IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM
DATED THIS THE 31st DAY OF JANUARY 2020
Present: - Sri. E.M.Muhammed Ibrahim, B.A, LLM. President
Smt.S.Sandhya Rani. Bsc, LLB ,Member
Sri.Stanly Harold, B.A.LLB, Member
CC.No.277/2016
Somanathan Pillai C.J.,
Chittattu House, Kottakkakam,
Perinad P.O., Kollam.
(By Adv.Gayathri V.R.) : Complainant
V/S
- The Divisional Manager,
United India Insurance Co.Ltd.,
Divisional Office, SKP Building,
Beach Road, Kollam 691 001.
(By Adv. S.Subhash Chandra Babu) : Opposite parties
- MD India Health Care Services (TPA)
Pvt.Ltd., S.No.46/1, E-Space,
A Wing, 3rd Floor, Pune Nagar Road,
Vadgaon Sheri, Pune 411014.
FAIR ORDER
Sri.Stanly Harold, B.A.LLB, Member
This is a case based on a complaint filed U/s 12 of the Consumer Protection Act 1986.
The averments in the complaint in short are as follows:-
The complainant and his family were the insured of the 1st opposite party and they took Health Insurance Policy bearing No.1007002815 P 105489101 covering the period from 21.08.2015 to 20.08.2016. At the time of issuing the policy the 1st opposite party has agreed that the company will be liable for all the treatment expenses to be incurred for treatment as per the terms and conditions of the policy. On 01.08.2016 the complainant was admitted as he was suffering from Multi Nodular Goiter and total Thyroidectomy under GA at Kerala ENT research Foundation (KERF) in Kollam. The petitioner was admitted there as inpatient and after completing the treatment discharged on 03.08.2016. While discharging, the complainant was served discharge bill for an amount of Rs.56356/-. The same been remitted by the complainant at the hospital and discharged accordingly. After discharging the complainant from the hospital, all medical records were sent before the 2nd opposite party for processing as per the directions of the 1st opposite party. But the complainant has not obtained any trust worthy reply, only sent a meger amount incurred to the treatment of the complainant violating the conditions of policy which amounts to deficiency in service and unfair trade practice. Hence the complaint.
1st opposite party filed version resisting the averments in the complaint and opposite party would admit the issuance of Ext.P1 policy and its condition. The opposite party further contends that they have issued the health insurance policy-Gold bearing No.1007002815 P 105489101 has coverage from 28.01.2015 to 20.08.2016 in favour of the complainant, his wife and 2 sons. The total sum insured for each persons named in the policy was Rs.50,000/- and terms and conditions of the policy also was handed over to the complainant. It is further contended by the 1st opposite party that as per the clause 1.1 of the policy it is described that the policy is subject to the terms and conditions of the exclusions and definitions contained herein or endorsed or otherwise expressed here on the company undertakes that during the period stated in the schedule, if any insured person contracts any disease or suffers from any illness (herein after called (Disease) or sustain any bodily injury here in after called (Injury) and if such disease or injuries requires such insured person upon the advice of a duly qualified physician/medical specialist herein after called medical practitioner or of a duly qualified surgeon to incur hospitalization/domiciliary hospitalization for medical/surgical treatment at any nursing Home/Hospital in India as here in defined (here in after called Hospital) as an inpatient. The company will pay through TPA to the Hospital/Nursing Home or the insured person the amount of such expense as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of insurance stated in the schedule here to. The coverage of the policy as per clause 1.2 in the event of any claim becoming admissible under the scheme the company will pay through TPA to the Hospital/Nursing Home such expenses will fall under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on the behalf of the insured person but not exceeding the sum insured in aggregate mentioned in the schedule here to.
