IN THE CONSUMER DISPUTES REDRESSAL  FORUM, KOLLAM

Dated this the   11^th    Day of  February 2019

  Present: -  Sri. E.M.Muhammed Ibrahim, B.A, LL.M. President

                   Smt.S.Sandhya Rani, BSc,LL.B, Member

                                                        CC No.71/17

J.Pradeep Kumar                              :         Complainant

S/o Janardhanan Pillai

Indu Bhavan,Neelikulam

Vavvakkavu P.O

Kollam-690528

[By Adv.R.Sethunathen Pillai]

V/s

1. The Manager                           :         Opposite parties

         United India Insurance Co.Ltd.,

        Kundara-691520

        Policy No.100702/28/15/P1/11567406

         [By Adv.S.Dileep Kumar]

2. The Branch Manager

          MD India Health Care TPA Pvt.Ltd.,

          No.EL 63/521

          Kassim Lane,

          Near Augustine School

          Kaloor,Ernakulam.

ORDER

E.M.MUHAMMED IBRAHIM , B.A, LL.M,President

          This is a case based on a consumer complaint filed under Section 12 of  the  Consumer Protection Act.

 The averments in the complaint in short are as follows:-

          The complainant is a special skilled worker in charge Hand of Kerala Electrical and Allied Engineering Co.Ltd., Kundara unit.  The company is covered under the Mediclaim Group Insurance Policy of the opposite parties through 2^nd opposite party United India Insurance Company.  The Insurance Policy No.   is 100702/28/15/P111567406 and it is valid from 01.01.2016 to 31.12.2016.

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The complainant’s father Janardhanan Pillai aged 70 yeats was hospitalized at Travancore Medical College Hospital, Mylapore, Kollam due to fall on 12.03.2016.  He was admitted and treated for backache for 3 days and discharged on 15.03.2016.   Due to severe pain, the  complainant’s father was treated again at Pandalam Mannam Ayurveda College from 16.03.2016 to 28.03.2016  under Panchakarma treatment.  A Mediclaim along with supporting treatment details and medical bills worth Rs.10,887/-  and other necessary documents in original was filed on 11.04.2016 before the 1^st opposite party seeking medical reimbursement.  But it was repudiated by the opposite parties vide letter  dated 28.04.16.  The explanation given in the repudiation letter by the opposite party  is that “as per claim document received it is observed that the treatment given to the patient does not support the need for hospitalisation hence claim is repudiation.    The  said  explanation  put forward by the opposite party is sustainable for rejecting the claim amount.  The Discharge summary of the Travancore Medical College hospital, Kollam from 12.03.16 and 16.03.16, Ayurveda Medical College treatment from 16.03.2016 to 15.04.2016 would show urgent need of the hospitalisation and treatment to be given to the patient.  The complainant was informed stating that the claim is being denied stating five reasons mentioned in the letter dated 18.05.16.  The denial of the claim of the complainant is illegal, unsustainable and improper.  The insurer knowingly denied the claim to which the complainant is entitled.  Hence the complaint.

          Opposite party No.1 resisted the complaint by filing a detailed written version raising the following contentions. 

          The complaint is not maintainable either in law or on facts.  The complainant approached this forum with  un clean hands  by suppressing material facts.  However it is admitted that the opposite party had issued  Mediclaim   Group    Insurance   Policy   covering   the employees of the Kerala Electrical   and   Allied   Engineering   Co. Ltd.   For a period commencing from

