D.O.F:14/02/2019
D.O.O:10/01/2022
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.35/2019
Dated this, the 10th day of January 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
1. Vikram Ramachandra, aged 43 years
S/o K.P Ramachandra
M/s Vikram Electronic
Bustand cross road,
Kasaragod District – 671121
2. K.P Ramachandra, aged 76 years
M/s Vikram Electronic : Complainants
Bustand cross road,
Kasaragod District – 671121
And
The Branch Manager
National Insurance Company Ltd. : Opposite Party
Third Floor, High Lane Plaza,
M.G Road, Kasaragod -671121
(Adv: C. Damodaran)
ORDER
SRI.KRISHNAN.K :PRESIDENT
The case of complainant is that he obtained Medi claim insurance policy on 12/05/2002. Complainant suffered neck pain and numbness over his upper right hand. He was admitted KMC Manglore on 16/06/2018. Final bill of hospital was Rs. 24,334/-. He was under the treatment of Dr. Muralidhar Pai. He claimed cashless treatment covered under the insurance policy. But claim is repudiated for the reason that admission is for investigation and evaluation, complainant claims settlement of Rs. 24,334 and for compensation and cost of litigation.
2. The Opposite Party filed its written version denying liability to satisfy the claim. As per Opposite Party admission is on 16/06/2018. There was no active treatment and admission was only for investigation and evaluation for which admission is not medically necessary. Further 72 hours prior notice is necessary before admission and intimation is belated and remedy is against hospital and TPA has not recommended.
3. Both parties did not adduce any oral evidence. Complainant produced the insurance policy marked as Ext A1 and entire file marked as Ext X1. Opposite Party produced documents marked as Ext B1 to B4. Opposite Party filed argument notes also.
4.. The following points arise for consideration in the case, they are:-
a) Whether the repudiation of the claim by the Opposite Party is justifiable.
b) Whether there is any deficiency in service from Opposite Party? Whether complainant is entitled for compensation? If so for what reliefs?
5. The complainants case is that Opposite Party rejected the claim on the ground that complainants admission in the hospital not medically necessary. Facts remains that only doctor and not the insurance company can decide the line of the treatment given to patient. Complainant was suffering from neck pain with numbness of right upper hand and altered sensation. He was seen in OPD on 12/06/2018 and was on medication. Thereafter admitted for which he underwent treatment for three day at the hospital. Ext B2 discharge summary, it is shown that for treatment of patient was admitted and following drug administered. Medicine details are also given. Review is also advised. Ext B4 show that explanation for delay in sending pre – authorization within 24 hours.
During hospitalization, the doctor prescribed medicines. But the insurance company rejected the claim giving reason that no active treatment was given. Discharge report along with doctors certificate that mentioned health condition and the treatment offered to him. Opinion of doctors who treated patient is more truthful than the TPA’s options which based on examination of case papers. It is submitted that complainant was admitted in the hospital and under the treatment of Dr. Muralidhar Pai, the insured remind hospitalized from 10/06/2018 till 18/06/2018 and was under treatment for his ailment diagnosed by the treating doctor as neck pain and numbness of right upper head. A sum of Rs. 24, 334/- was paid on behalf of the complainant. It is claimed that exclusion clause 4,19, and 22 was not at all applicable in so for as after deficit and conclusive diagnosis, treatment for the ailment was done. It is true that several investigations were carried out, both such investigations were absolutely necessary for proper treatment with medication under the advice of the treating doctor. The repudiation on the part of the Opposite Party was arbitrary and thereby deficiency in service on their part is established.
6. Advocate for Opposite Party submitted there was no advice line of treatment in respect of the complainant during the period of hospitalization. Hospitalization for the purpose of some tests does not justify the claim of the complainant as excluded by the policy terms. Repudiation is this legally justified by Opposite Party.
During hospitalization the complainant was treated with medicine is evident from medical records. It is established during the hospitalization period the ailment was treated after the clinical tests for which the hospital claimed the bill. Merely because prior referral order from medical Board was not obtained, such bills cannot be rejected. Individuals claims covered by policies not to be rejected on technical grounds like slight delays in intimation. IRDA has advised insurance companies that contractual conditions should not prevent thus from considering genuine claims.
Hence complainant is entitled to receive insurance benefit of Rs. 24,334/- in the case and there is deficiency in service in Opposite Party in wrongly repudiating the genuine claim for which complainant is entitled for compensation and also the cost of litigation.
In the result complaint is allowed in part Opposite Party is directed to pay insure benefit of Rs. 24,334/- with interest at 6% from date of complaint till payment Rs. 5000/- (Rupees Five thousand only) for deficiency in service and Rs. 5000/- (Rupees Five thousand only) for cost of litigation with 30 days of receipt of the order.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Repudiation letter
B1- copy of the policy
B2- Discharge Summary
B3- MRI Scan Report
B4- Letter issued by KMC Hospital
X1- Claim file
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
