SRI.R. VIJAYAKUMAR, MEMBER.
This is a complaint filed Under Section 12 of the Consumer Protection Act.
The complainant’s case is that the opp.parties rejected his claim for re-imbursement of Medical expenses citing unwarranted excuses.
The case of opp.party is that the claim of the complaint is not admissible as per 4.10 of the policy condition as the complainant was admitted in hospital only for investigation purpose.
From the side of the complainant PW.1 examined. Exts. P1 to P11 marked.
Opp.parties have no oral evidence.
Heard both side
The points that would arise for considerations are:
1. Whether the complaint is maintainable in the Forum?
2. Whether there is any deficiency in service from the part of opp.party?
3. Compensation and cost.
Point: 1
The 1st opp.party contented that the complaint is not maintainable in this Forum as the complaint is beyond the scope of the territorial jurisdiction of this Forum. The complainant had availed the medi claim Insurance Policy from the branch of the 1st opp.party at Ernakulam and is seeking medical reimbursement of his claim from 1st opp.party branch at Ernakulam and as such there is no jurisdiction for the Forum to entertain this matter.
As a matter of fact the complainant availed Medi-claim Insurance Policy from the 1st opp party as an account holder of 3rd opp.party and 3rd opp.party induced the complainant to join the scheme. The complainant in his complaint had stated that he had made the payment through 3rd opp.party for availment of policy. He had availed the policy on 14..3..2007 and renewed the same on 13..3..2008 through the same party. This fact was not challenged by the opp.parties. Hence part of cause of action araised within the jurisdiction of this Forum and the Forum has ample jurisdiction to entertain the complaint
Points 2 and 3::
The complainant’s case is that he had taken a Medi claim policy from the 1st opp.party through 3rd opp.party vide policy No.100100/48/06/14/00001049 and it was in force till date on 13..8..2008 The complainant was admitted to Kerala Institute of Medical Science [KIMS] with chest pain and breathing problems. On examination the complainant was diagnosed with systematic hypertension and allergic Rhinitis. On 14..8..2008 he was discharged and visited hospital again on 4..7..08 as per the direction of the hospital and admitted there.
On 13..8..2007 the complainant forwarded a pre authorization request to TTK Health Service Ltd. But his request was rejected citing unwarranted excuses. On subsequent admission also the complainant forwarded pre-authorization. But it was again rejected with remarks “Admission only for investigation not payable”. The complainant preferred1st notice to the 2nd opp.party and then to their Grievance Cell. But the opp.party did not care to reply. Even though the complainant incurred more than Rs.15,000/- no amount is reimbursed to the complainant.. Deniel of Medical expenses by 1st and 2nd opp.parties amounts to deficiency in Service. The 3rd opp.party is also liable to compensate as the complainant was forced by this opp.party to avail the service from 1st opp.party
The case of opp.parties is that the 1st opp.party had issued a Medii claim Insurance Policy from the office of the 1st opp.party at Ernakulam for a period from 14..3..2008 to 31..3..2009. The 2nd opp.party is designated as the 3rd party administration for setting claims arising under the policy. The complainant requested for reimbursement of medical expenses of the complainant’s treatment at KIMS hospital. As per the details in the requests given by the complaint through fax messages, the complainant was admitted in KIMS hospital for investigation purpose only and no treatment was taken by the complainant in the KIMS hospital in both occasions. As per 4.10 of the policy condition no claim is admissible where the investigations are not followed by any active treatments. The complainant has not taken any active treatments from the said hospital. Even though the complainant had got an option to put up the claim in writing with all relevant treatment records, such as discharge summary, investigation report, medical bills ands certificate from treated Doctor etc., he had not submitted such an application before 2nd opp.party in writing.. The complainant’s request through fax messages rejected upon valid grounds. The complainant had not put his claim with the 2nd opp.party in proper manner for considering the genuiness of the complaint. The complainant is not entitled the claim any medical benefits from the opp.parties for the expenses incurred for investigation undergone by him at KIMS hospital, Thiruvananthapuramh. There is no deficiency in service. The complainant is not eligible to get compensation and cost.
.
The 3rd opp.party contented that he is not a necessary party in this case. The reliefs sought by the complainant from opp.parties 1 and 2 only. The 3rd opp.party has no acknowledge regarding the allegation in paragraph number .2 to 7
The main issue to be determined in this case is that whether or not the 1st and 2nd opp.party is liable to reimburse the medical expenses of the complainant considering the pre-authorization request. According to the complainant opp.parties 1 and 2 are liable for re-imbursement of medical expenses as he holds a valid policy.
The contention of opp.parties 1 and 2 is that as per exemption clause 4.10 of the policy condition a claim is not admissible where the investigation made at a hospital are not followed by active treatment. The complainant has not produced any documents such as treatment record or any discharge summary. The only record produced by the complainant is pre-authorization request. The claim preferred by the complainant is not admissible. The expenses incurred by the complainant for investigation purpose only and it was not followed by active treatment. The complainant has not produced any documents such as treatment records discharge summary etc. The only document produced before the 1st opp.party is pre-authorization issued from KIMS hospital. Details of the investigation alone is mentioned and not mentioned about treatment expenses. The complainant produced the discharge summary and treatment record only before the Forum. The 2nd opp.party had repudiated the claim of the complainant on valid grounds that the complainant had not produced any document to show that he had undergone active treatment subsequent to the investigation at KIMS hospital. The 2nd opp.party has no option other than rejecting the complaint. The complainant failed to convince the admissibility of the claim.