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01.01.2016 to 31.12.2016 subject to the terms and conditions  of the policy.  As per the endorsement in the policy, M/s MD India health Care Services Pvt.Ltd has been specifically mentioned in the policy as 3^rd party administrator which is the competent authority to decide the admissibility and eligibility of a claim payable under the policy.  The IRDA guidelines are applicable while deciding the admissibility of the claim arising under the policy.  The complainant had reported two consecutive claims through the employer to the 2^nd opposite party claiming hospitalization expenses for Rs.10887/- and Rs.19735/- respectively alleged to have incurred for the treatment of the complainant’s father.    The complainant also produced necessary documents supporting the claim.  However the claim was not payable as per clause 4.2 of the policy condition.  Since the discharge summary issued by the treated doctor would indicate that the complainant’s father was suffering from the above complaints within  the 1^st 30 days from the commencement of the date of policy and as  such the claim is not payable as per exclusion clause 4.2 of the policy.  As per the diagnosis and the treatment given  to the patient  it does not support the need for hospitalisation as well.   As per the policy condition  the insured person is eligible to claim under the policy only of there is absolute need for inpatient care for a particular disease.  The 2^nd opposite party informed the complainant about   their    decision   to    repudiate   the   respective   claims   for the reasons specifically mentioned in the repudiation letter.  The claim of the complainant was repudiated by the  2^nd opposite party on valid ground.  Hence the claim advanced  by the complainant is liable to be dismissed with costs and compensatory costs of the opposite party.

2^nd opposite party has not filed any written version.

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In the light of the above pleadings, the points that arise for consideration are:-

1. Whether the repudiation of the 2 claims lodged by the complainant is proper?
2. Whether there is any deficiency in service on the part of the opposite parties?
3. Whether the complainant is entitled to get the reliefs sought for?
4. Relief and costs.

Evidence on the side of the complainant consists of the oral evidence of PW1 and Ext.P1 series, P2 series,P3,P4 series, P5 to P8 documents.  The opposite party 1&2 have not adduced any oral evidence, however the 1^st opposite party  got marked Ext.D1 policy document with conditions.

Both sides have filed notes of arguments also.  Heard both sides.

Point No.1&2

          For avoiding repetition of discussion of materials these 2 points are considered together.  The following are the admitted facts in this case.

The complainant has been working as the  Special Skilled worker in charge Hand of Kerala Electrical and Allied Engineering Co.Ltd., Kundara unit.  The said company is covered under the Mediclaim Group Insurance Policy issued by the 1^st opposite party and the 2^nd opposite party is the  Third Party Administrator of the policy.  The premium amount  has been deducted from the salary of the complainant by the 1^st opposite party and remitted to the 2^nd opposite party. Policy Number allotted to the complainant is 100702/28/15/P111567406 and was valid from 01.01.16 to 31.12.16.  It is also an undisputed fact that the complainant’s father  Janardhanan Pillai aged 70 years  was admitted at Travancore Medical College Hospital, Mylapore, Kollam due to fall at house on 12.03.16 and was treated for backache for 3 days and discharged on 15.03.2016.  It is also an admitted fact that the factory manager of   the   Kerala   Electrical   and   Allied   Engineering   Co.Ltd  has  forwarded

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mediclaim filed by the complainant to the 2^nd opposite party on 11.04.2016 along with Ext.P1 series bills for Rs.10887/- along with supporting documents.  However the opposite party has repudiated the claim vide Ext.P3 letter.  It is also an undisputed fact that due to severe pain the complainant’s father was again admitted at Pandalam Mannam Ayrveda College from 16.03.2016 to 28.03.2016 for Panchakarma treatment.  The 2^nd  mediclaim  Ext.P2 series including  supporting documents and medical bills worth Rs.19735/-  was forwarded   to   the   2^nd   opposite    party   by    the    Manager  of    the  Kerala Electrical and Allied Engineering Co.Ltd.  However the 2^nd claim was also repudiated vide Ext.P4 letter.  Now the question  to be considered is whether the repudiation of the  2  medi claims filed by  the complainant is  legal  and proper.Ext.P3&P4 are  true copy of the 2 repudiation letters received from MD India Health Care  TPA Pvt.Ltd(2^nd opposite party) out of which Ext.P3 is repudiation letter dated 28.04.16 relating to Ext.P1 series medi claims for Rs.10877/- and Ext.P4 is  the repudiation letter  of Ext.P2 series medi claim for Rs.19735/-.  In Ext.P3 repudiation letter it is stated that the claim has been repudiated on the 5 grounds which are as follows:-