According to the opposite parties the admission of the complainant in the Kerala ENT Research Foundation, Kollam on 01.08.2016 in connection with regard to the disease Multi nodular Goiter where Thyroidectomy done and discharged on 03.08.2016. Thus the period of IP was 3 days. As per the policy conditions the complainant is not entitled to get the discharge bill amount as such. After the permissible deductions are to be done on each head of the discharge bill. It can be assessed has RMO charges etc. are totally 1% if the sum assured per day. Room rent for 3 days 500x3=Rs.1500/-, as per clause 1.2(A) of the policy conditions. Similarly the complainant was admitted in the ICU after surgery only for one day. The permitted bill amount under that head is 2 % of the sum assured per day ie Rs.1000/- only. As per the policy conditions the complainant is not entitled to get separate nursing charges/monitoring charges on the ground that all nursing charges, IV fluid etc are inclusive of the amount allowed under the head of room rent. The operation are correlated charges are also limited to the charges applicable to entitled category as per the note 1 and 2 clause 1.2 of the policy conditions. Hence after the permissible deductions on each item of the submitted discharge bill to the tune of Rs.44,000/- and the other bills showing lab test, investigation , registration of the patient in the hospital etc the complainant was entitled to get only a total sum of Rs.23,942/- from the sum assured after permissible deductions under the policy conditions. On the basis of the terms and conditions of the policy the 2nd opposite party being the TPA of the 1st opposite party computed in detail and tabulated the deserving treatment expenses for the complainant and settled the case on 09/09/2016 itself. The opposite parties have no liability to pay the full discharge bill amount or any other bills against the policy conditions. It is contended by the opposite parties they had made all efforts to settlement of the claim and verified the treatment records settled and paid the settlement amount. The act of settlement of the claim by opposite party was fully on the basis of the terms and conditions of the policy. The opposite party further contends that there is no willful latches or negligence or deficiency in service or dereliction of duty or any unfair trade practice in dealing the claim petition preferred by the complainant in this matter. It entitled to get any relief and medi claim with insurance as stated prayer (a) of the complainant or compensation from the 1st opposite party in the matter. The complainant approached the Hon’ble forum with unclean hands. Hence according to the opposite party, the complainant is not entitled to get compensation or costs and complaint liable to be dismissed.
In the light of the above pleadings the points that arise for consideration are:-
- Whether there is any deficiency in service on the part of the opposite parties?
- Whether the complainant is entitled to get the amount incurred at the hospital for medical bills?
- Reliefs and costs?
Evidence on the side of complainant consists of oral evidence of PW1 and Ext.P1 to P2 documents. Evidence on the side of the opposite party consists of the oral evidence of DW1 and D1series to D8 documents.
The learned counsel for the complainant and opposite party had filed notes of argument.
Heard both sides.
Point No.1 to 3
For avoiding repetition of discussion of materials these three points are considered together. PW1 is the complainant in this case. He filed affidavit in lieu of chief examination by reiterating the averments in the complainant and got marked Ext.P1 to Ext.P2. Ext.P1 is the copy of the policy issued by the 1st opposite party bearing Reg.No.1007002815P105489101 during the period from 21.08.2015 to 20.08.2016. Ext.P2 is the Copy of discharge bill issued from the Kerala ENT Research Foundation (KERF) Hospital, Kollam.
The opposite parties strongly resisted the averments of the complainant and filed version and got marked Ext.D1series to D8 documents. Ext.D1series is the certified copy of the policy with conditions dated 21.08.2015. Ext.D2 is the photocopy of discharge bill issued by KERF Hospital dated 03.08.2016. Ext.D3 is the claims payment statement issued from MD India Health Insurance TPA Pvt.Ltd. Ext.D4 is the calculation sheet issued from United India Insurance Company Ltd dated 03.08.2016 . Ext.D5 is the claim form issued from MD India Health care services(TPA) Pvt.Ltd. Ext.D6 is the Medi claim Medical Report issued by ENT surgeon dated 10.08.2016. Ext.D7 is the Original discharge bill issued from KERF Hospital dated 03.08.2016. Edt.D8 is the photocopy of discharge summary dated 03.08.2016.
There is no dispute with regard to the fact that the 1st opposite party had issued Health Insurance Plan Policy No.1007002815 P 105489101 having coverage from 28.01.2015 to 20.08.2016 in favour of in the complainant, his wife and 2 sons. According to the opposite party total sum insured for each person named in the policy was Rs.50,000/-(fifty thousand only). It is contended by the 1st opposite party that the terms and conditions of the policy issued to the complainant was as per the clause 1.1 of the policy which would state that the policy is subject to the terms, conditions exclusions and definitions contained herein or endorsed or otherwise expressed here on the company undertakes that during the period stated in the schedule. It is also mentioned in the policy that if any insured person contracts any disease or suffers from any illness which is mentioned as (DISEASE) or sustain any bodily injury which is mentioned as (INJURY) and if he contacts recognize medical practitioner or of a duly qualified medical surgeon to incur hospitalization as medical surgical treatment at any nursing Home/Hospital will be dealt by the company under the clause 1.2 envisages in the policy condition. According to the opposite party as per clause 1.2 of the policy conditions. The company will pay through TPA to the Hospital/Nursing Home or the insured person and such expenses will fall under different heads. Hence such as Room, Boarding and nursing expenses as provided by the Hospital/Nursing Home up to 1 % of the sum insured per day. It is categorically mentioned that the policy conditions investment nursing care, RMO charges, IV fluid or blood transfusion/injection administration charges and similar expenses and also if admitted in the ICU the company will pay up to 2 % of the sum assured per day or actual amount whichever is less.
