This complaint coming up before us for final hearing on                      14-06-11 in the presence of Sri P.Krishna, Advocate for complainant and of Sri S.A.Khadar, Advocate for opposite party, upon perusing the material on record, hearing both sides and having stood over till this day for consideration, this Forum made the following: 

O R D E R

PER SMT.T.SUNEETHA, LADY MEMBER:

                This complaint is filed under section 12 of the Consumer Protection Act, 1986 by the complainant seeking directions on opposite party to pay medical expenses amounting to Rs.74,258.10ps. and to pay compensation of Rs.25,000/- towards mental agony with interest @ 18% p.a. from the date of mediclaim till realization and for costs of complaint.

2.      The averments of complaint in brief are as follows:

                The complainant got mediclaim insurance policy bearing No.550500/48/08/8500000/06 dt.06-08-08 from the opposite party valid from 06-08-08 to 05-08-09.  On 02-05-09 the insured namely K.Silvy and K.Collins admitted in Karuna Super Specialty Hospital at Kamjikuzhi District, Kerala State while they were on summer holidays.  K.Silvy got admitted on 02-05-09 and was discharged on 16-05-09 under IP No.A070454.  K.Collins was admitted on 03-05-09 and was discharged on 13-05-09 under IP No.DO5288.  The total bill for K.Silvy treatment was Rs.49,990/- and K.Collins treatment expenditure was Rs.24,268.10ps.  The complainant paid total amount.  The complainant has intimated to insurance company i.e., opposite party about the admissions by a letter dt.14-05-09 with all the reports, discharge summary and prescriptions and same was acknowledged on            15-05-09.   The opposite party did not reply satisfactorily and failed to give the claim amount. The complainant addressed a written complaint dt.09-03-10 for which opposite party gave reply dt.26-03-10 with all false averments and stated that the claim cannot be entertained.  The insurance company collected Rs.2350/- from the complainant towards net premium for insurance coverage of the said claim.  The insurance company has failed to give proper service to the complainant, which amounts to deficiency of service.  Hence, the opposite party is liable to pay the estimated cost and compensation to the complainant.

3.      The opposite party filed its version, which is in brief as follows:

        The claim of K.Silvy and K.Collins was repudiated on the following reasons:

K. Silvy   

1. Mentioned as a case of RA RV enlarged PAH-TR-? PTE

2. Narration in the discharge summary is not technically sound and the findings of the investigation written in the discharge summary are not matching with the investigation reports and bills are not in proper.   

K. Collins

1. The discharge summary is not in correct syntax with so many spelling mistakes (final diagnosis) and present illness infection on liver, heart and lungs.
2. It clearly shows that was not written by a medical practitioner   
3. The entire discharge summary was like that with no proper diagnosis and narration is not in medical terminology and no investigation reports are supporting the diagnosis are submitted and no discharge summary, case sheet copy, investigation reports was sent to the company.

                The disease occurred to K.Silvy and K.Collins are preexisting diseases and they are not covered under the risk of policy as per terms and conditions of policy.  Hence, repudiated.  The bills submitted by complainant to opposite party for a sum of Rs.73,491/- were just in order to gain wrongful advantage and get benefit from this policy and hence, the complaint is liable to be dismissed. 

4.             Both parties have filed their respective affidavits.  Ex.A1 to A10 on behalf of complainant and Ex.B1 to B6 on behalf of opposite party were marked.

5.      Now the points for consideration are

1. Whether the repudiation of claim by opposite party is reasonable or not?
2. Whether there is any deficiency of service on the part of opposite party?
3. To what relief the complainant is entitled to?

6.      POINT No.1

                The complainant obtained Hospitalization Benefit Policy bearing No.550500/48/088500000106 on 06-08-08 covering all his family members for a sum of Rs.50,000/- each from opposite party and is valid from 06-08-08 to midnight of 05-08-09. The complainant’s wife K.Wilson Silvy was hospitalized on 02-08-09 with IP No.A070454 and his elder son K.Wilson Collins was hospitalized on 03-05-09 with IP No.D05288 and both got discharged on 16-05-09 and on 13-05-09 respectively. 

