IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Wednesday the 18th day of November, 2009
Filed on 30.01.09
Present
- Sri. Jimmy Korah (President)
- Sri. K. Anirudhan (Member)
- Smt. Shajitha Beevi (Member)
in
C.C.No.20/09
between
Complainant:- Opposite Party:-
Sri.Anilkumar.P.T, The Branch Manager,
Thayil Nikarth, United India Insurance Co Ltd.,
Pattanakkad.P.O, Branch Office, N.S.S. Building
Cherthala-688531. Cherthala. (By Adv.C.Muraleedharan)
O R D E R
SRI.JIMMY KORAH (PRESIDENT)
The complainant case is as follows: - The complainant is a daily wage earner. He is the holder of the Individual Health Insurance Policy from the opposite party. Consequent to an ailment as to the complainant's spine, the complainant consulted the concerned doctor for treatment. The doctor prescribed medicines and MRI scan for the proper diagnosis of the complainant's ailment. Strictly in line with the doctor's instruction, the complainant on 1st January 2008 underwent MRI scan in 'Tidewear MRI Scan and Research Centre’. For the said purpose, the complainant had to pay an amount of Rs.4500/-(Rupees four thousand five hundred only). On the basis of the scan report, the doctor prescribed some medicines and advised rest to the complainant. Thereafter, on 22nd December 2008, the complainant lodged a claim for the treatment expenses of Rs.5165.67/-(Rupees five thousand one hundred sixty five and sixty seven paisa only) with the opposite party. The opposite party turned down the complainant's claim, vide letter dated, l2th January 2009 on flimsy ground. The opposite party inflicted untold mental agony to the complainant. Aggrieved on this, the complainant approached this Forum for compensation and relief.
1. On sending notice, the opposite party appeared and filed version. The contention of the opposite party is that the complainant did not undergo any treatment for any ailment. He made only check-ups through MRI Scan which is absolutely beyond the scope of the said policy, the opposite party forcefully argues. The complainant is entitled to hospitalization expenses for some disease. From the records, it is clear that the expenses claimed are for MRI scan, and not for treatment. Hence the opposite party is not liable. The said aspect has duly been informed to the opposite party vide registered letter. There is no deficiency on the part of the opposite party. The complaint is only to be dismissed with cost to the opposite party, the opposite party submits.
2. The evidence of the complainant consists of the testimony of the complainant as PWl and the documents Exbts Al to A6 were marked. On the side of the opposite party, the documents Exbts Bl and B2 were marked. No oral evidence adduced.
3. Bearing in mind the contentions of the parties, the questions come up for consideration are:-
(a) Whether the complainant underwent any treatment?
(b) .Whether the opposite party is liable to honor the claim of the complainant?
4. Admittedly, the complainant was the holder of the policy at the material point of time. Indisputably, the complainant was subjected to MRI scan. In this context, the immediate short question arises for consideration is whether the negation of complainant's claim by the opposite party is good enough. The complainant's claim was repudiated on the ground that the complainant did not undergo any treatment, but only subjected to check-up through MRI scan. The opposite party is liable to indemnify the expenses for treatment, not for check-ups, the opposite party fervently contends. The complainant case is that on having afflicted with an ailment as to his spine, he consulted a doctor. On his advice, he was subjected to MRI scan. Admittedly, the complainant underwent MRI scan to get the disease or the nature of the disease diagnosed. In this context, the contention of the opposite party sounds strange rather unnatural. For the treatment of a disease, detecting its nature is inevitable. Diagnosis is the pre-requisite of the treatment. In other words, diagnosis is inseparable from disease treatment. Diagnosis of the disease and the treatment of the same are intertwined and indivisible. To put it more clearly, we hold that the diagnosis is all the more one of the parts of the process of treatment. In view of this, the contention of the opposite party that the complainant is disentitled to the amount he spent for scanning does not merit acceptance. We have no hesitation to hold that the complainant underwent scanning as part of the treatment and the opposite party is liable to indemnify the same.
In view of the facts and circumstance of the instant case, the opposite party is directed to pay the complainant an amount of Rs.5165.67/-(Rupees five thousand one hundred sixty five and sixty seven paisa only) with interest @ 12% per annum from the date of the complaint lodging the claim with the opposite party. The opposite party is further directed to pay a compensation of Rs.1000/-(Rupees one thousand only) to the complainant. The opposite party shall copy with the order within 30 days of receipt of this order.
Complaint stands disposed accordingly. No order as to cost.
Pronounced in open Forum on this the 18th day of November, 2009.
Sd/-Sri. Jimmy Korah
Sd/-Sri. K. Anirudhan
Sd/-Smt.N.Shajitha Beevi
Appendix:-
Evidence of the complainant:-
PW1 - Anilkumar.P.T(Witness)
Ext. A1 - Individual Health Insurance Policy, No.101502/48/07/97/00001518
Ext.A2 - Receipt of the MRI Scan No.TW-MRI-HO-10722 dated, 01/12/2008
Ext.A3 - IP Bill from KVM Super Speciality Hospital dated, 01/12/2008 and claim form
Ext.A4 - Doctor’s certificate
Ext.A5 - Registered letter from United India Insurance Co. Ltd with A/D
Ext.A6 - Notice of the Insurance company
Evidence of the opposite party:-
Ext.B1 - Registered letter to Anilkumar
Ext.B2 - Mediclaim Insurance Policy claim form
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite Parties/S.F.
Typed by:- k.x/-
Compared by:-
