DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the 30^th day of January 2018

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P. Member                                  Date of filing:  13/01/2017

               : Sri.V.P.Anantha Narayanan, Member

(C.C.No.10/2017)

V.Sreedevi,

W/o Gangadharan Menon,

Residing at 3D Gangothri,

Bhadra Deepam Apartments,

D.P.O Road,

Palakkad – 678 014.                                                                            -           Complainant

(By.Adv.V.V.Girish)

 V/s

1.  The Oriental Insurance Co.Ltd,

     Diamond Branch, Mumbai.

     (Correspondence Address),

     The Oriental Insurance Co.Ltd,

     Divisional Office, IDBI Buildings,

     Chittur Road, Palakkad – 13

    (Rep.by Authorized signatory)

    (By.Adv.P.Ramachandran)

2.  E.Medictek Corporate Office,

     Plot No.577, Udyog Vihar,

     Phase V Gurgaon,

     Haryana -122 016

    (TPA Service Provider of Oriental Insurance Co.Ltd)

    (Rep.by Authorized signatory)

                                                                                                            -           Opposite parties
 

O R D E R

By Smt.Suma.K.P. Member,

The complainant’s case in brief is that her son V.Gopakumar had taken medi claim policy form the 1^st opposite party covering the risks of his family members including his mother, the complainant herein.  The complainant was undergoing treatment for cancer, (carcinoma right breast) at Laksehsore Hospital, Kochi, Kerala.  Later the doctors asked the complainant to take whole body PET & CT scan, in order to ascertain the complainant progress of her treatment.  On 03.02.2016 she went to the Aster Medicity Hospital, Kochi, as directed by her doctors, for taking whole body PET & CT scan.  The complainant claims that she was treated as IP for a day in the hospital and spent Rs.30,891/- there.  The complainant send the medical bills and the medical certificates to the 2^nd opposite party, TPA service provider, for getting reimbursement of her medical expenses.  The 2^nd opposite party, after verification of records sent by the complainant and the conditions of the policy, informed the complainant that her claim for reimbursement of medical expenses is not maintainable as she has not been treated as inpatient in the hospital for a minimum period of 24 hours and hence repudiated her claim.  The complainant who was aggrieved by the findings of the 2^nd opposite party filed the complainant against the opposite parties alleging deficiency in service on their part. 

Notice was issued to the opposite parties for appearance.  1^st opposite party entered appearance and filed their version.  2^nd opposite party remained absent and hence was set ex-parte. 

1^st opposite party contended that the complaint itself disclosed at the 1^st opposite party was made a party as a correspondence address of the 1^st opposite party.  The issuance of the alleged medi claim policy and its denial were from Mumbai and Haryana respectively.  All the documents in respect of the policy and other transaction between the complainant and the respondents were in the respective office of the party.  The cause of action for this complaint has not arose within the limits of this Forum.  The complaint disclosed that the complainant was treated at Kochi.  The policy was issued from the office of the 1^st opposite party at Mumbai.  Whereas the claim was denied by the 2^nd opposite party functioning at Gurgaon, Haryana.  In such circumstances this Forum has no jurisdiction to enquire about this complaint.  The 1^st opposite party further contended that they had repudiated the complainant’s claim as there was violation of the terms and conditions of the policy.  The complainant has not been admitted and treated as inpatient there in the hospital for 24 hours.    The 2^nd opposite party is processing the claim arisen under the medi claim policies.  It is a statutory body constituted for the purpose of processing the claim under medi claim policies.  The company which issue medi claim policies has to follow the recommendations of the TPA provider.  Their recommendations are binding on the party.  The 2^nd opposite party has perused the document produced by the complainant and had come to the conclusion that the claim is not maintainable.  Hence, the complaint is not maintainable and it has been dismissed. 

Complainant filed chief affidavit.  1^st opposite party also filed their chief affidavit.  Exts.A1 to A7 was marked from the side of the complainant, and Ext.B1 series was also marked from the side of the opposite parties.  1^st opposite party filed application seeking permission to cross examine the complainant.  Further the application was not pressed by the 1^st opposite party.  Hence evidence was closed and the matter was heard. 

The following issues that arises for consideration are.

1. Whether the Forum has jurisdiction to entertain this complaint?
2. Whether there is any deficiency of service from the part of opposite parties ?
3. If so, what are the relief and cost?

