : Medical Bills.
A.A.VIJAYAN, PRESIDENT
R.K.MADANAVALLY , MEMBER
MINI MATHEW, MEMBER
