BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

C.C. No. 241/2009 Filed on 10.09.2009

Dated : 31.01.2012

Complainant :

P. Gopalakrishna Pillai, B17, Uthradam, S.S. Kovil Lane, Kowdiar P.O, Thiruvananthapuram.

(Party in person)

Opposite party :

The Senior Manager, Oriental Insurance Company, Aristo Junction, East Thampanoor, Thiruvananthapuram.

(By adv. Varkala B. Ravikumar)

This O.P having been heard on 20.12.2011, the Forum on 31.01.2012 delivered the following:

ORDER

SRI. G. SIVAPRASAD: PRESIDENT

The facts leading to the filing of the complaint are that complainant was admitted in S.K. Hospital, Thiruvananthapuram from 21.03.2009 to 26.03.2009 because of severe pain in the left leg, that the pain was originated one month before his hospitalization, that at that time complainant had used some Ayurvedic oil, that thereafter complainant had consulted a doctor at S.R.K Hospital, Sasthamangalam, and the doctor gave medicine for 14 days, that as there was no betterment, complainant consulted the orthopedic surgeon of S.K. Hospital, that doctor gave medicine for 5 days, since there was no betterment complainant got admitted in S.K. Hospital, that complainant had taken a mediclaim policy from the opposite party Oriental Insurance Company, that the policy was valid from 01.01.2008 to 31.12.2008, that again the same was renewed for another one year from 01.01.2009 to 31.12.2009 vide revised policy No. 442301/48/2009/1253, that complainant got admitted in one of the approved hospitals of the opposite party where cashless treatment is available, that hospital authorities received a fax message on 24.03.2009 stating that cashless hospitalization is denied under 4.3 of the revised policy terms, as the illness originated within the first two years of the policy, that complainant forwarded the claim for reimbursement of hospitalization charges, which was repudiated by the opposite party, under clause 4.3, that when made appeal it was disallowed by the appellate authority under clause 4.10, that the said clauses are not applicable to him as investigations are part of the medical treatment. Hence this complaint to direct opposite party to pay the claim amount with interest from 24.03.2009.

Opposite party filed version contending interalia that complaint is not maintainable either in law or on facts, that complainant has no cause of action to file this complaint, that complainant has not preferred any appeal against the repudiation of the claim, that the existence of mediclaim policy in favour of the complainant is admitted, that policy includes policy schedule and policy conditions attached therein, that liability of the opposite party arises as per the policy conditions, that complainant was not admitted or treated for any disease as alleged. The allegation that the complainant is eligible for cashless treatment as per the policy conditions is denied, that the complainant was suffering from “non-infective arthritis and age related osteo arthritis”, that as per condition No. 4.3 the said diseases are not covered by the policy for the first four years, that the claim of the complainant is made within the excluded period and is not admissible as per the said conditions, that as per the condition number 4.10 company is not liable to reimburse any amount spent by the insured for investigation procedures not followed by active treatment and that complainant in this case has spent the alleged amount only for investigation procedures and he has not underwent any active treatment. Hence the claim is not admissible. The claim is repudiated on valid, legally sustainable grounds. There is no deficiency in service on the part of the opposite party. Hence opposite party prayed for dismissal of the complaint.

The points that arise for consideration are:-

1. Whether the claim repudiated by the opposite party is justifiable?

2. Whether there is deficiency in service on the part of the opposite party?

3. Whether the complainant is entitled to get claim amount with interest and compensation?

    

In support of the complaint, complainant has filed proof affidavit as PW1 and has marked Ext. P1 to P8. One witness from the side of the complainant has been examined as PW2. In rebuttal, opposite party has filed affidavit and has marked Ext. D1 to D5.

