Complaint filed on: 07.02.2015
Complaint Disposed on:15.12.2016
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.
COMPLAINT NO.36/2015
DATED THIS THE 15th DAY OF DECEMBER 2016
:PRESENT:
HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT
HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER
HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER
COMPLAINANT:
Sri. C.S.Murthy Rao S/o Santhoji Rao,
A/a 58 years, Tailor, Lakshmeesha Nagara,
Raghavendra Nilaya, Chikmagalur City.
(By Sri/Smt. Hareesh Sangetagere, Advocate)
V/s
OPPONENT:
1. The Branch Manager,
LIC of India,Spencer Road,
Chikmagalur.
2. The Divisional Manager,
LIC of India, UDUPI.
(By Sri/Smt. D.K.Lakshmikanth, Advocate)
By Hon’ble President Sri. Ravishankar,
:O R D E R:
The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos. 1 & 2 alleging deficiency in service in not settling the medical claim to the tune of Rs.5,00,000/-. Hence, prays for direction against OP Nos. 1 & 2 to pay the medical claim along with compensation of Rs.2,00,000/- for deficiency in service.
2. The brief facts of the complaint is that:
The complainant had obtained medical policy of Insurance from OP No.1 under policy No.628207313 on 16/12/2013. The OP has issued a policy by covering medical treatment of the complainant. Such being the case, on 11/07/2014 the complainant fell down in the bathroom of his home and suffered injuries. Immediately he took treatment at M/s Ramaiah Institute of Neuro Science, Bangalore as on outpatient. In spite of best efforts made by Doctors, the back pain was not cured. Hence, the Doctors at M.S.Ramaiah Hospital were advised the complainant to hospitalize for the purpose of surgery. Accordingly, the complainant was admitted to the hospital on 28/07/2014 and took treatment as an inpatient and discharged on 06/08/2014. During the said hospitalization, the complainant underwent surgery and Nerve root decompressed and issued a discharge summary. The Doctors also issued a certificate with respect to the said treatment. The complainant had spent nearly Rs.5,00,000/- towards treatment during his hospitalization. After taking the treatment, the complainant claimed for reimbursement of the said medical expenses by furnishing original documents to OP/Company, but the Ops instead of settling the claim have rejected the claim without any valid reasons and they have rejected the claim for the reason that the complainant had taken a treatment for Degenerative problem. But the complainant had not taken any treatment for the said alleged Degenerative problem. The complainant suffered nerve problems (Nerve Compressed) to his back and same has been treated by the Doctors at M.S.Ramaiah Hospital and the same is released by decompressing. Hence, the complainant had not taken any treatment for Degenerative problem.
The OP/Company had repudiated the claim with an intention to avoid settlement of the claim. Hence, the OP rendered a deficiency in service in not settling the claim. Hence, prays for settlement of the claim along with payment of compensation of Rs.2,00,000/- for deficiency in service as prayed above.
3. After service of notice the OP Nos. 1 & 2 appeared through their counsel and filed the version and contended that the complainant had not revealed the actual facts which are as follows:
The complainant had taken Jeevan Aroghya Policy Plan No.903 which is nothing but a medi claim type policy commencing from 16.12.2013 with installment of Rs.7,115/- with conditions detailed in the booklet given. The hospital cash benefit was Rs.2,000/- and surgical benefit was Rs.2,00,000/-. But here as per the terms and conditions two types of payments are made. Hospital cash benefit (HCB) and Surgical benefit for the premium paid by the insured payments are made in the following order. HCB is maximum amount payable in respect of hospital admission as opted by the insured. Again in Surgical benefit there are two types one is Major surgical benefit (MSB) and the other is minor surgeries or investigation procedures wherein for minor ailments Day care procedure benefit up-to five times the HCB is paid. There is a schedule of ailments which is part and parcel of the policy wherein every ailment is categorized and reveals for which ailment or surgeries whether HCB or MSB or Day care benefit is applicable and also for what ailments the claim is not payable if the treatment is taken within a specific period from the date of commencement of the policy.
