DOF.20.08.2010
DOO.18.08.2011
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR
Present: Sri.K.Gopalan : President
Smt.K.P.Preethakumari : Member
Smt.M.D.Jessy : Member
Dated this, the 18th day of August 2011
CC.204 /2010
K.V.Dharma Rajan,
Divya Theatre,
Keloth,
P.O. Payyannur Complainant
(Rep. by Adv.B.P.Saseendran)
Manager,
United India Insurance Co. Ltd.,
U.I.,B.O.Payyannur,
P.B.No.29, Shenoy’s Building,
South Bazar, Temple Road,
Payyannur.
(Rep. by Adv.V.V.Gopinathan) Opposite parties
O R D E R
Sri.K.P.Preethakumari, Member
This is a complaint filed under section 12 of consumer protection Act for an order directing the opposite party to pay the claim amount of `31,993 along with `50,000 as compensation and cost.
The case in brief of the complainant is that he is the policy holder of Individual health Insurance Policy having No.100803148/09/97/00000417 and its validity is from 28.5.09 to 27.5.10 and his wife Geetha is also having coverage under the policy. She had fallen down on 8.9.09 and treated as inpatient in B.K.M. Hospital, Payyannur up to 10.9.09 and due to fall she had suffered fractured and luxated tooth and treated for that. Root Canal treatment and replacement of extracted tooth by artificial fixation and capping was done and had incurred `31,993. The complainant had submitted claim with relevant documents on 30.10.09. But the opposite party rejected the claim of the complainant on 28.11.09 by saying that the claim is not admissible as patient admitted with case of dental treatment and it is not payable under medi claim under clause 4.7 of medi claim policy. The exclusion in clause 4.7 is applicable to cosmetic dental treatment and Dental treatment of surgery if any kind unless requiring hospitalization. The injury sustained by the complainant’s wife is due to a fall and was hospitalized due to the fracture of the tooth. Immediately after the discharge from the hospital, complainant issued lawyer notice to opposite parties on 8.2.10 to pay the claim amount. The complainant has been taken the medi-claim policy for the last 15 years continuously, he has made much more trust and faith upon the service of Insurance company. When the complainant approached the company for the claim the authorities behaved in an irresponsible manner. The mental agony and pain suffered by the complainant due to such harsh and cruel behaviour cannot be compensated in terms of money. The complainant is claiming `50,000 from the opposite parties as compensation. The opposite parties are liable to pay compensation due to deficiency of service and unfair trade practice. Hence this complaint.
In pursuance to the notice issued by the Forum opposite party appeared and filed version contending that the complaint is bad for non-joinder of necessary parties, since the patient
Mrs. Geetha and Medi Save Health Care (TPA) Ltd. 2nd floor, Central Aracade, Azad Road, Kaloor are not made as parties. The opposite party admits that they have issued policy having NO.100803/48/09/97/00000417, but contended that the liability of opposite party is limited as per the terms and conditions, exceptions, clauses and other endorsement contained in the policy. As per the discharge summary the patient had history of fall and fractured upper left 6, 3, 1 and upper right 1, 2, tooth’s and fixation in upper left 5 and lower left 6 and from the treatment record it can be seen that the root and canalling and capping were done on teeth upper left 2,7,65 and upper right 1,3,4,5 which is not practically possible due to fall in the bath room. So as per terms and conditions of policy any type of expenses for dental treatment or any Surgery of any kind unless requiring hospitalization are not covered under exclusion clause No.4,7 of the policy. Hence there is no deficiency of service on the part of opposite party. So the complaint is liable to be dismissed.
Upon the above contentions the following issues have been taken for consideration:-
1. Whether the complaint is bad for non-joinder of necessary
parties?
2. Whether there is any deficiency on the part of opposite
Party?
3. Whether the complainant is entitled for the remedy as
prayed in the complaint?
4. Relief and cost.
The evidence consists of oral testimony of PW1, DW1 and Ext. A1 to A6 and Ext.B1 to B9.
Issue Nos.1 to 4
The complainant has the case that he is a valid insurance policy holder of individual health insurance policy from 28.5.09 to 27.5.10 and his wife also have the coverage of the same. On 8.9.09, she had fallen down and sustained fractured tooth and undergone treatment and had incurred `31993.Inorder to prove his case he was examined as PW1 and documents like photocopies of discharge summary, cash bills dt.10.9.09, copy of lawyer notice and the policy etc. were produced. The opposite party examined the treated doctor as DW1 and produced documents like the original of discharge summary, bills dt. 10.9.09, Bills dt.8.9.09 and health Insurance claim form. The opposite party contended that the wife of the complainant Mrs.Geetha and Med Save Health care are not made as parties and hence they are to be included as parties and hence the complaint is bad for Non-joinder of necessary parties. The policy taken by the complainant is admittedly a group policy and the above said Geetha who is the wife of the complainant is also covered under the policy. Complainant took the policy by paying consideration and Geetha is the beneficiary of the Insurance policy and hence complainant can file the complaint. Admittedly the privity of contract is between the opposite party and the complainant and the MedSave Health Care is only a TPA. So the complaint is maintainable even without arraying them as parties and hence complaint is not bad for non-joinder of necessary parties and hence issue No.1 is found in favour of the complainant..
