By Jayasree Kallat, Member

 

 

             The petition is filed on 30-3-2006. The complainant has filed the petition alleging deficiency of service on the part of the opposite parties.    The complainant was insured by the first opposite party in December 2003. As per the terms and conditions of the policy the complainant is entitled for service and treatment from the Net work hospitals of the opposite parties or non net work hospital and guaranty of payment of the medical expenses. Necessary premium amount was regularly paid on behalf of the complainant by Housing Development Financial Corporation Bank, and the amount was deducted from the salary of the complainant. The policy was renewed every year. The complainant had undergone treatment for Torsion test during the period 16-4-04 to 19-4-04. For this treatment complainant had got the cashless medical services from the opposite parties. There after complainant had undergone treatment for left ureteric stone during the period 14-11-05 to 16-11-05 in Baby Memorial Hospital, Kozhikode which is included in the network hospitals of the opposite parties. The expenses for treatment incurred by the complainant was rs.22387.36. As per the terms and conditions of the policy the opposite parties are liable to reimburse the medical expenses incurred by the complainant. The hospital authorities had sent the medical reports of the complainant to the 2nd opposite party. In the old medical reports of 4/04 sent to the 2nd opposite party the hospital authorities had committed an error with regard to the duration of illness. In the medical report the duration of the illness was mentioned as 5 years instead of 5 weeks. The 2nd opposite party had rejected the claim on the basis of this error which crept in the report. Thereafter complainant had preferred the claim for reimbursement before the 2nd opposite party on 24-11-05 with all supporting documents and medical bills. But the claim was again rejected by the 2nd opposite party for the same reason that the duration of the illness is 5 years, so the disease was pre-existing. The 2nd opposite party had subsequently received the correct medical report from Baby Memorial Hospital dated 22-12-2005 after rectifying the error which had crept in the earlier report. The complainant had made a request again to the opposite party to re-look into the matter and settled the claim. Second opposite party had again rejected the claim for the same reason that the disease was pre existing. The act of the opposite parties is unjustifiable and there was deficiency of service on the side of the opposite parties. Hence this complaint.

 

            O.P. No.1 and 2 filed a joint version. Opposite party-1 and 2 are acting as a third party administrator to the Insurance company Reliance General Insurance. As per the policy details available with O.P-1 and 2 the complainant is insured with effect from 6-10-03. The claimant Bju Samul was admitted at Baby Memorial Hospital from 14-11-05 to 16-11-05 for the treatment of left ureteric stone.    He had requested O.P.1 and 2 for cashless benefit. O.P.-1 and 2 after receiving the admission request had requested for further details ie supporting documents and discharge summary of 2004 in which the complainant was earlier treated.   It was reported that the complainant was treated from 16-4-04 to 18-4-04 for torsion tests from Baby Memorial Hospital, Calicut, which clearly mentioned that the complainant was suffering from ureteric stone since 5 years, even prior to the inception of the policy. Therefore the cashless facility was denied vide letter dated 16-11-05. The complainant had submitted claim documents again for re-consideration for reimbursement. There was no mention of history and duration of stone disease which was mentioned in the discharge summary sent to O.P.1 and 2 at the time of seeking cashless facility. The claim was rejected as the complainant disease was a pre-existing one. Complainant was intimated about the rejection vide letter dt. 15-11-05. Subsequent to the rejection O.Ps -1 and 2 received a certificate dt. 26-12-05 from Baby Memorial Hospital mentioning that the duration of the stone disease is 5 weeks and not 5 years. Along with the certificate and altered discharge summary of the year 2004 of Baby Memorial Hospital was enclosed which does not make a mention about the history and duration of the stone disease. O.P.1 and 2 had rejected the complainant's claim for cashless facility because it was clear that the complainant was submitting different version regarding the duration of stone disease to mislead the insurance company. As per the terms and condition of the medi claim policy O.P1 and 2 are not liable to pay any amount. The petition is liable to be dismissed.

 

                        O.P.3 the Reliance General Insurance Company was subsequently impleaded. O.P.3 filed a version denying the averments in the complaint except those that are expressly admitted. There was no deficiency on the part of the opposite party as alleged by the complainant. O.P.3 admits that the complainant had taken a policy with effect from 6-1-03. The complainant is entitled for services and treatment subject to the terms and conditions of the policy. The complainant had undergone treatment for torsion tests and he was admitted from 16-4-04 to 19-4-04 at Baby Memorial Hospital . He was again admitted at B.M.H. from 14-11-05 to 16-11-05 for left ueriteric stone. The old hospital admission records had shown that the duration of the illness as 5 years.    O.P.3 had rejected the claim since the disease was a pre existing one. The duration of the illness was 5 years. O.P. had received a request for reconsideration along with a certificate from Baby Memorial Hospital stating that the duration of the illness was 5 weeks and not 5 years. There was an altered discharge summary of year 2004 which also did not mention about history and duration of the said disease. O.P.3 had rejected the claim as the disease was pre existing. There was no deficiency on the part of opposite party, hence complainant is not entitled for any amount from the opposite party. O.P.3 prays to dismiss the petition.

