Complaint filed on: 28.05.2015
Complaint Disposed on:03.12.2016
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT CHICKMAGALUR.
COMPLAINT NO.91/2015
DATED THIS THE 3rd DAY OF DECEMBER 2016
:PRESENT:
HON’BLE SRI RAVISHANKAR, B.A.L, LL.B., - PRESIDENT
HON’BLE SMT B.U.GEETHA, M. COM., LL.B., -MEMBER
HON’BLE SMT H. MANJULA, B.A.L., LL.B., - MEMBER
COMPLAINANT:
N.M.Gayathri
Aged about 56 years,
W/o Malathesh Rao N
Represented by her GPA
Holder Mr.Malathesh Rao N.
S/o Late Neelakanthaiah
Aged about 62 years,
“MALATHI” Sipani Hindi School Cross,
Belt Road, Chikmagalur.
(By Sri/Smt. H.L.Vishwanath, Advocate)
V/s
OPPONENT:
1. The Manager,
M/s Canara Bank,
Togarihankal Branch,
Chikmagalur.
2. Appollo Munich Health
Insurance Company,
Ground Floor, Sri Nilaya,
Cyber Spazio Road,
No.2, Banjara Hills,
Hyderabad, A.P.
(OP-1 By Sri/Smt. H.N.Arundathi, Advocate)
(OP-2 By Sri/Smt. K.S.S., Advocate)
By Hon’ble President Sri. Ravishankar,
:O R D E R:
The complainant filed this complaint U/s 12 of the Consumer Protection Act 1986 against OP Nos. 1 & 2 alleging deficiency in service in not settling the medical claim of Rs.2,08,094/-. Hence, prays for direction against OP Nos. 1 & 2 to pay the said amount towards reimbursement of the medical expenses along with compensation of Rs.1,00,000/- for deficiency in service.
2. The brief facts of the complaint is that:
The complainant has purchased health insurance policy from OP No.2 through OP No.1 who is an agent of OP No.2 vide policy bearing No.900001/12001 /2013/A003282/01. The said policy commences from 31.10.2013. After purchase of the said policy, the complainant was suffering from low back and consulted a Doctor at Chikmagalur, where she was advised to approach Kasturba Hospital, Manipal. Accordingly, the complainant on 04/07/2014 went to Kasturba Hospital at Manipal and reported that she was suffering from low back pain. Immediately she was advised to get admitted for the treatment. She was admitted and pre-operative assessment was done on 08/07/2014, she was underwent surgery and samples were sent to decompression and biopsy. The result of the biopsy came as TUBULARETIOLOGY and PCR was positive for Tuberculosis (TB). The Doctors were stated treatment towards Tuberculosis and they were clarified that it was Tuberculosis. The complainant took the treatment at the same Hospital. The said Kasturba Hospital at Manipal is one of the network hospitals of the OP No.2 Company. At the time of admission of the complainant, the hospital authorities have enquired about the insurance policy, for which the complainant furnished the policy issued by OP and requested for cashless facility from OP/Company. But the OP/Company had not provided the cashless facility at Hospital as the said hospital is non network hospital for AMHI card holders. Hence, due to refusal of the cashless facility, the complainant herself paid the entire medical expenses to the tune of Rs.2,08,095/- to the hospital. Subsequently, after discharge the complainant submitted the claim form for the reimbursement of the expenses spent towards the treatment of the complainant. But the OP/Company repudiated the claim through their letter for the reason that the surgery for PIVD to Tuberculosis be excluded for one year as per the policy terms and conditions. The repudiation made by OP/Company is illegal. The disease is not within the Clause. Hence, the OP rendered a deficiency in service in not reimbursing the claim of the complainant. Hence, prays for direction against Ops to settle the claim and to pay compensation for deficiency in service as prayed above.
