By Smt. Bindu. R, President:
This complaint is filed by Noushad. M, Aged 37 years, S/o. Alavi, Mattil House, Mess house Road, Kalpetta, 673 122, Wayanad District against The New India Assurance Company Ltd as Opposite Party alleging deficiency of service and unfair trade practice from their side.
2. The Complainant states that the Complainant had joined in New India Mediclaim Policy bearing No.76220034219500000001 with the Opposite Party for covering his health related complications. The coverage period of the policy was from 09.04.2021 to 08.04.2022. The Complainant states that during the period of the said policy the Complainant was admitted at GMC Ortho Foundation Hospital at Calicut due to post Covid 19 medical illness and health issues on 14.06.2021.
3. Immediately after the admission the Complainant informed the Opposite Party about hospitalization and submitted a claim form. The Complainant states that he had submitted all the claim papers, pre hospitalization medical bills and post hospitalization medical bills before the insurance company. The Complainant states that he had received a notice dated 08.07.2021 denying the claim on the ground “treatment possible on OPD basis”. According to the Complainant he is entitled to get an amount of Rs.22,596/- from the Opposite Party for the expenses incurred for the treatment and hence the complaint praying for issuing a direction to the Opposite Party to pay an amount of Rs.22,596/- with interest and for other reliefs.
4. Upon notice Opposite Party entered into appearance and filed their version stating that the complaint is not maintainable and there is no deficiency of service from the part of the Opposite Party. The New India Mediclaim Policy bearing No.76220034219500000001 valid from 09.04.2021 to 08.04.2022 in favour of the Complainant is admitted by the Opposite Party. According to the Opposite Party, as per the policy, in eligible cases, the hospital expenses up to 30 days and post hospitalization for 60 days is covered. As per policy clause 2.17, hospitalization means admission in a hospital for a minimum period of 24 consecutive hours of in patient care except for specified procedures/treatments as mentioned in Annexure -1, where such admission could be for a period of less than 24 consecutive hours. Procedures/treatment usually done in out patient department are not payable under the policy even if converted as an inpatient in the hospital for more than 24 consecutive hours. In this case the Complainant was admitted in the hospital on 14.06.2021 for an ailment LUMBAR IVDP. SCIATICA and the admission is only for local triamcinolone injection which does not require hospitalization and this treatment is possible on OPD basis and the same is not covered under day care list mentioned in Annexure-1. Hence the claim was rejected. The Opposite Party contented that the Complainant is not entitled to get the sum of Rs.22,596/- and prayed for dismissal of the complaint.
5. Evidence in this case consists of the oral testimony of PW1 and Exts.A1 to A3 from the side of the Complainant and Exts.X1 series from the side of the Opposite Party.
6. The following are the main points to be analysed in this complaint to derive in to an inference of the fact.
- Whether the Complainant had sustained to any deficiency of service or unfair trade practice from the side of the Opposite Party?
- If so the quantum of compensation and other reliefs for which the Complainant is eligible to get?
7. Heard both sides and perused the records. Ext.A1 is the copy of policy in
the name of Noushad. M. Ext.A2 is the rejection letter given by the Opposite party. Ext.A3 is the copy of notice issued by the Complainant to the Regional Office New India Assurance Company Ltd. The entire claim file submitted by the Opposite Party as directed by the Commission is marked as Ext.X1 series from the side of the Opposite Party.
8. According to the Complainant he was in the hospital for more than 24 hours and hence the repudiation of the claim by the Opposite Party is not correct. But according to the Opposite Party clause No.2.16 of the policy says “Hospitalisation means admission in a hospital for a minimum period of Twenty Four consecutive hours of inpatient care except for specified procedures/treatments as mentioned in Annexure-1 where such admission could be for a period of less than Twenty Four consecutive hours. Note to clause 2.16 says “procedures/treatments usually done in out patient departments are not payable under the policy even if converted as an inpatient in the hospital for more than twenty four consecutive hours. Complainant in the box as PW1 deposed that “sImtdmW _m[n¨v Duc-th-Z\ (\-Sp-th-Z-\) h¶n-«mWv Dr sd ImWm³ t]mbXv Bip-]-{Xn-bn t]mbn C³P-£³ h¨v ]nsä Znhkw aS-§n-h-¶p”. 14/6 \v D¨bv¡v AUvanäv sNbvXp Hcp aWn Bbn-«p-mhpw Discharge sNbvXXv ]ntä Znhkw Dt±iw 3 aWn Bbn«pmhpw AUvanäv sNbvX-Xn-sâbpw Discharge sNbvXXnsâbpw tcJ-IÄ Insurance Company  sImSp-¯n-«p-v”. Further verification of Ext.X1 series reveals that the Complainant is admitted in the hospital on 14.06.2021 at 1.45 PM and discharged on 15.06.2021 at 2.47 PM in Room No.207 D, under the treatment of Dr. P. Gopinathan. Discharge summary reveals that some tests are also done in the hospital and the Diagnosis is Lumbar IVDP with sciatica. In the column – Course in the hospital records reads as “patient was admitted with above mentioned complaints Diagnosed to have lumbar IVDP with sciatica . managed conservatively. Local Triamcinolone injection administered to trigger point (LS) corset applied. Improved symptomatically and is being discharged”. From this it is seen that the Complainant was admitted in the hospital for 24 hours and treated for the alleged pain. But the Opposite Party had repudiated the claim, as per the medical opinion from TPA. It is the treated doctor who has to decide how the patient is to be treated and the Opposite Party had not taken any steps to prove that hospitalization is not required for the treatment of ailment in the case of the Complainant in the instant case.
9. Considering the entire aspects in detail, the Commission finds that point No.1 is proved in favour of the Complainant and hence the following orders are passed.
- Opposite Party is directed to pay an amount of Rs.22,596/- (Rupees Twenty Two thousand Five Hundred and Ninety Six only) towards the claim with interest at the rate of 6% per annum.
- Opposite Party is also directed to pay an amount of Rs.10,000/- (Rupees Ten thousand only) towards compensation to the Complainant.
- Opposite Party is also liable to pay an amount of Rs.2,000/- (Rupees Two thousand only) towards costs of the proceedings.
10. Needless to say that the above ordered amounts are to be paid within 30
days of receipt of the copy of the order otherwise the Opposite Party will be liable to pay interest for the said amount at the rate of 9% from the date of order till date of realization except for the amount that is awarded as costs.
Hence the Consumer Case is allowed.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 22nd day of July 2024.
Date of filing:27.05.2022.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Noushad Complainant.
Witness for the Opposite Party:
Nil.
Exhibits for the Complainant:
A1. Police Schedule.
A2. Letter. dt:04.05.2022.
A3. Copy of Letter. dt:05.04.2022
Exhibits for the Opposite Party:
X1 series Claim file.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
