DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 18th day of July, 2022
Present : Sri.Vinay Menon V., President
: Smt.Vidya A., Member
: Sri.Krishnankutty N.K., Member Date of Filing: 13/03/2019
CC/64/2019
- C.Venugopalan,
S/o.Late C.P.Chandrasekharan Nair,
Aiswarya, Madathil veedu, Pullode (PO),
Puthiyankam Via, Palakkad – 678 545
- M.Suseela,
W/o.C.Venugopalan,
Aiswarya, Madathil veedu, Pullode (PO),
Puthiyankam Via, Palakkad – 678 545 - Complainants
(Party in person)
Vs
1.Manager,
M/s.Vidal Health Insurance TPA Pvt.Ltd.,
Door No.40/3232, 2nd Floor,
SL Plaza, Near Rajarajeswari Temple,
Palarivattom, Cochin – 682 025
2. Branch Manager,
United India Insurance Co.Ltd.,
Bancassurance Office,
3rd Floor, Vettukattil Building,
Jos Junction, MG Road,
Ernakulam – 682 016 - Opposite Parties
(OPs by Adv.Priya Anil)
O R D E R
By Sri. Vinay Menon V., President
- 1st complainant is the husband of the 2nd complainant. Both complainants are beneficiaries of a health policy issued by the opposite parties.
- Quintessentially complaint pleadings are to the effect that the complainant alongwith his wife are beneficiaries under Synd Arogya Group Health Insurance Policy issued by the opposite parties. They are entitled to cover for treatments stated in the policy document. 2nd complainant underwent treatment for Pemphigus Vulgaris in the Medical College Hospital, Thrissur. The 2nd complainant had to undergo hospitalization on 4 occasions under the advice of the treating doctor for availing costly injection. Upon raising claim for the amounts expended for treatment, the claim was repudiated by the opposite parties on the ground that the treatment underwent by the 2nd complainant could have been carried out as OP and not as IP. Hence, the claim was rejected. Aggrieved thereby, this complaint is filed seeking for an amount of Rs.56,478.32 being the hospital expenses and for incidental and ancillary expenses.
- The opposite parties entered appearance and filed version countering the complaint allegations. They stated that the procedure underwent by the beneficiary was only a Day procedure not requiring hospitalization for 24 hours and was therefore not covered under clause 3.1 of the policy document and sought for dismissal of the complaint as the complainant’s claim was beyond the scope of the cover provided by the policy. Prior approval was not obtained. They also contended that the complaint is not maintainable in view of arbitration clause in policy document.
- The following issues arise for consideration.
- Whether the complaint is maintainable in view of arbitration agreement in the policy document ?
- Whether, the treatment underwent by the beneficiary is strictly excluded under the terms and conditions of the policy document.
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties ?
- Whether the complainant is entitled to the reliefs sought for?
- Reliefs, as to Compensation and Cost ?
5. Complainant 1 conducted the proceedings for and on behalf of 2nd complainant. Exts.A1 to A28 were marked on the part of complainants. He was examined as PW1. Eventhough opposite party produced documents for marking, it was not marked since the said document was already marked as Exts.A7(a) & (b).
Exts.A5 & A9 were objected to by the counsel for opposite party on the ground that the said documents could be marked only through the doctor who issued them. Exts.A16 to A28 were objected to as they were photocopies. Since this Commission is not bound by the strict procedures contemplated under the Indian Evidence Act and considering the fact that the opposite parties had no case that the documents objected to were forged / fabricated, the objections raised by the opposite parties are overlooked.
Issue No. I
6. The opposite party has disputed the jurisdiction of this Commission to proceed with this complaint in view of the arbitration clause in Exts.A7(a) & A7(b). The Honourable Supreme Court has in various cases upheld that the reliefs granted under the Consumer Protection Act is over and above the reliefs granted in other statutes and has reiterated that an arbitration clause will not exclude the jurisdiction of this Commission. Hence, we hold that this Commission has jurisdiction to try this complaint.
Issue No.2
7. The procedure underwent by the beneficiary is not disputed. The only dispute raised by the opposite party is that the treatment underwent by the second complainant could have been carried out as OP instead of IP.
The complainant asserts that insofar as the 2nd complainant is concerned, the treatment could be done only as an inpatient and not as an outpatient. He deposed in the same vein regarding the treatment provided to his wife viz. the second complainant. The opposite parties denied these contentions stating that the treatment underwent by the 2nd opposite party could be carried out as an outpatient and it was only to avail benefits under the insurance policy that the 2nd complaint was made to undergo treatment as an inpatient.
8. In order to ascertain the facts and circumstances in disputes in a clear manner we need to understand the relevant provisions of the terms and conditions provided in Ext.A7(b).
