BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE URBAN

    09^th DAY OF DECEMBER 2019

Complainant/s: -                           

1. Sri.Mahendra Raju.J

S/o Junjaraju

Aged about 46 years

2. Smt.N.Veena

W/o Mahendra Raju.J

Aged about 38 years

Both are R/at No.120, Behind Thirumala Stores, Vinayaka Nagara, Immadihalli Post,

Whitefield,

Bengaluru-66

By Adv.Sri.Jeevan.K

V/s

Opposite party/s:-    

1. The Manager

The Oriental Insurance Company Ltd.,

No.22, II, D.V.G Main

Road, Basavanagudi, Bengaluru-04.

By Adv.Sri.Manojkumar.M.R

2. Raksha TPA Pvt., Ltd.,

No.412, 4^th Floor,

Jindal Centre,

4^th Floor, 100 ft Road,

4^th Block, Koramangala, Bengaluru-34.

Ex-parte

ORDER

SRI. S.L PATIL, PRESIDENT

The Complainant no.1 & 2 (herein after called as the Complainants) have filed this complaint U/s 12 of Consumer Protection Act 1986, seeking direction against the Opposite Party no.1 & 2 (herein after called as OPs) to pay Rs.38,337/- with interest at 18% from 05.12.14 towards claim; to pay Rs.50,000/- towards damages; to pay Rs.5,000/- towards cost and to award such other reliefs.

2. The brief facts of the complaint are as under:

The Complainants submit that, Complainant no.1 has been buying the mediclaim policy from OP.1 since from 2006 and the latest policy no….2351 valid from 09.01.14 to 08.01.15 which covers the life risk of the Complainants including their two children. On 01.12.14 Complainant no.2/wife had admitted to the Columbia Asia Hospital, Bengaluru for some medical complications and after required treatment was discharged on 03.12.14 and paid all the medical bills. The Complainant no.1 submitted the claim form for Rs.38,337/- with all available records on 05.12.14. Again furnished certain documents as requested by the Ops on 02.01.15. But on 09.02.15 received a letter from OP.2 rejecting the claim on the ground that ‘as per policy sublimits, expenses incurred at hospital primarily for evaluation/diagnostic purposes is excluded from the policy clause no.4.10. Hence claim is rejected altered bowel movements since her 2^nd child birth – Anorectal Pelvic Floor Dysynergia Cuasing Defecatory Problems, Cystocele for Gastroscopy, Diagnostic Colonoscopy and Biopsy. The same brought to the notice of the doctor who treated the Complainant no.2 for which the doctor had issued a letter dtd.14.02.15 clarifying all the points raised by the OPs. Though submitted the said letter, OPs not even bothered to see it saying that since the claim is already rejected. In this context, they issued legal notice dtd.06.04.15 to which also OPs failed to comply. Hence this complaint.

3. After issuance of notice, OP.1 did appear and filed version. OP.2 did not appear, hence placed exparte.  OP.1 in its version submits that, it admits in respect of issuance of the said policy subject to various terms and conditions. OP.1 further submits that, based on the medical records, in particular the discharge summary and initial assessment medical and allied record of the said hospital does not indicate as to the necessity of the Complainant no.2 for any hospitalisation and that was so hospitalised in the said hospital from 01.12.14 to 03.12.14 only for the purpose of evaluation and in particular had so undergone several tests and was admitted for only investigation purpose. OP.1 further submits that, the Complainant was admitted as in patient for a period of 3 days in the said hospital and after several medical tests, which fact itself goes to prove that the Complainant no.2 had so got admitted to the said hospital for a thorough check up/investigations/general checkup followed by several investigation and was subject with several investigations like Gastrocopy, Diagnostic/ Colonoscopy and Biopsy etc., and was not suffering from any ailment/disease nor was treated for any disease.  Accordingly, repudiated the claim on 09.02.15 based on the terms and conditions of the policy in particular clause 4.10 of the policy. Panel doctor of OP.2, after due scrutiny of the policy particulars, claim form and other relevant records with reference to the terms and conditions of the policy, had infact justified the repudiation of the claim. As such the claim was repudiated under clause 4.10 as the investigations done and hospitalisation period, several test being conducted, in fact did not need admission, which as well the Complainant no.2 ought and could have been subjected for such tests as well on OPD basis. OP.1 further submits that, the treating doctor by colluding with the Complainants has issued the certificate dtd.14.02.15 to establish the claim falls within the purview of policy conditions. Hence, the claim was not considered by the OP.2, since repudiation letter justified the contention of the OPs. Hence, submits that, there is no deficiency of service/negligence on the part of OPs. Hence on these grounds and other grounds OP.1 prays for dismissal of the complaint.

