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. 111/2008 Filed on 22.05.2008
Dated : 15.11.2010
Complainant:
L. Parameswaran, 'Aswathy', 3/2398, Pattom, Thiruvananthapuram-4.
(By adv. Narayan. R)
Opposite parties :
The Senior Divisional Manager, LIC of India, Jeevan Prakash, Pattom, Thiruvananthapuram-4.
(By adv. S. Sreekumar)
The Senior Divisional Manager, New India Assurance Co. Ltd., Kottarathil Buildings, Palayam, Thiruvananthapuram.
(By adv. Sreevaraham G. Satheesh)
This O.P having been heard on 31.08.2010, the Forum on 15.11.2010 delivered the following :
ORDER
SMT. S.K. SREELA, MEMBER
The facts leading to the filing of the complaint are as follows: The complainant and his spouse have been covered under a Medical Reimbursement Scheme in the name and style as “LIC Medi-claim Insurance Scheme” launched by the 1st opposite party under arrangements by them with the 2nd opposite party. The complainant and his spouse had to take treatment for 'Sleep Apnea'-Disturbed Sleep with loud snoring etc. at the KIMS Hospital, Trivandrum by two stages on 30th, 31st January and 15th and 16th February 2008 vide Hospital Nos. 296708 and 296608. In compliance with the Rules for Reimbursement of medical expenses, the complainant submitted the Hospital bills for self and spouse for an amount of Rs. 8,000/- each totalling to Rs. 16,000/- on 03.03.2008 for settlement. But to the utter dismay and disappointment, the complainant received a letter from the 1st opposite party stating that the “claims for Rs. 8,000/-(self) and Rs. 8,000/-(spouse) are repudiated (No active treatment) by the New India Assurance Company Ltd. The stand taken by the opposite parties in repudiating the claims contravenes the provisions laid down in the Medical Reimbursement Scheme and is totally against natural justice and fair-play. This decision is found to be arbitrary and unilateral in nature.
1st opposite party has filed their version contending as follows: The complainant had submitted Hospital Discharge Certificate along with the bills for reimbursement of medical expenses as stated at para 4 and 5 of the complaint. Those documents were forwarded to 2nd opposite party on 03.03.2008. However the documents have been returned by the 2nd opposite party on 25.03.2008 stating the reason “no active treatment”. Risk covered, perils excluded, special conditions etc. are specifically stated in the policy conditions. The 1st opposite party is only a facilitator in arranging Group Mediclaim Insurance to its employees and retired employees and reimbursement of mediclaim is done by 2nd opposite party subject to terms and conditions of policy. The opposite party has no role in reimbursement as it is dealt with by 2nd opposite party as per the terms and conditions of policy. Therefore this opposite party is not responsible for repudiation of the medical claim of the complainant. The 2nd opposite party alone is responsible for the same. The policy covers reimbursement of hospitalization expenses for illness, disease or injury sustained. No specific disease is mentioned or excluded. The claim has been repudiated stating the reason “No active treatment”. The 2nd opposite party alone is responsible to illucidate what actually he meant by no active treatment. For the reasons said above no relief can be claimed against this opposite party for repudiation of any medicalim under the policy on account of deficiency of service. The complainant has also not stated in which manner this opposite party was responsible for repudiation of the claim by the 2nd opposite party.
2nd opposite party in their version has taken out a contention that the complaint is not maintainable. Further the 2nd opposite party has contended that this opposite party has issued a Group Mediclaim Insurance policy to the Life Insurance Corporation of India covering their employees and their dependants as per the clauses attached. The complainant who was an employee of LIC also will come under the coverage of the policy. He submitted two claim forms through LIC claiming an amount of Rs. 8,000/- for his treatment for obstructive sleep Apnaea and an amount of Rs. 8,000/- for the treatment of his wife for obstructive sleep Apnaea. The two claims were processed to the opposite party and were repudiated as it was found that there was no active treatments and the claim will not fall under the coverage of the policy. This fact was informed to the insured LIC. The documents produced revealed that as part of diagnosis sleep study was done on 31.01.2008 and CPAP was done on 16.02.2008. Apart from that no active treatments which will come under the cover of the policy were done. As per the clause 4.10.1 of the policy, the charges incurred for diagnostic studies are not payable. Similarly expense for CPAP is not payable under this policy as per clause 1.0.(c). No bills were submitted by the complainant. The claim was repudiated on genuine reasons. The same are not payable as per the policy conditions. The complainant is not entitled for any of the reliefs prayed for. The complaint is only to be dismissed with cost of this opposite party.
Complainant has been examined as PW1 and marked Exts. P1 to P12. On the application of the complainant, Dr. Arjun has filed interrogatories. On the part of the opposite parties, Ext. D1 was marked on behalf of 1st opposite party and Ext. D2 & D3 were marked on behalf of 2nd opposite party.
