O R D E R<br /> <br /> M.R. DEVAPPA, PRESIDENT<br /> <br /> Briefly stated the case of the complainant is as follows;<br /> <br /> 1. That the complainant is a planter and obtained insurance policy by insuring his life and his wife Remya Jayanth including two daughters with the opposite party under hospitalization benefit policy / mediclaim policy by paying required fee and thereafter every year he used to renew the same. The insurance policy was obtained on 19-3-2003.<br /> <br /> 2. That the wife of the complainant who has been covered under the said policy, started feeling ill and hence on 19-1-2007 she was admitted as an inpatient to Amritha Institute of Medical sciences and Research Centre, Amritha Lane, Kochi and upon examination she was diagnosed for bilateral periarthritis shoulder – right / left, hypothyroidism, type 2 Diabetes Mellitus, Dyslipidemia and Bronchial Asthma and she underwent treatment for the aforesaid illness as an inpatient therein and after treatment she was discharged from the said hospital on 29-1-2007 with advice for physiotherapy and Ayurvedic therapy for non specific polyarthralgia and in this regard she incurred a sum of Rs.22,306/- towards the medical and pharmacy charges.<br /> <br /> 3. That the wife of the complainant as per the advise of Amritha Institute of Medical Sciences and Research Centre, Kochi, the complainant got admitted his wife, the said Mrs. Remya Jayanth to PKM Ayurvedic Hospital and Research Centre, Taliparamba for Aurvedic therapy on 1-2-2007 as an inpatient and after a prolong treatment for about 3 months she was discharged on 28-4-2007 and thus she has incurred expenditure to the extent of Rs.51,041/- towards room rent, nursing fees, medicines and other Ayurvedic treatments.<br /> <br /> 4. That the complainant thereafter telephonically lodged a claim for insurance during the 2nd week of May 2007 with the opposite party from Kannur and thereafter submitted necessary papers and bills in respect of the said treatment and claim was made for a sum of Rs.73,347/-.<br /> <br /> 5. That the complainant received a claim status report dated 27-7-2007 by paramount health services (P) Ltd., Bangalore stating that the claim of the complainant is not admissible as per the terms and conditions of the policy and hence the ailment does not require hospitalization and procedure done in the hospital are purely of OPD procedures hence the claim is considered as no claim, without giving reasons. <br /> <br /> 6. That the complainant repeatedly requested to reconsider the claim made and in this regard in August 2008 approached to the Branch Manager of the opposite party at Madikeri but the later refused to settle the claim. Thus the act of the opposite party has caused mental agony and stress to the complainant. By omitting to consider the claim of the complainant the opposite party has committed deficiency in service.<br /> <br /> 7. The complainant has prayed for following relief;<br /> <br /> a. To pay to the complainant, the sum ofRs.73,347/- being the medical expenses incurred by the complainant, together with interest at the rate of 18% p.a. on and from 28-4-2007 till the date of payment;<br /> b. To pay to the complainant, further sum of Rs.25,000/- or such other sum, by way of damages for non-settlement of claim, mental agony and deficiency of service.<br /> c. To pay to the complainant, the costs of this proceedings and such other relief deemed fit.<br /> <br /> 8. The complainant has filed the following documents;<br /> <br /> Sl.No. Date, if any of document Nature and Description of the document <br /> 1 23-7-2006 Xerox copy of hospitalization and demiciliary hospitalization benefit policy, for the period from 19-3-2006 till 18-3-2007<br /> 2 23-7-2007 Xerox copy of the hospitalization and Domiciliary hospitalization benefit policy, for the period from 19-3-2007 till 18-3-2008.<br /> 3 29-1-2007 Xerox copy of discharge summary issued by Amrita Institute of Medical Sciences and Research Centre.<br /> 4 29-1-2007 Xerox copy of inpatient collection and Appropriation, issued by Amrita Institute of Medical Sciences and Research Centre.<br /> 5 28-4-2007 Xerox copy of the Discharge summary, issued by P.K.M., Ayurvedic Hospital & Research Centre<br /> 6 28-4-2007 Copy of Medical certificate, issued by P.K.M. Ayurvedic hospital & Research Centre.<br /> 7 28-4-2007 Xerox copy of cash bill, issued by P.K.M Ayurvedic Hospital & Research Centre.<br /> 8 27-7-2007 Xerox copy of claim status letter, issued the paramount Health Services (P) Ltd.,<br /> 9 20-7-2007 Xerox copy of claim Form for Mediclaim Insurance policy.<br /> 10 20-7-2007 Xerox copy of letter written by the complainant to the respondents.<br /> 11 Xerox copy of the Mediclaim Insurance policy clause. <br /> <br /> 9. Upon admitting the complaint the notice was ordered to be sent to the opposite party namely the M/s. New India Assurance Company Ltd., M.G. Road, Madikeri and on receipt of the notice from this Forum the opposite party appeared through their counsel and filed the following version and taken several contentions and prayed for dismissal of the complaint justifying the repudiation of the claim of the complainant.