By Smt. Beena. M, Member:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
2. The complainant’s case in brief is as follows:- The case of the Complainant is that the 1st Opposite Party is engaged in the service of Medical Insurance, 2nd Opposite Party is the third party Administrator to the National Insurance Co. Ltd. The Complainant has joined in the Senior Citizen Mediclaim Insurance Policy (Hospitalization Benefit Policy) and the period of coverage was from 01-07-2018 to 30-06-2019.
3. During the validity of Insurance Policy the Complainant consulted Dr. Aneesh Kumar at MIMS Hospital Calicut on 18/06/2019 whereby he was suffering from constipation and severe pain in the stomach, and was advised to take medicines for one week. However, since the pain did not subside, the Complainant again consulted Dr. Aneesh Kumar on 21/06/2019 and was admitted in the Malabar institute of Medical Science Hospital at Calicut and he was discharged on 23-06-2019 after spending more than Rs. 20,250/-. Thereafter the Complainant informed the Opposite Party regarding the admission and treatment. Subsequently, the Complainant has approached the Opposite party and applied for reimbursement with medical bills on 24/06/2019, but the claim of the Complainant was rejected on the ground that the expense incurred at hospital or nursing home primarily for evaluation/diagnostic purpose which is not followed by active treatment for ailment during hospitalization period. The Complainant alleged that the act of the Opposite Parties in not settling the claim of the Complainant would amount to deficiency in service and unfair trade practice. Due to the deficiency in service/ unfair trade practice on the part of the Opposite Parties the Complainant has suffered loss, hardship, agony, and damage. The Opposite Parties are legally liable to reimburse the hospital expense to the Complainant and also for compensation and cost.
4. The Opposite Party No.1 entered appearance, filed version and contested the case. The Opposite Party No.2 called absent, and set ex parte on 21/01/2020. The first Opposite Party admitted the policy, hospitalization and challenged the maintainability of the complaint. The reason for rejection of the claim of the Complainant is that it does not fall within the purview of policy terms and conditions. The expenses incurred at Hospital or Nursing home primarily for evaluation/diagnostic purpose which is not followed by active treatment for the ailment during the hospitalized period is not payable. The Opposite Parties denied the allegation of deficiency in service /unfair practice on their part and any type of negligent attitude from the side of the Opposite Parties as such the Complainant is not entitled for any of the reliefs as prayed in the complaint. Hence the first Opposite Party praying dismissal of the complaint.
5. On perusal of complaint, version, and documents and oral evidence adduced, the Commission raised the following points for consideration:-
Whether there has been deficiency in service/ unfair trade practice from the part of the Opposite Parties?
- Whether the Complainant is entitled to get reimbursement of medical claim form the Opposite Parties?
- Whether the Complainant is entitled to get any relieves as prayed for?
6. Point No. 1 to 3 :- For the sake of convenience and brevity all points are considered together.
The Complainant was examined as PW1 and the documents produced were marked as Ext.A1 to A5. M. K. Somanathan Nair, the Divisional Manager was examined as OPW1 from the side of the Opposite Parties and the documents produced by the Opposite Party were marked as Ext. B1 to B6.
7. According to the Complainant, as per the insurance policy incepted by him through the first Opposite Party, he is entitled to get all the treatment expenses and he has undergone treatment as inpatient for 3 days and the claim submitted by him with all treatment records was rejected by the first Opposite Party insurance company without genuine reason. Whereas the First Opposite Party contended that as per the terms and conditions of the policy, the Complainant is not entitled to get any amount towards the claim submitted by him, since he was admitted in the hospital only for evaluation purpose, which is excluded as per policy terms and conditions. The first Opposite Party has no case that the Complainant was not admitted in the hospital and treated there. By looking in the discharge summary, Ext. A5 shows the reason for admission, what procedure was done, and what examination, diagnosis, and treatment were done during the admission period. We found that the Complainant underwent active treatment there. This requires hospitalization and institutional care which is active treatment. No documents produced from the side of the Opposite Party to show that the treated doctor admitted the patient unnecessarily for 3 days in the hospital only for the purpose of diagnosis the disease and advised to take medicines unnecessarily without any real cause and need. So, the insurance company could not simply wash their hands from their responsibility. The Opposite Parties are liable to reimburse the admissible amount claimed to the Complainant. The object of seeking a mediclaim policy is to seek indemnification in respect of a sudden illness or sickness, which is not expected or imminent. If the insured suffers a sudden sickness or aliment, which is not expressly excluded under the policy, a duty is cast upon the insurer to indemnify the Complainant for the expenses incurred there under.
8. Hence in the instant case, the repudiation of the policy by the Opposite Party insurance company was illegal and not in accordance with law. Consequently the Complainant is entitled to be indemnified under the policy. In the view of the aforesaid discussion, we hold that the petitioner is entitled to get reimbursement of claim amount and compensation.
In the result, the complaint is partly allowed as follows.
- The Opposite Parties are directed to indemnify the Complainant for the expenses incurred by him towards his medical treatment i.e. Rs. 20,250/-(Rupees Twenty Thousand Two Hundred and Fifty only) within a period of one month from the date of receipt of the copy of the order with interest at the rate of 6% per annum from the date of filing the petition till realization.
- The Complainant is also entitled to Rs 7,000/- (Rupees Seven Thousand
only) towards compensation.
© The Complainant is also entitled to Rs. 4,000/- (Rupees Four Thousand
only) towards the cost of litigation.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 28th day of June 2022.
Date of filing:06.11.2019.
PRESIDENT: Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the complainant:
PW1. Soopy Complainant.
Witness for the Opposite Party:
OPW1. K. Somanathan. Divisional Manager, New India Assurance
Co. Ltd.,
Exhibits for the complainant:
A1. Policy Schedule.
A2. Copy of Letter. dt:22.07.2019.
A3. Letter. dt:30.08.2019.
A4. Copy of Claim form for Health Insurance Policies of the New India
Assurance Co. Ltd- Part A.
A5. Copy of Discharge Summary.
Exhibits for the Opposite Party:
B1. Policy Schedule.
B2. Claim form for Health Insurance Policies of the New India
Assurance Co. Ltd- Part A.
B3(a) Lab Report dt:18.06.2019.
B3(b) Lab Report. dt:18.06.2019.
B4. Colonoscopy Report. dt:22.06.2019.
B5. Discharge Summary.
B6(a) Bill. dt:18.06.2019.
B6(b) Bill. dt:18.06.2019.
B6© Bill. dt:18.06.2019.
B6(d). Outpatient Bill dt:18.06.2019.
B6(e) Bill. dt:21.06.2019.
B6(f) Pharmacy Bill. dt:22.06.2019.
B6(g) Pharmacy Bill. dt:22.06.2019.
B6(h) Advance Receipt. dt:21.06.2019.
B6(i) Bill Payment details. dt:23.06.2019.
B6(j) Discharge Bill. dt:23.06.2019.
