By Sri. Ananthakrishnan. P. S, President:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
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2. The Complainant’s case in brief is as follows:- The complainant is an insurance advisor of SBI Life insurance company. He is a member of Group Health Insurance Scheme of first opposite party with policy No.130426-0000-04 which was valid from 24.06.2016 to 23.06.2017. While so, on 29.05.2017, he was suffering from fibromyalgia with cervical sprain and was not in a position to move his hands and head. Therefore on the same day itself, he was admitted in Malabar Hospital, Calicut and after treatment, he was discharged on 05.06.2017 with an advice to continue physiotherapy and medicines. He continued the treatment even after the discharge. Thus he spent Rs.18,500/- as hospital expenses and Rs.4,000/- towards physiotherapy and medicine. At the time of treatment, he made a request for cashless treatment. But, opposite parties have informed that the complainant has to pay the cash and thereafter claim the amount. After the discharge on 06.06.2017, he had submitted all the required documents like bills, discharge summary etc to the first opposite party on 17.06.2017. The second opposite party sent a letter requiring some more documents like details from attending doctor. The complainant furnished all those documents within 3 days. Thereafter, again the opposite parties sent another letter dated 12.07.2017 for furnishing more details regarding the treatment. On
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14.08.2017, he furnished all the required details. For collecting the documents, he spent more than Rs.2,500/-. Even then, the opposite parties have not settled the claim. So, there is deficiency of service from the opposite parties which caused financial loss and damages to the complainant. Hence this complaint to get Rs.22,500/- towards treatment expenses and Rs.10,000/- as damages from the opposite parties with cost.
3. The first opposite party is ex-parte.
4. The Second Opposite party filed version which in short is as follows:- They admitted that the complainant was a member of Group Health Insurance Scheme of first opposite party as alleged by him. But they denied that he was suffering from fibromyalgia with cervical sprain and was not in a position to move the hands and head and that he was admitted in Malabar hospital Calicut for treatment on 29.05.2017 and was discharged on 05.06.2017. They denied that the complainant requested for cashless treatment and opposite parties informed that after payment, he can claim the amount. They denied that this opposite party has repeatedly asked the complainant to furnish documents which had been already furnished. They denied that the complainant spent Rs.2,500/- to
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collect documents. The fibromyalgia is not a disease. It is a medical condition. Therefore, there is no need of admission in the hospital to clear this condition. The complainant stayed in the hospital not for any regular treatment, but for evaluation. The exclusion clause of the policy excluded hospitalization for evaluation or diagnostic purpose. The treatment undergone by the complainant could have been managed without admission. The complainant after having been diagnosed was discharged from hospital with advice to undergo physiotherapy. The expenses incurred by the complainant at the hospital were primarily for diagnostic. The claim for hospitalization falls beyond the purview of the policy coverage and hence the claim was repudiated. Therefore there is no deficiency of service from this opposite parties. So the complainant is not entitled to get anything with compensation and cost. Hence this complaint is liable to be dismissed with cost of this opposite party.
5. On the above contentions, the points raised for consideration are:-
1. Whether there is any deficiency in service on the part of opposite
parties.
2. If so, whether the Complainant is entitled to get anything
as claimed?
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3. Reliefs and Cost.
6. The evidence in this case consists of oral testimonies of PW1, Ext.A1 to A9 and Ext.B1. There is no oral evidence from second opposite party. Heard both sides.
7. Points No.1 & 2:- Admittedly, the complainant was a member of Group Health Insurance Scheme of the first opposite party with policy No.130426-0000-04 which was valid from 24.06.2016 to 23.06.2017. The complainant’s case is that within this period ie. on 29.05.2017, he was suffered from fibromyalgia with cervical sprain and was not in a position to move his hands and head. So accordingly, he was admitted in Malabar Hospital, Calicut and after the treatment, he was discharged on 05.06.2017. His grievance is that even though, he submitted a claim before opposite parties, they have not given anything. According to him, he spend Rs.22,500/- towards treatment and he wants this amount and Rs.10,000/- as compensation with cost.
8. The first opposite party is ex-parte. The case of the second opposite party is that fibromyalgia is not a disease. According to them, it is only a medical condition and therefore admission is not necessary for treating this condition.
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According to them, as per the exclusion clause of the policy, hospitalization for evaluation or diagnostic purpose is excluded. They contended that the treatment undergone by the complainant could have been managed without admission. Therefore, they affirmed that the complainant is not entitled to get anything from them towards his claim.
