DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE
PRESENT : Sri. P.C. PAULACHEN, M.Com, LLB : PRESIDENT
Smt. PRIYA.S, BAL, LLB, MBA (HRM) : MEMBER
Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER
Thursday the 22nd day of December, 2022
C.C. 278/2016
Complainant
M. M. Dominic, S/o Mathew,
Mannukusumbil House, Anakkampoyil P.O,
Thiruvambady, Kozhikode – 673603.
(By Adv. Sri. Thrivikraman Namboodiri & Tessy. C. T)
Opposite Parties
- STAR HEALTH AND ALLIED INSURANCE CO. LTD,
Regd Corporate Office, New Tank Road,
Valluvarkottam, High Road, Nangambakkam,
Chennai – 600034.
(By Adv. Sri. Bhagaval Das)
- Malabar Institute of Medical Sciences Ltd.,
Represented by its Manager/Superintendent,
Mini Bypass Road, Govindapuram P.O, Calicut – 673016.
(By Adv. Sri. Ajith Prasad. R. S)
Suppll 3. STAR HEALTH AND ALLIED INSURANCE CO. LTD.,
Area office, 3rd Floor, Veepee Space No. 2/1955.
D5 and D6, Civil station, Eranhipalam P.O,
Calicut – 673006.
Suppll 4. Dr. Sajan. P,
Department of Surgery, MIMS Hospital,
Bypass Road, Govindapuram P.O,
Kozhikode – 673016.
(By Adv. Sri. Jeril Babu. P)
(Op 1 and 3 were removed from the party array as per order dated 14/03/2019
in IA 11/2019)
ORDER
By Sri. P.C. PAULACHEN – PRESIDENT.
This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.
2. The case of the complainant, in brief, is as follows:
In April 2016 the complainant felt some pain and swelling on the right second toe. He was admitted in the second opposite party hospital on 08/04/2016 and had undergone a surgery and was discharged on 13/04/2016. The complainant had taken a Family Health Optima Insurance policy from the first opposite party for the period from 31/08/2014 to 31/08/2015. Thereafter, the policy was renewed from 31/08/2015 to 31/08/2016. The complainant preferred a claim for re-imbursement of the medical and hospitalisation charges before the first opposite party. On 21/05/2016 the claim was repudiated by the insurance company stating the reason of pre-existing disease and complication of pre-existing disease. The grounds stated for repudiation are absolutely wrong and baseless.
3. The complainant never told the doctors in the second opposite party hospital that he was suffering from any illness for the last 2 years. What was written in the discharge summary is not correct. The illness occurred only after the inception of the policy. It was on the basis of a false and wrong printing in the discharge summary of the second opposite party that the first opposite party repudiated the claim. It amounts to deficiency of service on the part of the opposite parties. Prior to 08/04/2016 the complainant never made any consultation or availed any treatment from any hospital or doctors for any illness. Due to the wrong entry made in the discharge summary given by the second opposite party, the complainant suffered a lot of mental agony and inconvenience. Hence the complaint to direct the opposite parties to pay the claim amount of Rs. 26,235/- with interest along with compensation of Rs. 50,000/-.
4. Separate written versions were filed by the opposite parties.
5. The 1st and 3rd opposite parties have virtually alleged similar facts against the complainant. They have admitted the policy. According to them, the complainant was admitted in the second opposite party hospital on 08/04/2016 and diagnosed with right second toe abscess and after treatment he was discharged on 13/04/2016. In the discharge summary it is clearly stated that the complainant was suffering from recurrent pustules over second toe right foot for the past 2 years. The policy commenced on 31/08/2014. The illness commenced prior to that. So the complainant was well aware of his health condition before the inception of the policy. The illness for which the complainant had undergone treatment was pre-existing. Hence the claim was repudiated on the ground of pre-existing disease which was suppressed by the complainant. There is no deficiency of service on the part of the insurance company. With the above contentions, the first and third opposite parties pray for dismissal of the complaint.
6. The contentions in the written version of the second and fourth opposite parties are almost similar. The complainant was admitted in the hospital on 08/04/2016 with complaints of recurrent pustules over second toe right foot for the past 2 years. It was the complainant himself who stated the medical history to the doctors. He was having severe pain and pustules over the same site at the time of admission. Debridement of second toe of the complainant was done and he was discharged on 13/04/2016. The entry in the medical history was not disputed by the complainant at the time of discharge. There is no reason for doctors to record any information which has not been elicited from the patient. It may be noted that there was no objection about the past medical history mentioned in the discharge summary prior to the rejection of the medical claim by the insurance company. They have nothing to do with the repudiation of the claim. There was no negligence or deficiency of service on the part of the hospital or the doctor. The complainant has no cause of action against them and none of the reliefs is allowable. It is, therefore, prayed to dismiss the complaint with costs.
