Date of filing : 13-04- 2012
Date of order : 23-11 -2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.104/2012
Dated this, the 23rd day of November 2012
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT. K.G.BEENA : MEMBER
P.Balakrishnan, } Complainant
S/o.Late.Kunhikannan Nair,
Near L.V. Temple, Hosdurg, Kanhangad.
(In Person)
The Manager, } Opposite party
United India Insurance Company, Kasaragod.
(Adv. C. Damodaran, Kasaragod)
O R D E R
SRI.K.T.SIDHIQ, PRESIDENT
Complainant is the holder of Synd Arogya MediClaim policy issued by opposite party. Complainant used to renew the policy from time to time. While so, as per the advise of Dr. Ramachandran he admitted in Saraf hospital Ernakulam and at the time of admission he informed about his mediclaim policy with the third party administrator engaged by the opposite party and they advised the cashless admission. But when he discharged on 17-10-2011 the third party Administrator TT.K. Health care service instructed the complainant to pay the hospital bill and told the complainant that the amount will be reimbursed. Subsequently he submitted the claim before opposite party with all medical bills and documents. But the opposite party repudiated his claim. Hence the complaint alleging deficiency in service on the part of opposite party.
2. According to opposite party claim is rejected in view of clause 4-10 of the policy. As per this clause Routine Investigation to find out anything normal with any of the system is not payable and only anything abnormal followed by active time of treatment is payable. According to opposite party the medical bill produced by the complainant were for `4801/-.
3 Complainant filed proof affidavit. Exts A1 to A3 series marked. On the part of opposite party Exts B1 to B4 marked. Both sides heard. Documents perused.
4. Whether the repudiation of the claim of complainant relying on clause 4.10 of the policy amounts to deficiency in service is the only issue to be settled in this case.
5. Ext.B1 is the certificate of insurance with policy exclusion clause as per that charges incurred at Hospital or Nursing home primarily for diagnosis X-ray or Laboratory examinations or other diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at a hospital/nursing home are excluded from claim.
6. Ext.B3 series bills shows that complainant had consumed medicines worth more than `2000/-. If this is not an active line of treatment, then what else it is? Had it been only diagnostic procedures with no result of any abnormality then there should not have any prescription of medicines.
7. In Ext.B2 discharge summary it is noted that the complainant is treated with Zaart and drugs for IBS (Irritable Bowel Syndrome) and he improved well and agreed to continue treatment at home. He was advised to continue medicines also. All this would indicate that the complainant had some Irritable Bowel Syndrome and for which he had undergone active line of treatment. Therefore opposite party should not have excluded the claim adhering on clause 4.10 of the policy.
8. The act of opposite party is therefore amounts to deficiency in service.
Complaint is therefore allowed and opposite party is directed to pay `4800/- to the complainant with a cost of `2000/-. Time for compliance is limited to 30 days from the date of receipt of copy of the order. Failing which `4800/- would further carry interest @ 9% per annum from today till payment.
MEMBER MEMBER PRESIDENT
Exts.
A1.Policy Schedule.
A2. Prescription of the complainant.
A3 series bills.
B1. Policy schedule.
B2. Discharge summary of Balakrishnan.
B3 series bills.
B4. Mediclaim computation.
MEMBER MEMBER PRESIDENT
Pj/
