Heard learned counsel for both sides.
2. Here is an appeal filed u/s 15 of the erstwhile Consumer Protection Act, 1986 (hereinafter called the ‘Act’). Parties to this appeal shall be referred to with reference to their respective status before the District Forum.
3. The case of the complainant in nutshell is that the complainant has purchased a Health Plus policy commencing from 14.12.2009 for a period of 10 years from the OPs. It is alleged inter alia that the complainant being a cancer patient was admitted in Good Luck Hospital, Mangalabag, Cuttack for chemo therapy on 18.6.2014 and has spent Rs.97,404/-. He made the claim before the OPs but the OPs kept silent. Thereafter, he sent a lawyer’s notice on 24.4.2015 for settlement of the claim but the OPs communicated him on 28.11.2015 rejecting the claim. Thereafter, the complaint was filed.
4. OPs filed written version admitting about purchase of the policy by the complainant. He also admitted that the complainant was admitted in Good Luck Hospital on 18.6.2014 at 8.02 AM and relieved on the same day at 7.57PM. It is also averred that according to policy condition since he remained less than 48 hours, he is not entitled to the reimbursement of medical expenses. Therefore, they have repudiated the claim. There was no deficiency in service on their part.
5. After hearing both the parties, the learned District Forum passed the following order which is as follows:-
“xxx xxx xxx
The complainant be and the same is allowed against the OPs on contest. OPs are directed to settle the claim of Rs.97,404/- and pay cost of litigation of Rs.1,000/- within 30 days from the date of receipt of this order. In the event of non-compliance of order within the stipulated time, OPs shall pay interest @9% PA on the claim amount from the date of order till the date of payment.”
6. Learned counsel for the appellants submitted that the learned District Forum has committed error in law by not considering the written version and the policy in question with proper perspectives. According to him clause 2(1)(a) of policy is clear to show that the policy holder has to be hospitalized for more than 48 hours, then he is eligible for reimbursement medical expenses. Learned District Forum ought to have considered such fact and law, but passed the impugned order which is not legal and proper. There is no deficiency in service on the part of the insurer by repudiating the claim. Therefore, he submitted to set aside the impugned order by allowing the appeal.
7. Learned counsel for the respondent submitted that under the policy, the complainant is entitled to the reimbursement cost because he has remained as indoor patient for a period of 12 hours and the clause 2(1)(c) requires for continuous period of 4 hours to stay to claim any benefit under the medi-claim policy. Since the case of the complainant is a case of chemo therapy but not it is an accidental injury or sickness, therefore, the complainant is entitled to reimbursement cost. So, he supports the impugned order.
8. Considered the submission of learned counsel for the respective parties and perused the DFR including the impugned order.
9. The only question to be decided whether the complainant has proved the deficiency in service on the part of the OPs for not reimbursing the medical expenses.
10. It is admitted fact that complainant has purchased Health Plus policy from the OPs for a period of 10 years commencing from 14.12.2009. It is also not in dispute that the complainant was admitted on 18.6.2014 in the Good Luck Hospital to receive chemo therapy because he is a cancer patient. It is not in dispute that he was admitted in the morning and discharged from the hospital in the evening.
11. Complainant in order to prove the case has examined himself and produced the documents in his favour. The crucial document in the policy on which both the parties relied upon and we have gone through the policy. The provision of the policy relied upon by the learned counsel for the appellants is clause - 2 (1)(a) which is as follows:-
“xxx xxx xxx
- In case of Hospitalization in the general or special ward(i.e. a non-intensive Care Unit ward/room) of a Hospital:
The Applicable Daily benefit in a Policy Year, reckoned under sub-clauses (i) and (ii) below, for each continuous period of 24 hours or any part thereof (after having completed the 48 hours as above) provided any such part stay exceeds a c continuous period of 4 hours of Hospitalization necessitated solely by reason of the said Accidental Bodily Injury or Sickness, shall be payable.”
12. For better appreciation now we discuss the entire clause 2(1)(b) and (1)(c) which are as follows:-
“xxx xxx xxx
- In case of Hospitalization in the Intensive Care Unit of a Hospital:
Two times the Applicable Daily Benefit reckoned under clause 2(1)(a) and its sub-causes above for each continuous period of 24 hours or part thereof(after having completed the 48 hours as above) provided any such part stay exceeds a continues period of 4 hours of Hospitalization in the Intensive Care Unit of a Hospital during any period of Hospitalization necessitated solely by reason of the said Accidental Bodily Injury or Sickness shall be payable.
c. Combined stay in Non-ICU and ICU ward/room:
During one period of 24 continuous hours (i.e. a single day) of Hospitalization, if the said Hospitalization included stay in an intensive Care Unit as well as in any other in patient (non-Intensive Care Unit) ward of the Hospital, the Corporation shall pay benefits as if the admission was to the Intensive Care Unit provided that the period of Hospitalization in the Intensive Care Unit was at least 4 continuous hours. In any other case where the overall period of hospitalisation exceed 4 hours in a one period 24 continuous hours (i.e. a single day), the Applicable Daily Benefit shall be payable.”
13. When the complainant is not accidentally, bodily injury or the sickness first occurring for the purpose of hospitalization, Clause – 2(1)(a) is not applicable because in such cases 48 hours hospitalization is must to lay claim for reimbursement. But at the same time, if we go through Clause – 2(1) (c) as stated above, it is very clear that a patient in the ICU and non-ICU has remained for continuous 4 hours in one period of 24 hours of continuous hour, then he is entitled to daily benefits. Therefore, the applicable of daily benefit which is defined under Clause – 1(4) and 1(6) of policy which are to be read together and they all referred to the schedule of the policy for calculation benefits. In the instant case, since complainant has remained continuously for more than 4 hours as indoor patient and this 4 hours is part of continuous 24 hours as stated clause 2(1)(c) of policy, we are of the view that he is entitled to the applicable daily benefit for reimbursement of his medical expenses. So the repudiation of claim by the OPs on the ground as stated by them is not correct. The case of the complainant ought to be considered under clause – 2(1) (c) read with 1 (iv) and (vi) of the policy. By that he is entitled to reimbursement of cost as per the schedule of the Health Plus policy. The repudiation of entire claim of the complainant by the OPs is deficiency in service on the part of the OPs.
14. When the complainant has already proved the deficiency in service of the OPs as per above discussion, we do not find any reason to interfere with the impugned order. Hence, the impugned order is confirmed and the appeal stands dismissed. The OPs are directed to comply the impugned order directing to pay Rs.97,404/- as medical expenses besides litigation cost of Rs.1,000/- to the complainant within 45 days from today failing which the amount would carry interest at the rate of 9% per annum from the date of impugned order till the amount is paid. No cost.
DFR be sent back forthwith.
Supply free copy of this order to the respective parties or the copy of this order be downloaded from Confonet or Website of this Commission to treat same as copy supplied from this Commission.
