BEFORE THE DISTRICT CONSUMER FORUM : MEDAK AT SANGAREDDY

PRESENT: Sri Patil Vithal Rao, B.Sc., LL.B.,President

              Sri G.Sreenivas Rao, M.Sc., B.Ed.,LL.B.,PGADR (NALSAR),Member

Friday, the 08^th day of March, 2013

CC. No. 14 of 2012

Between:                 

1.           Human Rights & Consumer Protection Cell – BMRWS (Regd.,)

BHEL MIG 982, Hyderabad – 502 032, Andhra Pradesh, India.

Rep. by:-

Thakur Rajkumar Singh S/o Shri. T. Deen Dayal Singh

General Secretary & Authorised Representative of complainant – 2.

Aged about : 40 years, Occ: Right Activist, R/o BHEL MIG 982,

Serilingampally, Hyderabad – 502 032, A.P.

2.           T. Mahipal Reddy S/o T. Gopal Reddy,

Aged about 34 years, Occ: Business,

R/o BHEL MIG 1065, Serilingampally, Hyderabad – 502 032, A.P.

           …. Complainants

And

1.   The Branch Manager,

United India Insurance Company Limited

D.No. 12-2, 1^st Floor, Main Road,

Patancheru – 502 319, Medak District, A.P.

2.   Raksha TPA Private Limited,

H.No. 6-3-662/B/A, Flat No. 4,

Suvrna House, Sangeet Nagar,

Somajiguda, Hyderabad, A.P.                                    … Opposite parties

                This case came up for final hearing before us on 26.02.2013 in the presence of Thakur Rajkumar Singh, authorized by the complainant and       Sri K. Prabhakar Reddy, Advocate for opposite parties, on perusing the record and having stood over for consideration till this day, this forum delivered the following:

O R D E R

(Per se G. Sreenivas Rao, Member)

                          This complaint is filed U/s 12 of Consumer Protection Act, 1986 to direct the opposite party No. 1 to pay a medi claim bill of Rs. 35,671/- to the complainant No. 2 and also direct the opposite parties to pay an amount of Rs. 59,329/- towards compensation, mental agony, negligence and deficiency in service together with Rs. 5,000/- for the costs.

Brief facts of the case:

                   The averments to the complaint are that the complainant No. 2 (Rep. by complainant No. 1) is a policy holder of opposite party No. 1 company with the policy period from 29.08.2010 to 28.08.2011 for a sum assured Rs. 1,25,000/-. The complainant No. 2 was admitted in Yashoda Hospital, Somajiguda, Hyderabad for recurrent chest pain and pain in the right upper limb and on the advise of the doctor he stayed in the hospital from 16.08.2011 to 18.08.2011 with I.P. No. 144730. During this period the complainant No. 2 under went number of medical tests and was examined in the hospital. The Yashoda Hospital charged an amount of Rs. 35,671/- which includes the room rent, laboratory test & doctor fees etc. Subsequently, he raised a claim for Rs. 35,671/- with the opposite party No. 2 initially on 19.08.2011 and again on 08.09.2011. The Medical claim was rejected by the opposite party No. 2 through their letter dated. 19.09.2011, stating that, as per clause 4.10 of the Insurance Policy, expenses incurred at Hospital or Nursing Home for evaluation/diagnostic purpose which is not followed by active treatment for the ailment during the hospitalized period was not covered. Even the opposite party No. 1 through his letter dated. 23.11.2011 has refused to clear the medi claim stating that “As per Platinum Policy condition No. 4.8 charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home. The complainant submits that, seeing the diagnosis and report of the Yashoda Hospital it is very clear that the complainant No. 2 had undergone medical tests, examinations and treatment simultaneously. After discharge from the hospital, the treatment continued as per the advise given by the hospital. Due to the repudiation of the claim by the opposite parties the complainant No. 2 did not have any other alternate, other than approaching the complainant No. 1 to file a complaint before this Forum.

2.            The opposite parties filed a combined counter in which they admitted the issuance of medi claim policy to the complainant No. 2 for Rs. 1,25,000/- subject to confirmation of the policy and terms & conditions of the policy issued by opposite party No. 1. The opposite parties express that they are not aware of the hospitalization of the complainant No. 2 in Yashoda Hospital and subsequent tests and examination conducted in it. As per policy’s condition, there is an exclusion clause 4.8 which says that the charges incurred at hospital / Nursing Home primarily for diagnosis x-ray or laboratory examinations and other diagnostic studies or consistent with or incidental to the diagnosis and treatment of position existence and presence of any ailment or sickness or injury for which confinement is required at the Hospital or Nursing Home. So as per this clause, the tests and examinations or other diagnostic studies not followed by inpatient treatment at the hospital does not cover under policy so no relief is entitled. It is also submitting that opposite party No. 1 addressed a letter dated. 23.11.2011 to the complainant No. 2, rejecting his claim.

3.                Both the parties adduced evidence affidavit and got the documents marked as Exs. A1 to A8 for the complainant and Exs. B1 on behalf of opposite parties. In addition both of them filed written arguments.

4.           Now the point for consideration is, Whether the opposite parties caused any deficiency in service? If so, to what relief?