7. During the pendency of this complaint, the matter was settled between the complainant and the first and third opposite parties and the insurance claim was settled. The 1st and 3rd opposite parties were removed from the party array as per the order dated 14/03/2019 in IA-11/2019 passed by our-learned predecessors-in-office and the complaint as against the opposite parties 2 and 4 was proceeded with.
8. The points that arise for determination in this complaint are;
(1). Whether there was any deficiency of service on the part of the second and fourth opposite parties?
(2) Reliefs and costs.
9. Evidence consists of the oral evidence of PW1 and Exts A1 to A8 on the side of the complainant. No evidence was let in by the 2nd and 4th opposite parties.
10. Heard.
11. Point No. 1 : As already stated, the complaint as against opposite parties 1 and 2 was settled and now what remains is the complaint against the 2nd and 4th opposite parties. The allegation against the 2nd and 4th opposite parties is that they have made false entry in the discharge summary which amounts to gross deficiency of service.
12. In a consumer case, the onus to prove deficiency of service is on the complainant. Without proof of deficiency, the opposite parties cannot be held liable.
13. Bearing in mind the above settled position, let us now examine whether there was any deficiency of service on the part of the hospital or the doctor. In order to substantiate his case, the complainant got himself examined as PW1. PW1 has filed proof affidavit and deposed in terms of the averments in the complaint. PW1 has maintained that prior to the admission in the second opposite party hospital on 08/04/2016, he had no such complaints and had never sought treatment in any hospital and so the entry in the discharge summary that he was suffering from the said illness for the last 2 years is incorrect and false.
14. Ext A3 is the copy of the discharge summary. It shows that he was admitted in the second opposite party hospital with complaints of recurrent pustules over the second toe right foot for the past 2 years and now presented with severe pain and pustules over the same site. The procedure done in the hospital was debridement right second toe. He was discharged on 13/04/2016.
15. The case advanced by the opposite parties 2 and 4 is that the complainant himself informed the doctor about his medical history and the same has been recorded in the medical records and there was absolutely no negligence or fault on their part. In this context, it may be noted that it is the duty of the doctor to ascertain the medical history from the patient at the time of consultation. Usually, when a patient comes, the doctor will enquire about his complaints and record in the clinical history notes of the medical records. Any past medical history disclosed by the patient will also be recorded along with other relevant information. According to opposite parties 2 and 4, it was based on the statement given by none other than the complainant at the time of admission that the history was recorded. In this context, it may be noted that the complainant has no case that he had not disclosed anything to the doctor about the medical history. Equally, he has no case that any other person accompanying him had disclosed about his complaints to the doctor. There is absolutely no reason for the doctor to record any information which has not been elicited from the complainant. There is no reason to disbelieve the doctor. It is pertinent to note that the medical history stated in the discharge summary was not disputed by the complainant at the time of discharge. Equally, it may be noted that the complainant has not objected any other information recorded in the discharge summary including diabetes mellitus. It was only after rejection of the medical claim by the insurance company that the complainant has come up with objection. Prior to that, he had never raised any objection about the past medical history mentioned in Ext A3. Moreover, while in the box as PW1, the complainant has admitted in the cross-examination that he would not have raised such a complaint if the medical claim was allowed by the insurance company. So it is crystal clear that the allegation against the hospital and the doctor is an afterthought in order to get over the objection in granting the medical claim. The opposite parties 2 and 4 have nothing to do with the repudiation of the claim and they have no role in providing insurance to the complainant. As already stated, the medical claim was subsequently granted by the insurance company.
16. From the above discussion, what emerges is that the complainant has failed to prove that the opposite parties 2 and 4 have committed any negligence while recording the medical history. There is no proof of deficiency and consequently the complaint must fail.
17. Point No.2: In view of the finding on the above point, the complainant is not entitled to claim and get any relief.
In the result, the complaint is dismissed. However, no order as to costs.
Pronounced in open Commission on this, the 22nd day of December, 2022.
Date of Filing: 28/06/2016.
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PRESIDENT
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MEMBER
APPENDIX
Exhibits for the Complainant :
Ext. A1 – Policy schedule of Star Health and Allied Insurance Company Ltd.
Ext. A2 – Advance premium receipt .
Ext. A3 – Copy of the discharge summary.
Ext. A4 – Notice of the repudiation of claim.
Ext. A5 – Copy of the lawyer notice.
Ext. A6 – Copy of the postal receipt.
Ext. A7 – True copy of the discharge bill issued by the MIMS Hospital.
Ext. A8 – Medical bills issued by the MIMS Hospital.
Exhibits for the Opposite Party
Nil.
Witnesses for the Complainant
PW1 – M. M. Dominic (Complainant).
Witnesses for the opposite parties
Nil.
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PRESIDENT
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MEMBER
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MEMBER
Forwarded/By Order
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Assistant Registrar