3. After service of notice the OP Nos. 1 & 2 appeared through their counsel and filed the version.
a) The OP No.1 in his version has contended that it is true that this OP is the licensed corporate agent of second OP and complainant had obtained health policy from second OP. The liability of this OP may be determined in accordance with the terms and conditions of the policy. This OP is only an agent to the second OP who issued the policy to the complainant on behalf of second OP. The second OP is answerable to the complainant with respect to the claim made by complainant regarding reimbursement of the medical expenses. There is no previty of contract to this OP and complainant with respect to reimbursement of the medical expenses.
This OP had not know that the complainant claimed for cashless facility during hospitalization and 3rd OP refused the said facility. This OP is not liable to answer the claim made by complainant and there is no any deficiency in service as alleged by the complainant. Hence, prays for dismissal of the complaint.
b) The OP No.2 in his version has contended that the complainant had filed this false complaint by suppressing the material facts and wrongly interpreted the clause and filed this complaint in order to gain wrongfully. The complainant duly filled and signed an enrollment form for taking an easy group health insurance policy for sum insured at Rs.2,00,000/-. On the declaration made by complainant in the enrollment form, this OP issued a policy to the complainant vide policy No.900001/22001/2013/A003286/012 and they have accepted the risk commencing from 31.03.2013 to 30.10.2014. The benefits under the policy however subject to certain conditions and exceptions of the policy. This OP has received a claim form the complainant on 05/08/2014 along with clinical reports, discharge card and medical bills for reimbursement of Rs.1,55,749/- which was spent by complainant during hospitalization from 04/07/2014 to 21/07/2014 at Kasturba Hospital, Manipal.
The discharge summary reveal that the complainant was a known case of Diabetes Mellitus on medication, Hypothoroidism. The complainant further was investigated and diagnosed as a case of L5 S1 Tubercular Spondylodiscitis with DM T2, for this the patient was managed with L5S1 decompression and biopsy. Post procedure was uneventful and the patient was discharged with advice. Upon the scrutiny of the medical documents an additional information was called for assessment of the admissibility of the claim vide letter dated:26.08.2014. In spite of the said letter, the complainant failed to prvide such documents. Again, they have wrote another reminder letter dated:10/09/2014 and 16/10/2014 and called the complainant to produce attested copy of indoor case papers of hospitalization including admission notes and progress notes, residence proof, Doctors certificate for past history duration of diabetes and hypothyroidism and when diagnosed for the first time and doctors certificate regarding duration and past history of the present ailment (Tubercular Spondylodiscitis). The complainant submitted only few documents on 15/09/2014 and upon scrutiny of the said documents, it was observed that the complainant is known case of DM and on treatment from 2009 and complainant was diagnosed to have hypothyroid during July 2014. Further, this OP has scrutinized and noticed by the operation report that the complainant was operated for L5 S1, decompression, discectomy and biopsy done. It was categorically written under procedure that L5 S1 level was marked using imaging. Then the complainant was prepared and dropped. Incision was made over the marked site, skin and subcutaneous vertebral spinos process and facets exposed. Interspinous ligament was cut L5 and disc material was removed and canal decompression was done and then curatle was used and inter vertebrate space cutted and sent for biopsy. Upon Conspicuous perusal of the specific waiting period under Clause-5 of the policy, the claim is not admissible. Further, the Clause-5 of the policy issued to the complainant which reads as follows:-
“Section 5 : Exclusions
Specific waiting periods:
c) The illness and treatments listed will be covered subject to waiting period of 1 years:
i) Illness: arthritis if non infective; calculus disease of gall bladder and urogenital system, cataract, fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant), osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.
ii) Treatments; benign, ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectimony, ttonsillectomy and tympanoplasty); dilatation and curettage ( D & C); hysterectomy for menorrhagia or fibromyoma or prolapsed of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery of gallbladder and bile duct unless necessitated by malignancy; surgery of genitor urinary system unless necessitated by malignancy; surgery of benign prostatic hypertrophy; surgery of hernia; surgery of hydrocele; surgery for prolapsed inter vertebral disk; surgery of varicose veins and varicose ulcers; surgery on tonsils and sinuses.”