4. To substantiate the case, the Complainant no.2 filed affidavit evidence and produced the documents. OP.1 filed affidavit evidence. Both filed written arguments. Heard. We have gone through the available materials on record.

5. The points that arise for our consideration are:

1. Whether the Complainants prove the deficiency of service on the part of OPs, if so, entitled for the relief sought for?

2. What order?

        6. Our answer to the above points are as under:

Point No.1:- In the negative

Point No.2:- As per final order

REASONS

7. Point No.1: We have briefly stated the contents of the complaint as well as the version filed by OP.1. It is not in dispute that, the Complainant has undergone for certain medical tests in the Columbia Asia Hospital, Bengaluru. In this context, the bill has been raised for an amount of Rs.37,667 which can be seen on going through the inpatient bill found at inkpage no.17 & 18 produced along with the list of documents. The Complainant has sought for refund of the said amount which has been negated by the OPs on the ground that as per clause no.4.10 of the policy “expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period.”

8. As rightly pointed out by the learned counsel for the OP.1, the refund sought for is in respect of hospitalization bill towards evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period of the Complainant no.2. In this context, further placed reliance on the certificate/Doc.A6 dtd.14.02.15 issued by the concerned Dr.Vidyasagar Ramappa, Consultant in Clinical Gastroenterology and Hepatology, Columbia Asia Hospital-Whitefield found at inkpage no.59 reads thus:

To whomever it may concern

Mrs.Veena.N was under my care at Columbia Asia Hospital, Whitefield for management of her medical problems as outlined in her discharge summary.

The history, clinical examination and investigations were suggestive of anorectal/pelvic floor dysynergia causing defecatory problems and possible irritable bowel syndrome overlap. There is no clear cause ascertained to the aetiology (cause) of these problems and in most cases the cause may not be discernable but may be correlated to an event in personal life or may be linked to a health related event. Clearly her symptoms became a troublesome symptom only prior to consulting me in Nov/Dec 2014.

The management or treatment of this condition is outlined in the discharge summary which is a combination of stool softeners and bulking laxative agents, kugels exercise and mebeverine. Please note that all treatments may not need medications or surgery but sometimes reassurance, physiotherapy or psychotherapy are well recognized modalities of treatment.

I have issued this letter on request by Mrs.Veena for the purposes of health insurance claims. I personally feel that this application should be supported if satisfies the terms and conditions of her health insurance policy.

Hence submits that, the claim is not sustainable.

9. We find there is considerable force in the contention taken by the OP.1 with reference to the clause 4.10 of the policy, letter/Doc.A6 issued by Dr.Vidyasagar Ramappa and also repudiation letter/Doc.A5 dtd.09.02.15 found at inkpage no.60. When the terms and conditions are expressly disclosed that expenses incurred in the hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period is come in the exclusion clause. Under such circumstances, the claim as sought for by the Complainant no.1 & 2 has no legs to stand since the Complainant no.2 has not undergone for any kind of treatment/surgery during the evaluation period. Accordingly we answered point No.1 in the negative.

          10. Point No.2: In the result, we passed the following:         

  O R D E R

The complaint filed by the Complainant is dismissed. Looking to the circumstances of the case we direct both parties to bear their own costs.

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 09^th day of December 2019)

        MEMBER                                             PRESIDENT

Witnesses examined on behalf of the Complainants dated.23.02.15

Smt.N.Veena, Complainant no.2

Copies of Documents produced by the Complainant:

Witnesses examined on behalf of the OP dated.17.03.16

Sri.G.Kantharaju, Authorized Signatory of OP.1   

Copies of Documents produced by OP.1

                MEMBER                                       PRESIDENT