The Ops further contended that as per the discharge summary issued by M.S.Ramaiah Hospital, the insured was in the hospital from 28/07/2014 to 06/08/2014. The illness being due to the history of fall before 15 days which resulted in low back pain, insidious in onset increased on movement decreased on taking rest and anelgesics. The complainant underwent L5 S1 MISS TILF on 01. 08. 2014 and under ETGA the patient in prone position on bolsters 15s1 disk space identified under ‘c’ arm guidance right vertical paramedical skin incision marked and screws placed and ultimately he had taken treatment for degenerative joint conditions of the spine at L5 S1. Further, as per the hospital records, they diagnosed SPONDYLOLISTHESIS OF L5 OVER S1 WITH BILATERAL L5 SPONDYLOLYSIS AND DEGENERATIVE CHANGES AT L5 S1 PLATES.
The Ops further contended that the policy issued by these Ops i.e. Jeevan Aroghya Plan is a fixed plan and as per the conditions of the policy there is a waiting period for policy to claim the benefits and it is clearly mentioned in Clause-6(xii) of the policy
1) General waiting period
2) Specific waiting period
Under specific waiting period, no benefits are payable for any claim if occurred within two years for the ailments they have taken treatment which are listed in the booklet. In this case, the policy commences from 13.12.2013 and operation was done on 01.08.2014 for degenerative problem of spine LS 51 which comes under specific waiting period and basing on the said exclusion clause they have repudiated the claim of the complainant. Hence, there is no deficiency in service on the part of these Ops in repudiating the claim and they are not liable to pay any claim made in the complaint and prays for dismissal of the complaint.
4. The complainant filed affidavit and marked the documents as Ex.P1 to P10. The Ops have also filed affidavit and marked the documents as Ex.R1 to R8.
5. Heard the arguments:
6. In the proceedings, the following points do arise for our consideration and decision:
- Whether there is deficiency in service on the part of OPs.
2. Whether complainant entitled for any relief & what Order?
7. Our findings on the above points are as follows:-
- Point No.1: Affirmative.
- Point No.2: As per Order below.
: R E A S O N S :
POINT NOs. 1 & 2:
8. There is no dispute that the OP Nos. 1 & 2 have issued medical claim policy called Jeevan Arogya by collecting a premium of Rs.7,115/- from complainant which commences from 16.11.2013. After obtaining the policy the complainant on 11.07.2014 due to fall in the bathroom, had taken a treatment for injuries suffered in the accidental fall. He took treatment at M.S.Ramaiah Hospital from 28.07.2014 to 06.08.2014, where the Doctors at M.S.Ramaiah Hospital have treated the complainant for low back pain and surgery was done for the nerve compressed at his back by doing decompressing the nerve root and discharged on 06/08/2014.
9. The complainant has sworn that he has spent Rs.5,00,000/- during hospitalization towards medical expenses and claimed for reimbursement of the said amount by furnishing required documents to OP/Company as per the policy terms and conditions. But OP Nos. 1 & 2 have repudiated the claim for the reason that the complainant had taken a treatment for degenerative problem of L5 S1 and the said disease is not covered for the particular period and the said treatment is comes under the exclusion clause of 6(xii) of policy terms and conditions and further contended that as per specific waiting period, it occurred within two years. Hence, they are not able to settle the claim and repudiated the claim for the said reason and submits no deficiency in service.
10. On going through the policy issued by OP there is no dispute that there is an exclusion clause for particularly treatment for degenerative joint conditions as per Ex.P1 and further the complainant has produced repudiation letter, marked as Ex.P2, which indicates that the complainant had claimed for Rs.41,347/- which was repudiated for the reason that the complainant had taken a treatment for degenerative problem of spine at L5 S1. The complainant and Ops also produced the discharge summary along with a report issued by the Department of Radiology which shows that the said Department has given an impression with respect to the treatment given to the patient it reads as follows:-
“SPONDYLOLISTHESIS OF L5 OVER S1 WITH BILATERAL L5 SPONDYLOLYSIS AND DEGENERATIVE CHANGES AT THE L5-S1 END PLATES”
Whereas as per Ex.P5 i.e. discharge summary given by M.S.Ramaiah Institute of Neurosciences, we noticed that they have finally diagnosed L5-S1 Grade I Listhesis and they have noticed the complainant’s history of present illness as follows:-
H/o fall days back at his house, after which he had severe low back pain, insidious in onset, increased on movement, decreased on taking rest and analosics. Pain radiates to both lower limbs since 15 days. Lt > Rt insidious in onset. Pain increases on coughing, sneezing and straining.