1. Policy coverage for Janardhanan Pillai  is for Third year/years.
2. Current illness Acute Ivdp L4-5 is since ACUTE Days as per Discharge Summary.
3. Explanation:- As per claim documents received it is observed that the treatment given to the patient does not support the need for hospitalization hence claim is repudiated.
4. As per Policy terms and conditions, claim is not payable, Under clause No.4.11.
5. As per claim documents received it is observed that the patient was diagnosed acute PVPD L4-5 and L5-1 and managed on conservatively, treatment given to the patient does not support the need for
6.  
6. hospitalisation hence claim is repudiated.   Similarly  Ext.P2 series  claim has been repudiated by P4 repudiation letter wherein  also the  following 5 reasons has been stated.  The above 5 reasons stated in Ext.P3&P4 are more or less same except ground No.2 and 5 where in the diagnosis is stated.  According to the complainant all the 5 reasons stated in Ext.P3&P4 are not correct, valid and proper to  deny the claims. 

The learned counsel for the 1^st opposite party would argue that as per the exclusion clause No.4.11 in Ext.D1 mediclaim policy the claim  is not  payable towards the charges incurred at hospital for preliminary diagnosis and treatment of positive existence or persons of any ailment, sickness or injury for which confinement is required at hospital.  However according to  the  learned counsel for 1^st opposite party the discharge summary of the complainant’s father would indicate that he was treated in a conservative manner for the complaint of low back pain and the treatment given to the patient does not support the need for hospitalisation.  It is further contented that the complainant has not produced any documentary evidence showing that the patient was admitted  in the hospital for the complaint of acute IVDP L4-5 and L5-1 vertebra in a conservative manner  without any active treatment procedure.  According to the 1^st opposite party the above treatment taken by the complainant does not support the need of hospitalisation, and hence the  two  claims of the complainant are not payable as per  4.11 of policy condition and therefore the repudiation of the claims by the 2^nd opposite party is legal and proper.

The above contentions of the learned counsel for the 1^st opposite party are actually and factually incorrect.  Page No.2 of  Ext.P1 is the discharge summary issued by the consultant doctor of  Travancore Medical College Hospital, Kollam.  Under the heading ‘history and examination’ it is stated in Ext.P(b) discharge summary that history of fall at home-one week back-was initially seen at the  local clinic.  K/C/O DM and  HTN on treatment.O/E:Tenderness noted at

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L3-L4,L4-L5.SLRT B/L 40.  Under the Heading treatment  and Hospital Course, 70/M admitted with backache following  trauma to back at home for which MRI lumbosacral  spine was taken with screening of dorsal and cervical spine which showed L4-L5 circumferential annular disc bulge with facetal  arthrosis causing spinal canal stenosis, grade II B/L neural foramina compromise.  He was given Neurosurgery consultation  for the same and was advised surgery and patient not  willing for surgery now.  He was treated here with oral steroid(Medrol) and other supportive.  The patient is now symptomatically better and hence discharged.  The above endorsement in Ext.P1(b) would prove the duration of illness and need for hospitalisation and injuries noted  the line of treatment etc.

It is true that Ext.D1 policy document would go to show that the medical policy is subject to the terms and conditions, exclusions and definitions attached to the  policy. It is well settled that insurance policy is an uberiameafide contract and has to be interpreted strictly.  But is should not be interpreted so  as to defeat the very object and purpose of the contract and to defeat the rights of the insured who believed the wordings of the policy and paid a substantial sum as insurance premium.

It is seen specified in Ext.D1 policy that the insurance company undertakes during the period stated in the schedule for any insured persons contracts any  disease or suffers from any illness/disease or sustains any bodily  injury through accident and if such disease   or   injury   requires   such   insured   person   upon the advice of a duly qualified physician/medical specialist/medical practitioner or of a duly qualified surgeon to incure  hospitalisation, domiciliary hospitalisation expences  for medical/surgical treatment at any nursing home/hospital in India as an inpatient.  The company will pay through TPA to the hospital/nursing home or the insured person,  the amount of such expenses as are reasonably and necessarily incurred  in respect  from all by or on such

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behalf of such insured person  but not exceeding the sum insured any aggregate in any period of insurance. According to the learned counsel for the complainant the policy was taken in the name of the father of the complainant by believing the above representation in the policy and hence the opposite parties shall not be allowed to turn round and deny the benefit of the policy by alleging flimsy grounds.  We find force in the above argument.  Ext.P1series and Ext.P2 series documents would substantiate that the father of the complainant  was  admitted  at  the  Travancore  Medical  College  Hospital and

subsequently at  the  Ayurvedic  Medical College Hospital, Pandalam as advised by duly qualified surgeons and treated as inpatient at the above 2 hospitals.

