BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL

FORUM AT BANGALORE URBAN

04^th DAY OF JUNE 2015

               PRESENT:- SRI. J.N.HAVANUR                  PRESIDENT

                                SMT. M. YASHODHAMMA        MEMBER                                                         

                  O R D E R

SRI. J.N. HAVANUR, PRESIDENT              

This is a complaint filed by the complainant against the OPs.1 & 2 Under Section 12 of the Consumer Protection Act, praying to pass an order directing the OPs to pay a totally sum of Rs.15,000/-along with 12% interest from the date of filing of the complaint till realization and to pay litigation cost and other reliefs.

2. The brief facts of the complaint can be stated as under:

Complainant who being the senior citizen took medical insurance policy No.071800/48/08/14/00003654.  TTK I.D card No.BLR-01-SA-01-000-0001346-B from OP-1 insured with OP-2 United India Insurance Company Ltd., on 16.01.2009 covering period from 12.01.2009 to 11.01.2010.  The complainant was admitted as inpatient in Wockhardt Hospital, situated in 80 feet Road, Gurukrupa Layout, 2^nd Stage, Nagarbhavi, Bangalore at 9.30 A.M on 04.12.2009 to 12.28 P.M on 05.12.2009 including stay in emergency ward for more than 24 hours.  The stay in the hospital for more than 24 hours is certified by Dr.Bhojamma of the said hospital by certificate dated 08.05.2010.  The complainant has sent a letter dated 09.01.2010 along with original bills to OP-1 to reimburse the inpatient hospital charges.  OP has sent a letter dated 20.01.2010 to complainant demanding original discharge summary and all investigation reports assuring to process the claim on receipt of the above documents.  The complainant forwarded to first OP the original documents issued by Wockhardt Hospital.  The complainant issued a reminder on 07.04.2010 requesting OP-1 to expedite the reimbursement.  OP-1 issued a rejection letter to complainant stating that the hospitalization is from 04.12.2009 5.36 PM to 05.12.2009 12.28 PM and above stay is less than 24 hours and as such the claim of the complainant is rejected under clause 2.3 of the policy.  As per the admission of duration in the hospital by first OP in its rejection letter, it is made clear that the complainant stayed in hospital for more than 24 hours.  The OP did not respond.  So complainant has sent legal notice dated 20.09.2010 demanding settlement of medical claim.  OP sent a reply stating that claim falls outside the scope of policy.  OP-1 has not settled the medical claim amount stating one or the other reasons.  So the complainant has come up with present complaint.    

3. After service of the notice, OP-2 appeared through its counsel and filed version but OP-1 did not appear and he has been placed ex-parte.

The averments of version of OP-2 can be stated as under:

The complaint of the complainant is not maintainable either in law or on facts.  OP has issued certificate of insurance of individual group Health Insurance Policy in favour of the complainant subject to terms and conditions and stipulations contained therein attached to the said policy.  As per the terms and conditions of the policy the risk of the complainant has not covered as per clause 2.3 but in the present case the patient was admitted to the hospital on 04.12.2009 5.36 PM and discharged on 05.12.2009 at 12.28 PM which is less than 24 hours hospitalization.  Complainant was Hypertension and Diabetes patient and is on mediclaim since 18 years and he is also known case of Asthma since 35 years.  Since hospitalization is less than 24 hours.  So the claim of complainant is not permissible and this OP is not liable to pay any compensation as prayed in the complaint.  First OP has repudiated the claim of the complainant as per the terms and conditions of the policy and there is no negligence or deficiency of service on the part of OP.  The OP settles the claim as per the terms and conditions of the policy.  The averments of complaint of complainant is denied totally.  There is no cause of action to file the present complaint. This OP is not liable to pay an amount of Rs.7,183/- towards damage for mental agony and cost of the proceedings of Rs.7,000/- along with interest and litigation cost as prayed in the complaint.  Hence, it is prayed to dismiss the complaint of complainant.

4. So from the averments of the complaint of the complainant and version of Opposite Party-2 the following points arise for our consideration as under:

5. Our answer to the following points:

REASONS

6. So as to prove the case the complainant has filed his affidavit by way of evidence and produced documents along with complaint and also 7 documents along with memo.  On the other hand Lal Bopanna, Administrative Officer of OP-2 has filed affidavit and produced the terms and conditions of the policy.

