Date of Filing : 06/10/2015
Order No. 17 dt. 30/01/2018
The case of the complainant in brief is that the complainant during the subsistence of his mediclaim policy with o.ps. became ill and as per the advice of Dr. Avik Dey the complainant contacted the o.ps. and he was informed that after undergoing operation and such payment to be borne by the complainant himself the complainant can reimburse the same afterwards. On the basis of the said fact the complainant got admitted into the hospital on 3.3.15 and he was discharged on 4.3.15. During the period the patient was put catheter for a week since admission the complainant after getting discharge from the hospital made claim to o.ps. for reimbursement of the medical expenses incurred by him to the tune of Rs.30,543.30. After submission of the claim of the complainant the o.p. no.4 sought for various information which were provided by the complainant. The complainant also intimated the said fact to other o.ps. but the claim of the complainant was repudiated stating that cystoscopy procedure is an OPD procedure which does not require hospitalization without having any justified cause for which the complainant filed this case praying for direction upon the o.ps. for reimbursement of the medical bill of Rs.20,543.30 as well as compensation of Rs.70,000/- and litigation cost.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that o.ps. issued an Individual Medishield Insurance Policy to the complainant vide policy no.52389547 for the period of 1.8.14 to 31.7.15. The complainant was admitted to the hospital and he was diagnosed as a case of stricture urethra and underwent cystoscopy which was an OPD procedure and does not require hospitalization. The claim was repudiated as per the following terms and conditions of the policy: exclusion 13 and policy definition 21, 15 and 34. The o.ps. after going through the record and the terms and conditions of the policy and after taking the expert report of the doctors repudiated the claim of the complainant. There was no deficiency in service on the part of o.ps. and as such, o.ps. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.ps. at the relevant point of time?
- Whether the complainant was admitted in the hospital for his treatment?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant during the subsistence of his mediclaim policy with o.ps. became ill and as per the advice of Dr. Avik Dey the complainant contacted the o.ps. and he was informed that after undergoing operation and such payment to be borne by the complainant himself the complainant can reimburse the same afterwards. On the basis of the said fact the complainant got admitted into the hospital on 3.3.15 and he was discharged on 4.3.15. During the period the patient was put catheter for a week since admission the complainant after getting discharge from the hospital made claim to o.ps. for reimbursement of the medical expenses incurred by him to the tune of Rs.30,543.30. After submission of the claim of the complainant the o.p. no.4 sought for various information which were provided by the complainant. The complainant also intimated the said fact to other o.ps. but the claim of the complainant was repudiated stating that cystoscopy procedure is an OPD procedure which does not require hospitalization without having any justified cause for which the complainant filed this case praying for direction upon the o.ps. for reimbursement of the medical bill of Rs.20,543.30 as well as other reliefs.
Ld. lawyer for the o.ps. argued that o.ps. issued an Individual Medishield Insurance Policy to the complainant vide policy no.52389547 for the period of 1.8.14 to 31.7.15. The complainant was admitted to the hospital and he was diagnosed as a case of stricture urethra and underwent cystoscopy which was an OPD procedure and does not require hospitalization. The claim was repudiated as per the following terms and conditions of the policy: exclusion 13 and policy definition 21, 15 and 34. The o.ps. after going through the record and the terms and conditions of the policy and after taking the expert report of the doctors repudiated the claim of the complainant. There was no deficiency in service on the part of o.ps. and as such, o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant during the subsistence of the policy became ill and he consulted with the doctor and as per the advice of the doctor the complainant had some tests and on perusal of the test reports the doctor asked the complainant for admission in the hospital for his treatment and as per the advice of the doctor the complainant took admission in the hospital. In support of the said contention the complainant filed the photocopies of the bill and also the discharge certificate wherefrom it is evident that the complainant had to take admission on 3.3.15 and he was discharged on 4.3.15. It also appears from the materials on record that the complainant took admission in the hospital as per the advice of the doctor. The o.ps. claimed that the treatment provided to the complainant was an OPD treatment and there was no need of getting admission in the hospital. It appears from the documents filed by the complainant that the complainant had to take admission in the hospital as per the advice of the doctor and after getting discharge from the hospital he submitted the bill to o.ps. for reimbursement. The o.ps. though claimed that as per the terms and conditions of the policy the complainant was treated as OPD patient, but whenever the complainant was under the treatment of the doctor and as per the advice of the doctor he had to take admission in the hospital. Since the doctor realized that the proper treatment could be rendered to the patient by getting admission in the hospital, therefore the complainant was referred to take admission in the hospital for his treatment. On the basis of the said fact it appears that the complainant submitted the bill of Rs.20,543.30, but the same was repudiated by o.ps. by interpreting the treatment of the complainant that he ought to be treated as OPD patient. From the materials on record it appears that the complainant from time to time clarified all the queries made by TPA. In spite of such clarification of the points raised by TPA the claim of the complainant was repudiated which was done in a most illegal manner in order to avoid the payment to the complainant, such plea was taken by o.ps. Having regard to the said fact we hold that there was deficiency in service on the part of o.ps. and the complainant will be entitled to get the relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
that the CC No.496/2015 is allowed on contest with cost against the o.ps. The o.ps. are jointly and/or severally directed to pay the claim amount of Rs.20,543.30 (Rupees twenty thousand five hundred forty three and paise thirty) only to the complainant along with compensation of Rs.10,000/- (Rupees ten thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