The learned counsel for the complainant has argued that the complainant had suffered mental agony and pain due to the negligence and deficiency in service from the part of opp.party. The percept of availing the Medi claim policy is totally failed and he had forced to bare the medical expenses even though a valid policy was in existence. The complainant had spent more than Rs.17,000/-
The complainant had produced discharge summary issued to him by the hospital. At the time of admission he has no history of Diabetic Mellitus or Hypertension. The Medical examination reveals that BP level of the complainant was at the range of 160/100 monthly which is higher than normal range. After investigation the complainant was detected with systematic Hypertension and Allergic Rhinitis. Medication for controlling BP is started immediately Hypertension can only be controlled with proper medication and Hypertension patients were advised to take medication through out their life to avoid risks of cardiac vascular accidents and cerebral vascular accidents. The complainant was taking medicines till date to contro0l Hypertension. Doctors advised not to stop medicines without consultation with a doctor.
We have carefully perused the documents adduced by the parties. Copy of the policy along with terms and conditions was produced by the opp.parties and marked as Ext. D1. Exclusion clause 4.10 of Ext.D1 shows that charges incurred at hospital or Nursing Homes primarily for diagnosis, X-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailments, sickness or injury for which confinement is required at a hospital Nursing home.
AS per this condition, the claim is not payable for admission in a hospital for investigation not followed with effective treatment.
Ext. P8 and Ext.P9 are discharge summaries. Ext.P8 shows that the complainant was admitted in the said hospital on 13..8..2008 due to chest pain , breathlessness and Nasal Blocks and discharged on 14..8..2008. Investigations were made and diagnosed systematic Hypertension and Allergic Rhinitis. Tab Amlnog Tab Levocetrizine were recommended and follow up appointment was fixed for review on 28..8..2008 at 11 AM
It is seen in Ext.p10 that the complainant was admitted in KIMS
on 2..9..2008 and discharged on 4..9..2008. Further investigations were made and his condition was stable at the time of discharge. Diagnosed with systemic Hypertension and Allergic Rhinitis. Discharge Recommendations and Medications shows that Tab Amlong, Tab Levocetrizine, Tab Rupanex and Oetrivine Nasal drops were recommended to him and directed that ‘do not stop medicines till you see your Doctor” Follow up appointment for review was also fixed as on 18..9..2008. From these documents it is obvious that the complainant had undergone effective treatment subsequent to the investigation.
Another contention of the 1st opp.party is that the complainant had not produced any document other than the pre authorization request. Discharge certificate or treatment certificate was not produced before 2nd opp.party. The complainant had denied the matter while in cross examination.. It is clearly stated in the column provisional diagnosis ‘systematic hypertension and Allergic Rhinitis’
Ext.P6 [a] is the letter sent to the Grievance Cell of 1st opp.party. In this letter the complainant had clearly stated that in the Medical report his TMT result was negative and had undergone treatment.
Ext. P6 [b] is the letter sent by the complainant to the 2nd opp.party. In this letter also the complainant had specifically stated that in the Medical report his TMT result is negative he had to undergo immediate treatment.
In Ext.P7, Advocate notice it is stated that the complainant had already spent an amount of Rs.13,070/- towards examination and treatment charges and had also spent Rs.923/- towards conveyance charges.
It is pertinent to note here that even after receiving Exts P6 [a], P6[b] and P7 the opp.parties 1 and 2 had not made any attempt to enquire about the matter or to conduct any investigation. It reveals the deficient attitude of I and II opp.parties.
For all that has been discussed above, we are of the considered opinion that there is deficiency in service from the part of 1st and 2nd opp.parties. As the contractual liability is only between the complainant and the 1st and 2nd opp.parties, we find that there is no irregularity and denial of service from the part of 3rd opp.party.
In the result the complaint is allowed in part. The opp.parties 1 and 2 are directed to pay medical expenses Rs.13,070/- along with interest at the rate of 12%per annum from the date of repudiation of claim till the date of payment of the amount. The opp.parties are further directed to pay Rs.3,500/- towards compensation and Rs.1500/- as cost.
The order is to be complied with within one month from the date of receipt of the order.
Dated this the 30TH day of June, 2012.
I N D E X
List of witnesses for the complainant ; Dathakumar
List of documents for the complainant
P1.. - Copy of request to 2nd opp.party dt. 13..8..2008
P2. – Pre authorization Request.
P3. – Repudiation letter
P4. – Medi Claim policy
P5. – Notice dated 19..9..2008
P6. – Complaint dt. 19..9..2008
P6 [a] – Receipt
P6[b]Receipt
P7.- Advocate notice
P8. – Discharge summary
P9. – Discharge summary dt. 4..9..08
P10. – Examination reports of KIMS
P11. – series – Medical bills.
List of witnesses for the opp.party :NIL
List of documents for the opp.parties
D1. – Policy condition
D2. – Authorization request from KIMS Hospital, Thiruvananthapuram.