Hence, the surgery for prolapsed inter vertebral disk was clearly excluded in the policy to a specific waiting period of one year thus the said claim was denied vide letter dated:15.11.2014 to the complainant. Thereafter this OP received another claim form from complainant on 03.11.2014 along with clinical reports, discharge card and medical bills for reimbursement of Rs.52,345/- incurred upon the management of 3 months old operated L5 S1 Tuberculosis during his hospitalization from 13.10.2014 to 16.10.2014 at Kasturba Hospital, Manipal. The said hospitalization was for the illness which has a specific one years(s) of waiting period as per the policy. Hence, the claim again repudiated stating that there is exclusion for the said disease for the period of one year as per the policy terms and conditions. Hence, there is no deficiency in service on the part of this OP in repudiating the claim and this OP is not liable to pay any claim made by complainant. Hence, prays for dismissal of the complaint.
4. The complainant filed affidavit and marked the documents as Ex.P1 to P16. The OP Nos. 1 & 2 also filed affidavit but no documents marked. The OP No.2 filed memo with policy proposal form and terms and conditions in support of their case.
5. Heard the arguments:
6. In the proceedings, the following points do arise for our consideration and decision:
Whether there is deficiency in service on the part of OPs.
Whether complainant entitled for any relief & what Order?
7. Our findings on the above points are as follows:-
Point No.1: Affirmative.
Point No.2: As per Order below.
: R E A S O N S :
POINT NOs. 1 & 2:
8. On going through the pleadings, affidavits and documents produced by the complainant and OP Nos. 1& 2, there is no dispute that the OP No.2 had issued a policy bearing No.900001/22001/2013/A003286/012 which is valid from 30/10/2013 to 30/10/2014 through OP No.1 who is an agent of OP No.2 to the complainant. After obtaining the policy, the complainant underwent surgery and during hospitalization at Kasturba Hospital from 04/07/2014 to 21/07/2014 the Doctors at Kasturba Hospital have advised that she has a positive for Tuberculosis and treatment for Tuberculosis was started by the Doctors and the Doctors have certified that it was Tuberculosis.
The complainant in his complaint alleges that at the time of hospitalization the complainant requested the hospital authority to provide cashless benefit as she being the beneficiary of the policy. But the OP No.2 had refused to provide cashless facility and complainant spent hospitalization expenses. Further she alleged that the OP/Company without valid reason had repudiated the claim for the reason that the said disease is not covered under the policy for one year as per exclusion the said disease covers only after waiting period of one year and repudiated the claim. Hence, alleges deficiency in service and prays for settlement of the claim to the tune of Rs.2,08,094/- which was spent towards the medical treatment.
9. On contrary, the OP No.2 being insurer has taken a contention that the complainant before taking the policy was a diabetic patient having diabetes mellitus and taking treatment. Further she underwent the surgery for prolapsed inter vertebral disk. Hence, the said surgery is not covered under the policy for the first year and exclusion 6-C of the policy clearly shows that the said policy is not covered for one year. Hence, they are not liable to reimbursement any amount claimed by the complainant and submits no deficiency in service.
10. The complainant sworn affidavit and produced documents such as policy issued by OP No.2 marked as Ex.P2, policy kit marked Ex.P3, Doctor certificate issued by Doctor at Chikmagalur marked as Ex.P5, admission order marked as Ex.P6, discharge summary issued by Kasturba Hospital at Manipal, marked as Ex.P7. Letter dated:28/07/2014 towards claim for medical expenses, marked as Ex.P8 in patient cash bill, marked as Ex.P10, MRI observation marked as Ex.P12, another lab report from of Department of Radiology, marked as Ex.P13, two claim forms submitted to OP/Company, marked as Ex.P14 & P15 and another discharge summary issued by Kasturba Hospital, marked as Ex.P16.