9. Ext.A7(b) is the health insurance policy alongwith the policy schedule pertaining to the policy issued to the 2nd complainant. The opposite party relies on clause 3.1 of the policy conditions. Policy 3.1 reads as follows :
“3.1 – Expenses on hospitalization for minimum period of 24 hours are admissible. However this time limit is not applied to specific treatments such as ………………”
The above heading is followed by a list of 35 instances. Then clause 3.1 continues :
“Or any other surgeries / procedures agreed by the TPA / Company which require less than 24 hours hospitalization and for which prior approval from TPA / Company is mandatory. This condition will also not apply in case of stay in hospital of less than 24 hours provided –
- The treatment is such that it necessitate hospitalization and the procedure involves specialized infrastructural al facilities available in hospitals
- Due to technological advances hospitalization is required for less than 24 hours only.
- They are carried out in Day Care Centre networked by TPAs where requirement of minimum number of beds overlooked but having (i) fully equipped Operation Theatre (ii) fully qualified Day Care Staff (c) fully qualified Surgeons / Post Operative attending Doctors.
Note 1 : Procedures / treatments usually done in outpatient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres.”
Note 2: xxxxxxx (not relevant)”
10.(a) It would be appropriate to dissect clause 3.1 to understand the nature, ambit and spirit of the clause.
This clause (3) has three parts.
1)The first line which states the minimum period requirement for admissibility;
2) Rest which deals with exclusion; and
3) Notes
11.(b) i) First line deals with expenses on hospitalization for minimum period of 24 hours. That is, the beneficiary should have spent at least 24 hours in the hospital.
ii) But, if the patient or the beneficiary is suffering from any of the 35 conditions stated in the schedule, the beneficiary need not spent 24 hours in the hospital.
iii) The necessity to stay in the hospital for a minimum of 24 hours will not apply also where the treatment is undertaken under GA or LA due to advancement in technology.
iv) It also follows that, if in the normal course, the hospitalization requirement was more than 24 hours but took only lesser time, indemnification is possible even if stay in the hospital was for less than 24 hours.
12. Spending of over 24 hours in the hospital by the 2nd complainant is not disputed. Hence, the question that is to be answered is whether the procedure carried out on the beneficiary is a Day procedure not requiring hospitalization for a period of over 24 hours. The opposite party relies exclusively on clause 3.1 to hold their ground, more specifically on Note 1 in the said clause. Note 1 in the said clause is repeated herein below for easy reference.
“Note 1: Procedures / treatments usually done in outpatient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres.”
The procedures and treatment done on outpatient basis are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours. But this Note is qualified by insertion of the word “Usually”. What transpires from a reading of this Note 1 is that, even though the contract excludes many procedures as stated in 3.1, it is not an outright exclusion. It can be seen that the said Note 1 is a complete sentence even-if the word “usually” is avoided and would convey a complete sensible meaning. The word “usually” is therefore added to imply situations that may arise wherein an application of mind might be called for rather that outright mechanical application. The word “usually” waters down the blanket exclusion and brings in situations where a deviation from usual, customary, established or frequent usage is contemplated. Had the intention of the framers of Ext.A7(b) been to put in place an iron clad clause denying any benefits in its entirety, the word “usually” would not have found place.
The fact that the beneficiary suffers from various other ailments is undisputed. The opposite party has no case that the 2nd complainant is not suffering from any other disease and is otherwise healthy. The beneficiary herein an aged women, is suffering from various ailments. We would have appreciated the resort of the opposite party to clause 3.1 in Ext.A7(b), had the patient been young, healthy and afebrile. But applying the same conditions to a person of ill health and of advanced age as like the beneficiary herein, will not serve justice and is arbitrary and unconscionable in nature. We are of the opinion that the opposite party has resorted to one-size-fits-all attitude while applying the terms and conditions to the beneficiary herein. The spirit behind insertion of “usually” was given a blatant go-by without any application of mind.
13. Yet another relevant factor that requires to be considered is whether the admission of the second complainant was medically necessary. Clause 2(23) of Ext.A7(b) reads as follows:
2.23 – Medically necessary
Medically necessary treatment is defined as any treatment, test, medication, or stay in hospital or part of a stay in a hospital which
- is required for medical management of the illness or injury suffered by the insured ;
- must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope,duration or intensity;
- must have been prescribed by a medical practitioner;
- must confirm to the professional standards widely accepted ininternational medical practice or by the medical community in India.
What was medically necessary for the 2nd complainant is not something to be decided by the terms and conditions of an agreement. It is to be decided by the doctor who treated her. In the absence of a pleading by the opposite party that the doctor had unnecessarily and without considering the gravity of the condition of the second complainant had admitted the second complainant in the hospital, in total violation of 2.23, the opposite party is estopped from pleading that the complainant’s admission and treatment as IP was uncalled for. While the opposite party made a pleading that in the condition of the beneficiary, she required only lesser than 24 hours of hospitalization, it was incumbent upon the opposite party to prove the same with proper evidence. The opposite party should have adduced evidence like deposition by the Doctor who treated the beneficiary to prove that she did not require more than 24 hours of treatment.
14. A further cause for repudiation of the claim is that the complainant had not availed prior sanction from the opposite party. This sanction was necessary only if Clause 3.1 is applicable. Having found that clause 3.1 is not applicable, this question does not even arise for consideration.