7. Sri.P.V Subrahmanyam, who being complainant has stated in his affidavit that he being senior citizen took medical insurance policy No.071800/48/08/14/00003654.  TTK I.D card No.BLR-01-SA-01-01-000-0001346-B from OP-1 insured with OP-2 on 16.01.2009 covering period from 12.01.2009 to 11.01.2010.  He was inpatient in Wockhardt Hospital, situated in 80 feet Road, Gurukrupa Layout, 2^nd Stage, Nagarbhavi, Bangalore from 9.30 A.M on 04.12.2009 to 12.28 P.M on 05.12.2009 including stay in emergency ward for more than 24 hours.  It is certified by Dr.Bhojamma by certificate dated 08.05.2010 issued by Wockhardt hospital.  He sent a letter dated 09.01.2010 along with original bills to OP-1 claiming reimbursement of inpatient hospital charges.  OP sent a letter dated 20.01.2010 demanding original discharge summary and all investigation reports assuring to process the claim on receipt of the said documents.  He forwarded the original documents issued by Hospital to OP and issued reminder dated 07.04.2010 requesting OP-1 to expedite the reimbursement of medical claim amount of Rs.7,183/-.  OP-1 issued a rejection letter stating that the hospitalization is from 04.12.2009 at 5.36 PM to 05.12.2009 at 12.28 PM and above stay is less than 24 hours, so the hospital is not payable.  The stay in the hospital more than 24 hours and it is certified by Dr.Bhojamma by certificate dated 08.05.2010.  Both OPs did not respond.  So he has issued the legal notice dated 20.09.2010 OP demanding to settle the mediclaim amount.  He was admitted in the hospital not for ailments that were pre-existing.  So he has come up with present complaint.  So complaint be allowed and grant reliefs as prayed.

8. Let us have a look at the relevant documents of the complainant.  Document No.1 of the list dated 29.04.2011 of complainant is the copy of TTK letter card issued by OP-2 in the name of complainant and his wife having validity from 12.01.2009.  Document No.2 is the copy of letter of complainant dated 09.01.2010 addressed to OP-1 praying to reimburse inpatient amount of Rs.7,183/- as he was inpatient in the hospital for treatment.  3^rd document is the copy of settlement receipt issued by Wockhardt hospital in the name of complainant for having paid Rs.7,183/-.  4^th document is the letter issued by OP-1 addressed to complainant dated 20.01.2010 requesting to send original discharge summary and all investigation report within 7 days for processing his claim.  5^th document is the copy of reminder letter of complainant addressed to OP-1 dated 07.04.2010 to expedite his claim and reimburse the amount of hospital expenses incurred.  6^th document is the rejection letter of OP-1 addressed to complainant stating that hospitalization of complainant is less than 24 hours so it is not payable and his claim has been rejected under clause 2.3 of the policy.  7^th document is the copy of letter of complainant along with certificate of Dr.Bhojamma working in Wockhardt Hospital stating that the complainant stayed in the hospital for more than 24 hours including stay in emergency ward.  8^th document is the legal notice of complainant dated 20.09.2010 addressed to OP-1 and 2 stating that complainant was hospitalized for more than 24 hours.  So reimburse the amount of Rs.7,183/- within 7 days failing which he will take legal action against OP.  Complainant has produced postal receipts for having issued notice to OPs by RPAD and also produced AD cards for having served notice as document No.9.  Document No.10 is the rejection letter of OP-1 addressed to Lawyer of complainant dated 20.10.2010 as claim of complainant falls outside the scope of policy.  However, he can approach insurance company.  The letter of OP-1 produced at document No.10 by the complainant contained investigation reports and terms and conditions of the policy of OP-2 and in the terms of conditions of the policy under clause 2-1.3 it is stated as under:

Expenses on hospitalization for minimum period of 24 hours are not admissible.  However, this time limit is not applied to specific treatments i.e., Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery Lithotripsy (Kidney Stone removal).  D & C and treatment is such that it necessitates hospitalization. 

9. The complainant has produced one certificate dated 30.12.2014 issued by the Fortis hospital stating that complainant came to Fortis hospital on 04.12.2009 at 9.30 AM and got admitted in Special Ward at 5.36 PM and discharged on 05.12.2009 at 12.28 PM and as per the procedure they do not mention patients arrival timing in discharge summary.  Discharge summary of Fortis hospital produced by complainant shows that the complainant was admitted on 04.12.2009 at 5.30 PM and discharged on 05.12.2009 at 12.28 PM and he came to hospital with history of giddiness associated with sweating, palpitations and general weakness.  So making calculation of stay of complainant in the hospital as per discharge summary it is no doubt true that the stay of complainant in the hospital is less than 24 hours.  As per the certificate issued by Dr.Bhojamma the complainant was admitted to hospital i.e., shifted to in ward on 04.12.2009 at 5.36 PM for giddiness with sweating, palpitation, tinnitus, nausea, abdominal distention excertional dyspnea and general weakness.

