BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
VAZHUTHACAUD, THIRUVANANTHAPURAM.
PRESENT
SRI. G. SIVAPRASAD : PRESIDENT
SMT. BEENAKUMARI. A : MEMBER
SMT. S.K.SREELA : MEMBER
C.C. No. 397/2010 Filed on 14.12.2010
Dated : 31.01.2012
Complainant :
Sunitha Krishnadas, Aardra, PNRA – F10A, Perur Nagar, Ambalamukku, Thiruvananthapuram.
(By adv. N.R. Ravikrishnan)
Opposite party :
The Branch Manager, Star Health & Allied Insurance Company Ltd., Zonal Office, S.S. Kovil Road, Thampanoor, Thiruvananthapuram.
(By adv. K.S. Radhika Devi)
This O.P having been heard on 23.01.2012, the Forum on 31.01.2012 delivered the following:
ORDER
SRI. G. SIVAPRASAD: PRESIDENT
The facts leading to the filing of the complaint are that complainant availed a medi-claim policy from the opposite party Star Health & Allied Insurance Company vide policy No. P/181100/01/2010/007198 for a sum of Rs. 1,00,000/-, that as per the terms of the policy the opposite party undertook to pay the insured all amounts incurred by her for treatment in case she is admitted in the hospital within the amount covered by the policy, that complainant was hospitalized as inpatient from 16.09.2010 to 18.09.2010 in connection with a surgery to remove a nasal blockage in the Uthradam Thirunal Hospital, Thiruvananthapuram and incurred an expense about Rs. 16,454/-, that the complainant underwent Nasal Endoscopy, SMD, Nasal Polyptectomy and AWO, that after the treatment complainant put forward claim with opposite party vide claim No. 0047219, that opposite party rejected the claim vide letter dated 18.09.2010 stating that petitioner was treated for sinusitis and the same is beyond the coverage of the policy, that the doctor who treated the petitioner had issued a certificate narrating the nature of the surgery which was done by him wherein the name of the operation was clearly stated. Opposite party has arbitrarily reached into false conclusions without any basis and the tactics adopted by the opposite party is only for escaping from their liability of payment as per the terms of the contract. The act of the opposite party amounts to deficiency in service and unfair trade practice. Hence this complaint to recover an amount of Rs. 16,500/- towards treatment expenses incurred by the insured with interest from the opposite party along with compensation and costs.
Opposite party filed version contending interalia that complaint is not maintainable either in law or on facts, that opposite party admitted that they had issued the aforesaid policy to the complainant, that the policy was issued strictly according to the terms, conditions and exclusions set in the policy, that opposite party received a pre-authorization request on 16.09.2010 prepared and signed by Dr. H.O. Paulose, Consultant ENT Surgeon, SUT, Pattom for extending the cashless facility to the client for his admission at SUT, that on verifying the pre-authorization request it was found that complainant was suffering from nasal obstruction + Headache & Allergic Rhinitis + Sinusitis. Since the admission was for sinusitis and related disorders, cashless facility was denied as the illness falls under first year exclusion clause of the policy, that on 30.09.2010 opposite party received the completed claim form, medical certificate, discharge summary, lab reports and bills for the treatment, that on verifying the said discharge summary it was found that complainant had undergone the diagnosis of Allergic Rhinitis & Sinusitis and had undergone Nasal Endoscopy, SMD, Nasal Polyptectomy and AWO, that thereafter opposite party obtained a subject expert opinion from Dr. R. Rajesh, ENT Surgeon, Medical College, Thiruvananthapuram, that the doctor in his opinion clearly stated that Nasal endoscopy submucous diathermy, nasal polypectomy and antral wash out are treatment options for sinusitis and its related condition. The policy was repudiated on the ground of exclusion clause of the aforesaid policy, that the claim was repudiated and claim repudiation letter dated 07.12.2010 was sent to the complainant by post. In the light of the said exclusion clause 4 opposite party is not liable for payment of treatment expenses. Hence opposite party prayed for dismissal of the complaint.
The points that arise for consideration are:-
Whether the claim repudiated is justifiable?
Whether there is deficiency in service on the part of the opposite party?
Whether the complainant is entitled to compensation and costs?
In support of the complaint complainant has filed proof affidavit as PW1 and has marked Ext. P1 to P3. In rebuttal opposite party has filed proof affidavit and has marked Exts. D1 to D8.
