BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

O.P. No. 388/2004 Filed on 08.10.2004

Dated : 16.02.2009

Complainant:

K. Bodhanandan, 'Nandanam', T.C 30/740, Pettah, Thiruvananthapuram – 695 024.

(By adv. K.V. Karmachandran)

Opposite parties:

1. The Oriental Insurance Co. Ltd., Divisional Office No. I, Jeevan Vihar Building, 4^th Floor, Sandsad Marg, New Delhi – 110 001.

    

2. Kumar Vikram, Gunins India Ltd. 41, Arun Vihar, Sec. 37, Nodia, U.P – 201 303.

(By adv. Varkala B. Ravi Kumar)

This O.P having been heard on 16.01.2009, the Forum on 16.02.2009 delivered the following:

ORDER

SMT. BEENAKUMARI.A: MEMBER

The facts that lead to the complaint are as follows: The complainant was insured in group mediclaim policy for the pensioners of Employees Provident Fund Organization and the complainant was issued the Personal Index Number 00049 of the 1^st opposite party. The 2^nd opposite party is the third party administrator appointed by the 1^st opposite party to assist the 1^st opposite party in the processing and settlement of the group insurance with effect from 24.10.2003.

The complainant submitted mediclaim for Rs. 37,619/- being the reimbursement of the expenses of his hospitalization for surgery and enlarge prostat operation and impatient treatment at KIMS, Thiruvananthapuram from 16.12.2003 to 22.12.2003 to the 1^st opposite party. The opposite party allowed an amount of Rs. 32,304/- and disallowed Rs. 5,315/-. The disallowed amount of Rs. 5,315/- is towards electricity charges and water charges, A/C charges, registration charges, cafeteria, linen etc. As per the complainant the act of the opposite party in disallowing the amount is against the terms and conditions of the medi claim policy. Hence the complaint.

The opposite parties entered appearance and filed version stating that the complaint is not maintainable. The amount disallowed under the heads electricity and water charges, A/C charges, linen, cafeteria etc. are not covered by the policy and the 1^st opposite party has no liability to reimburse the amount spent on the above heads and that the said expenses are not inevitable part of the treatment expenses. The opposite party has repudiated only inadmissible claim and there is no violation of policy conditions and hence there is no question of deficiency of service or any compensation being paid to the complainant. Hence they prayed for the dismissal of the complaint.

On evidence the complainant was examined as PW1 and Exts. P1 to P7 were marked on his side and on the side of the opposite parties, the Divisional Manager of the 1^st opposite party was examined as DW1 and Ext. D1 was marked.

Points that would arise for consideration are:-

1. Whether there is deficiency in service from the side of the opposite parties?

2. Whether the complainant is entitled to get the reliefs claimed?

3. Costs and compensation?

    

Points (i) to (iii):- In this case the complainant has produced 7 documents to prove his claim. Ext. P1 series is the copy of claim form with claim statements submitted by the complainant to the opposite parties for Rs. 37,169.37. Ext. P2 is the letter issued by the 2^nd opposite party informing the complainant that as per policy conditions they allowed an amount of Rs. 32,304/- and repudiated the claim of Rs. 5,315/- under the heads of electricity charges, cafeteria, telephone charges, A/C charges etc. Exts. P3 to P6 are the letters and reply letters of complainant and opposite parties and postal records. Ext. P7 is the copy of certificate issued by the KIMS hospital certifying that the amount deducted from the hospital expenses by the opposite parties are related to the hospitalization and treatment expenses of the complainant. Ext. D1 is the policy copy produced by the opposite parties. As per this policy Clause A of the condition 1.1, the insurer is liable to reimburse room, boarding expenses as provided by the hospitalization. The learned counsel for the complainant argued that room and boarding expenses include the electricity charges, water charges, A/C charges, linen charges, cafeteria, registration charges, special nursing fees, miscellaneous expenses and telephone charges. The above mentioned expenses are part and parcel of the inpatient treatment because it is incumbent of the patient to meet these items of expenditure as part of the hospital accommodation charges to avail inpatient treatment and without hospital accommodation, it is impossible to get inpatient treatment. Therefore these expenses are incidental to hospitalization for inpatient treatment. And further he argued that Ext. P7 certificate issued by the hospital certified that these charges are related to the hospitalization and treatment expenses of the complainant. Further certified that the full amount has been settled by the complainant at the time of discharge. Hence disallowing of these charges is unfair and this amount is to be reimbursed. The opposite parties argued that these expenses are not covered by the policy and the 1^st opposite party has no liability to reimburse the amount spent on the above heads and that expenses are not inevitable part of the treatment expenses.

From the oral and documentary evidence and arguments of both the parties it is seen as per clause A and B of the condition 1.1 of policy copy i.e Ext. D1 the insurer is liable to pay the expenses incurred towards room, boarding expenses, provided by the hospitalization/nursing home. If the opposite parties are liable to pay the expenses towards room, boarding expenses etc. as above, it should obviously include the electricity charges, water charges etc. without which the room is not suitable for use. Hence we find that even though it has not been specifically stated in the policy, the said facilities are found to be inevitable part of the same. Hence the complaint is partly allowed. In this case according to the opposite party, they have paid the claim amount in time. Since the opposite party has disbursed the amount without any delay, which according to the opposite party, the complainant is eligible, we find no deficiency in service from their side. Hence this Forum do not allow any compensation.

In the result the 1^st opposite party, the insurance company, is directed to pay Rs. 600/- towards electricity and water charges, Rs. 2,400/- for A/C charges, Rs. 50/- towards nursing fee, Rs. 900/- towards linen charge and Rs. 25/- towards registration charges ie; Rs. 3,975/- + 12% interest from 30.03.2004 to the complainant and also shall pay Rs. 1000/- as costs of the proceedings. Time for compliance one month. Thereafter 12% annual interest shall carry the above said amounts till the date of realization.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the day of 16^th February 2009.

BEENAKUMARI. A : MEMBER

G. SIVAPRASAD : PRESIDENT

S.K. SREELA : MEMBER

O.P. No. 388/2004

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - K. Bodhanandan

II COMPLAINANT'S DOCUMENTS :

P1 - Copy of claim intimation letter dated 17.12.2003 of

mediclaim insurance with cash bill.

P2 - Letter dated 30.03.2004 issued by opposite party to the

complainant.

P3 - Copy of letter dated 08.04.2004 issued to the opposite party

by the complainant.

P4 - Copy of advocate notice dated 22.06.2004.

P5 - Copy of postal receipt dated 23.06.2004.

P6 - Postal acknowledgement card.

P7 - Copy of certificate dated 15.09.2005 issued to the opposite

party.

III OPPOSITE PARTY'S WITNESS :

DW1 - R.S. John

IV OPPOSITE PARTY'S DOCUMENTS :

D1 - Copy of Group Mediclaim Insurance Policy.

PRESIDENT