<br /> <br /> 1. That the complaint is bad in law as it is not filed by Smt. Remya Jayanth.<br /> <br /> 2. That it is false that Smt. Remya Jayanth fell ill as claimed and was admitted on 19-1-2007 as an inpatient as claimed and it is denied that she was inpatient till 29-1-2007.<br /> <br /> 3. That the complaint disclose that only diagnosis was done and the same should have been done as an outpatient. There was no need for her to be an inpatient. <br /> <br /> 4. That there was no need for her to again get admitted in Taliparamba Hospital for her treatment from 1-2-2007 till 28-4-2007 and it is denied that she was so admitted. <br /> <br /> 5. That no material is placed to show that hospitalization was required and that she was treated as claimed. <br /> <br /> 6. The 3rd party administrator after scrutinizing the documents have repudiated the claim and the same is legally valid and same is to be upheld. <br /> <br /> 7. That the repudiation clearly mentions that in case the complainants meets and further clarifications he could do so by contact them again and subsequently no clarification was sought by the complainant or Smt. Remya Jayanth.<br /> <br /> 8. That as per the condition 5-3 thereof notice with full particulars should be sent to the company within 7 days from the date of hospitalization and as per condition 5-4 the claim should be made within 30 days from the date of the discharge. <br /> <br /> 9. That as per condition 5-11 there of, if the party does not claim within 12 calendar months does not in writing express his non acceptance, the claim for all purposes be deemed to have been abandoned.<br /> <br /> 10. That there is thus a clear violation of the terms of the policy by the complainant and his wife. <br /> <br /> 11. That it is false that the complainant telephonically informed the company and the same is totally denied and the same is of after thought attempt.<br /> <br /> 12. That the complaint is filed ignoring the contract regarding the time limits of the contract namely the policy.<br /> <br /> 13. That there is no deficiency or delay in taking the decision in respect of the claim made by the opposite party and hence the complaint is liable to be dismissed.<br /> <br /> 10. The complainant has produced the insurance policy and the medical insurance policy clauses.<br /> <br /> 11. Both the complainant and the opposite party have filed their affidavit evidence in lieu of examination in chief. <br /> <br /> 12. Learned advocates of the parties have been heard.<br /> <br /> 13. Having regard to the averments in the complaint and the defence taken by the opposite party we have to determine the following issues;<br /> <br /> 1. Whether the opposite party company has committed any deficiency of service ?<br /> <br /> 2. To what order?<br /> <br /> R E A S O N S<br /> <br /> 14. It is submitted by the learned advocate for the complainant that if the insured suffer from any illness and after diagnosing the illness, if the doctor who has advised the insured to take treatment and accordingly if the insured being a patient takes treatment after having admitted in a particular hospital whether it is Alopothy or Ayurvedic he or she is entitled for reimbursement of the expenditure incurred towards that end and has relied on the following decisions in support of his submission;<br /> <br /> 1. 1995(2) CPJ 1 Service- Medical service- Held that medical services are to be covered under the inclusionary part of the definition of service.<br /> 2. 1993(2)CPJ245 : Mediclaim- Estoppel, Insurance Co. issued a certificate in favour of the insured. In this certificate no mention was made by the insurance company about the exclusion clause---------- state commission was exclusion clause in view of the principles of promissory Estoppel.<br /> 3. 1994(1) CPJ 509 P-545 (Mad HC-DB): Service –para medical service- Is service- The medical practitioners or hospitals undertaking and providing paramedical services of any categories or kind cannot claim similar immunity from the provisions of The Act and they would fall, to the extent of such services rendered by them within the definition of service and a person availing of such service would be a consumer with the meaning of the act.<br /> <br /> 15. It is further submitted by the learned advocate for the complainant that the wife of the complainant Ramya Jayanth in the month of January 2007 was admitted as an inpatient on 19-1-2007 to Amrita Institute of Medical Science and Research Centre Kochi and as per the advice of the doctors at the said institute she was examined by the doctors and she was diagnosed for bilateral periarthritis shoulder – right / left, hypothyroidism, type 2 Diabetes Mellitus, Dyslipidemia and Bronchial Asthma and she underwent treatment for the aforesaid illness and there after she was discharged from the said hospital on 29-1-2007 with advice for physiotherapy and Ayurvedic therapy and therefore she got herself admitted to PKM Ayurvedic hospital and Research Centre, Taliparamba for further treatment and incurred expenditure both in Amrita Institute of Medical Science and Research Centre and PKM Ayurvedic Hospital and Research Centre a total sum of Rs.73,347/-.