11. On going through the discharge summary which is marked at Ex.P7, we noticed that the Doctors at Kasturba Hospital have diagnosed as L5 S1 TUBERCULAR SPONDYLODISCITIS biopsy LZ by through check-up and subsequently on observing another discharge summary i.e. Ex.P16 the complainant was treated for the said ailment. Further the complainant had undergone surgery on 08/07/2014 and the Doctors at Kasturba Hospital had provided treatment towards TUBULARETIOLOGY and PCR. In addition of the said treatment, they have operated L5 S1 as the complainant was complained with respect of low back ache since six months. The said ailment was noticed by the complainant after obtaining policy from OP Nos. 1 & 2. We are of the opinion that the complainant is not suppressed any diseases at the time of taking policy from OP No.2/Company. The complainant after taking treatment had claimed for reimbursement of the medical expenses to the tune of Rs.2,08,094/-, for which the OP No.2 had repudiated for the reason that she has taken treatment for prolapsed inter vertebral disk as per the exclusion Clause-6 of the policy. But the discharge summary disclosed that she has taken treatment for T.B. continuously and after taking she also underwent surgery for L5 S1 Tuberculosis. The said surgery is not excluded from coverage for one year. The exclusion clause furnished by OP No.2 has not mentioned that the treatment for Tuberculosis is not covered for the first year. Hence, repudiating the claim made by complainant by OP No.2 amounts to a deficiency in service. The complainant was not underwent for the surgery of prolapsed inter vertebral disk as mentioned in the exclusion clause. Hence, we are of the opinion that the claim made by complainant is genuine one as per the policy terms and conditions. The OP made an error in noticing the discharge summary given by Kasturba Hospital. Hence, the OP No.2 being the insurer is liable to reimburse the eligible medical expenses to the complainant.
12. The OP No.1 is only an issuing agent who acted on behalf of OP No.2. There is no any deficiency in service on the part of OP No.1 with respect to the claim made by complainant. As such the complaint is liable to be dismissed against OP No.1. The OP No.2 being insurer failed to observe the discharge summary and by wrongfully interpreted the exclusion clause, had repudiated the claim which amounts a deficiency in service, for which the OP No.2 is liable to pay compensation of Rs.5,000/- for deficiency in service along with litigation cost of Rs.2,000/-. As such for the above said reasons, we answer the above points accordingly and proceed to pass the following:-
: O R D E R :
The complaint filed by the complainant is allowed in part.
The OP No.2 is directed to pay eligible claim to the complainant under policy No.900001 / 12001 /2013/A003282/012.
The OP No.2 is further directed to pay Rs.5,000/- towards compensation and Rs.2,000/- towards litigation cost to the complainant.
The OP No.2 is further directed to comply the above order within 30 days from the date of receipt/knowledge of the order, failing which the payable amount shall carry interest @ 9% P.A. from the date of complaint to till realization.
The complaint is hereby dismissed against OP No.1.
Send free copies of this order to both the parties.
(Dictated to the Stenographer transcribed typed by him, transcript corrected by me and then pronounced in Open Court on this the 3rd day of December 2016).
(RAVISHANKAR)
President
(B.U.GEETHA) (H. MANJULA)
Member Member
ANNEXURES
Documents produced on behalf of the complainant:
Ex. P1 - Power of attorney given by complainant
Ex.P2 - Policy issued by OP No.2
Ex.P3 - Policy Kit
Ex.P4 - True copy of the Adhar Card
Ex.P5 - Dr.Certificate issued by Dr.Vinal, Chikmagalur
Ex.P6 - Admission order
Ex.P7 - Discharge summary issued by Kasturba Hospital Manipal
Ex.P8 - Letter dated:28.07.14 towards the claim of medical expenses
By complainant
Ex.P9 - Cancelled cheque original
Ex.P10 - In patient cash bill
Ex.P11 - Lab report
Ex.P12 - MARI observation
Ex.P13 - Another lab report from Dept. of radiology
Ex.P14&15 - Two claim forms submitted to OP Company
Ex.P16 - Another discharge summary issued by Kasturba Hospital, Manipal
Documents produced on behalf of the OPs:
NIL
Dated:03.12.2016 President
District Consumer Forum,
Chikmagalur.
Tss
