By Sri. Chandran Alachery, Member:
The complaint filed under section 12 of the Consumer Protection Act 1986 for an order directing the Opposite Parties to pay Rs.26,845 with 12% interest being the balance amount claim payable to the Complainant together with Rs.10,000/- as compensation for the deficiency of service of Opposite Parties and subsequent mental agony and financial loss sustained to the Complainant.
2. The case of the Complainant in brief as follows:- The Complainant took a Family Health Insurance Policy vide Policy No.101602/48/11/6/00002038 with the Opposite Parties having coverage for the period 18.01.2012 to 17.01.2013 on 13.02.2012, the Complainant admitted at Regional Cancer Centre, Thiruvananthapuram for the treatment of breast cancer and discharged on 21.02.2012. The total expenses for the treatment is Rs.41,845/-. Thereafter the Complainant submitted claim form with the Opposite Parties with all relevant records and bills. But the Opposite Parties allowed only Rs.15,000/- towards the expenses repudiating the balance amount. So the Complainant states that there is deficiency of service from the part of the Opposite Parties and hence this complaint.
3. On receipt of complaint, notices were issued to the Opposite Parties and notices were served to the Opposite Parties. Opposite Party No.2 appeared and filed version. Opposite Party No.1 not appeared even after getting notice and 1st Opposite Party is set exparte on 20.07.2013. The 2nd Opposite Party stated in the version that the Complainant had already received Rs.54,284/- towards medical expenses for a treatment availed at Baby Memorial Hospital, Kozhikode for the treatment of Cacinoma Breast. The present claim of Rs.41,845/- is for the continuation of the same ailment post hospitalisation treatment availed at Regional Cancer Centre, Thiruvananthapuram on 09.03.2012, 12.03.2012, 19.03.2012 and 21.03.2012 without admission in the hospital, out of which, Rs.15,000/- were allowed by the Opposite Parties as cashless benefit as per clause 1.2 of the policy condition ie 10% of sum assured. The Complainant is eligible to get only Rs.15,000/- and not entitled for the balance amount of Rs.26,845/-.
4. On perusal of complaint, proof affidavit, and documents of Complainant, version of 2nd Opposite Party the Forum raised the following points for consideration.
1. Whether there is deficiency of service from the part of Opposite Parties?
2. What order as to cost and compensation?
5. Point No.1:- In this case, the Complainant is examined as PW1 and Ext.A1 is marked. Ext.A1 is the authorisation letter. 2nd Opposite Party filed version stating that as per the medicare policy condition, the Complainant is entitled to get only 10% of the sum insured in pre and post hospitalisation. As per policy condition No.3.2, the relevant medical expenses incurred during the period up to 60 days after hospitalisation will be considered as part of claim and as per condition 1.2 of the policy, the reimbursement for the pre and post hospitalisation in respect of any illness is limited to actual expenses subject to the maximum of 10% of the total sum insured. Sum insured is Rs.1,50,000/-, 10% of Rs.1,50,000/- is Rs.15,000/-. So the 2nd Opposite Party allowed Rs.15,000/- to the Complainant. The Complainant contends that as per policy condition 2.3, Chemotheraphy is specific treatment and hospitalisation is not necessary and even if treatment is for less than 24 hours, such treatment will be considered under hospitalisation benefit. On verification of the condition, the Forum found that it is correct and as per condition 2.4, reasonable and necessary expenses shall be given to the Complainant. Reasonable and necessary expenses shall mean the cost of surgical or medical expenses that is necessary for treating the condition of the insured person to the extent relatable to such conditions. Here the Forum analysed that Chemotharaphy is a treatment which involves specialised infrastructure facilities and the whole expenses incurred for such treatment the related expenses for the special treatment which the Complainant is entitled to get. This treatment cannot be considered under condition 1.2 and 3.2 of the policy. This treatment must be considered separately as per conditions2.3 and 2.4. Here the Complainant incurred a sum of Rs.41,845/- and submitted all bills. But 2ndOpposite Party allowed only10% of sum insured ie Rs.15,000/-. The actual expense incurred is more than that. Unlike other ailments, this treatment requires special consideration and the Forum is of the view that the complainant is entitled to get the entire expenses as reimbursement. Here the 2nd Opposite Party considered the claim as a general case. So the Forum found that there is deficiency of service from the part of 2nd Opposite Party in dealing the matter. Point No.1 is found accordingly.
6. Point No.2:- Since the point No.1 is found in favour of Complainant, the complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the 2nd Opposite party is directed to pay the balance amount of Rs.26,845/- with 12% interest from filing of the complaint till realisation along with Rs.1,000/- as compensation and Rs.1,000/- as cost of the proceedings. The 2nd Opposite Party shall pay the amount within 30 days of the receipt of this order.
Dictated to the C.A transcribed by him and corrected by me and pronounced in the Open Forum on this the 25th day of April 2014.
Date of filing:06.06.2013.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True copy/
PRESIDENT, CDRF, WAYANAD.
A P P E N D I X
Witness for the Complainant:
PW1. Steephen Saju Business.
Witness for the Opposite Parties:
OPW1. Sajeevan. Manager, United India Insurance Co. Ltd., Sulthan Bathery
Exhibits for the Complainant:
A1. Authorisation Letter. dt:09.10.2013.
Exhibits for the Opposite Parties:
B1. Family medicare Policy.