Issues No.1 & 2

            We have perused the affidavit and documents of both parties, produced before the Forum.  The complainant is a cancer patient and was taking treatment with Dr.Gangadharan, Dr.Anupama, Dr.Arun Warrier, oncologist of Lakeshore Hospital, Maradu, Kochi.  Since there were no cancer specialists available in Palakkad, the complainant used to go from Palakkad to Kochi often to attend chemotherapy etc.  Apart from being a cancer patient, the complainant suffers from type 2 diabetes, hypertension and hypothyroidism.  The complainant’s breast (RT) has been removed because of cancer.  As a part of treatment and under the direction of Dr.Anupama the complainant was directed to take a whole body PET & CT scan from Aster Medicity, Kochi, Department of Nuclear Medicine as this was the only hospital in Kerala having the above facility.  The complainant went to the above hospital on 03.02.2016 and was directed to the scan department and asked to pay a sum of Rs.19,100/- towards PET – CT imaging and registration.  The above document has been produced and marked as Ext.A5 series, which contain 24 documents.  In the bill No.OPCA 16/302681 dated.03.02.2016 the time shown in 9.14 am (Doc.No.16 in Ext.A5 series).  The complainant was administered IV fluids during PET scan, after its administration the complainant started having difficulty in breathing, de-saturation, hypotension and reduced responsiveness, she was immediately resuscitated and shifted to emergency department and treated with supportive meditation and was admitted for observation on these aspects are clearly mentioned in the discharge summary, part of Ext.A5.  It is crystal clear in the discharge summary that complainant was admitted as inpatient having No.16/1522 datted.03.02.2016 and discharged on 04.04.2016 at 12.49 hours.  The documents produced by the complainant would clearly show that she was in the hospital from 9.14 hours on 03.02.2016 upto 12.49 hours 04.02.2016, which is clearly more than 24 hours.  The complainant has spent a sum of Rs.30,891/- as medical expenses at Aster Medicity would evidence the above fact.  The complainant is therefore entitled to reimbursement of her medical expenses.  The complainant’s son had submitted all the documents to get the reimbursement and the same was sent to the 2^nd opposite party who is the T.P Administrator of the 1^st opposite party.  The documents were received by the 2^nd opposite party on 02.03.2016.  The above claim was repudiated by the opposite parties vide letter dated.12.03.2016 for the reason that the complainant did not undergo 24 hours hospitalization.  The repudiation is per-se-illegal.  Perusal of the records provided by the complainant would clearly go to show that she was in hospital from 9.14 am on 03.02.2016 to 12.49 pm on 04.02.2016.  The complainant further submits that the opposite parties have repudiated the claim without even perusing the documents by the complainant.  The opposite parties know about the past treatment of the complainant as they have reimbursed her earlier claims. 

            The opposite party had contended that no part of the cause of action of this complaint has arose within the limits of the Forum.  The complainant had processed the claim form through the 1^st opposite party through which the claim was made, had its Divisional Office situated in Palakkad.  The 1^st opposite party is also having its branch office at Palakkad and under section 11 of the provision of Consumer Protection Act this Forum has jurisdiction to entertain this complaint. 

            Issue No.1 & 2 answered accordingly. 

            In the result the complaint is allowed and we direct the opposite parties to pay an amount of Rs.30,891/- as the amounts spent by the complainant towards hospitalization.  We also direct the opposite parties to pay an amount of Rs.2,000/- (Rupees two thousand only) as compensation for the mental agony suffered by the complainant and also an amount of Rs.1,000/- (Rupees one thousand only) as cost of this proceedings. 

            This order shall be executed within one month from the date of receipt of this order; failing which the complainant is entitled to realize from the opposite party interest at 9% p.a on the total amount due to him from the date of this order till realization. 

Pronounced in the open court on this the 30^th day of January 2018.

                       Sd/-

                  Shiny.P.R.

                   President 

                       Sd/-      

                   Suma.K.P.

                    Member

                        Sd/-

    V.P.Anantha Narayanan

                    Member

Appendix

Exhibits marked on the side of complainant

Ext.A1 -  Photocopy of the prescription issued from Lakeshore Hospital for taking

                PET-CT Scan

Ext.A2 -  Photo copy of Medi claim card of the complainant issued by 1^st opposite party valid

    from  01.04.2015

Ext.A3 - Photo copy Health card issued by 2^nd opposite on behalf of 1^st opposite party valid from

               01.04.2016 to 31.03.2017

Ext.A4 - Photocopy of the details of family covered of the policy

Ext.A5 series    -  Check list for submission of claim submitted by the complainant to 2^nd opposite

                            party consisting of original bills, prescription, discharge summary, lab results

                            etc.

Ext.A6 -  Photocopy of draft covering letter issued by 2^nd opposite party dated.12.03.16

Ext.A7 -  Photo copy of Repudiation letter dated.12.03.2016 issued by 1^st opposite party

Exhibits marked on the side of Opposite parties

Ext.B1  series    -  Photo copy of the findings of the 2^nd opposite party and their draft repudiation    

                           letter (2 sheets)

Witness examined on the side of complainant

Nil

Witness examined on the side of opposite party

Nil

Cost

  Rs.1,000/-