DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 10th day of March, 2023
Present : Sri. Vinay Menon V., President
: Sri. Krishnankutty N.K., Member Date of Filing: 11/02/2021
CC/23/2021
T. Krishnakumar,
‘Devinandanam’, Kamadhenu,
Alathur P.O., Palakkad – 678 541. - Complainant
(By Adv. M. Raveendran)
Vs
- The Manager,
United India Insurance Co. Ltd.,
Palakkad Branch, Palakkad – 678 014
2. Manager/ Medical Superintendant
Lakshmi Hospital, Chittoor Road
Palakkad – 678 013. - Opposite parties
(O.P.1 by Adv.K.K.Sreenivasan(Name of Counsel for OP1
changed from T.P.George to Adv.K.K.Sreenivasan by Order
dated 4/4/2023 in MA/6/2023)
O.P.2 by Adv. M/s A.V. Ravi & Venugopal G.P.)
O R D E R
By Sri. Vinay Menon V., President
- Essential grievance of the complainant relates to the partial indemnification of the amounts expended by the complainant for the surgery underwent by the complainant’s daughter in the 2nd O.P. hospital by the 1st opposite party.
Per complainant, he and his family are beneficiaries of an Insurance package floated by the 1st O.P. Complainant’s daughter underwent a surgery for a boil in the 2nd O.P. hospital. Eventhough the complainant was entitled to indemnification of the entire Rs. 45,672/- expended by the complainant, the 1st opposite party reimbursed only part bill and the complainant had to pay Rs. 22,260/- out of his pocket. Aggrieved thereby, this complaint is filed.
2. (1) The 1st O.P. filed version admitting the complaint pleadings, but justifying their conduct as being in harmony with the terms and conditions of the insurance policy. Daughter of the complainant being insured for Rs. 1,25,000/- alone, was only entitled for pro-rata indemnification. Eventhough the complainant’s room rent was Rs. 2250/-, the complainant was entitled to Rs. 1,250/- only. Consequently, other expenses were also given a pro-rata reduction. There is no deficiency in service and sought for dismissal of the complaint
(2) The 2nd O.P. also filed version. They stated that they had charged the amount from the complainant after what the 1st O.P. would pay. There is no collusion whatsoever with the 1st O.P. Complainant is not entitled to any reliefs from the 2nd O.P.
3. Pleadings and counter pleadings give rise to the following Issues:
I. Whether the payment effected by the 1st O.P. is in accordance with the terms and conditions of Policy conditions?
II. Whether there is any deficiency in service on the part of the 2nd O.P.?
III. Whether there is any deficiency in service or unfair trade practice on the part of the O.P.s?
IV. Whether the complainant is entitled to any reliefs sought for?
V. Any other Reliefs?
4. (i) Complainant filed proof affidavit and marked Exts. A1 to A4.
(ii) Opposite party filed proof affidavit and marked Exts. B1.
Issue No.I
5. Per complaint pleadings, the complainant incurred Rs. 45,675/- as treatment expenses. O.P.1 indemnified amount to a tune of Rs. 23,405/-. Complainant had to pay Rs. 22,260/-.
O.P. 1 admitted the said fact. But they concreted their position stating that the amount had been arrived at in terms of the policy conditions. And in the absence of any cogent evidence adduced by the complainant disputing the calculation on the ground that the said calculation is not made in accordance with the clause 1.2.A and Note 1 of Ext B1 Policy conditions we refrain from indulging in an Accounting witch hunt.
6. We therefore hold that the complainant has failed to prove that the O.P. has varied the Terms and Conditions of Ext. B1 Policy Conditions.
Issue No. II
7. The 2nd O.P. is the hospital where complainant’s daughter was treated. Complaint allegations are that the 2nd O.P. consorted with the 1st O.P. to defraud the complainant. No evidence was adduced by the complainant to prove his allegations of an unholy nexus between the O.P.s. In the absence of any evidence to that effect from the part of the complainant, we cannot hold that there is any deficiency in service or unfair trade practice on the part of the 2nd O.P.
8. The complainant has failed to prove any deficiency in service or unfair trade practice on the part of the 2nd O.P.
Issue No. III
9. Findings in Issue no. I apart, there is one glaring irregularity in Ext. B1. We are not disputing the contents of clause 1.2.A. of Ext. B1. But we have difference of opinion as to the way same is interpreted by the opposite party 1.
10. Opposite party 1 insists that room rent includes nursing charges. In order to appreciate this contention of the opposite party we need to dissect Clause 1.2.A.
“Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing Home not exceeding 1% of Sum Insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/ Blood transfusion/Injection administration charges and similar expenses.”
This clause expressly covers three factors;
- Room; (2) Boarding; and (3) Nursing Expenses.