Clause 1.2 of Ext.D1 policy certificate would further indicate that in the event of any claim being admissible under the scheme the company will pay through TPA to the hospital/nursing home for the insured person the amount of such expenses  would fall under different heads mentioned below.

1. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home  up to 1% of the sum insured per day including nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses.
2. If admitted in ICU the company will up to 2% of the sum insured per day for actual amount  whichever is less.
3. Surgeon, Anaesthetic, Medical Practitioner, Consultants, Specialists Fees.
4. The expenses for relevant laboratory/diagnostic tests, X Ray and such similar expenses which are medically necessary.
5. All hospitalisation expenses(excluding cost of organ if any) incurred for donor in respect of organ transplant to the insured.

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As per clause 1.3 pre and post hospitalisation expenses payable in respect of each hospitalisation shall be the actual expenses incurred subject to a maximum of 10% of the sum insured, whichever is less.

Clause 2.1 of the policy would indicate that expenses on hospitalisation for a minimum period of 24 hours are admissible.  However the time limit is not applied to  specific  types of treatments stated in the schedule.

Clause 2.3 for Ayurvedic treatment, hospitalisation expenses are admissible only when the treatment has been undergone in a Government hospital or any Institute recognised by the Government and/or accredited by Quality Council of India/ National Accreditation Board on Health.

The opposite party has no case that any of the conditions enumerated above  are violated by the complainant  either  in the case of Ext.P1 series Alopathic treatment  or   Ayurvedic  treatment  covered  by  Ext.P2 series bills.  However during cross examination  by the   learned   counsel  for   1^st opposite  party  it is brought out in evidence that in Ext.P2 series certificate  the duration of the back pain is 2½ months prior to the date of  admission.   PW1 would admit  during cross examination  in Page No.3 that Ext.D1 policy Page No.11 would indicate the exclusion clause wherein it is stated that within 30 days from the date of taking policy the cover of insurance will not  be available.  It is brought out in evidence that the complainant has been taking policy for the benefit of his father for  several years continuously.  The complainant has also  produced and got marked Ext.P5 policy  relating to the period 1/01/13 to 31.12.13.  Ext.P6  policy related to 01.01.14 to 31.12.14, Ext.P7 policy related to 01.01.15 to 31.12.15 and Ext.P8 policy related to 01.01.16 to 31.12.16.

In view of Ext.P5 to P8 policy it is clear that the complainant has been taking policy insuring his father Janardhanan Pillail, the father of the complainant  for the last 4 years and Ext.D1 policy is for the period from 01.01.16 till 31.12.16.  In view of   Ext.P5   to  P8   and   D1   policy  it is clear that the complainant has

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insured his father  Janardhanan Pillai for the last 4 years continuously including the period wherein he has sustained ailment alleged in the claim.  Therefore the contention of the opposite party that the illness of the insured sustained injuries within 30 days from   the date of  taking the policy is devoid of any merit. 

     Now we shall consider whether clause 4.11 of the policy condition will disentitled the complainant from  getting the insurance claim.  Section 4 of the policy  condition   relates to exclusion.    Accordingly   the   insurance company shall not to make  any payment under this policy in respect of any explanation what so ever incurred by any insured person in connection with or  in respect of any pre-existing condition as defined in the policy until 48 months of continuous coverage  of such insured person  have elapsed since inception of  his 1^st policy with the company.  In  this connection it is to be pointed out that any “pre-existing condition” is not defined in the policy.  But clause 3.30 would define  “pre-existing disease” which would read any condition, ailment /injury or condition for which the insured had signs or symptoms and/or were diagnosed and/or received medical advice within 48 months prior to the 1^st policy issued by the insurer.    Here  in  this case Ext.D1 is the  last  policy   and Ext.P5 is the 1^st policy relating the calendar year 2013.  The policy cover in Ext.P5 policy starts from 01.01.13 and end on 31.12.13.  The complainant has no case nor even the opposite party has any contention or whisper  that the policy holder was having any disease  during  48 months prior to 01.01.13  from the date of commencement of the 1^st policy.  In the circumstance exclusion clause under 4.1 is not at all applicable.