10. As per clause 2.1.3 (a) it is made clear that the treatment is such that it necessitates hospitalization and the ailment mentioned in the certificate of Dr.Bhojamma cannot be stated as unnecessary treatment for hospitalization as giddiness with sweating and palpitation may take into serious heart attack problems all of a sudden.  Though the complainant was not hospitalized for more than 24 hours as per the discharge summary still then the hospitalization of complainant on 04.12.2009 was inevitable as he was ailing due to giddiness with sweating and palpitation etc., which is coming under proviso to clause 2.1.3 (a) of terms and conditions of the policy.  So looking to the ailment of complainant as per discharge summary and certificate of Dr.Bhojamma and proviso to section 2.1.3 (a) of the policy, we are of the view that on account of giddiness associated with sweating and palpitation it made the complainant to admit to the hospital on 04.12.2009 at 5.36 pm and took treatment and got discharged on 05.12.2009 at 12.28 pm which is less than 24 hours and it is coming under proviso to 2.1.3 (a) of terms and conditions of the policy.  The oral evidence of complainant that on account of giddiness with sweating and palpitation etc., he took treatment as inpatient in the hospital on 04.12.2009 and discharged on 05.12.2009 at 12.28 pm and incurred hospital expenses and that incurring of hospital expenses is coming under the policy stands corroborated by proviso to clause 2.1.3 (a) of policy terms and conditions and whatever rejection made by OP-1 is in correct as the case of the complainant is coming under the proviso to 2.1.3 (a) of the policy issued in the name of the complainant.       

11. Let us have glance at the material evidence of OP.  Lal Bopanna, Manager of OP-2 has stated in his evidence that they have issued Health Insurance Policy in favour of the complainant subject to terms and conditions.  OP-1 has rejected the claim of the complainant as he was not hospitalized for more than 24 hours as per clause 2.1.3 and rejected the claim of complainant and whatever rejection made by OP-1 is correct as per the terms and conditions of the policy.  There is no negligence and deficiency of service on the part of OPs.  The complainant is not entitled to claim any amount as prayed in the complaint.  So complaint be dismissed with costs.

12. OP-2 has also produced the terms and conditions of the policy.  As per the policy terms and conditions i.e., 2.1.3 (a) it is made clear that this condition i.e., 2.1.3 (a) will not apply in case of stay in hospital of less than 24 hours.  However provided (a) the treatment is such that it necessitates the hospitalization.  So viewing the case of the complainant on the background of ailment mentioned in the discharge summary and doctor certificate produced by the complainant and proviso to clause 2.1.3 of policy terms and conditions, we are of the considered opinion that the ailment of complainant i.e., giddiness associated with sweating, palpitation etc., cannot be termed as ordinary ailments and said ailments may give sudden heart attack in case patient does not attend the same immediately and as such the complainant was made to rush to the hospital on 04.12.2009 and got admitted and took treatment and discharged on 05.12.2009 at 12.28 PM which is less than 24 hours.  Still then it covers under proviso to clause 2.1.3 of policy terms and conditions and complainant is entitled to claim the hospital expenses from OPs.  The rejection of claim of complainant by OP-1 is not in accordance with terms and conditions of the policy as it failed to scrutinize papers of the complainant in view of proviso to sec.2.1.3 of the policy.  So we are inclined to come to the straight conclusion that the oral and documentary evidence of complainant placed before the Forum are more believable, trust worthy and acted upon than the material evidence of OP-2 and thereby we hold that the complainant who comes to Forum seeking relief has proved with the believable material evidence that OPs are negligent and there is a deficiency of service on the part of OPs in not making settlement of claim of the complainant.  Accordingly, we answer this point in a affirmative.

13. In view of our affirmative finding on point No.1 the complainant is entitled to claim Rs.7,183/- from OPs.1 & 2.  So OPs.1 & 2 are jointly and severally directed to pay Rs.7,183/- to the complainant within 30 days from the date of receipt of this order failing which OPs.1 & 2 shall pay said amount to the complainant along with 6% interest on the said amount from the date of the complaint to till the date of realization.  OPs.1 & 2 are further directed to pay Rs.2,500/- to the complainant towards cost of litigation.  Accordingly, we answer this point.  In the result, for the foregoing reasons, we proceed to pass the following:    

       O R D E R

The complaint of the complainant is partly allowed.  OPs.1 & 2 are jointly and severally directed to pay Rs.7,183/- to the complainant within 30 days from the date of receipt of this order, failing which OPs.1 & 2 shall pay the said amount to the complainant along with interest @ 6% p.a on the said amount from the date of complaint to till the date of realization.  OPs.1 & 2 are further directed to pay Rs.2,500/- to the complainant towards cost of litigation. 

Supply free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this 04^th day of June 2015)

MEMBER                                                                 PRESIDENT

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Witnesses examined on behalf of the complainant dated 12.08.2011

1. Sri.P.V Subrahmanyam

Witnesses examined on behalf of the OP-2 dated 15.09.2011

1.      Sri.Lal Bopanna

MEMBER                                                                 PRESIDENT

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