BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 21/08/2010

Date of Order : 29/10/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 465/2010

Between

And

O R D E R

C.K. Lekhamma, Member.

1. The case of the complainant is as follows :

The complainant is a holder of an Individual Health Insurance Policy issued by the opposite party. The complainant's wife was suffering from acute stomach pain and immediately consulted Dr. Mathew Abraham, Lakshmi Hospital, Ernakulam on 20-07-2009 after preliminary examination, the doctor prescribed some medicines. But there was no relaxation. Again on 22-07-2007, consulted Dr. C. Balachandran and she was admitted as inpatient in that hospital. ET/MRI scan was preferred by the Doctor to find out the reason for the stomach pain. Thereafter, she continued in Hospital for two more days and medicines were given. Thereafter, an insurance claim application was forwarded to the TPA. The claim was rejected, stating the reason, no active line of treatment is followed by the patient in which case the same is not payable under the terms and conditions of the policy. The treatment was done as per the directions of the eminent doctors and the scanning was done in order to ascertain the decease. The patient undergone treatment as per the directions of the doctors. So, the above act of the opposite party is against the policy conditions and there is deficiency in service rendered by the opposite party. Hence the complainant prays for the following reliefs against the opposite party :

1. To direct the opposite party to pay Rs. 11,769/- for the treatment expense of the complainant's wife.

2. To direct the opposite party to pay Rs. 10,000/- towards compensation for mental agony and costs of the proceedings.

2. Version filed by the opposite party :

This opposite party had granted an individual health insurance policy to the complainant subject to the terms and conditions of the policy issued and it is settled law that the parties to the insurance contract are bound by its terms and conditions. The third party administrator of this opposite party has rightly repudiated the claim of the complainant in connection with the treatment of his wife. From the documents submitted by the complainant, it reveal that the admission in the hospital was for evaluation purpose, and there is no active line of treatment. Eventhough the insured was taken scan, the result was normal and there was no positive existence of any ailment, and the claim of the complainant clearly attracts the exclusion clause 4.8 of the policy conditions. The complainant had claimed a sum of Rs. 6,350/- towards MRI Scan, the complainant is not entitled for the said amount since the insured had undergone the scan on 20-07-2009 and not in the course of hospitalization. Moreover, the said charges were not incurred in any hospital or nursing home due to that reason the said expense is not payable as per the terms and conditions of the policy, hence the complainant is not entitled for the said sum of Rs. 6,350/-. There is no deficiency in service on the part of the opposite party. The opposite party had never caused any mental agony and damages to the complainant as alleged in the complaint. The complainant is not entitled for the reliefs as prayed in the complaint.

3. The complainant and the opposite party appeared through counsel. PW's 1 to 3 were examined on the side of the complainant. Exts. A1 to A6 were marked on his side. Ext. B1 was marked on the side of the opposite party. Thereafter, we have heard both sides.

4. The points that emerge for determination are :-

1. Whether the complainant is entitled to get mediclaim insurance of his wife?

2. Compensation and costs, if any?

5. Point Nos. i. and ii. :- There is no dispute with regard to the issuance of the policy. The reason for repudiation as per Ext. A6 is that there was no active line of treatment. The same is come under the purview of clause No. 4.8 of Ext. B1 terms and conditions of the policy. Ext. A1 is the scanning report and Ext. A2 is its bill. Ext. A3 is the pharmacy bill. Ext. A4 is the test reports. PW2, the doctor who treated the complainant's wife deposed that she had some pain below the right ribs before admission, she was given some clinical treatments for four days out patient but when the condition did not improve she was admitted in the hospital. PW3, as well treated the complainant's wife. He deposed that he had given some antespar medicine and analgesic tablet and anti aid drugs. Medication was suggested to relieve the pain. During cross-examination, a question was put before him which reads as follows :

“Whether the hospitalization of the patient was necessary (q). The patient was to be relieved of the pain cause of the pain was to be found out (A).”

Ext. A4 scanning was advised by PW3. In the aforementioned discussions, it is clear that the treatment of the complainant's wife was in accordance with the advice of the doctors. Therefore, we are of the opinion that the complainant is entitled to get the claim amount with interest in respect of the treatment of complainant's wife from the opposite party. The opposite party further contended that the complainant is not entitled to get the scanning charge, since the same had taken outside the hospital and not in the course of hospitalisation. PW2 deposed that the scan test advised as a part of an attempt to identify the problem and he further deposed that “the scan was not taken in hospital, there is no scanning machine in the hospital.” It revels that scanning test was necessary to identify the disease. Therefore, we are of the opinion that the complainant is also entitled to get the scanning charges from the opposite party. It seems that the same has been included in the claim amount. In the facts and circumstances of the case, we are not ordering any compensation and litigation costs. Since, we have already ordered claim amount with interest.

6. Accordingly, we allow the complaint as follows :-

The opposite party shall pay Rs. 11,770/- being the insurance claim amount, in respect of the treatment of the complainant's wife, to the complainant with interest at the rate of 12% p.a. from the date of complaint till realisation.

The order shall be complied with, within a period of one month from the date of receipt of a copy of this order.

Pronounced in open Forum on this the 29^th day of October 2011.

Sd/- C.K. Lekhamma, Member.

Sd/- A. Rajesh,President.

Sd/- Paul Gomez, Member.

Forwarded/By order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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