It is true that the complainant was diagnosed his Multi Nodular Goiter and was admitted in the Kerala ENT Research Foundation (KERF) Kollam on 01.08.2016 where Thyroidectomy done and discharged on 03.08.2016. Thus the period of inpatient was for 3 days. It is further contended by opposite party as per the policy conditions the complainant is not entitled to get the discharge bill amount as such. As per the policy conditions stated above the permissible deductions are to be made on each head of the discharge bill . Hence after the permissible deductions on each item of the submitted discharge bill to the tune Rs.44,000/- and the other bills showing lab test, investigation, registration of the patient in the hospital etc are the complainant is entitled to get only a total sum of Rs.23942/- from the sum assured after permissible deductions under the policy conditions.
It is further contended by the opposite party on the basis of terms and conditions of the policy the 2nd opposite party being the nodal agency of the 1st opposite party computed in detail and tabulated the deserving treatment expenses for the complainant and settled the case on 09.09.2016 itself. It is made clear by the opposite parties they have no liability to pay the full discharge bill amount or any other bills amount or any other bills against the policy conditions. We find force in the above contentions.
It is from the available materials that the 2nd opposite party has settled the claim for Rs.23942/- according to policy conditions. It is clear from the facts and circumstance that the opposite party has disposed off the claim on the basis on the terms and conditions of the policy. In the circumstance no willful latches or negligence or deficiency in service or dereliction of duty or any unfair trade practice in dealing the claim petition preferred by the complainant can be inferred.
It is true that the complainant admitted in the KERF, Kollam on 01.08.16 and Thyroidectomy done and discharged on 03.08.2016 thus the period of IP was 3 days. But simply because of the treatment in the said hospital the forum cannot direct the opposite parties to pay the benefit covered under the policy by ignoring the terms and conditions of the policy. It is well settled that the terms and conditions of insurance policy are to be strictly interpreted and while considering and interpreting the terms and condition of the insurance policy the forum cannot add or subtract anything as contract of insurance is an ubariem-a-fide contract.
On evaluating the entire facts and circumstance available on the record we find no illegality, irregularity or impropriety in rejecting the claim of full amount of discharge bill or any other payment against the policy conditions. As the opposite party had acted in tune with the terms and conditions of the policy one cannot infer any deficiency in service or unfair trade practice or derelictions of duty on the part of the opposite parties. We find no merit in the complaint and the same is only to be dismissed.
The points answered accordingly.
Point No.3
In the result the complaint stands dismissed. Parties are directed to suffer respective costs.
Dictated to the Confidential Assistant Smt.Minimol S. transcribed and typed by her corrected by me and pronounced in the Open Forum on this the 31st day of January 2020.
E.M .MUHAMMED IBRAHIM:Sd/-
S.SANDHYA RANI:Sd/-
STANLY HAROLD: Sd/-
Forwarded/by Order
Senior Superintendent
INDEX
Witnesses Examined for the Complainant:- C.J.Somanathan Pillai
Documents marked for the complainant:-
Ext.P1:-Registration certificate
Ext.P2:- Copy of discharge bill
Witness examined for the opposite party:-Bindu B.
Documents marked for the opposite party:-
Ext.D1series:- Certified copy of the policy with conditions dated 21.08.2015
Ext.D2:- photocopy of discharge bill issued by KERF Hospital dated 03.08.2016.
Ext.D3:-claims payment statement issued from MD India Health Insurance TPA Pvt.Ltd.
Ext.D4:- calculation sheet issued from United India Insurance Company Ltd dated 03.08.2016
Ext.D5:- claim form issued from MD India Health care services(TPA) Pvt.Ltd.
Ext.D6:- Medi claim Medical Report issued by ENT surgeon dated 10.08.2016.
Ext.D7:- Original discharge bill issued from KERF Hospital dated 03.08.2016.
Ext.D8:- photocopy of discharge summary dated 03.08.2016.