 

 

                        The only point for consideration is whether the complainant is entitled for the relief sought in the petition.

 

                        PW1 and PW2 were examined and ext.A1 to A8 were marked on complainant's side. No oral evidence adduced or documents marked on O.P.'s side.

 

                        The case of the complainant is that he had taken the medi claim policy of Opposite parties. O.P.1 and 2 were the 3rd party administrators of O.P.3 the Insurance Company. As per the terms of the policy the complainant was entitled for cashless treatment from the Network hospitals of the opposite parties or non network hospital and guaranty of payment of the medical expenses. The complainant had paid necessary premium. During the policy period the complainant had undergone treatment for torsion test from 16-4-04 to19-4-04 for which he got the cashless medical services from the opposite parties. The complainant had undergone treatment for left ueriteric stone during the period 14-11-05 to 16-11-05 in Baby Memorial Hospital. The expenses incurred by the complainant was Rs.22,387.36 for the teatment. As per the terms and conditions of the policy the opposite parties were liable to reimburse the medical expenses incurred by the complainant. Hospital records were sent to the second O.P. on 14-11-05. Second O.P. had demanded for supporting reports and discharge summary of previous admission of the complainant in Baby Memorial Hospital. In the report the duration of the illness was mentioned as 5 years.    Hence the O.P. rejected the claim because the disease was a pre existing one. Opposite parties are not liable to give cashless facility for a pre existing disease.   But it was stated by the complainant that a error had crept in the hospital records instead of 5 weeks the hospital had written duration of the illness as 5 years. Complainant had approached the hospital when the claim was rejected by the opposite parties. In deposition of PW1, the complainant Page-2, he has deposed that Hospital authorities had committed a mistake and later on hospital had given a letter stating that an error had crept in and instead of 5 weeks it was typed as 5 years. Complainant has produced Ext.A4 which is sent by Baby Memorial Hospital to the 2nd O.P. which clearly states that a mistake has occurred on the part of the Hospital. As per the records available in the hospital the history of the illness was recorded as 5 weeks duration while preparing the summary in a hurry typographical error occurred. The history of the illness was typed as 5 years instead of 5 weeks. But the opposite party did not accept Ext.A4. Hence they had again rejected the claim of the complainant. To prove his case complainant had sited Dr. Abdul Azeez as a witness in this case. Dr. Abdul Azeez who had treated the complainant was examined as PW2. Dr. has admitted that due to a typographic error the duration of the illness of the complainant was wrongly recorded as 5 years instead of 5 weeks. Doctor had also cleared that the illness treated for the complainant on two different occasions were for different disease. Complainant had undergone treatment during the period 16-4-04 to 19-4-04 for torsion test. The complainant had again undergone treatment from 14-11-05 to 16-11-05 for left ueriteric stone. Doctor has cleared the suspicion of the opposite parties that the disease was e pre existing one. In his deposition Doctor has stated that the treatment done on 16-4-04 was for torsion test and not for stone disease. From the evidence of the Doctor and the documents we have come to the conclusion that the complainant had undergone treatment on two occasions for different diseases.   The hospital has also given a letter to the opposite party stating that there was a typographical error by which instead of 5 weeks duration of the disease it was wrongly mentioned as 5 years. Under these circumstances we are of the opinion that the complainant is entitled for the relief sought in the petition.

 

                        In the result the petition is allowed and the opposite parties are directed to pay the amount of Rs.22387.36/- along with a cost of Rs.500/-.to the complainant within one month from the date of receipt of copy of the order

 

Pronounced in the open court this the 21^st day of June 2010.

 

                        SD/-PRESIDENT                    SD/- MEMBER           SD/- MEMBER

 

 

 

 

 

 

 

 

APPENDIX

 

Documents exhibited for the complainant:

 

A1. Photocopy of Beneficiary’s Guide.

A2. Photocopy of letter dt. 24-11-2005.

A3. Photocopy of Claim form for Group Mediclaim Insurance Policy.

A4. Letter dt. 22-12-2005.

A5. Photocopy of letter dt. 26-12-2005.

A6. Letter dt. 31-12-2005.

A7. Photocopy of letter dt. 19-1-2006.

A8. Copy of Regd. Letter dt. 25-1-2006.

 

Documents exhibited for the opposite party.

            Nil

 

Witness examined for the complainant:

 

PW1. Biju. T. Samuel (Complainant)

PW2.  Dr. Abdul Azeez, Urologist, Baby Memorial Hospital, Calicut.

 

Witness examined for the opposite party.

            None

                                                                        Sd/- President

 

                        // True copy //

 

Date of filing                 : 30-3-06.

Date of order                : 21-6-2010.

 

                        (Forwarded/By order)

 

 

            SENIOR SUPERINTENDENT.