7.   The claim of K.Wilson Silvy is repudiated by opposite party on the following grounds:

        1.  Mentioned as a case of RA RV enlarged PAH-TR-? PTE

       2.    Narration in the discharge summary is not technically sound and the findings of the investigation written in the discharge summary are not matching with the investigation reports and bills are not in proper.  

8.             In the discharge summary in final diagnosis column RA RV – Enlarged, PAH – TR -? PTE is mentioned.  The nature of disease was not explained properly in discharge summary and in the complaint also, the complainant was silent for which disease they took treatment like wise Ex.A5 notice dated nil.   

9.             In the treatment summary of discharge summary it was mentioned that patient on examination advised admission taken Cardiologist opinion and treated with antibiotics, anti platelets, anti thrombolytic therapy, dyspnoea decreeing drugs, antihistamines, anti epileptics, Be complex drugs, anti emetics, and general supportive and Neuro supportive care given, patient recovered well advised medical treatment on follow up.

                In the above passage ‘dyspnoea decreeing drugs’ has no meaning.  The complainant needs to clarify about the same to the opposite party, but failed to do so.   

10.           Some of the bills are not having all the details pertaining to the quantity, batch number and price to compare with medicines prescribed in the treatment advise sheet of the discharge summary (Ex.A2).  The complaint as well as Ex.A5 notice created a doubt in the minds of the Forum about the genuineness of their taking treatment.  Further the bills are not counter singed by the doctor.          

11.           There is no signature and the stamp of the doctor treated on the “treatment advise sheet” and on the “list of medicine prescribed during the course of treatment sheet”, to authenticate the document.  The discharge summary is not having the registration number of the hospital or doctor. 

12.    The claim of K.Wilson Collins is repudiated on the following grounds:

1. The discharge summary is not in correct syntax with so many spelling mistakes (final diagnosis) and present illness infection on liver, heart and lungs.
2. It clearly shows that was not written by a medical practitioner  

1. The entire discharge summary was like that with no proper diagnosis and narration is not in medical terminology and no investigation reports are supporting the diagnosis are submitted and no discharge summary, case sheet copy, investigation reports was sent to the company.

13.   The treatment column of Ex.B2 reads as follows:

                Treatment – The patient requested on seniors fever and breathing difficulty condition.  During tests and investigations made clear that the patient was suffering from eiosnophilia and bronchian asthma which affected the heart liver and lungs.  Applied the attached list of medicine and the patient recovered very well.  The patient is advised to continue the medicine prescribed for 15 days more and reviwe the same.  

                 The words like the ‘patient requested’, ‘seniors fever’ ‘reviwe the same’ are not meaningful.  The above discrepancies in discharge summary though simple, raises a doubt in the minds of the Forum whether they were given by the doctor.  The opposite parties are justified in repudiating the claim and hence, no deficiency of service.

14.    POINT No.2

                There are many laxities like spelling mistakes in the discharge summaries, and mismatch in terms of prices and quantity in between the bills and list given in the discharge summary, lack of signatures on the documents by doctors or concerned persons, lack of inpatient card, registration number on the discharge summary issued by the hospital authorities in the documents produced by the complainant regarding both Silvy and Collins for the best reasons known to him.

15.           In view of the above discussion, the Forum comes to a considered opinion that the opposite party has not committed any deficiency of service and the repudiation is justified.  The point is answered in favour of opposite party.

                In the result, the complaint is dismissed without costs.

Typed to my dictation by the Junior Steno, corrected by us and pronounced in the open Forum, this the 29^th day of June, 2011.     

           Sd/- x x x                       Sd/- x x x                             Sd/- x x x      

          MEMBER                               MEMBER                            PRESIDENT

APPENDIX OF EVIDENCE

                                        DOCUMENTS MARKED

For Complainant:         

For opposite party:

                                                                                        Sd/- x x x

                                                                               PRESIDENT