Definitions of the words used in the said clause can be referred to have a better understanding of the clause. We can resort to layman parlance to that extent.
- A “Room” is a part of a building that has its own walls, floor and ceiling and is usually used for a particular purpose. (per Oxford Advanced Learner’s Dictionary, 7th Edn.)
- “Board” means the meals that are provided when you stay in a hotel, guest house, etc.; what you pay for the meals (per Oxford Advanced Learner’s Dictionary, 7th Edn.)
- “Nursing” means to care for somebody who is ill/sick or injured; to take care of an injury or illness. (per Oxford Advanced Learner’s Dictionary, 7th Edn.)
11. As stated supra, opposite party holds that room rent includes nursing charges.
12. Herein, we beg to differ. Room and Board can be taken to be of one category. It can be for the patients or the by-standers. But Nursing care can be provided solely to the patient.
Imagine that a patient is admitted for 10 days from 01.01.2023 to 10.01.2023. He is taken directly to ICU. No room is taken for 5 days, that is, till 05.01.2023. The patient incurs no room rent, but will surely incur nursing expenses as nursing care is to be provided to the patient. The bill will inevitably show Nursing Expenses. Thereafter on 06.01.2023, upon the patient’s release from ICU, a room is taken. Invariably room rent will be charged from 06.01.2023 onwards.
As per O.P.’s contentions, from 06.01.2023 onwards, the nursing expense merges with the room rent. And room rent will include nursing charge. The opposite parties, by their interpretation, tries to club two items, namely room rent and nursing charges, which are of entirely different category altogether and having no common thread running through them.
The second part of clause 1.2.A, i.e. “This also includes ……………………………………………… and similar expenses” can never be equated with room rent. Components therein are (1) Nursing care; (2) RMO charges ; (3) IV Fluids/Blood transfusion / injection administration charges; and (4) similar expenses. Here, the 4th item, namely, “similar expenses” is the key. The word “similar expenses” can only be taken to allude to expenses that are required and connected to care for recuperation administered to the patient.
Room rent can in no way be attributed to have any similarity to the “similar expenses” referred to in clause 1.2.A. Room rent and nursing charges therefore cannot be termed ejusdem generis and are on entirely different footing altogether.
13. In our opinion the interpretation resorted to by the opposite party to club two separate expenses of entirely different nature having no similarities and of entirely different properties is an absurd proposition with no intelligible or logical ratio.
But it does serve a nefarious purpose. It reduces the amount that the opposite party will have to indemnify, thus enabling unlawful enrichment. If the interpretation to 1.2.A given is like 1% of room rent and 1% of Nursing Expense, the interpretation of the clause would be more rational. But the total amount the opposite party would have to cough up would be double the amount payable than what the O.P.s hand out at present.
14. In the case at hand owing to the interpretation, the opposite party stands to gain unlawfully. One can only imagine the unlawful gain the opposite party makes per day with such illegal deductions, pan India.
15. It is true that the complainant has affixed his signature to Ext. B1. But we cannot agree to the fact that any prudent person would agree to such regressive terms curtailing a beneficiary’s contractual rights. In agreements of the like of Ext. B1, a common man cannot be expected to go deep into the interpretations and implications of the terms and conditions. Even if the complainant had agreed to the generality of the terms and conditions, we cannot digest that any person of a basic intellect would willfully agree to terms and conditions that would curtail their entitlements. We therefore hold that there is willful Unfair Trade Practice perpetrated by the 1st O.P., violating the rights of the complainant.
Issue Nos. IV & V
16. Consequent on the findings in Issue no. III, we hold that the complainant is entitled to compensation for unwittingly falling prey to the unfair trade practice willfully carried out by the 1st O.P.
A. The complainant is entitled to Rs. 50,000/- as compensation for the unfair trade practice on the part of the 1st O.P.
B. The complainant is entitled to Rs. 25,000/- as cost from the 1st O.P.
C. The 1st O.P. shall comply with the Order within 45 days from receipt of a copy of this order failing which the complainant will be entitled to receive solatium at the rate f Rs. 250/- per month or part thereof from the date of this Order till date of final payment of the entire amount.
Pronounced in open court on this the 10th day of March , 2023.
Sd/-
Vinay Menon V
President
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant :
Ext.A1 – True copy of Individual Health Insurance Policy Schedule and Terms and Conditions
alongwith ID card of the complainant.
Ext.A2 (series) – 2 bills issued from OP2 hospital
Ext.A3 (series) – Lawyers notice and acknowledgment card of notice issued to OP2 hospital
Ext.A4 – Copy of notice issued to Ops by Forum for Consumer Justice
Exhibits marked on the side of the opposite party:
Ext. B1: True copy of Individual Health Insurance Policy Schedule and Terms and Conditions.
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
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.
