IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOLLAM
DATED THIS THE 22nd DAY OF DECEMBER 2021
Present: - Sri. E.M.Muhammed Ibrahim, B.A, LLM. President
Smt.S.Sandhya Rani. Bsc, LLB ,Member
Sri.Stanly Harold, B.A.LLB, Member
CC.No.270/2016
Dr.Aju Mohan,
Chithira, Kottapuram,
Paravur P.O.,
Kollam 691301. : Complainant
(By Adv.Kizhakkanela Sudhakaran)
V/s
1. The Manager,
Muthoot Finance Ltd.,
Parippally P.O., Kollam 691 574.
2. The Director,
GYS Global,
RELIGARE HEALTHINSURANCE : Opposite parties
COMPANY LTD.GYS GLOBAL PLOT
No.A3,A4,A5 Sector 125, Noida, U.P
Pin 201 301.
(By Adv.S.Dileepkumar)
ORDER
Smt.Sandhya Rani, B.Sc, LLB, Member
1. This is a case based on a complaint filed U/s 12 of the Consumer Protection Act 1986.
2. The averments in the complaint in short are as follows:-
Dr.Aju Mohan the complainant has been employed in Al-Noor Hospital at UAE has availed a Health Insurance Group Policy No.10277419 issued by 2nd opposite party RELIGARE HEALTH INSURANCE COMPANY LTD. bearing certificate No.1120000615743 for a sum of Rs.2,00,000/- as single premium mode under the plan dated 8th January 2016 through an intermediary, 1st opposite party Muthoot Insurance Broker Pvt.Ltd., Parippally, Kollam. While the complainant was practicing as a Medical Practitioner at UAE she suffered non stop vomiting when the senior doctors failed to diagnose the appeared disease she flew to Trivandrum and been admitted to KIMS Hospital on 7th May 2016 and also undergone an urgent surgical correction to the intestinal system on the same day itself. After the surgery the complainant demanded the opposite party to meet the hospital expenses through hospital communication system but they have rejected the demand on 12th May 2016 by stating that there should be two year waiting period for ailments leading to surgery of Genetic Urinary System unless necessitated by Malignancy. But the opposite parties’ scheme of insurance supposed to cover the ailments suffered and is eligible for reimbursements. The reason for denial shown by the 2nd opposite party is against the terms and conditions of insurance policy. The actual treatment done by the KIMS Hospital was for the intestinal system of the complainant which is evident from the discharge certificate issued from KIMS Hospital. Hence there is deficiency in service on the part of opposite parties. That the certificate of insurance No.112000015743 issued by the opposite parties cover all the ailments suffered by the complainant. That the policy quote, key exclusions, for medical expenses incurred for diagnosis or treatment of any pre existing disease shall not be admissible until the completion of first 24 months of continuous insurance coverage from the first cover start date under the first policy with us and genetic disorders, External Congential. Ailments, Dental Treatments(other than accident), infertility/impotency treatments. HIV of related complications. But from the discharge summary and clinical finding of the complainant it can be seen that “33 year old lady presented with loose stools, vomiting, abdominal pain followed by constipation since 3 days. She had loose stools 3 days prior. Developed vomiting later multiple episodes, biliosis. She had diffuse abdominal pain, sever, intermittent and constipation 3 days. No fever, altered bladder habits, Jaundice. Past illness and treatment. Nil comorbidities. No H/o surgery in the past, and the Discharge Diagnosis read as “Acute small bowel obstruction-adhesion of distayileum in pelvic adhesions”. From all these it is very obvious that the disease suffered by the complainant is within insurance policy since the complainant underwent abdominal surgical correction. The discharge certificate issued from the KIMS Hospital also shows that the actual treatment done by the KIMS Hospital was for the intestinal system which was not against the conditions of insurance policy. Hence the complainant’s claim is within the scope of the insurance scheme. The treatment of the complainant shall not come under the exclusion clause as alleged by the opposite parties. Thereafter the complainant send legal notice to opposite parties on 21.05.2016 demanding to take necessary steps to reimburse the amount paid by the complainant in respect of the treatment bill produced. Though the same was received by both opposite parties the 2nd opposite party replied by high lighting the Exclusions clauses 4, 4.1 etc. that the claim is not within the scope of policy terms and conditions. The reason for rejection shown in the reply notice amounts to conscious negligence and omission of expected duty and non-compliance of the basic rule of law prevailing in the insurance scheme which caused mental agony irreparable loss, injury and damages to the complainant. By considering all the above narrated facts and the financial loss suffered by the complainant the opposite parties are liable to compensate the damages. The complainant prays to allow him 1) to realize an amount of Rs.20,000/- for pain, mental agony and for deficiency in service. 2) to realize 1,19,850/- as reimbursement of the bill amount paid for treatment from both the opposite parties jointly and severally. Hence the complaint.
