PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1)This is complaint regarding the deficiency in service on the part of Opposite Party as it rejected the mediclaim of the Complainant.
2) The facts of this complaint as stated by the Complainant are that, the Complainant has obtained a Mediclaim Insurance Policy bearing Number 11180/34/09/11/00012915, valid from 15/11/2009 to 14/11/2010. The total sum assured was Rs.6 Lacs. The policy was 1st incepted on 15/11/97 and thereafter renewed from time to time. During the validity of the above said mediclaim insurance policy the Complainant was hospitalized in Bombay Hospital from 30/05/2010 to 01/06/2010 as he sustained some accidental injuries when slipped form the staircase of his office. Dr.Shekhar Shah advised him to get admitted in the hospital and accordingly he was admitted in Bombay Hospital on 30/05/2010 and was discharged on 01/06/2010.
3) During the hospitalization and during post hospitalization period, he incurred expenses of Rs.57,120/- for the above said hospitalization and post hospitalization treatment. Thereafter, the Complainant submitted his claim form to the Opposite Party claiming the above said amount on 30/06/2010. The Complainant also submitted all the original medical bills, prescriptions, discharge card alongwith the said claim form. But the Complainant received the letter dtd.02/08/2010 from the TTK, the Authorized Representative of the Opposite Party informing that the claim was rejected as there was no need for the Complainant to be admitted in the hospital. Thus, the Complainant states that, the Opposite Party rejected the claim on unjust, unreasonable ground, arbitrarily.
4) Thereafter, the Complainant narrated the facts as to how he had an accidental fall, how he received the injuries and how he was hospitalized as per the advice of Dr. S.T. Shah. According to the doctor’s opinion he was required to be hospitalized. The Opposite Party, in absence of independent expert’s opinion cannot be permitted take a stand that the hospitalization was not necessary. Thus, the Opposite Party has avoided the payment of his legitimate claim of the Complainant and therefore, the Complainant has prayed that the Opposite Party be directed to pay Rs.57,120/- towards his legitimate claim alongwith interest and compensation of Rs.50,000/- for the medical agony caused to the Complainant.
5) The Complainant has attached the xerox copies of the following documents alongwith his complaint. Insurance policy claim form dtd.30/06/2010, letter dtd.02/08/2010, letter dtd.17/08/2010, letter dtd.31/08/2010.
6) The Complainant was admitted and notice was served on the Opposite Party who appeared before this Forum through its Ld.Advocate and filed its written statement wherein it denied the allegation of deficiency in service on its part and specifically stated that the Complainant had an accidental fall on 29/05/2010 but he was taken to the hospital on 30/05/2010. The letter dtd.16/08/2010, of Dr. Shekhar Shah proves that no suggestion was given by him before hospitalization but he has only stated that he had examined the Complainant on several occasions for consultation during the above treatment.
7) It is further submitted by the Opposite Party that the claim was scrutinized by the TTK Health Care TPA Ltd. The said TPA came to the conclusion that hospitalization was not required for the treatment of the Complainant. The treatment taken by the Complainant could have been taken on OPD basis and this is as per the terms and conditions of the policy. It is also alleged by the Opposite Party that the letter dtd.17/08/2010 was afterthought. It is submitted by the Opposite Party that repudiation of the Complainant’s claim by it is just and proper. Hence, the complaint needs to be dismissed with compensatory cost.
8) Thereafter the Complainant submitted his affidavit of evidence and written statement wherein he reiterated the facts mentioned is the complaint. The Ld.Advocate of the Opposite Party has given a pursis stating that the written statement to be treated as written argument.
9) We heard the Ld.Advocate for the Complainant and perused the papers submitted by both the parties and our findings are as follows.
10) Main point of dispute between the Complainant and the Opposite Party is whether the hospitalization was necessary for the injuries sustained by the Complainant during the accidental fall ?
In this case, the Complainant is 59 years old person. According to him, he was Hospitalized as per the suggestions of his family Doctor-Mr.S.J. Shah. A letter dtd.16/08/2010 is on record which has been issued by Dr. S.J. Shah. In this letter he has clearly mentioned that “as his family doctor, I had examined him on several occasions for consultations. I firmly believe his hospitalization, medical treatment, and expenses incurred both at hospital and at home are fully justified. Thus, a medical practitioner, MBBS, FCPS has certified the hospitalization of the Complainant. At the same time casualty paper of Bombay Hospital dtd.30/05/2010 shows that the doctor on duty at Bombay hospital has put a remark “Admit in R.No.1002 as 1st class. This also shows that the Complainant was admitted as per the advice of the medical officer. Further, it is the contention of the Opposite Party that as per the opinion of the TTK (TPA), the hospitalization was not necessary. But the Opposite Party has not given any concrete reason as to why the hospitalization was not required. Even the Opposite Party has not mentioned according to which term and condition, the Complainant’s treatment did not require hospitalization. In this respect, we carefully scrutinized all the terms and conditions of the policy and we find the relevant conditions and provisions of the policy are as follows.
11) The coverage clause prominently states as follows –
“Now this policy witnesses that, subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the Company undertakes that if during the period stated in Schedule any Insured Person shall contract any disease or suffer from any illness or sustain any bodily injury through accident, and if such disease or injury shall require any such Insured Person, upon the advice of a duly qualified Physician/Medical Specialist/Medical Surgeon to incur Hospitalization Expenses for medical/surgical/treatment at a Nursing Home/Hospital in India as herein defined (hereinafter called Hospital/Nursing Home/Day Care Centre) as an in-patient, the Company will pay to the Hospital/Nursing Home/Day Care Centre or reimburse the insured person, through the Company/Third Party Administrator, amount of such expenses as would fall under different heads mentioned below in respect thereof by or on behalf of such Insured Person but not exceeding in any one period of insurance the amount stated hereunder.”
12) We also thoroughly scrutinized the whole document containing the terms and conditions but we do not find any term or condition which stipulated that the treatment availed by the Complainant was not required hospitalization as alleged by the Opposite Party in its written statement. Therefore, in our candid view the Opposite Party has taken a lame excuse to avoid its contractual obligation to reimburse the mediclaim of the Complainant for Rs.57,120/- and this act of the Opposite Party amounts to deficiency in service and this must have caused mental agony to the Complainant. Hence, the Complainant deserves some compensation for his mental agony caused because of the deficiency in service on the part of Opposite Party. Therefore, we pass the order as follow -
O R D E R
i. Complaint No.272/2010 is partly allowed.
ii The Opposite Party is directed to pay Rs.57,120/- (Rs. Fifty Seven Thousand One Hundred Twenty Only) to the
Complainant as a reimbursement of his mediclaim alongwith interest @ 10 % p.a. from 30/07/2010 till its
payment.
iii.Opposite Party is directed to pay Rs.10,000/-(Rs. Ten Thousand Only) to the Complainant for mental agony
caused to the Complainant because of the deficiency in service on the part of Opposite Party.
iv.Opposite Party is also directed to pay Rs.5,000/- (Rs. Five Thousand Only) to the Complainant towards the cost
of this complaint.
v.Opposite Party is directed to comply with the above order within 30 days from the receipt of this order.
vi.Certified copies of this order be furnished to the parties free of cost.
