Date of filing : 29-12-2010
Date of order : 24 -08-2011
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC. 272/2010
Dated this, the 24th day of August 2011
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT. K.G.BEENA : MEMBER
Chacko.V.J, } Complainant
Vadakkemuriyil House,
Punjakkara, Rajapuram.Po,
Kasaragod District. 671 532.
(Adv.M.Narayanan, Hosdurg)
1. The Branch Manager, L.I.C. of India, } Opposite parties
Kanhangad Branch, Nithyananda Building,
Kanhangad.Po. Kasaragod.Dist.
2. The Divisional Manager (Health Insurance),
Divisional Office, P).B.No.177,
Jeevan Prakash, Huzur Road, Kozhikode. 673001.
(Adv. A.B. Nair, Kasaragod.)
O R D E R
SRI.K.T.SIDHIQ, PRESIDENT
Case of the complainant in brief is as follows:
Complainant is the holder of Health Plus Plan Policy of LIC. Wife of the complainant is also a beneficiary of the said policy. As per the terms of the policy if the insured or his wife is admitted in any hospital for more than 48 hours then the insured will get Health Claim Benefits. As per the policy the complainant is entitled for `2500/- per day and his wife is entitled for `1500/- per day. Complainant’s wife Mariyam admitted at Father Mullers Hospital, Mangalore for radiation therapy in connection with her cancer treatment from 28-12-2009 to 1-1-2010 and from 24-02-2010 to 7-4-2010 i.e. 47 days. But when the claim is preferred it was rejected. As per the terms and condition of policy the complainant’s wife is entitled for `67,500/- (47 x 1500) as Hospital Claim Benefits. Hence the complaint alleging deficiency in service against opposite parties.
2. According to opposite parties the claim is rejected relying on policy condition 6(1) XVI. As per this policy condition for the sole purpose of physiotherapy or any ailment for which hospitalization is not warranted due to advancement of Medical Technology is excluded. The complainant’s wife was hospitalized only to avoid journey from Kanhangad to Mangalore as Chemotherapy and radiotherapy could have been taken day to day basis without hospitalization.
3. Complainant filed proof affidavit. Exts A1 to A9 marked through PW1. For opposite party Sri. Shivananda Moily, the Manager Health Insurance, LIC of India, Divisional Office, Kozhikode filed affidavit and Exts B1 to B4 marked through him. Counsels of both parties heard and documents perused.
4 The points to be settled in this case are:
1. Whether the rejection of the claim of the complainant amounts to deficiency in
service?
2. If so, what order as to relief & costs?
5. Points Nos 1 & 2: According to opposite parties the exclusion of the benefits are detailed in clause 6 of the policy clause 6(1) (XVI) reads as under.
“Hospitalization for the sole purpose of physiotherapy or any ailment for which hospitalization is not warranted due to advancement in medical technology”.
The said clause nowhere says that radiation therapy and chemotherapy is excluded. Further it is the doctor who decides whether the patient needs hospitalized treatment or not. PW1 in cross-examination by the learned counsel for opposite parties Sri. Balakrishnan Nair has deposed that he know that radiation and chemotherapy requires only one day’s treatment. But he added that the doctor advised for admission in the hospital since the health condition of the patient was weak and the patient was admitted more than 26 days for radiotherapy since her health condition was not good for every days radiation.
6. This version of PW1 is corroborated by Ext.A8 certificate issued by Dr. Hasib.A.G. of Father Mullers Oncology Centre. In Ext.A8 the doctor certified that Mariyam is admitted in their hospital from 24-02-2010 to 07-04-2010 with complaints of weakness and also for radiation as she has to travel from Kanhangad to Mangalore daily.
7. The opposite party has no case that the weakness or general weakness is not an ailment warranting hospitalization. Further it is a fact that nobody would like to stay in hospitals unless the situation warrants. Here the general weakness coupled with doctors advice compelled the wife of the complainant to stay in the hospital.
8. At this juncture it is important to mention that the terms used in clause 6 (1) (XVI) is in most ambiguous and it did not convey the true intention. We feel that it is introduced solely for the purpose of misinterpretation for the purpose of repudiation or rejection of a claim according to the whims and fancies of the opposite party. The term “The advancement in medical technologies” does not lead to any conclusive inference. The treatment facilities and equipments available may vary from hospital to hospital. Therefore particular disease which requires hospitalization in one hospital may not be necessary in another hospital. It cannot be presumed that each and every hospital in the country are equipped with all the modern infrastructure facilities. Therefore this clause is extremely ambiguous. We are fully aware that the FORA constituted under the Consumer Protection Act is not vested with the power to re write the terms of a contract however ambiguous it is. But the principle to be followed is that whenever the terms of a contract are ambiguous then it shall be interpreted in favour of the consumer. Therefore we do so.
In the result, complaint is allowed and opposite parties are directed to honour the claim of the complainant. Opposite parties are directed to pay expenses @ `1,500/- per day for 47 days which amounts to `67,500/- with a cost of `3000/-. Time for compliance is limited to 30 days from the date of receipt of copy of order. Failing which opposite parties shall further liable to pay interest @ 9% for `67,500/- from today till payment.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exts.
A1. Photocopy of policy
A2.Preliminary discharge note of Mariyam
A3.Peliminary discharge note of Mariyam
A4. 12-4-2010 photocopy of letter sent by Mareyam A/s March Chako to OP No.1.
A5. 13-7-2010 photocopy of letter sent by Chacko V.J. to OP No.2.
A6. 22-11-2010 photocopy of letter sent by Chacko V.J to OP NO.2.
A7.7-4-2010 Discharge Summary of Mariyam
A8. 23-09-2010 Photocopy of Certificate issued by Father Muller Charitable Institution,
Mangalore.
A9. Photocopy of repudiation letter
B1. 28-9-2010 Photocopy of letter sent by Chacko.V.J to Senior Divisional Manager,
LIC of India, Kozhikode.
B2. 23-09-2010 Photocopy of certificate issued by Father Muller Hospital
B3. Copy of LIC’s Health Plus conditions and privileges referred to in the policy document
B4. 14-9-2010 copy of repudiation letter.
PW1. Chacko
DW1. Shivananda Moily
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Pj/ Forwarded by Order
SENIOR SUPERINTENDENT
