For the Complainant nos.1 &2 : Mrs. Modani, Advocate
For the Opposite Party no.1 : Mrs.D.S.Kulkarni, Advocate
Opposite Party no.2 : Ex-parte.
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Per :- Mr. J. L. Deshpande, President Place : Bandra
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::::: JUDGMENT :::::
Facts giving rise to this complaint may be stated, in brief, as follows :-
The Opposite party is Insurance Company. The Complainant had availed Medi-claim Insurance Policy from the Opposite party no.1 for the period of 2005-2006 and later on it was renewed.
2 The Complainant had previously suffered venous sinus thrombosis when she was hospitalized at Citicare Super Speciality Hospital from 19.06.2004 to 29.06.2004 for which the Complainant’s claim of Rs.34,115/- was paid by the same the Opposite party no.1 confirmed by the clarification given 7 months later by Opposite party no.1 vide letter, dated, 13.07.2005 to query, dated, 05.12.2006 of the Opposite party no.2.
3 The Complainant again suffered coronary Venal Sinus and was hospitalized at Bombay Hospital as an emergency patient on 20.07.2006 and discharged on 24.07.2006 after treatment for which claim for Rs.14,208/- was filed with the Opposite party no.1.
4 The Complainant received from the Opposite party no.2 letter, dated, 30.08.2006 requesting further documents viz. letter from Treating Doctor which Complainant furnished vide letter, dated, 18.09.2006 including Discharge Summary of hospital. Copy of the Opposite parties letter, dated, 30.08.2006 and the Complainant’s letter, dated, 18.09.2006 with Discharge card.
5 The Opposite party no.2 repudiated the Complainant’s claim vide letter, dated, 28.07.2007 on the ground, exclusion clause 4.10 of policy, that the treatment for the disease did not require hospitalization as the same could be treated at O.P.D.
6 The Complainant sent letter, dated, 26.09.2007 with a certificate given by Neurosurgeon Dr. B.S.Singhal but the Opposite party refused to reconsider their earlier order and vide letter, dated, 28.12.2007, the Opposite party finally repudiated the claim of the Complainant. Then the Complainant filed present complaint before this Forum on 01.09.2008.
7 In response to the notice, the Opposite party no.1 appeared and filed written version of defence. According to the Opposite party no.1 –Insurance Company, the applicant got admitted in the hospital for the medical check up only. The tests which were carried out on the applicant could be done otherwise at O.P.D. also. The tests which were carried out on the applicant did not need any hospitalization. As regards, the letter given by Dr. B.S.Singhal, the Opposite party no.1 explained that Dr. B.S.Singhal was treating Doctor of the applicant and on requests made by the applicant he has given the certificate. Thus, the Opposite party called the certificate has bias-one.
8 The Complainant filed affidavit of evidence as well as documents. The Opposite party no.1 made a statement that their written version be treated as affidavit of evidence. Thereafter, oral arguments of the Complainant’s advocate were heard. The Opposite parties were absent.
9 The Opposite party no.2 is agent of the Opposite party no.1 but the Opposite party no.2 remained absent and was set ex-parte.
10 We have gone through the complaint, written version, affidavits and documents. Following points arises for our determination and our findings thereon are as follows.
Nos. | Points | Findings |
1 | Whether the Complainant has proved that the Opposite party no.1 is guilty of deficiency in service on account of repudiation of the claim of the Complainant vide their letter, dated, 28.07.2007 ? | Yes |
2 | Whether the Complainant is entitled to recover compensation from the Opposite party no.1 ? | Yes |
3 | What order ? | Complaint is partly allowed. |
REASONS FOR FINDINGS :-
11 Repudiation letter, dated, 28.07.2007 (Exhibit-E) sent by the Opposite party no.1 to the Complainant reveal that the Opposite party no.1 repudiated the claim on the ground that hospitalization of the Complainant was not necessary and the Complainant could have undergone as O.P.D. patient. From the averments in the complaint as well as from the documents it is seen that the Complainant had headache and vomiting from 12 days. On examination of Medical Officer at the Bombay Hospital diagnosed as residual cortical venous sinus thrombosis in the brain venous. She was admitted at the hospital on 20.07.2007 and discharged on 24.07.2007. During that period certain tests were conducted. The Complainant has produced the certificate issued by Dr. B.S.Singhal who was Professor and Head of Department of Neurology at Bombay Hospital. In his certificate Dr. B.S.Singhal observed that the Complainant was admitted for headache and vomiting. She needed investigation and the hospitalization for the treatment. Thus certificate issued by Dr. B.S.Singhal shows that Doctors at Bombay Hospital found that hospitalization of the Complainant was necessary.
12 The Opposite party no.1 in its written version of defence has tried to overcome the effect of the certificate issued by Dr. B.S.Singhal by making statement that Dr. B.S.Singhal was treating Doctor and might have issued certificate at the instance of the Complainant. This explanation is hardly satisfactory and convincing. Ultimately, it is for the treating Doctor to decide whether admission of the patient at the hospital is essential for giving treatment. Thus treating Doctor has to decide whether the patient could be treated as O.P.D. patient or indoor patient. We are not inclined to hold that Head of Department of Neurosurgery at the Bombay Hospital would issue false certificate to favour the Complainant.
13 In addition to this, the Complainant in the complaint paragraph no.4 has averred that she had similar problem in June, 2004 and was hospitalized at Citicare Super Speciality Hospital during the period of 19.06.2004 to 29.06.2004 and the Complainant’s claim for reimbursement of the expenses was paid by the Opposite party no.1 vide its letter, dated, 13.07.2005. This shows that at earlier instance, the Opposite party no.1 had alleged the claim of the Complainant for treatment of similar nature. However, this time the Opposite party preferred deviate from its earlier stand.
14 In view of the above, we hold that the Opposite party wrongly repudiated the claim of the Complainant and thereby the Opposite party is guilty of deficiency in service.
The Complainant has sought compensation in sum of Rs.5,000/- besides interest on the original sum. However, we have allowed the claim with interest. Therefore, we are not inclined to award separate compensation. With this, we proceed to pass the following order.
::::: ORDER :::::
(1) Complaint is partly allowed.
(2) The Opposite party no.1 is directed to pay to the Complainant sum of Rs.14,208/- with 9% interest there from 29.07.2007 till the payment of amount.
(3) The Opposite party no.1 shall also pay costs in sum of Rs.5,000/- to the Complainant.
(4) Certified copies of this order to be furnished to both the parties, free of costs, as per rule.