The opposite party admits that they issued the policy having No.100803/48/09/97/06000417. But contended that the liability of opposite party is limited as per the policy since any type of expenses for dental treatment or any surgery of any kind unless requiring hospitalization are not covered as per exclusion clause No.4.7 of the policy. But clause 4.7 of Exclusion clause in Ext.A6 policy states that “Dental treatment or surgery of any kind unless requiring hospitalization”. The complainant’s case is that she had sustained fractured and luxated tooth due to fall in a bath room. Ext.B1 is the Discharge summary and A1 is the photo copy of the same. As per Ext.B1 and A1 the patient had admitted on 8.9.09 and discharged on 10.9.09 and the diagnosis done by the treated doctor is “Fractured and Luxated tooth” and he was examined as DW1. He admitted that “he had treated one Geetha and Ext.B1 discharge summary is issued by him. The opposite party contended that fractured upper left 6,3,1 and upper right 1,2 tooth and fixation in upper left 5 and lower left 6 and root canalling and root capping on teeth Nos. upper left 2,7,6,5 and upper right 1,3,4,5 are not practically possible due to fall in the bathroom. But the doctor answered as “it is possible” to a question put to him by the opposite party’s counsel that “ whether RCT and capping can be done on teeth number upper left 2,7,6,5 and upper right 1,3,4,5 practically possible due to fall in the bath room?”. The doctor further deposed that he had advised root canal treatment and replacement of extracted tooth by artificial fixation as per X-ray report. The doctor again deposed that “in this case she was admitted on 8.9.09 and discharged on 10.9.09 and was admitted for dental treatment”. So from the above deposition of DW1 doctor it is clear that the patient was hospitalized for dental treatment and hence the claim will not come under the purview of exclusion clause 4.7. Moreover admittedly there is valid policy for the relevant period. So we are of the opinion that the complainant’s wife will came within the coverage of the policy.
Then the next question to be decided is the quantum. The complainant contended that he had incurred `31,993 for the treatment. The opposite party has produced Ext.B2 to B7 bills which were produced by the complainant before them and the complainant also produced the photo copies of the same. Total amount incurred by the complainant for the treatment of his wife as per these bills are `31,993. The DW1 doctor deposed that “Ext.B2 and B3 is the receipt dt.10.9.09 issued by hospital and signed by me”. The other bills are the bills for incidental expenditure. So the complainant is entitled for refund the above amount of `31,993 from the opposite party. Moreover there is deficiency of service of the opposite party since they have repudiated the claim wrongly and hence the complainant is also entitled to get `2500 as compensation and `1000 as cost of this proceedings and order passed accordingly.
In the result, the complaint is allowed directing the opposite party to pay `31993(Rupees Thirty one thousand Nine hundred and Ninety three only) as treatment expenses along with `2,500 (Rupees Two thousand five hundred only) as compensation and `1000 (Rupees One thousand only) as cost of these proceedings to the complainant within one month from the date of receipt of this order, otherwise the complainant is entitled to execute the order as per the provisions of consumer protection Act.
Sd- Sd/- Sd/-
President Member Member
APPENDIX
Exhibits for the complainant
A1. Copy of the discharge card issued by BKM Memorial
Hospital
A2. Copy of the cash bill issued from BKM Memorial Hospital,
Payyannur.
A3. Copy of the receipt issued by Dr.Ranju Vinay
A4. Copy of the letter dt.28.11.09 issued by OP
A5. Copy of the lawyer notice sent to Ops
A6. Individual health insurance Policy & conditions
Exhibits for the opposite party:
B1. Discharge summary of Geetha issued from BKM Memorial
Hospital
B2. & B3. Receipts dt.10.9.09 issued by Dr.Ranju Vinay
B4 & 5. Cash bills issued by BKM Hospital
B6 & 7. Bill issued from BKM Hospital dt. 8.6.09.
B8. Medical report issued by Dr.Ranju Vinay
B9. Health insurance policy claim form dt.30.10.09 executed
by complainant
Witness examined for the complainant
PW1.Complainant
Witness examined for the opposite party:
DW1. Dr.Ranju Vinay
/forwarded by order/
Senior Superintendent
Consumer Disputes Redressal Forum, Kannur.
