DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, LUCKNOW
CASE No.220 of 2010
Sri B.C. Pandey, aged about 37 yrs.,
S/o Sri B.D. Pandey,
R/o 84, Sri Ram Kunj,
Faridi Nagar, Indira Nagar, Lucknow.
……Complainant
Versus
M/s The Star Health & Allied Insurance Co. Ltd. No.1,
New Tunk Road, Velluvar Kottam, High Road,
Nanamkam, Chennai-34.
.......Opp. Party
Present:-
Sri Vijai Varma, President.
Smt. Anju Awasthy, Member.
JUDGMENT
This complaint has been filed by the Complainant against the OP for payment of medical expenses of Rs.9,950.00 with 15% interest, compensation of Rs.50,000.00 and cost of litigation of Rs.5,500.00.
The case in brief of the Complainant is that the Complainant opted insurance coverage from OP for self, his wife and two sons under Family Heath Optima Insurance Plan for the period 29.11.2008 to 28.11.2009. Unfortunately, the Complainant’s wife became unconscious on 10.04.2009 and she was taken to Dr. D.P. Bhatnagar and on his advice many tests were done on her and medicines etc. were given to her but she was not completely cured. According to doctor’s advice on 15.05.2009 the Complainant’s wife was admitted to Fatima Hospital, Mahanagar, Lucknow where she was admitted till 20.05.2009. The Complainant had spent Rs.9,950.00 on the treatment of his wife. On 25.05.2009 the Complainant sent claim form alongwith bills which duly
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certified by the doctor to the representative of OP Sri Prashant for the reimbursement but the OP did not reimburse Rs.9,950.00 despite many requests made by the Complainant. The Complainant is legal holder of policy of OP and he is entitled to get the medical expenses from the OP but the OP is harassing the Complainant. The OP repudiated the claim of the Complainant vide repudiation letter dated 10.07.2009 by saying that there was no need to admit Complainant’s wife in the hospital for treatment. Thereafter the Complainant sent registered notice to the OP but the OP did not pay the medical expenses and replied the notice on 16.11.2009. The Complainant is entitled to get reimbursement of medical expenses incurred by the OP but the OP did not pay, hence this complaint.
The OP has filed the WS wherein it is submitted that the Complainant opted insurance coverage from OP for self, his wife and two sons under Family Heath Optima Insurance Plan for the period 29.11.2008 to 28.11.2009 for a sum of Rs.1,00,000.00. The claim was lodged with the OP for the insured Smt. Punita Pandey. The claim stands denied prior to filing of this misconceived complaint case. Claim is settled only as per insurance policy terms and conditions. In the light of claim intimation and on detailed scrutiny by the in house medical expert of OP of the medical papers submitted with OP by the Complainant with regard to her wife Mrs. Punita Pandey it could be revealed that at the time of admission in hospital, the provisional diagnosis was MYXOEDEMA with CERVICAL SPONDYLOSIS. MYXOEDEMA is a complication of THYROID disorder for which she was already under medication prior to admission in hospital therefore the admission in hospital for such ailment was not required. Due to pain around neck region, Xray was got done. The report of such X-ray revealed that no abnormalities would be observed thereby it is evident that pain was muscular which was fit for
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treatment on OPD basis requiring no I.P. admission in the hospital. From the investigations done of Mrs. Punita Pandey during her hospitalization it is evident that she was admitted as indoor patient only for investigations and not for any specialised treatment. The OP settled the claim whereby denied the claim as per requirements and applicability of Exclusion clause No.13 of the insurance policy on the present facts and circumstances of the matter/claim. The repudiation letter dated 10.07.2009 was issued to the Complainant by OP explaining therein the cause to deny the claim. Exclusion No.13 of the insurance policy is “Charges incurred at hospital or nursing home primarily for diagnostic, Xray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at hospital/nursing home.” The claim has been settled as per insurance policy provisions, the only basis of contract between the parties which are binding upon both parties i.e. the Complainant and the OP. There is no deficiency in the service of OP either in processing the claim or in it’s settlement thereby to deny the claim. For the alleged grievance the complaint ought to have been filed by the insured Mrs. Punita Pandey herself. The present Complainant has no right to file the present complaint alone for his wife Mrs. Punita Pandey. OP is not at all harassing the Complainant as the claim had already been settled as per policy exclusion clause. The Complainant is not entitled for any relief. The complaint is liable to be dismissed with special cost.