Points (i) to (iii):- There is no dispute on the point that complainant availed a medi-claim policy from the opposite party for a sum of Rs. 1,00,000/-. There is no point in dispute that complainant had incurred an expense of Rs. 16,454/- in connection with a surgery to remove a nasal blockage in SUT Hospital. Further there is no point in dispute that complainant underwent Nasal Endoscopy, SMD, Nasal Polyptectomy and AWO. The issue herein is whether the complainant was treated for sinusitis, it was on that ground opposite party repudiated the claim. According to opposite party, sinusitis is beyond the coverage of the policy. Complainant's evidence consisted of the oral testimony of PW1 and Exts. P1 to P3. Ext. P1 is the copy of the policy issued by opposite party. Ext. P2 is the copy of the rejection letter issued by the opposite party. It is stated in Ext. P2 that as per the submitted documents the claim falls under first year exclusion clause of the given medi-claim policy. Ext. P3 is the copy of the discharge summary. On perusal of Ext. P3 it is seen that complainant was admitted on 16.09.2010 and discharged on 18.09.2010. In the operation column it is stated as Nasal Endoscopy, SMD, Nasal Polyptectomy and AWO under G.A. Complainant has been cross examined by the opposite party. In her cross examination PW1 has deposed that the symptoms for the disease stated in the discharge summary started 3 months before the date of surgery. Further PW1 has deposed that the claim was repudiated by the opposite party on the ground that complainant had suffered from sinusitis and sinusitis and associated symptoms falls under the exclusion clause of the policy. Complainant has deposed further that though opposite party repudiated the claim on the ground of sinusitis, she had never undergone for sinusitis surgery. According to complainant nasal Polyptectomy is related to growth in the nose and nasal polyptectomy is not related to sinusitis. To substantiate that aspect complainant has furnished two copies of advertisement related to Nasal polyptectomy and Submucous diathermy. The very stand of the complainant is that Nasal polyptectomy is having no link with sinusitis. It is revealed by the documents furnished by the complainant that the polyps can block odours from reaching the part of the nose which responds to scent resulting in some loss of sense of smell. It is further stated therein that a polyp is a growth. They are usually benign, meaning not harmful. Polyps appear as soft swellings which hang down like small grapes. Polyps come in many shapes and sizes. The aim of a nasal polypectomy operation is to remove the polyps from the inside of patient's norms. Removing the polyps will relieve patient's blocked nose. It is further stated in the furnished document that the cause of polyp is unknown. The very stand of the opposite party is that the patient was suffering from sinusitis and related disorders. Opposite party's evidence consisted of oral testimony of the legal officer of the opposite party and Ext. D1 to D8. Ext. D1 is the Family Health Optima Insurance Plan. On perusal of Ext. D1 exclusion clause 4 it is seen that company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by any insured person in connection with expenses on treatment of diseases such as Benign Prostate Hypertrophy, Hernia, Hydrocele, Congenital Internal disease/defect, Fistula in anus, Piles, sinusitis and related disorders, gallstones and renal stone removal are not payable. Ext. D2 is the copy of the discharge detailed bill for Rs. 16,453.33 issued by SUT Hospital. Ext. D3 is the copy of the discharge summary issued by SUT Hospital. Ext. D4 is the copy of the outpatient treatment card issued by SUT Hospital. Ext. D5 is the copy of the policy schedule issued in the name of Krishna Das, Sunitha and Aardra Krishna. Ext. D6 is the copy of the Lab Test Report. Ext. D7 is the expert opinion given by Dr. R. Rajesh stating that Nasal endoscopy, submucous diathermy, nasal polypectomy and antral wash out are treatment options for sinusitis and its related conditions. It is to be noted that Ext. D7 expert opinion was marked subject to objection. Complainant challenged the said document stating that polypectomy is not related to sinusitis. Ext. D8 is the copy of the clinical notes issued by SUT. DW1 is the legal officer of the opposite party who is incompetent to give the medical aspect of the said treatment. The very stand of the opposite party is that complainant was suffering from sinusitis and surgery was done for sinusitis and claim was repudiated on the ground that complainant had undergone operation for sinusitis. Ext. D7 expert opinion remains challenged by the complainant as such it is the duty of the opposite party to establish that the treatment undergone by the complainant was for sinusitis. Opposite party never attempted to examine the expert who had issued Ext. D7. As Ext. D7 remains challenged and the doctor who had issued Ext. D7 has not been examined by the opposite party, opposite party failed to establish the fact that complainant had undergone treatment for sinusitis and related disorders. There is nothing on record to show that complainant underwent operation for sinusitis. As such the act of the opposite party in repudiating the claim of the complainant on the ground of sinusitis is not justifiable. In view of the above, we deem that complainant had undergone operation for nasal polypectomy which is not related to sinusitis. As such we find by repudiating the claim, opposite party has committed deficiency in service. There is no ground to deny the cashless facility to the complainant for her admission at SUT Hospital. In view of the above discussions and evidence available on record we are of the opinion that complainant is entitled to get the claim amount of Rs. 16,454/- from the date of the complaint (14.12.2010) with 9% interest.
In the result, the complaint is allowed. Opposite party shall pay the complainant Rs. 16,454/- with 9% interest from 14.12.2010 along with Rs. 3,000/- towards compensation and Rs. 1,000/- towards costs within two months from the date of receipt of this order, failing which, Rs. 16,454/- will carry interest at the rate of 12%.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 31st day of January 2012.
Sd/-
G. SIVAPRASAD : PRESIDENT
Sd/-
BEENAKUMARI. A : MEMBER
Sd/-
S.K. SREELA : MEMBER
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C.C. No. 397/2010
APPENDIX
I COMPLAINANT'S WITNESS :
PW1 - Sunitha Krishnadas
II COMPLAINANT'S DOCUMENTS :
P1 - Copy of policy No. P/181100/01/2010/007198.
P2 - Rejection letter dated 18.09.2010
P3 - Discharge summary
III OPPOSITE PARTY'S WITNESS :
DW1 - Padma Prabha . P
IV OPPOSITE PARTY'S DOCUMENTS :
D1 - Family health optima insurance plan
D2 - Copy of discharge detailed bill for Rs. 16,453.33
D3 - Copy of discharge summary issued by SUT Hospital.
D4 - Copy of outpatient treatment card issued by SUT Hospital.
D5 - Copy of policy schedule
D6 - Copy of Lab Test Report.
D7 - Expert opinion given by Dr. R. Rajesh
D8 - Copy of clinical notes issued by SUT.
Sd/-
PRESIDENT
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