By. Smt. Renimol Mathew, Member:-
Brief of the complaint:- The complainant is a beneficiary of health insurance scheme given by opposite party. On 17.07.2012 complainant's wife admitted in Malabar Institute of Medical Science Hospital, Calicut and she was examined by Neurologist, dermatologist and Gynecologist. Various tests were conducted and diagonized that she is having Bilateral carpal tunnel syndrome lichen amyloidosis in forearms and she was discharged on 18.07.2012. She was admitted for 26.30 hours. The very next day itself claim form submitted to opposite party, but her claim was rejected by opposite party on 15.12.2013 stating that the treated deceases are not so serious to treat as inpatient. Complainant alleges that this act of the opposite party is deficiency in service and complainant prays for an order to get the claim amount that shown in the bills together with compensation and cost of this proceedings.
2. Notice sent to opposite party, opposite party appeared and filed written version.
3. Opposite party filed written version in short it is as follows:- Opposite party admitted that claim form submitted by the complainant was forwarded to third party settlement authority known as Paramount Health Services Authority. They have on careful examination reached in a conclusion that “ the present claim of a 50 years old female patient, who was admitted in the hospital as a case of Bil Capal Tunnel syndrome with Lichen Amyloidosis in Forearms. As per the submitted documents it is evident that the treatment given did not necessitate hospitalization which could have been done on OPD (Out Patient Department) basis. Hence this claim is not admissible as hospitalization not justified”. Opposite party further stated that according to clause 2.3.1 of policy conditions “procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours”. Hence there is no deficiency of service from the part of the opposite party. So opposite party prays for the dismissal of the complaint.
4. On considering the complaint, affidavit, version and documents the following points are to be considered:-
1. Is there any deficiency in service on the part of the opposite parties?
2. Relief and Cost.
5. Points No.1 & 2:- Complainant's evidence consist of testimony of PW1 and Exts.A1 and A2 documents. Ext.A1 is the Claim Form submitted by complainant to opposite party. Ext.A2 is the hospital bills issued from Malabar Institute of Medical Science Hospital, Calicut. Opposite party was examined as OPW1 and Exts.B1 to B5 documents marked. Ext.B1 is the policy documents. Ext.B2 is claim form. Ext.B3 is the discharge summary, Ext.B4 is the letter of Paramount Health Services (Third Party Authority) and Ext.B5 is the letter of United India Insurance company dated 18.09.2012.
6. On perusal of the documents Exts.A1 and A2 it is clear that complainant admitted in Malabar Institute of Medical Science Hospital, Calicut for consecutive 26.30 hours and paid the bill amount of Rs.8,217/-. There is no dispute in policy. She was examined by three specialist Doctors, and various lab tests were conducted and finally diagonized her decease. All the investigation procedures took 26.30 hours, after a detailed evaluation they diagonized her decease. In this case we assume that this lady was admitted by the advice of consulted physician not on her request. Only the Consulted Doctor can decide whether a patient need hospitalization or not. On perusal of Ext.B1 document clause 2:3 states that “Hospitalization means admission in Hospital/Nursing Home in India upon the written advice of a Medical Practitioner for a minimum period of 24 consecutive hours”. In this case she was admitted for more than 24 hours but in clause 2.3.1 note “procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours”. According to Exts.B4 and B5 the treatment given to this lady did not necessitate hospitalization which could have done on inpatient department basis. In this case this 50 year old lady approached with neck pain radiating to left arm. She was examined by specialized Doctors. At the time of hospitalization complainant doesn't know whether it is for diagnosis or not. In this case final findings is not 'so series' is not at all considered as a fault from the part of the complainant. If it be so serious what was the result?. For every findings need an investigation, the Doctor can do only to admit the patient showing severe symptoms, so in this circumstances denial of the claim is a clear deficiency of service from the side of opposite party. So complainant is entitled for claim from the Insurance company with cost and compensation. Points No.1 & 2 decided accordingly.
In the result the complaint is partly allowed and complainant is entitled to get bill amount of Rs.8,217/- (Rupees Eight Thousand Two Hundred and Seventeen) only from opposite party. The opposite party is directed to pay the amount and also directed to pay interest at the rate of 10% for the bill amount from the date of this complaint that is on 16.02.2013 and opposite party is also directed to pay Rs.2,000/- (Rupees Two Thousand) only as cost and compensation. This Order must be complied by the opposite party within 30 days from the date of receipt of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 30th day of September 2013.
Date of Filing:-16.02.2013
PRESIDENT :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. Thariyath. Complainant.
Witness for the Opposite Party:
OPW1. Sajeev. Opposite Party.
Exhibits for the complainant:
A1. Copy of Claim Form.
A2. Copy of Bills.
Exhibits for the opposite Party.
B1. Policy Document.
B2. Copy of Claim Form.
B3. Discharge Summary.
B4. Letter. Dt:07.08.2012.
B5. Letter. Dt:18.09.2012
Sd/-
PRESIDENT, CDRF, WAYANAD.
