<br /> COMPLAINT FILED: 25.09.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> <br /> 13th JANUARY 2009<br /> <br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT <br /> SMT. M. YASHODHAMMA MEMBER <br /> SRI.A.MUNIYAPPA MEMBER <br /> <br /> COMPLAINT NO.2097/2008<br /> <br /> <br /> COMPLAINANT Dr.Annaji A.GAged about 36 years,No.72, Arati post,Malur,Kolar.Advocate – Smt.Shashikala AV/s.<br /> OPPOSITE PARTIES 1. Corporate Office,The Star Health & Allied Insurance Company Ltd.,No.1, New Tank Street,Velluvar Kottam High Road,Nungambakkam,Chennai – 34.2. Branch Office,The Star Health & Allied Insurance Company Ltd.,Basavanagudi,Bangalore – 1,S-1, (55) 2nd Floor,P.S.N Plaza, D.V.G Road,Basavanagudi,Bangalore – 4.Advocate – Sri.Ravi S.Samprathi<br /> <br /> <br /> O R D E R<br /> <br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to reimburse the medical expenses and pay compensation on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> <br /> Complainant availed the ‘Family Health Optima Insurance Policy’ from OP, which was valid from 27.11.2007 to 26.11.2008 for a sum of Rs.2,00,000/-. OP issued the identity card. On 05.07.2008 complainant suffered some pain then he got admitted at Sagar Hospital, Jayanagar at Bangalore. On 07.07.2008 various tests were conducted, he was subjected to investigation and a proper treatment was given. Thereafter he was discharged on 09.07.2008. He was in-patient for two days. Complainant spent nearly Rs.29,666/- towards hospitalization and treatment, then made a claim to OP to reimburse the same. Unfortunately OP repudiated the said claim on the ground that complainant got admitted in the hospital only for investigation and evaluation and not for treatment and the investigation expenses are not covered under the policy. The repudiation is illegal, arbitrary without due application of the mind. For no fault of his, he is made to suffer both mental agony and financial loss. When his repeated requests and demands went in futile he felt deficiency in service hence he is advised to file this complaint and sought for the reliefs accordingly.<br /> <br /> 2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP under the policy issued by it, it has covered the risk for the treatment under went for the disease and not for the expenses incurred for diagnostic or investigation much less evaluation purpose. The so called treatment alleged to have been taken by the complainant is not a treatment for disease but he underwent certain investigation and evaluation and incurred the expenses. Those expenses are not covered under the policy. Hence OP is justified in repudiating the claim after thorough investigation. There is no deficiency in service of any kind on the part of the OP. Complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint.<br /> <br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced some documents. OP has also filed the affidavit evidence of two witnesses and produced the documents. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainant has Proved <br /> the deficiency in service on the part of <br /> the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the relief’s now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. At the outset it is not at dispute that the complainant took ‘Family Health Optima Insurance Policy’ from OP for Rs.2,00,000/-, which was valid from 27.11.2007 to 26.11.2008. OP issued the I.D card. It is produced. Now it is the grievance of the complainant that on 05.07.2008 he had some pain at the right upper quadrant. Hence he got admitted in Sagar Hospital, Jayanagar, he was in-patient for two days that is from 07.07.2008 to 09.07.2008. In order to given the treatment and to diagnose properly he was subjected to various investigation and tests including that of M.R.I, X-ray, blood test. Then cardiologist opinion, physician opinion were taken. A proper medication was given. When he became stable he was discharged on 09.07.2008. During the course of hospitalization he has incurred an expenses of Rs.29,666/-. Bills are produced including discharge summary.<br /> <br /> 7. It is further contended by the complainant that after the discharge he made claim to OP to reimburse the medical expenses but unfortunately OP repudiated the claim on the ground that the expenses incurred by complainant are towards investigation, evaluation and not for taking the treatment for any disease. The so called expenses are not covered under the policy conditions. Complainant felt that the said repudiation is unjust, improper and without due application of the mind. Hence he felt deficiency in service. According to the complainant for no fault of his he is made to suffer both mental agony and financial loss. Under the circumstances complainant is advised to file this complaint. The evidence of the complainant which finds full corroboration with the contents of the undisputed documents appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony.<br /> <br /> 8. As against this unimpeachable evidence of the complainant the defence set out by the OP appears to be defence for defence sake. According to OP the so called expenses incurred by the complainant is towards investigation, evaluation and diagnostic purpose and those expenses are not covered under the policy conditions. We don’t find force in the said defence. When a person gets some kind of chest pain, he was referred to M.R.I, U.S.G was done, x-ray was taken, E.C.G, Echo cardiograph, image report were taken. All these tests were done for the purpose of diagnosing the actual ailment the patient suffered. It is stated by the complainant that before start of the treatment cardiologist opinion, physician opinion were taken and thereafter the treatment was given to the ailment. In our view all these kinds of tests and other things come well within the purview of the treatment. Without diagnose and investigation there cant’ be any treatment. So for this simple reason we find the defence of the OP is not tenable.<br /> <br /> 9. We have gone through the discharge summary issued by the Sagar Hospital the contents of the same is not disputed by the OP. It is diagnosed<br /> <br /> - MITRAL VALVE PROLAPSE WITH PLEURSING RIGHT<br /> BASAL. <br /> - NON CARDIAC CHEST PAIN<br /> <br /> History is also noted including past history. So having considered the past history before taking any decision to give a particular kind of treatment and medicine thorough investigation, evaluation tests are mandatory that is what is done in this case. Under such circumstances all those tests, evaluation, lab report forms the part and parcel of the treatment. When that is so, OP is bound to reimburse the same. It is the competent expert doctor in the field who has to take the decision whether to admit the patient for treatment, evaluation and tests, whether hospitalization is necessary or such a test can be done only by referring him as out patient. We don’t think OP can challenge the said decision and discretion of the treating doctor. Whether the medication is oral or by some other mode it also rest with the discretion of the treating doctor.<br /> <br /> 10. So viewed from any angle we find the repudiation is unjust, improper and without due application of the mind. We are satisfied that complainant for no fault of his is made to suffer both mental agony and financial loss. There is a proof of deficiency in service. The amount claimed by the complainant is not exorbitant but it is what he has spent for which he has produced the supporting documents. In the interest of justice we find it is a fit case wherein complainant deserves the reimbursement of the said expenses. Accordingly we answer point No.1 & 2 and proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaint is allowed. OP is directed to reimburse the medical expenses of Rs.29,666/- and pay a litigation cost of Rs.1,000/-. This order is to be complied within four weeks from the date of its communication.<br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 13th day of January 2009.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> Vln* <br /> <br /> <br />