The Complainant has filed his affidavit with 7 annexures and 4 documents with the complaint. The Complainant has also filed written arguments. The OP has filed the affidavit of Sri R.S. Singh, Zonal Manager with 3 annexures.
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Heard Counsel for the Complainant but none appeared to argue the case from the side of OP but OP has filed written arguments. Perused the entire record.
In this case, it is not disputed that the Complainant had taken a family health optima insurance plan from the OP for the period 29.11.2008 to 28.11.2009 for himself, his wife and his two sons. When the Complainant’s wife Smt. Punita Pandey fell ill then she was admitted in the Fatima Hospital where the Complainant incurred expenses to the tune of Rs.9,950.00 and when he claimed this amount from the OP then they repudiated the claim on the ground that there was no need for Smt. Punita Pandey to be admitted to the hospital as she was already getting the treatment and that she was admitted into the hospital for investigation purposes only, therefore as per the conditions of the insurance policy the claim was repudiated as the reimbursement of the medical expenses incurred on the treatment diagnosis is not allowed under the policy conditions.
Now, it is to be seen as to whether the claim of the Complainant was wrongly rejected by the OP and if so then whether the OP committed deficiency in service in repudiating the claim or not.
The OP has repudiated the claim on the ground that in the instant case there was no need for the Complainant’s wife to be admitted into the hospital and that it was done with the intention of getting the diagnosis and therefore under the conditions of the policy the OP was not obliged to allow the claim of the Complainant for expenses incurred on the treatment of the Complainant’s wife. The Complainant has filed his affidavit wherein it is stated by the Complainant that his wife suddenly fell unconscious on 10.04.2009 and she was examined by Dr. D.P. Bhatnagar who had given certain medicines but as she did not recover completely, hence on the advice of the doctors she was admitted in the Fatima Hospital
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on 15.05.2009 where she remained admitted till 20.05.2009 where expenses to the tune of Rs.9,950.00 were incurred by the Complainant. Thus, there is evidence from the side of the Complainant to show that there was the need for the Complainant’s wife to be admitted in the hospital and she was admitted in the hospital where she remained for about 5 days. The OP has contended that there was no need for the admission of the Complainant’s wife in the hospital but there does not appear to be any plausible reason as to why the Complainant’s wife should not have been admitted into the hospital. The only ground given by the OP is that she was already under medication and therefore admission in the hospital was not required. It is also stated by the OP that there was no specialised treatment for the Complainant’s wife and that she was admitted in the hospital for diagnosis purposes for which the claim was not to be allowed. The Complainant has filed photocopies of the investigation reports as well as medical prescriptions and the treatment card given on days admitted in the hospital. There is also the photocopies of the discharge summary where the complaint/symptoms/diagnosis and the treatment given in the hospital are mentioned and also advice for the medication has also been given and from the aforesaid it is clear that the Complainant’s wife had to remain in the hospital for about 5 days and that she had to be treated for the disease suffered by her. There is no reasoning given as to why for such a treatment as was given to the Complainant’s wife in the hospital did not require hospitalisation. It goes without saying that if a person was admitted for treatment in the hospital then the investigation which are required for the purposes of diagnosis are to be done in the hospital and therefore there is no justification for the OP in just repudiating the claim of the Complainant on the ground that the hospitalisation of the Complainant’s wife was not required as she was already getting the treatment. Therefore, the OP has
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committed deficiency in service in repudiating the claim of the Complainant, hence the Complainant is entitled to get the reimbursement of the medical expenses incurred by the Complainant on the treatment of his wife.
Now, the question arises as to how much amount the Complainant is entitled to get from the OP. In this regard, the Complainant has filed receipts and has claimed Rs.9,950.00 for the expenses incurred, hence the Complainant is entitled to get Rs.9,950.00 with interest from the OP. As the Complainant has also been harassed in this regard, hence he is entitled to compensation as well as cost of litigation.
ORDER
The complaint is partly allowed. The OP is directed to pay Rs.9,950.00 (Rupees Nine Thousand Nine Hundred Fifty Only) with 9% interest from the date of filing the case till the final payment is made to the Complainant.
The OP is directed to pay Rs.3,000.00 (Rupees Three Thousand Only) as compensation and Rs.3,000.00 (Rupees Three Thousand only) as cost of the litigation to the Complainant. The compliance of the order is to be made within a month.
(Anju Awasthy) (Vijai Varma)
Member President Dated: 29 July, 2015