The issues that arise for consideration are:-
Whether the act of the 2nd opposite party in repudiating the claim is justifiable?
Whether the complainant is entitled for the reliefs claimed in the complaint?
Points (i) & (ii):- There is no dispute regarding the policies taken by the complainant. The complainant has alleged that the opposite parties have failed to reimburse the medical expenses for himself and his spouse for an amount of Rs. 8,000/- each totalling to Rs. 16,000/-. According to the complainant opposite parties have repudiated the claim on the ground that there is no active treatment. The 1st opposite party in their version has contended that they have no liability and the 2nd opposite party is responsible to compensate the complainant. The 2nd opposite party in their version has contended that as per clause 4.10.1 of the policy, the charges incurred for diagnostic studies are not payable. Further the 2nd opposite party has contended that there is no I.P Card or discharge card issued by the hospital showing the treatments if any undergone. So here the aspect to be looked into is whether the complainant is eligible for reimbursement as per the terms and conditions of the policy.
Exts. P1 to P5 are the records of KIMS hospital wherein the procedure charges have only been mentioned. As per Ext. P6 the opposite party has certified that the complainant has been admitted for Polysomnography. As per Ext. P7 Polysomnographic test was carried out as per the usual protocol. In Ext. P8 to P10 also the observation regarding Polysomnographic testing has been mentioned. Dr. Arjun in his interrogatories has answered that both Polysomnography and CPAP Titration are diagnostic tests involved in the evaluation of patients with sleep apnoea or SDB. Furthermore the Doctor has answered that based on the results of the CPAP Titration both of them were advised to use the CPAP machine at home regularly during sleep as their treatment modality for their ailment. As per Ext. D1 clause 4.10.1 reads as follows: “Charges incurred at a Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital/Nursing Home or at home under Domiciliary Hospitalization as defined. This means the diagnosis/investigations done in the hospital should be followed by treatment required to be taken in the hospital”. The complainant as PW1 has deposed that “നിങ്ങള്ക്കും നിങ്ങളുടെ ഭാര്യയ്ക്കും Polysomnography test-ഉം CPAP titration test-ഉം നടത്തിയതിന്റെ ചിലവാണ് claim ചെയ്തിരിക്കുന്നത് (Q) അതെ (A). Further “ഒരു active treatment ഇല്ലാതെ diagnosis-നുള്ള test-കള്ക്ക് മാത്രമായി amount payable അല്ല എന്ന വ്യവസ്ഥ ഉള്ളത് അറിയാമോ? (Q) വായിച്ചു നോക്കിയപ്പോള് മനസ്സിലായി (A)”. The treatment prescribed by Dr. Arjun was the use of CPAP machine at home regularly during sleep which evidences that no treatment is required to be taken in the hospital. Further the 2nd opposite party has contended that Exts. P1 to P4 are only bills and there is no evidence to show that the amount mentioned there had been paid by the complainant. It is true that from those documents the received payment column is blank and one cannot make out from those documents whether those amounts have been paid or not. But the issue herein is, as per the clause mentioned above whether the complainant is entitled for reimbursement. From the interrogatories and other evidence on record we have no hesitation in concluding that the amount claimed by the complainant comes under the said clause and since the Doctor has reported that both Polysomnography and CPAP Titration are diagnostic tests involved in the evaluation of patients with sleep apnoea or SDB, we find that the complainant is not entitled for any amount and the act of the opposite parties in repudiating the claim is justifiable. Hence the complaint is dismissed.
In the result, the complaint is dismissed.
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 15th day of November 2010.
S.K. SREELA : MEMBER
G. SIVAPRASAD : PRESIDENT
BEENAKUMARI. A : MEMBER
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C.C. No. 111/2008
APPENDIX
I COMPLAINANT'S WITNESS :
PW1 - L. Parameswaran
II COMPLAINANT'S DOCUMENTS :
P1 - Copy of Bill dated 31.01.2008
P2 - Copy of Bill dated 16.02.2008
P3 - Copy of Bill dated 30.01.2008
P4 - Copy of Bill dated 17.02.2008
P5 - Copy of discharge certificate
P6 - Copy of discharge certificate
P7 - Copy of Polysomnography Report dated 30.01.2008
P8 - Copy of Polysomnography Report dated 30.01.2008
P9 - Copy of CPAP Titration Report dated 15.02.2008.
P10 - Copy of CPAP Titration Report dated 16.02.2008.
P11 - Copy of letter dated 15.04.2008.
P12 - Copy of letter dated 15.04.2008.
III OPPOSITE PARTY'S WITNESS :
NIL
IV OPPOSITE PARTY'S DOCUMENTS :
D1 - Copy of Mediclaim policy for the relevant period.
D2 - Copy of policy schedule.
D3 - Copy of letter dated 10.06.2008.
PRESIDENT