15. Rejection of the claim without looking into the facts and circumstances and the underlying conditions of the beneficiary in a mechanical manner without application of mind, as had happened herein, in our opinion, tantamount to deficiency in service.
Issue No.3
16. In view of the discussion above, we hold that there is deficiency in service on the part of opposite parties in rejecting the claim of the complainant.
Issue Nos.4 & 5
17. In the facts and circumstances of the case, we hold as follows:
(a) The complainant is entitled to indemnification of the amount expended for the treatment incurred in hospitalization and medical treatment as admissible as per the terms and conditions of Ext.A7(b) policy schedule. The complainant is entitled to an interest of 10% per annum from the date of claim till the date of payment.
(b) The complainant is entitled to a compensation of Rs.10,000/- (Rupees Ten thousand only) as sought for by him.
(c) The complainant is further entitled to a cost of Rs.15,000/- (Rupees Fifteen thousand only)
Comply with the aforesaid order within 45 days of receipt of this Order failing which the complainant will be entitled to a solatium of Rs.250/- per month or part thereof from the date of this Order till full and final settlement of the amounts ordered above.
Pronounced in open court on this the 18th day of July, 2022.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 (a) – Photocopy of claim form for health insurance dated 8/10/2018
Ext.A1 (b) – Photocopy of claim form for health insurance dated 17/10/2018
Ext.A2 (a) – Print out of communication dated 24/10/2018 regarding claim
No.KOC-1018-CL-0004400
Ext.A2 (b) – Print out of communication dated 10/11/2018 regarding claim
No.KOC-1018-CL-0004400
Ext.A3 (a) – Original of communication bearing ref.No.4456/VIDAL HEALTH/42018
dt.27/11/2018
Ext.A3 (b) – Original of communication bearing ref.No.4456/VIDAL HEALTH/42018
dt.5/12/2018
Ext.A4 – Original of repudiation letter dated 29/1/2019.
Ext.A5 – Original of treatment certificate dated 24/1/2019 issued from Dept. of
Dermatology, GMC, Thrissur
Ext.A6 – Photocopy of ID card issued by United India Insurance Co.Ltd.
Ext.A7 (a) – Original of policy cum certificate bearing No.1013032817P108725428
Ext.A7 (b) – Original of policy cum certificate bearing No.1013032818P107850553
Ext.A8 – Original of electronic clearing service (credit) clearing mandate form dated
15/10/2018
Ext.A9 – Attested discharge summary with regard to IP No.201848547
Ext.A10 series – 13 medical bills
Ext.A11 – Original discharge card for IP No.45349 dated 29/9/2018.
Ext.A12 – Original discharge card for IP NO.201848547 dated 6/10/2018
Ext.A13 – Original discharge card for IP NO.49880 dated 13/10/18
Ext.A14 - Original discharge card for IP NO.20180339994 dated 20/10/18
Ext.A15 - Original discharge card for IP NO.201954725 dated 19/10/19
Ext.A16 – Photocopy of bill dated 18/9/18 for Rs.130/-
Ext.A17 (a) – Photocopy of bill dated 19/9/18 for Rs.36/-
Ext.A17 (b) – Photocopy of bill dated 19/9/18 for Rs.12/-
Ext.A18(a) – Photocopy of bill dated 19/9/18 for Rs.129/-
Ext.A18(b) – Photocopy of bill dated 19/9/18 for Rs.106/-
Ext.A19(a) – Photocopy of bill dated 20/09/18 for Rs.180/-
Ext.A19 (b) – Photocopy of bill dated 20/9/18 for Rs.6/
Ext.A20 - Photocopy of bill dated 21/9/18 for Rs.184.14/-
Ext.A21 (a) – Photocopy of bill dated 21/9/18 for Rs.30/-
Ext.A21(b) – Photocopy of bill dated 21/9/18 for Rs.36/-
Ext.A22 – Photocopy of bill dated 22/9/18 for Rs.120/-
Ext.A23 – Photocopy of bill dated 22/9/18 for Rs.49.60/-
Ext.A24 – Photocopy of bill dated 26/9/18 for Rs.88/-
Ext.A25(a) – Photocopy of bill dated 28/9/18 for Rs.12026/-
Ext.A25 (b) – Photocopy of bill dated 28/9/18 for Rs.12026/-(duplication of Ext.A25(a)
Ext.A26 (a) – Photocopy of bill dated 29/9/18 for Rs.30/-
Ext.A26 (b) – Photocopy of bill dated 29/9/18 for Rs.30/-(duplication of Ext.A26(a)
Ext.A27 – Photocopy of bill dated 29/9/18 for Rs.120/-
Ext.A28 – Photocopy of bill dated 18/9/18 for Rs.3025/-
Exhibits marked on the side of the opposite party
NIL
Witness examined on the side of the complainant
PW1 – C Venugopalan
Witness examined on the side of the opposite party
NIL
Cost : Rs.15,000/- allowed as cost.
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
