By Smt. Padmini Sudheesh, President: The case of complainant is that the complainant taken a mediclaim insurance policy of 3rd respondent vide policy No.441100/2007/1872 through the 2nd respondent. Meanwhile on 18.6.2007 the complainant was admitted in the first respondent hospital for the treatment to back pain and body pain. He was discharged on 20.6.07 with direction to undergo treatment for one month. The complainant had incurred medical expenses for an amount of Rs.2600/-. After the treatment he applied to the 2nd respondent along all the relevant documents through the first respondent. The 2nd respondent repudiated the claim by stating their inability to pay the amount. This is illegal and this complaint is filed. 2. The counter of 3rd respondent is to the effect that this respondent has issued a mediclaim hospitalization insurance policy which covers hospitalization expenses reasonably and necessarily incurred by the insured person. As per this policy if any insured person contract any disease or suffer from any illness which shall require upon the advice of a duly qualified medical practitioner “hospitalization”. The claim of complainant does not come under the purview of the policy. The complaints of the complainant were low backache and the final diagnosis is PIVD L5SI. In terms of clause 4.3 of the modified mediclaim policy the treatment/surgery in respect of the above disease is not payable for the first 2 years. There is also no justification for hospitalized treatment as the investigation and medicines could be availed as an outpatient. It is also learnt that oral medicines are only prescribed and no treatment requiring compulsory hospitalization is noted. The claims submitted to this respondent are sent to the 2nd respondent for detailed investigation and it is the second respondent who repudiate or favour the claim. The claim is repudiated by the 2nd respondent on just grounds since the claim for his disease is not payable for the first two years under the policy and since it is not a disease which requires hospitalization. This respondent denies the averments that an amount of Rs.2600/- is spent for treatment. No deficiency in service is committed by this respondent. The disease of complainant stated in the complaint is an exclusion under the policy. This respondent is not liable to pay any amount. Hence dismiss. 3. The other respondents remained exparte. 4. The points for consideration are: (1) Is there any deficiency in service on the part of respondents? (2) If so, reliefs and costs. 5. The evidence consists of Exts. P1 and P2 on the part of complainant and Exts. R1 to R6 on the part of 3rd respondent. No oral evidence adduced by both. 6. Points: This complaint is filed to get reimbursement of the medical expenses incurred to the complainant. According to the complainant, he was admitted in the first respondent hospital on 18.6.07 with complaints of back pain and body pain. After the treatment he was discharged on 20.6.07 with direction to continue the treatment. He states that he had incurred medical expenses of Rs.2600/-. According to him, being a mediclaim insurance policy holder he will be entitled for the reimbursement of this expense and he preferred claim to the 2nd respondent through first respondent. But it was repudiated by the 2nd respondent. He has filed only Exts. P1 and P2 documents only to prove his case. He has not adduced any oral evidence. 7. In the counter, the 3rd respondent insurance company contended that they are not liable to pay any amount to the complainant because the claim does not come under the purview of the policy. As per this policy if any insured person contract any disease or suffer from any illness which shall require upon the advice of a duly qualified medical practitioner “hospitalization”. They also stated that in terms of clause 4.3 of the modified mediclaim policy the treatment/surgery in respect of the above disease is not payable for the first 2 years. Thus the respondent taken two versions to disallow the claim of complainant. First version of company is with regard to hospitalization. According to them, this disease does not require hospitalization. They also stated that as per the policy the hospitalization must be upon the advice of a duly qualified medical practitioner. Ext. R3 is the discharge summary issued from first respondent hospital and in which it is stated that he was admitted on 18.6.07 and discharged on 20.6.07. The consultant doctor was Dr. Pramod Mohan, MS (Ortho) PGI. The hospital is a known hospital at Thrissur and the doctor who had treated the complainant was also qualified doctor. The 3rd respondent does not have a case that the doctor who had treated the complainant is not a duly qualified medical practitioner. They simply averred the conditions of the policy in the counter and failed to prove that this doctor is an unqualified medical practitioner. So this contention of the 3rd respondent will not sustain. In this case the complainant was hospitalized with the direction of this doctor as per the discharge summary and no contrary evidence adduced by the respondents. So it cannot be said that the hospitalization was unnecessary. According to the 3rd respondent, they learnt that no treatment requiring compulsory hospitalization is noted. As per the discharge summary the person was admitted in the Heart Hospital with the advice of Dr. Pramod Mohan. Since no other evidence is adduced it should be believed. 8. Another contention raised by the 3rd respondent is with regard to clause 4.3 of the policy. According to them in terms of clause 4.3 of the modified mediclaim policy the treatment/surgery in respect of the disease of complainant is not payable for the first 2 years. The copy of policy is produced by the 3rd respondent and marked as Ext. R1. Clause 4.3 of Ext. R1 would show that during the period of insurance cover, the expenses for treatment of some ailment/diseases/surgeries for specified periods are not payable if contracted and/or manifested during the currency of the policy. A table is shown in clause 4.3 and in which it is stated that surgery for prolapsed inter vertebral disk unless arising from accident – 2 years. So the 3rd respondent by relying this condition stated that the treatment for surgery in respect of the low backache is not payable for the first two years. But as per Ext. R1 there is no condition that treatment for the said disease is exempted from the payment. In the table it is specifically stated in No.xx that only surgery is exempted and no whisper about treatment. So this contention of the 3rd respondent also will not lie. 9. As per Ext. R5 the claim was repudiated on the ground of clause 4.3 of the modified mediclaim policy. In Ext. R5 it is stated that treatment/surgery in respect of the above disease is not payable for the first 2 years. The disease of the complainant stated in Ext. R5 is low backache and the final diagnosis is PIVD L5 S1. This repudiation is against the terms of the policy and deficiency in service is committed by the 2nd respondent. So the complainant is entitled for compensation also. 10. In the result, the complaint is allowed and the 3rd respondent is directed to pay Ext. R6 series bills amount to the complainant and the 2nd respondent is directed to pay an amount of Rs.2500/- (Rupees two thousand and five hundred only) as compensation to the complainant. Both respondents-2 and 3 are directed to pay an amount of Rs.600/- (Rupees six hundred only) as costs to the complainant. Comply the order within two months from the date of receipt of copy of this order. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 28th day of May 2010.
| | HONORABLE Rajani P.S., Member | HONORABLE Padmini Sudheesh, PRESIDENT | HONORABLE Sasidharan M.S, Member | | 