9. The complainant has given evidence as PW1. Though, the second opposite party has not given oral evidence, Ext.B1 was marked from their side. Ext.B1 is the copy of the policy with condition. Ext.A1 is the copy of Certificate with insurance schedule. Ext.A2 is the ID card of the policy holder. The second opposite party has not disputed that the complainant was a policy holder under them. The second opposite party has also not disputed that the complainant was admitted in Malabar hospital Calicut on 29.05.2017 and was discharged on 05.06.2017. Their only contention is that the complainant is not entitled to get any claim from them because, fibromyalgia is not a disease for which there is no need of admission in a hospital. According to them, it is only a medical condition which could be managed without admission and if there is any admission, it can be excluded. As per the definition clause in Ext.B1, hospitalization means consecutive admission in a hospital for a minimum period of 24 hours for in
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patient care. It is evident that complainant was admitted in the hospital for more than 24 hours. Clause 34 of exclusion clause of policy excluded hospitalization primarily for investigation purposes, diagnosis, x-ray examination, general or routine physical or medical examinations, not incidental to treatment or diagnosis of a covered disease or illness or any treatment which is not medically necessary and any preventive treatments, or examinations carried out by a medical practitioner. According to the second opposite party, the complainant need not be admitted in the hospital and he was admitted only for diagnosis and discharged with an advice to take rest and physiotherapy. So, we have to verify Ext.A4 and A9. Ext.A4 and A9 are the copy of the certificates issued by Dr. Nagaraj Desai of Malabar Hospital, Calicut who treated the complainant. Doctor has specifically given reasons for the admission of the complainant in this hospital in Ext.A4 and A9. According to the doctor, complainant needs physiotherapy two times a day and he needs to be seen by Orthopaedician on daily basis. The second opposite party has no case that Ext.A4 and A9 are fabricated documents. Moreover, even though the doctor who treated the complainant has issued Ext.A4 and A9, the second opposite party never bothered to examine any of the experts to disprove the reasons for admission given by the doctor or to prove that
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the complainant need not be admitted in the hospital for this treatment. They have also not examined any of the experts to prove that the complainant was admitted in the hospital only for evaluation or diagnosis or for any other purposes covered under exclusion clause 34 in Ext.B1. Therefore, we have no hesitation to accept the reasons stated in Ext. A4 and A9 by the doctor who advised the complainant for admission in the hospital. As already stated, evidently the complainant was admitted in the hospital for more than 24 hours. Therefore the evidence adduced herein by the complainant clearly proves that he is entitled to get insurance claim from the opposite parties.
10. The complainant sought Rs.22,500/- towards treatment expenses. From his evidence and on perusing the complaint, it can been seen that he spent Rs.18,500/- only towards hospital expenses. He admitted that he spent Rs.4,000/- only after discharge for physiotherapy and medicine. No doubt, an insured is entitle to get the expenses which is incurred only during the admission in the hospital. The counsel for the second opposite party contended that even though the complainant claimed Rs.18,500/- as the expenses incurred in the hospital, he has not produced any bills or certificates to prove it. But, the counsel for the
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complainant argued that the bills and other documents have already been given to the opposite parties. Ext.A6 and A7 are the letters from the second opposite party by which they demanded some more documents from the complainant. In Ex.A6 and A7, the second opposite party has not demanded for the bills. It means that the complainant had already given bills related to his treatment to second opposite party. Therefore, the reason put forth by the complainant for the non production of the bills before this commission is to be accepted. Moreover, the second opposite party has no dispute with regard to the expenses incurred by the complainant for his treatment in the hospital. They have not mentioned anything in their version challenging the alleged expenses incurred by the complainant for his treatment in the hospital. There must be a specific denial from the side of opposite party if they have not admitted anything contained in the complaint. The second opposite party has taken only one contention that the complainant is not entitled to get the claim because he need not be admitted in hospital for the alleged treatment. So, we have to assume that there is no dispute from second opposite party with regard to the expenses allegedly incurred by the complainant or they admitted this fact. Admitted fact need not be proved. Since, the complainant met Rs.4,000/- towards his treatment expenses only after discharge,
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he is not entitle to get this amount. So the complainant is entitled to get Rs.18,500/- from the opposite parties instead of Rs.22,500/-.
11. The complainant claims Rs.10,000/- as damages. It is evident that even though the complainant is entitled to get claim amount from opposite parties, they denied the same. The complainant put forth his claim on 06.06.2017. Till now, the opposite parties have not given anything. Before this commission also, they disputed that the complainant is entitled to get insurance claim. Therefore complainant is entitled to get compensation. But it is to be noted that claim of Rs.10,000/- is excessive. Rs.5,000/- is reasonable. He is also entitled to get Rs.2,000/- as cost. Hence the points are found accordingly.
12.Point No.3:- Since we found Point No.1 and 2 in favour of complainant, he is entitled to get Rs.18,500/- towards treatment expenses, Rs.5,000/- as compensation and Rs.2,000/- as cost.
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In the result the complaint is allowed and the opposite parties are directed to pay Rs.18,500/- (Rupees Eighteen Thousand and Five Hundred only) towards treatment expenses and Rs.5,000/- (Rupees Five Thousand Only) as compensation and Rs.2,000/- (Rupees Two Thousand only) towards cost to the complainant within 30 days from the date of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 15th day of October 2020.
Date of Filing: 19.12.2017. PRESIDENT :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the complainant:-
PW1. Pradeesh Chembra. Insurance Advisor.
Witness for the Opposite Parties:-
Nil.
Exhibits for the complainant:
A1. Copy of Premium Paid Certificate. Dt:04.07.2016.
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A2. Copy of ID Card.
A3. Copy of Denial of Cashless Access. Dt:30.05.2017.
A4. Copy of Certificate. Dt:01.06.2017.
A5. Copy of Discharge Summary.
A6. Copy of Deficiency Letter.
A7. Copy of First Reminder Letter. Dt:12.07.2017.
A8. Copy of Letter. Dt:14.07.2017.
A9. Copy of Certificate. Dt:14.08.2017.
Exhibits for the opposite parties:-
B1. Copy of Group Health Insurance Policy Schedule.
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
SENIOR SUPERINTENDENT,
CDRF, WAYANAD.