Points (i) to (iii):- There is no dispute on the validity of the policy. Admittedly, opposite party repudiated the claim of the complainant. It has been the case of the complainant that he got admitted in S.K. Hospital from 21.03.2009 to 26.03.2009 because of severe pain on the left leg and complainant was admitted in one of the approved hospital of the insurer where cashless treatment is available. It has also been the case of the complainant that S.K. Hospital informed M.D India that complainant was hospitalized there, that M.D. India informed that complainant was not eligible for cashless hospitalization asper clause 4.3 of the revised policy terms. According to complainant no conditions or terms were included in the policy certificate. Though complainant moved the claim in proper form with hospital bills and certificate given by the doctor as per the requirements of the company, the claim was repudiated by the opposite party on clause 4.10 of the policy terms. Complainant's evidence consisted for oral testimony of PW1 and PW2 and Ext. P1 to P8. Ext. P1 is the copy of the individual medi claim policy schedule vide policy No. 442301/48/2008/1577. Ext. P2 is the copy of the individual mediclaim policy schedule vide policy No. 442301/48/2009/1253. On perusal of Ext. P2 it is seen the policy is valid from 01.01.2009 to 31.12.2009, the sum assured is Rs. 50,000/-, and the domiciliary hospitalization limit is Rs. 10,000/-. It is to be noted that complainant was admitted in S.K. Hospital from 21.03.2009 to 26.03.2009, which is within the policy period. It is stated in the policy that Ayurvedic treatment in private hospital is not covered. Further it is mentioned in Ext. P2 that insurance under this policy is subject to conditions, clauses, warranties, endorsements as per forms attached, that the policy shall pay for hospitalization expenses for medical/surgical treatment taken as an inpatient at any Nursing Home/Hospital in India as defined in the policy. Ext. P3 is the letter issued by M.D India Health Care Services (TPA) Private Ltd. As per Ext. P3 the request for authorization letter is denied by TPA. It is stated in Ext. P3 that the cashless hospitalization is denied under Exclusion clause 4.3 as per the revised policy terms the illness is not covered under the first two years of the policy. Further it is stated in Ext. P3 that denial of authorization for cashless access is in no way to be construed as denial of treatment. The policy holder must obtain the treatment as per his/her treating doctor's advice. Denial of authorization letter shall not be construed to mean that the policy holder cannot claim under the terms, exclusions and conditions of the policy. Ext. P4 is the copy of the claim repudiation statement issued by M.D India Health Care Services. A perusal of Ext. P4 reveals that the claim has been repudiated on the following grounds: Claim not payable as per policy clause 4.10. It is stated in the repudiation letter that on scrutiny of documents it is observed that (1) the patient was admitted in S.K. Hospital from 21.03.2009 to 26.03.2009, (2) the patient is suffering from PIVD L5 WITH LT SCIATICA, (3) the patient is covered under the policy with SI 50000, (4) Policy in first year, (5) as per discharge card during hospitalization the patient was on the oral medication only, (6) as per policy clause hospitalization should be followed by the active line of treatment only and (7) Hence we repudiate the case under the clause 4.10 which is stated as, 4.10:- Expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period. Ext. P5 is the copy of the letter dated 5^th August 2009 issued by opposite party to complainant stating that the ground of repudiation stated by TPA is in order and no ground exists for a review. Ext. P6 is the copy of the claim form. As per Ext. P6 complainant has claimed Rs. 11,919/- towards expenses incurred by him. Ext. P7 series are various bills issued by S.K. Hospital to the complainant. Ext. P8 is the copy of the scan report. Complainant has been examined as PW1. The doctor who had treated the complainant has been examined as PW2. In his chief examination PW2 has admitted that Ext. P6 is filled and signed by him and in Ext. P6 there is a correction also. According to PW2, the said correction is done by himself. On perusal of Ext. P7(h) PW2 has deposed that it was he who corrected the certificate as disc prolapsed in the place of disc degenerated. In his cross examination PW2 has deposed that the patient came to him with the disease of disc prolapsed. When asked the reason for correction in Ext. P6 and P7(h), PW2 deposed during his writing some mistake had crept in. On being asked about the disc prolapse PW2 deposed that if a disc protrudes into the spinal canal it is a case of disc prolapse. When asked about the sciatica, PW2 said, it is radiating limb pain caused by impinged nerve. On suggestion by the opposite party that sciatica is not a disease and it is only a set of symptoms, PW2 said it is symptoms and signs. PW2 has further deposed that the patient had acute low back pain and sciatica. Asked about the reason for patient's low back pain, PW2 mentioned lumbar disc prolapsed with compressed nerve caused sciatica. As to the question as to what was the reason for disc prolapse in this particular case the doctor opined that the patient had back strain for which complainant saw him on 19^th March 2009. Asked about the diagnostic measure for diagnosing disc prolapse, PW2 said clinical evidence and MRI Report. On suggestion by the opposite party that persons having 50 years of age have a chance of having osteoporosis and osteoarthritis, PW2 deposed 'Yes'. When suggested by the opposite party that osteoporosis is a degenerative disease and it can result in disc prolapse, PW2 deposed that osteoporosis is not a degenerative disease while osteoarthritis is a degenerative disease. PW2 denied the suggestion put by the opposite party that the patient was suffering from osteoarthritis and diagnosis was also to that effect, that Ext. P6 and P7(h) were corrected by the doctor at the instance of the complainant for securing insurance claim from the opposite party without any bonafides. PW2 deposed that patient was not suffering from osteoarthritis. Diagnosis was not to that effect. Ext. P6 and P7(h) were corrected on the basis of MRI report and not at the instance of the patient. Opposite party's evidence consisted of oral testimony of DW1 and Exts. D1 to D5. DW1 in his chief affidavit stated that complainant was suffering from “Non-infective arthritis and age related osteoarthritis”. According to DW1 as per condition No. 4.3 the said diseases are not covered by the policy for the first four years. The claim of the complainant is made within the said excluded period and is not admissible as per the said condition. Further, as per condition No. 4.10 the company is not liable to reimburse any amount spent by the insured for investigation procedures not followed by active treatment. It has been the stand of the opposite party that the complainant has spent the alleged amount only for investigation procedures and he has not underwent any active treatment for the alleged disease. Opposite party has been cross examined by the complainant. In his cross examination DW1 has admitted that complainant got admitted in the approved hospital. DW1 has deposed that opposite party had repudiated the claim not on the basis of non-production of bills but on the basis of diseases preexisting. Ext. D1 is the individual medi-claim policy schedule with policy conditions. Ext. D2 is the certificate issued by Dr. Sudhir.S Pai. Ext. D3 is the claim form. Ext. D4 is the details of expenses incurred by the claimant. Ext. D5 is the copy of the proceedings of the Insurance Ombudsman. It has been argued by the opposite party that complainant was suffering from 'Non-infective arthritis and age related osteoarthritis' and the said diseases are not covered by the policy for the first four years and the claim is made within the said excluded period. It has also been argued by the opposite party that as per clause 4.10 company is not liable to reimburse any amount spent by the insured for investigation procedure not followed by active treatment and that complainant has spent the alleged amount only for investigation procedures and has not underwent any active treatment and hence the claim is not admissible. PW2, the treated doctor has deposed that complainant was suffering from prolapsed disc and sciatica and during his writing by mistake, it was written as degenerative instead of sciatica, immediately it was corrected as it was a known mistake. Complainant has produced copies of the in-patient bill for Rs. 11,919/- issued by S.K Hospital. In view of the above we are of the considered opinion that complainant was suffering prolapsed disc and sciatica which is not within the excluded clause, thereby the said disease is covered by the policy. As complainant has produced the inpatient bill issued by S.K Hospital, opposite party is liable to reimburse the bill amount (as per Ext. P7) spent by the insured. Non-payment of bill amount would definitely amount to deficiency in service.