Exclusion clause under clause 4.2 reads any disease other than those stated in clause 4.3  contacted by the insured person during the 1^st 30 days from the commencement of the date of policy.  The condition 4.2 is not applicable  in the case of the insured  person  who had  been covered under insurance policy with the company for a  continuous   period   of  4  years  without any break.  Here in

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this case nobody has a case that the complainant’s father who is the insured  is having any  insurance break during the preceding 12 months.  Hence  exclusion clause 2 is also not applicable.

 Ground No.1  stated in Ext.P3 and P4 repudiation letter is that policy coverage for Janardhanan Pillai(insured) for 3^rd year which  is totally incorrect.  The policy coverage as per Ext.P5 to P8 plus Ext.D1 is for 4 years and not for the 3^rd  year.  Ground No.2 is a vauge and incomplete statement which is also not applicable.  Ground No.3 would indicate that the  treatment given  to  the  patient  does  not  support  the  need for hospitalisation which is the main reason for repudiation of the claim which is incorrect as per Ext.P1 series and Ext.P2 series documents.

Ext.P2(a) is the discharge card issued by Mannam Ayurveda Co-operative Medical College Hospital, Pandalam, Pathanamthitta District wherein it is stated that radiating pain from low back region to both lower limb specially  on left side since 2½ month. Difficulty in movement.  Under the heading History of Complaints it is stated that patient was apparently healthy before 2½ month, he felt pain over the low back region and took Allopathic medicine.  Patient had a history of fall  2½ months  back after that back pain started.   In the heading Diagnosis  it is stated that DM, HTN, Lumbar Spondylosis with disc lesion , spinal canal stenosis.  Lumbar Spondylosis  with disc complaint is not a silly disease which would definitely justify admission at the Ayurvedic Medical College.  It is clear from  Ext.P2(b) discharge card that even though the patient has undergone Allopathic treatment he is having difficulty  in movement.  The person who suffers difficulty in movement due to pain as a consequence of  fall would definitely require inpatient Ayurvedic treatment.  It is true that in Ext.P2 (a) discharge summary the duration of illness has been stated as 2½ months.  The above duration noted by the doctor which is not correct in the light of the duration  noted  in Ext.P1(b) discharge summary and Ext.P1(c) claim form and

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Ext.P1(d) Medical certificate issued by the treated doctor at the Travancore Medical College Hospital, Kollam.

In the circumstance the ground No.3 explanation that the treatment given to the patient does not support the need for hospitalisation is devoid of any merit especially when no contra evidence is available  to that effect.

It is also brought out in evidence that  as the ailment has not cured due to Allopathic treatment the insured has approached the Ayurvedic Medical College complaining pain and lack of movement.  In the circumstances ground No.2&3 to reject the claim is not proper. 

It is further to be pointed out that clause No.4 would indicate that  insurance company  shall not be liable to make any payment under this policy  in respect of any expenses what so ever incurred by any insured person in connection with or in respect of  4(11) charge incurred at  hospital or nursing home primarily for diagnosis, X-ray/Laboratory examination or other diagnosis studies not consistent with incident to the diagnosis and treatment of positive existence or persons of any ailment /sickness/injury for which confinement is required at hospital/nursing home.  But the above exclusion clause appears to be deadly against the terms of insurance which is stated under clause 1.1 wherein it is clearly stated that the company is liable to meet the hospitalisation expenses for medical/surgical treatment at any nursing home/hospital in India as an inpatient. Now it is to be considered whether the inpatient treatment undergone by the father of the complainant would come under the category  of  hospitalisation for the purpose of mediclaim. The term hospitalisation is seen defined under clause 3.16 where in it is stated  that hospitalisation means admission in  hospital/nursing  home  for  a minimum period of 24 inpatient hrs except for specified procedures/treatment wherein such admission for a period of less than 24 consecutive hrs.  Here  in this case admittedly 3 days hospitalisation  is there.

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Hence the hospitalisation of the insured would come within the ambit of the policy. 