H/o neurogenic claudication (+)
No h/o difficulty in gripping footwear/lifting the foot above ground
K/c/o DM, HTn on regular treatment.
11. Hence, it is clear that the complainant had taken a treatment towards the accidental fall at his home which resulted in treatment towards decompression of nerve root and we also noticed that the said Doctors at M.S.Ramaiah Hospital have done L5 S1 facetectomy by doing nerve root decompression. Further, they have noticed disc space was narrow. Hence, pedicle screw placed at L5 and S1 after filling with bone cement, right retractor paramedian incision marked and we also noticed that nowhere in the discharge summary the Doctors have opined that the complainant was suffered from degenerative problem of L5 S1 end plates. The opinion given by Radiology Department is only an impression after the treatment. Hence, we consider the treatment taken by the complainant is well within the coverage as per the policy terms and conditions. The OP/Company without noticing the discharge summary have repudiated the claim by quoting exclusion clause which amounts to a deficiency in service.
12. The claim made by the complainant is a genuine claim as per the terms and conditions of the policy. He made a claim towards insurance issued to accidental fall at his home. It is also noticed that the Ops have not produced any further materials to show that the complainant had pre history of degenerative problem at the time of taking policy and also not produced any materials to show that earlier to this treatment the complainant had taken any treatment towards degenerative problems. In the absence of said materials, we cannot come to the conclusion that the complainant had taken a treatment for degenerative problem. As such the complainant is entitled to get eligible medical expenses towards the treatment taken at M.S.Ramaiah Hospital. The OP Nos. 1 & 2 are also liable to pay a compensation of Rs.5,000/- to the complainant for deficiency in service along with litigation expenses of Rs.1,000/-. As such for the above said reasons, we answer above points accordingly and proceed to pass the following:-
: O R D E R :
- The complaint filed by the complainant is allowed in part.
- The OP Nos. 1&2 are directed to pay eligible claim to the complainant under the policy.
- The OP Nos. 1&2 are further directed to pay Rs.5,000/- towards compensation and Rs.1,000/- towards litigation cost to the complainant.
- The OP Nos. 1&2 are further directed to comply the above order within 30 days from the date of receipt/knowledge of the order, failing which the payable amount shall carry interest @ 9% P.A. from the date of complaint to till realization.
- Send free copies of this order to both the parties.
(Dictated to the Stenographer transcribed typed by him, transcript corrected by me and then pronounced in Open Court on this the 15th day of December 2016).
(RAVISHANKAR)
President
(B.U.GEETHA) (H. MANJULA)
Member Member
ANNEXURES
Documents produced on behalf of the complainant:
Ex. P1 - Jeevan Arogya Policy issued by OP
Ex.P2 - Letter dated:23.12.2014 issued by Nodal Officer
Ex.P3 - Copy of the discharge summary
Ex.P4 - Lab report issued by Dept. Nueurosurgery, M.S.Ramaiah
Hospital, Bangalore-4.
Ex.P5 - Medical certificate dated:09.12.2014.
Ex.P6 - Letter dated:17.10.14 issued by complainant to OP
Ex.P7 - Requisition for claim form Dt:29.09.14
Ex.P8 - Requisition for claim of the medical expenses by complainant
Dated:18.08.2014
Ex.P9 - Copy of the medical bills
Ex.P10 - Repudiation letter dated:29.12.2014
Documents produced on behalf of the OPs:
Ex. R1 - Authorization letter
Ex. R2 - Copy of the proposal by complainant
Ex. R3 - Condition and privileges of LIC’s Jeevan Arogya
Ex. R4 - Hospital treatment form
Ex. R5 - Discharge summary issued by M.S.Ramaiah Institute
Of Neurosciences.
Ex. R6 - Report given by Radiology Department, M.S.Ramaiah Hospital,
Bangalore
Ex. R7 - Repudiation letter issued by OP
Ex. R8 - Another repudiation letter dated:23.12.2014
Dated:15.12.2016 President
District Consumer Forum,
Chikmagalur.
Tss