In the result, complaint is allowed. Opposite party shall pay the complainant an amount of Rs. 11,919/- with 9% interest from the date of complaint(that is from 10.09.2009). Opposite party shall also pay Rs. 2,000/- as compensation. Parties are left to bear and suffer their respective costs. Opposite party shall pay the said amount within two months from the date of receipt of this order, failing which Rs. 11,919/- will carry interest at the rate of 12% per annum.

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 31^st day of January 2012.

Sd/-

G. SIVAPRASAD : PRESIDENT

Sd/-

BEENAKUMARI. A : MEMBER

Sd/-

S.K. SREELA : MEMBER

jb

C.C. No. 241/2009

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - P. Gopalakrishna Pillai

PW2 - Dr. Sudhir Pai

II COMPLAINANT'S DOCUMENTS :

P1 - Copy of individual mediclaim policy schedule vide policy No.

442301/48/2008/1577.

P2 - Copy of individual mediclaim policy schedule vide policy No.

442301/48/2009/1253.

P3 - Letter issued by M.D India Health Care Services (TPA)

Private Ltd.

P4 - Copy of claim repudiation statement issued by M.D. India

Health Care Services.

P5 - Copy of letter dated 5^th August 2009 issued by opposite party

to complainant.

P6 - Copy of claim form

P7 - Copy of discharge bill

P8 - Copy of MR IMAGING OF LUMBER SPINE

III OPPOSITE PARTY'S WITNESS :

DW1 - Sunil V. Kariat

IV OPPOSITE PARTY'S DOCUMENTS :

D1 - Individual medi-claim policy schedule

D2 - Medical certificate dated 30.03.2009

D3 - Claim form

D4 - Details of expenses incurred by the claimant

D5 - Copy of the proceedings of the Insurance Ombudsman.

Sd/-

PRESIDENT

jb