The term medical expenses is defined under Section 3.23.  Accordingly medical expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner as long as these are  not more than what have been payable if the insured person had not been insured and not more than other hospitals for doctors in the same  locality would have charged for the medical treatment.    It    is   clear   from   the  above definition that the expenses incurred by the complainant for the treatment of his father and  claimed would come within the above definition of medical expenses.

The term medically necessary is defined under clause 3.24. Accordingly medically necessary treatment is defined as any treatment, test, mediation or stay in hospital or part of any stay in hospital required by the medical management of the illness/injury suffered by the insured.  But it must not exceed the level of care  necessary to provide safe, adequate and appropriate medical care  in  scope, duration or intensity.  It is also stated that the same must  have been  prescribed  by  a  medical  practitioner  and  must  confirmed  to the  professional standards widely accepted by the National Medical Practice or by the medical community in India.  The opposite parties have no case that the treatment undergone by the complainant would not come under the category of medically necessary treatment.

     In view of the definition of  hospitalisation  medical expenses and medically  necessary  treatment it  is clear that the exclusion clause under Section 4.11 in medi claim policy is not at all applicable towards the charges incurred at the hospital for preliminary diagnosis , treatment etc.  In the light of the above findings  the reasons stated under P3 and P4 repudiation letter by the 2^nd   opposite   party   are   not   legal   and   proper.  The pleadings and evidence

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available on record would make it clear that the denial of the mediclaim by the opposite party No.2 amounts to clear deficiency in service on the part of the opposite party No.1&2.  It is also clear from the available facts and circumstances that due to the denial of legitimate claim in respect of the treatment of the  father of the complainant has caused  much mental agony, harassment apart from financial loss to the complainant.  Therefore the complainant is entitled to get compensation and  costs of the proceedings also.  The point No.1 to 3  answered accordingly .

Point No.4

In the result the complaint stands allowed directing the opposite party No.1&2 to allow the  two claims lodged by the complainant vide P1 series for Rs.10,877/- and P2 series documents  for Rs.19,735/- along with interest @ 12% p.a from the date of raising the above two claims till realisation.

 The complainant is allowed to receive back P1 series and P2 series documents from this forum after substituting certified copies and transmit the same  to the 1^st opposite party for re-processing the above 2  claims at the earliest.

The opposite parties No.1&2 are also directed to pay Rs.10000/- as compensation  and  Rs.2000/- as costs to the complainant. 

The opposite parties No.1&2  are directed to pay the amount  of Rs.30622+10000 with interest @ 12% p.a along with costs Rs.2000/- within 45 days   from   the   date of receipt of the copy of the order or within 30 days from

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retransmitting P1 series and P2 series by the complainant to the 1^st opposite party whichever is earlier failing which the complainant is allowed to realise  the said amount with interest and costs  from opposite party No.1&2 jointly and severally and from their assets.

Dictated to the  Confidential Assistant  Smt. Deepa.S transcribed and typed by her corrected by me and pronounced in the  Open Forum on this the   11^th   day of  February  2019.

E.M.Muhammed Ibrahim:

            S.Sandhya Rani:

            Forwarded/by order

            SENIOR SUPERINTENDENT

INDEX

Witnesses Examined for the Complainant:-

PW1                     :         Pradeep Kumar

Documents marked for the  complainant

Ext.P1Series                  :         Claim application and related records

Ext.P2 Series        :         Discharge summary and medical bills

Ext.P3                  :         Copy of  repudiation letter.

Ext.P4                  :         Copy of repudiation letter

Ext.P5                  :         Copy of policy(1.1.2013 to 31.12.2013)

Ext.P6                  :         Copy of policy(1.1.2014 to 31.12.2014)

Ext.P7                  :         Copy of policy(1.1.2015 to 31.12.2015)

Ext.P8                  :         Copy of policy(1.1.2016 to 31.12.2016)

Witness examined for the opposite party:-Nil

Documents marked for the opposite party

Ext.D1                  :         Copy of policy

E.M.Muhammed Ibrahim:Sd/-

                                                                                   S.Sandhya Rani:Sd/-

                                                                                   Forwarded/by Order

           SENIOR SUPERINTENDENT