3. 1st opposite party set exparte. 2nd opposite party filed detailed version by stating that the complaint is not maintainable either in law or on facts. 2nd opposite party denied all the averments allegations expect those which are specifically admitted. As a customer of the 1st opposite party M/s Muthoot Finance Ltd. the 2nd opposite party had issued a mediclaim policy to the complainant via certificate of insurance bearing No.10504177 w.e.f. 9th June, 2016 till 8th June, 2017 for a sum insured Rs.2,00,000/- subject to policy terms and conditions. On 07.05.2016 when the complainant has got admitted at KIMS Hospital, Thiruvananthapuram he had requested cashless treatment facility with the 2nd opposite party via concerned Hospital Authorities. But the 2nd opposite party denied the request of the complainant for cashless treatment facility vide letter dated 12the May 2016 stating that her illness were included within the exclusion clause of the policy condition that she had undergone treatment for her complaints associated to Genito-Urinary System. As per the exclusion clause 3(3.1) (b) (i) (VI) of the policy condition any claim arising out of the surgical procedures relating to Genito-Urinary System during the 1st 24 consecutive months from the date of commencement of the policy shall not be payable unless the above surgical procedure is necessitated by malignancy. The cashless treatment facility provided by the 2nd opposite party is not a right of the policy holder but it is a benefit facility provided by the opposite party to its customers regardless to the policy condition which is absolutely as per the terms and conditions of the policy. In the instant case the opposite party denied the request of the complainant for cashless treatment policy on valid grounds, which are specifically mentioned in the denial letter issued by the opposite party. However the complainant had always got an option to file claim directly to the company for reimbursement of the hospitalization expenses by submitting original medical bills and the treatment records pertaining to the treatment undergone by the complainant after discharge from the hospital and the company will consider the claim afresh, if the claim is payable as per the terms and conditions of the policy. But the complainant never approached the company for considering reimbursement of her claim as provided in the policy terms though the request for cashless facility has been denied by this opposite party on valid reasons. Therefore the complainant cannot attribute any deficiency in service against this opposite party and the present complaint is liable to be dismissed being premature in nature. The complainant has no cause of action to attribute any deficiency in service against the opposite party for the mere denial of cashless hospitalization facility on valid grounds. The claim advanced by the complainant against this opposite party towards her treatment expenses and compensation are not allowable and are liable to be dismissed with compensatory cost of this opposite party.
4. In view of the above pleadings the points that arise for consideration are:-
- Whether there is any deficiency in service or unfair trade practice on the part of opposite parties?
- Whether the complainant is entitled to realize Rs.1,19,850/- as reimbursement of the bill amount paid for her treatment at the KIMS Hospital, Thiruvananthapuram from opposite parties?
- Whether the complainant is entitled to get any compensation from opposite parties as prayed for?
- Reliefs and costs?
5. Evidence on the side of the complainant consists of oral evidence of PW1, who is Mohana Kurup (Power of Attorney holder of the complainant) and Ext.A1 to A10 documents. 1st opposite party set exparte. No oral evidence on the side of 2nd opposite party but got marked Exts.D1 to D3 documents. Both parties filed notes of arguments and also advanced oral arguments.
Point No.1 & 2
6. For avoiding repetition of discussion of materials these two points are considered together. The following facts are undisputed rather admitted in this case. The complainant Dr.Aju Mohan is a medical practitioner employed at Al-Noor Hospital, UAE . She is represented by her father who is the power of attorney holder as per Ext.A1(deed of power of attorney). She had availed a mediclaim under group care (scheme for MEL) with 2nd opposite party RELIGARE HEALTH INSURANCE COMPANY LTD. bearing policy No.10277419 through 1st opposite party intermediary, Muthoot Finance Ltd. for Rs.2,00,000/- as single premium mode as per Ext.A2 insurance policy and the complainant had paid the premium amount Rs.2,411/- thus there existed a valid live health insurance contract between the complainant and the opposite parties. But on 07.05.2016 the complainant had undergone an urgent surgical correction to the intestinal system at KIMS hospital TVM. Though the complainant had demanded the opposite parties to meet the hospital bill Rs.1,19,856/- in respect of the treatment carried out by KIMS Hospital ,the 2nd opposite party rejected the demand by stating that there should be two year waiting period for ailments leading to surgery of Genetic Urinary System unless necessitated by malignancy.
