DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, Civil Station, Palakkad 678001, Kerala
Dated this the 29th day of April, 2009
Present: Smt.Seena.H, President Smt.Preetha.G.Nair, Member Smt.Bhanumathi.A.K, Member
C.C.No.107/2007
M.V.Abdullakutty, Mangattu Valappil House, Palappuram, Ottapalam, Palakkad. - Complainant (Party in person) Vs
1. United India Insurance Company Ltd. Fizal Building, Main Road, Ottapalam. (By Adv.C.Mohanram) 2. Paramount Health Services, Building No.CC50/127, Plot No.1, Krishna Vihar, Panampilli Avenue, Kochi 682 036. - Opposite parties
O R D E R
By Smt.Seena.H, President
Complainant took a mediclaim insurance policy from the 1st opposite party by paying an amount of Rs.5,709/- as premium on 21/08/2006. The period of the policy was from 22/08/06 to 21/08/07. Complainant had undergone treatment for leg pain and hip pain in Al Shifa Hospital from 15/11/06 to 18/11/06. Claim form for an amount of Rs.7,538/- was submitted to the opposite party. A letter dt.13/2/07 from the treating Doctor was also submitted as per the request of 2nd opposite party. Ultimately the claim was rejected by the 2nd opposite party as per policy conditions 4.10. Subsequently complainant had undergone treatment for leg pain and stomach pain in Valluvanad Hospital from 12/06/07 to 13/06/07. Claim form was submitted as per policy conditions on 15/11/06 for a total sum of Rs.3412/- A letter from the treating Doctor was also submitted as per the request of the 2nd opposite party. The said claim was also rejected by the opposite parties stating that hospitalisation was not justified. According to the complainant the act of the opposite parties amount to clear deficiency of service on their part. Complainant is claiming an amount of Rs.12,374/- towards medical expenses together with interest and Rs.25,000/- as compensation for mental and physical agony and Rs.2,000/- as cost of the proceedings.
2. 2nd opposite party was set exparte. 1st opposite party filed version with the following contentions. The issuance of policy and submission of claim form was admitted by 1st opposite party. But according to 1st opposite party the said claim was repudiated on valid grounds. As per clause 4.10 of the policy conditions, the expenses incurred for investigation, diagnosis etc will not be reimbursed. The complainant was hospitalized in Al Shifa Hospital (P) Ltd on 15.11.06 and he was discharged on 18.11.06. The complainant was diagnosed to be having type 2 diabetes mellitus with Neuropathy, IVDP, Hypothyroidism, B/L Varicose Veins, as mentioned in the discharge summary of Al Shifa Hospital Pvt Ltd. As per the discharge summary investigations such as blood sugar, blood urea, serum creatinine, serum TSH, fasting blood sugar etc has been done from 15.11.06 to 18.11.06 viz from the date of admission till the date of discharge. This clearly shows that the admission was particularly for investigations and not for any active line of treatment necessitating hospitalization. Further the discharge summary also shows that neurology consultation was taken for the patient. TSH levels and thyroxine and symptomatic therapy was started for neuropathy along with treatment for varicose veins. There is no mention of any acute emergent condition or treatment administered which required the patient to be confined to the hospital and the above mentioned medical services could have been done on an out door patient basis. This clearly shows that the admission was particularly for investigations and no active line of treatment requiring hospitalization.
3. The complainant was hospitalised in Valluvanad Hospital on 12.6.07 and he was discharged on 13.6.2007 with complaints of acute gastritis, peripheral neuropathy, NIDDM. As per the medical documents submitted, the patient was given some medicines mostly in the form of tablets and capsules for controlling the ailment, which could be administered on an outdoor patient basis. The investigations carried out were urine test, blood sugar test, USG of abdomen/pelvis etc. Hence the claim was repudiated by this opposite party since hospitalization is not justified and the treatment/investigation could have been done on out door patient basis.
4. Complainant and 1st opposite party filed affidavit. Exts.A1 to A14 were marked on the side of the complainant. 5. Now the issues for consideration are; Whether the act of opposite parties in repudiating the claim amounts to deficiency of service? If so, what is the reliefs and costs?
6. Point 1: Opposite party has repudiated the 1st claim relying mainly on the discharge summary wherein it was stated that blood sugar, blood urine, serum creatinine, serum TSH, fasting blood sugar etc have been done from 15/11/06 to 18/11/06. This reveals the fact that the admission was particularly for investigations and not for any active line of treatment necessitating hospitalization. Further there is no mention of any acute emergent condition or treatment administered which required the patient to be confined in the hospital.
7. In our view the authoritative person to decide whether the patient has to be treated as in patient or out patient and whether the admission was for any investigation purpose etc is the treating Doctor. The Doctor who treated the complainant has given report clearly stating the need of the admission and the line of treatment given. The said report is marked as Ext.A4. The said report states that the complainant was admitted for treatment after diagnosis. The act of opposite parties in repudiating the claim even after receiving the said report amounts to deficiency of service.
8. Regarding the 2nd claim, going through the exhibits marked including the Doctor's report, we do not find any clear justification for hospitalization for one day. Hence the repudiation of the same is justified.
9. It can be seen that the complainant has issued notice dt.25.04.07 to both opposite parties for settling his grievance for which opposite parties has not replied. Notice is marked as Ext.A13 and A14. From the foregoing discussion we are of the view that the act of opposite party in repudiating the 1st claim amounts to deficiency of service.
10. In the result, complaint is partly allowed. We direct the opposite parties to pay the complainant an amount of Rs.8,962/- (Rupees Eight thousand nine hundred and sixty two only) being the medical expenses together with Rs.3,000/- (Rupees Three thousand only) as compensation and Rs.1,000/- (Rupees One thousand only) as costs of the proceedings. Order shall be complied within one month from the date of receipt of the order failing which the whole amount shall carry interest @ 9% p.a from the date of order till realisation.
11. Pronounced in the open court on this 29th day of April, 2009 Sd/- Seena.H, President
Sd/- Preetha.G.Nair, Member
Sd/- Bhanumathi.A.K, Member Appendix Witness examined on the side of complainant Nil Witness examined on the side of opposite party Nil Exhibits marked on the side of complainant Ext.A1 – Receipt dt.21.08.06 Ext.A2 – Original policy Ext.A3(Series) – Claim form, consent letter, bills Ext.A4 – Letter from Treating Doctor dt.13.02.2007 Ext.A5 – Letter from 2nd opposite party dt.09.02.2007 Ext.A6 - Letter from 2nd opposite party dt.20.12.06 Ext.A7 - Letter from 2nd opposite party dt.04.04.07 Ext.A8 (Series) - Claim form, consent letter, bills Ext.A9 – Certificate from Valluvanad Hospital Ext.A10 - Letter from 2nd opposite party dt.30.06.2007 Ext.A11 - Letter from 2nd opposite party dt.26.07.2007 Ext.A12 – Copy of notice dt. 25.04.07 sent by complainant to 1st opposite party Ext.A13 - Copy of notice dt. 25.04.07 sent by complainant to 2nd opposite party Ext.A14 - Copy of notice dt. 07.05.07 sent by complainant to 2nd opposite party
Exhibits marked on the side of opposite party Nil Costs (allowed) Rs.1,000/- (Rupees One thousand only) allowed as cost of the proceedings
......................Smt.Bhanumathi.A.K
......................Smt.Preetha.G.Nair
......................Smt.Seena.H | | 