Point:

5.             The complainant No. 2 is a policy holder of opposite party No. 1 company through policy No. 050502/48/10/97/00000219 for the policy period from 29.08.2010 to 28.08.2011 for the sum insured at Rs. 1,25,000/-. The complainant got admitted in Yashoda Hospital, Somajiguda, Raj Bhavan Road, Hyderabad from 16-18 August, 2011 as inpatient with I.P.No. 144730 due to recurrent chest pain and pain in the right upper limb. During the course of stay in the hospital, he was given treatment and various diagnostic tests and examinations were also conducted which is evident from Ex.A3 – Discharge Summary of Yashoda Hospital for the period 16-18 August, 2011 consisting of 28 pages. The Ex. A4 is the Invoice of Yashoda Hospital with bill amount of Rs. 35,671/-. This document also shows the names of opposite parties No. 1 & 2 (United India Insurance Company and Raksha). This document consists of 05 pages giving details of accounts and the diagnostic tests under gone and also proves that the complainant no. 2 had been an inpatient in the said hospital for which hospital charges, room rent etc are also included. The Ex. A5 is the letter dated. 19.09.2011 issued by Raksha / opposite party No. 2 repudiating the claim with a specific information mentioning that under the clause 4.10 Expenses incurred for evaluation/diagnostic purpose which is not followed by active treatment for the ailment during the hospitalized period. The Ex. A6 is the opposite party No. 1 letter dated. 23.11.2011 sent to complainant No. 2, citing that the scrutiny of the discharge summary reveals Anxiety Neurosis, Cervical Radiculopathy for medical management, and clinical findings revealed “No abnormality detected in the most of the examination” and also made a mention that as per Platinum policy No. 4.8 the claim was rejected. The Ex. A7 is the office copy of the policy 2009 of complainant No. 2. The Ex. A8 is the registration certificate of complainant No. 1.  The opposite parties filed only one document i.e. Ex. B1 which is a duplicate policy copy same as Ex. A7.

6.                 It is a clear cut case without any ambiguity and all the documents are in favour of complainant No. 2 which proves his admission in the Yashoda Hospital for two days and thereby evaluation / diagnostic examination. The Ex. A3 (28 pages) is the discharge summary of the hospital which is self explanatory so the contention of opposite parties that the tests conducted were not followed by active treatment and which excludes as per clause 4.8 of the policy is incorrect. Adding to it the Ex. A4 proves that the complainant No. 2 incurred an expenditure of Rs. 35,671/- which includes fee for tests, doctor fee, room rent etc. This document contains 05 pages showing all details of the expenditure incurred. The complainant rightfully supported his stand by citing the order of “J & K State Commission”, dated 8.10.2010 in Appeal No. 314/2010. Where the rightful claims of the appellant (complainant) were allowed.

               Adding to the above, the exclusion clause 4.8 of the policy states that “charges incurred at Hospital or Nursing home primarily for diagnosis x-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury for which confinement is required at a Hospital/Nursing home”.

          On serious perusal of the documentary evidence of the complainant especially the Ex. A3 (28 pages) proves that the insured underwent diagnostic tests, laboratory examinations which are consistent  with positive existence of sickness (Anxiety Neurosis, Cervical Radiculopathy, Diabetes mellitus (denovo) and Hyperlipidemia) for which he was confined at the Hospital. The said pathological tests, in the circumstance, were necessary to diagnose the ailment. In other words the ailment of the insured was beyond diagnosis without said tests. And he underwent treatment for the same as inpatient, as noted above. Hence the opposite parties are liable to pay the charges incurred at the hospital as per Ex. A4 (5 pages). Moreover the opposite party No. 2/TPA in his letter of repudiation dated. 19.09.2011 (Ex.A5) he had wrongly mentioned the exclusion clause as 4.10 which actually states as “Injury or disease directly or indirectly caused by or contributed to by nuclear weapon / materials.” – Therefore the same is irrelevant. This proves that the opposite party No. 2/TPA is not at all serious in his conclusion / repudiation.

7.               In the light of the above discussion, the arbitrary decision of the opposite parties cannot stop the rightful and lawful claim of the complainant No. 2. Hence the complainant No. 2 is able to prove his case and he deserves payment of the amount under the medi claim policy along with compensation from the opposite parties.

8.               In the result, the complaint is allowed and the opposite parties No. 1 & 2 are jointly and severally directed to pay an amount of Rs. 35,671/- towards medi claim and Rs. 10,000/- as compensation for the mental agony, hardship, deficiency in service and Rs. 1,000/- as costs of the litigation. Time for compliance is one month.                        

        Dictated to Stenographer, after correction the order was pronounced by us in the open court this the 08^th day of March, 2013.

                Sd/-                                                      Sd/-

                    PRESIDENT                                     MALE MEMBER             

 APPENDIX OF EVIDENCE

                        WITNESS EXAMINED

For the complainant:                                             For the opposite parties;-

          -Nil-                                                                               -Nil-

DOCUMENTS MARKED

For the complainant:                                            For the opposite parties:-

                       Sd/-                                             Sd/-

                    PRESIDENT                           MALE MEMBER

Copy to

1)   The Complainant

2)   The Opp.Parties

3)   Spare copy