7. According to the 2nd opposite party they have denied request of the complainant for cashless treatment facility vide Ext.A3 letter stating that her illness were included within the exclusion clause of the policy condition that she had undergone treatment for her complaints associated to Genito-Urinary System. Therefore the denial of the claim of cashless policy is justifiable and that fact is mentioned in Ext.A3 repudiation letter. But the complainant would claim that the reason for denial shown in the repudiation letter send by the opposite parties are against the conditions of insurance policy. The actual treatment done by the KIMS hospital was for the intestinal system which is shown on the discharge certificate itself. The content of discharge certificate is reiterated in paragraph 10 of the complaint. The said fact is again reiterated in paragraph 5 of the proof affidavit. Though the PW1 was subjected to severe cross examination nothing material has been brought out to disbelieve the above case of the complainant stated in paragraph 10 and 11 of the complaint as well as paragraph 5 of the proof affidavit. The above case of the complainant stands corroborated by clinical findings noted in Ext.A8 discharge summary wherein it is stated that she was admitted in KIMS Hospital with ailments like loose stools, vomiting, abdominal pain followed by constipation since 3 days, multiple episodes, biliosis, diffuse abdominal pain. No fever, altered bladder habits, Jaundice, Past illness and treatment. Nil comorbidities. No H/o surgery in the past and the O/E: GC fair. Mildly rehydrated. Vitals: Stable. In view of the clinical findings noted in Ext.A8 discharge summary it is crystal clear that illness of the complainant for which she got admitted at KIMS hospital and undergone treatment would not come within the exclusion clause of Ext.D1 policy conditions and it is also crystal clear from Ext.A8 discharge summary that the actual treatment done by the KIMS hospital for the intestinal system of the complainant. Hence the reason for rejection of the cashless claim forward by the complainant while undergoing treatment at the KIMS hospital is not legal and proper.
8. It is further to be pointed out that during cross examination of PW1 the 2nd opposite party would admit that the insurance company is ready to settle the claim and reimburse the treatment expenses in case the complainant would file the claim form along with the connected documents. The complainant has also expressed her willingness. In view of the admission of the 2nd opposite party it is clear that the opposite party has realized its fault and now came forward to settle the claim. As the opposite party has not properly considered the cashless claim and settled the matter there is deficiency in service on the part of the opposite parties in Ext.A4 lawyer notice the complainant has specifically stated that since the insurance company has not settled the claim in time the complainant has suffered insecurity, financial loss and mental agony and all the suffering caused to the complainant is due to the irresponsible, non judicious and malicious act of the opposite parties. In view of the above materials on record we hold that the opposite parties have committed deficiency in service which resulted in much mental agony apart from financial loss to the complainant. Therefore the complainant is entitled to get reimbursement of the bill amount paid by her for the treatment at the KIMS hospital and also entitled to get compensation as prayed for in the complaint. The point answered accordingly.
Point No.3
In the result the complaint stands allowed in the following terms.
- Opposite parties 1 and 2 are directed to reimburse eligible medical expenses met by the complainant as per Ext.A9 series medical bills within 45 days from the date of receipt of a copy of this order.
- Opposite parties 1 and 2 are further directed to pay Rs.20,000/- as compensation for the deficiency in service and for mental agony sustained to the complainant due to the improper rejection of the medical claim raised by the complainant.
- The opposite parties are also directed to pay Rs.10,000/- as costs of the proceedings.
- It is made clear that in order to settle the claim, the complainant has to lodge a claim along with supporting medical bills and connected documents if any within 15 days of this order, after obtaining original medical bills (A9 series) from this commission on substituting the same with certified copies.
- If the opposite parties 1 and 2 failed to comply with the above directions the complaint is at liberty to realize Rs.1,49,850/-(1,19,850+ 20,000+10,000 along with interest at the rate of 12 % per annum except for costs from opposite parties 1 and 2 jointly and severally and from their assets.
Dictated to the Confidential Assistant Smt. Minimol S. transcribed and typed by her corrected by me and pronounced in the Open Commission this the 22nd day of December 2021.
S.SANDHYA RANI:Sd/-
E.M .MUHAMMED IBRAHIM:Sd/-
STANLY HAROLD:Sd/-
Forwarded/by Order
Senior superintendent
INDEX
Witnesses Examined for the Complainant:-
PW1 : Power of Attorney Holder of the complainant G.Mohana Kurup
Documents marked for the complainant
Ext.A1 : Power of Attorney issued by Dr.Aju Mohan in favour of
her father-Mohana Kurup
Ext.A2 : Certificate of Insurance/Application No.1120000615743
Ext.A3 : Letter stating Non-registration of claim
Ext.A4 : Legal notice dated 21.05.2016
Ext.A5 : Postal receipt
Ext.A6 : Acknowledgment card
Ext.A7 : Reply to legal notice dated 30.05.2016
Ext.A8 : Discharge summary issued by KIMS Hospital, Thiruvananthapuram
Ext.A9 series : Medical bill from KIMS
Ext.A10 : Histopathology report dated 09.05.2016
Witnesses Examined for the opposite party:-Nil
Documents marked for opposite party:-
Ext.D1 : Insurance Certificate
Ext.D2 : Discharge Summary dated 12.05.2016
Ext.D3 : Query Letter dated 09.05.2016