<br /> <br /> 16. It is also submitted that in the exclusion clause Naturopathy is mentioned but not physiotherapy or treatment in Ayurvedic hospital for any kind of illness is not excluded and therefore, the complainant wife being the beneficiary under the mediclaim policy is entitled for reimbursement of expenditure.<br /> <br /> 17. As against the above submission the learned advocate for opposite party company submitted that there was no necessity for getting admitted in the hospital i.e., both in Amrita Institute of Medical Sciences and Research Centre and PKM Ayurvedic Hospital and Research Centre, Taliparamba and complainant’s wife could have taken treatment as an outpatient and no material has been produced to show that hospitalization was required for which she was treated as claimed and further the complainant has violated the condition 5-3, condition 5-4 and condition 5-11 for having delayed to intimate the matter regarding diagnosis and the treatment obtained and the complainant has deliberately violated the time limits and for clear violation of the terms and condition of the policy the complainant and his wife is not entitled for any benefit under the policy and the opposite party company has neither unnecessarily delayed the matter and illegally repudiated the claim of the complainant and the repudiation is just and proper and as such for mental agony of the complainant or his wife the company is not responsible and as such has prayed for dismissal of the complaint.<br /> <br /> 18. The complainant has produced the discharge summary wherein the diagnosis of Ramya Jayanth is found and several illness have been diagnosed and after treating the patient for 3 months duration the doctor has advised for physiotherapy and further advised her to attend Ayurvedic clinic for further treatment. Therefore it is not correct to state that the complainant has not produced any documents in this behalf and the complainant has also produced the certificate to show that she was admitted in PKM Ayurvedic Hospital and Research Centre from 1-2-2007 to 28-4-2007 for Arthritics and she was given internal Ayurvedic medicines and panchakarma therapies and after symptomatically relieved she was discharged on 28-4-2007 with the advice to continue medicine for two months with rest. The relevant certificates for having given treatment are also produced for perusal and therefore it is not correct to state that the complainant has not produced any document to show that she was diagnosed and treated for illness as an inpatient. There may be some delay in claiming the reimbursement. In such matter we cannot be too technical because delay is reasonable hence the same is condoned.<br /> <br /> 19. We have perused the cash bill, but the room rent collected from PKM Ayurvedic hospital and Research Centre appears to be exorbitant and such kind of room rent paid; cannot be reimbursed. We don’t know the nature of room obtained from the complainant’s wife but the opposite party company is only liable to pay the reasonable rent and of course other charges of treatment cannot be deducted. However the room rent is assessed at Rs.10,000/- and for balance amount of Rs.8,875/- the complainant is not entitled for having deducted Rs.8,875/- from Rs.51,041/- it comes to Rs.42,166/- and hence the expenditure incurred at PKM Ayurvedic Hospital and Research Centre is calculated at Rs.42,166/- and in the Amrita Institute of Medical Sciences and Research Centre, Kochi claim is limited Rs.9,356/-. Moreover the complainant has not produced the medicine bills except the medical bill prepared by those two institutes. Therefore, the expenditure incurred totally assessed at Rs.51,522/- and the same is restricted to the above amount as she is not entitled for reimbursement of entire amount for the reasons stated above.<br /> <br /> 20. The above finding is given after considering that the complainant’s wife has obtained treatment for his several illnesses and as per the advice of the doctors of both the hospitals and the opposite party company has repudiated the claim illegally and improperly for which we hold that they have committed deficiency in service and hence we answer point no.1 positively and proceed to pass the following order;<br /> <br /> O R D E R<br /> <br /> The complaint is partly allowed. The opposite party is hereby directed to pay Rs.51,522/-only towards incurring of hospital expenditure and Rs.500/- for compensation for complainant has undergone mental agony and loss and Rs.500/- towards the cost of the proceeding to the complainant.<br /> <br /> The above order shall be complied by the opposite party within sixty days from the date of the order.<br /> <br /> Communicate the order to the parties. <br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the open Forum on this 21st day of January 2009.<br /> <br /> <br /> (M.R. DEVAPPA), (K.S. PRASAD), (A.S. HEMALATHA),<br /> PRESIDENT MEMBER MEMBER<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />