DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the 15^th day of June,  2022

Present      :   Sri.Vinay Menon V.,  President

                  :   Smt.Vidya A., Member                        

                  :  Sri.Krishnankutty N.K., Member                                   Date of Filing: 02/05/2019   

     CC/136/2019

R.P.Nair,

S/o.Late Madhavan Nair,

“Seafarer”, 100 Feet Road,

Sekharipuram P.O,Palakkad – 678 010                                  -          Complainant

(By Adv.K.Dhananjayan)                     

                                                                                                 Vs

1.United India Insurance Co.Ltd.,

    Regd. &  Head Office,

    24, Whites Road, Chennai – 600 014

2. Managing Director / Authorised representative

    United India Insurance Co.Ltd.,

    Regd. &  Head Office,

    24, Whites Road, Chennai – 600 014

3.Aminchand Ullas,

   Divisional Manager,

   United India Insurance Co.Ltd.
   PLI Branch, Surya Complex,

   Mission High School Jn.

   T.B.Road, Palakkad – 678 014

4.Manager

   Medi Assist India TPA Pvt.Ltd.

   4^th Floor, Chicago Plaza,

  Rajaji Road, Ernakulam – 682035                                        -           Opposite Parties

 (OPs by Adv.R.Ratnavally & Kiran G Raj)

O R D E R 

By Sri. Vinay Menon V., President

1. Complaint pleadings, abridged, are to the effect that the complainant alongwith his wife and unmarried daughter are beneficiaries under Individual Health Insurance Policy issued by the opposite parties. They are entitled to cover for treatments stated in the policy document.  Wife of the complainant (herein after referred to as beneficiary) underwent epidural steroid injection for primary cervical  canal stenosis. Wife of the complainant being a beneficiary under the insurance policy, the complainant is entitled to be indemnified for the expenses incurred for the treatment. But the opposite party repudiated the claim of the complainant which is a deficiency in service on the part of the opposite parties. Aggrieved thereby, this complaint is filed seeking indemnification amount together with interest and incidental accruals.
2. The opposite party entered appearance and filed version countering the complaint allegations.  They stated that the procedure  underwent by the beneficiary was only a Day procedure not requiring hospitalization for 24 hours and was therefore not covered under clause 2(1) (b) of the policy document and sought for dismissal of the complaint as the complainant’s claim was beyond the scope of the cover provided by the policy.
3. The following issues arise for consideration.

1. Whether, the condition suffered by the beneficiary is excluded under the terms and conditions of the  policy document.
2. Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties ?

3.         Whether the complainant is entitled to the reliefs sought for?

4.         Reliefs, as to Compensation and Cost  ?

4.         Eventhough the complainant was granted ample time from 4/1/2020 onwards for adducing evidence, they failed to adduce evidence. Hence, complainant’s evidence was closed on 10/11/2021. From then onwards, till date of taking this matter for orders on 26/05/2022 the complainant had not made any attempt to reopen evidence or substantiate their case by way of adducing cogent evidence. Opposite parties filed proof affidavit and marked Ext.B1, which is the policy document.

 Issue No. I  

5. As already stated supra, the complainant has failed to adduce any evidence. Hence, any examination of the facts and circumstances of the case, leading to this complaint will have to be based  on the admitted part of the complainant’s pleadings, version pleadings and Ext.B1.
6. The procedure underwent by the beneficiary is not disputed. Paragraph (2) of the version reads as follows:

2. “During the validity of the above policy, Mrs.Nirmala P Nair admitted at Ganga Medical Centre & Hospitals pvt. Ltd  Coimbatore on 2/8/2018 with complaints of pain in left lower limb since one month, mechanical type low back pain, associated bilateral hand numbness. As per submitted Discharge Summary, they diagnosed as Tandens Tenosis, L4-5 stenosis left lower limb Radiculopathy, C2-C6  ossified posterior longitudinal ligament nurik II mylopathy diabetes mellitus and undergone Epidural Steroid  injection administration in L3-4 space on 3/8/2018”. (SIC)

7.   In the next sub paragraph  of paragraph (2) the opposite parties state  the reason for rejection of the claim.

                  “Later after discharge from hospital, insured oblige (oblique) policy holder submitted the claim document for reimbursement of expenses incurred on treatment amount in Rs.50601, claim received under CCN. 17775203 AND WAS Processed as per policy conditions the claim was rejected under close (clause) 2(1) note as Epidural Steroid Injection Administration  In  L3-4  does not required 24 hrs hospitalization and is not listed in day case procedure list of the policy, the said procedure can be done on OPD basis.  Accordingly insurer up held the denial and recommendations given by the fourth respondent and repudiated the claim under close  “ 2.1 note (b) expenses on hospitalization  for minimum period of 24 hrs admissible.  However this time limit is not applied to specific treatments such as 1.Adenoidectomy 2.appendectmy 3.Ascetic pleural tapping 4.Autoplasty 5.Coronory  angiorgraphy  6.Cornory angioplasty 7.Entire surgery 8.Dialation & Curettage 9.Endoscopies 10.Excision of cyst 11. Eye surgery 12. Fracture oblige dislocation excluding  hairline fracture 13. Radiotherppy 14. Lithotripsy etc.,

                  Note (b) which would have otherwise required a hospitalization more than 24hrs. procedures oblige treatments usually done on outpatient basis are not payable under the policy even if converted as on in patient in the hospital for more than 24 hrs or carried out in day care centres.

            The repudiation on the claim  was made after verifying  the entire medical records coupled with the information obtain.” (SIC)(Bold letters provided by this Commission)

8.         Ext.B1 is the health insurance policy alongwith the policy schedule. The opposite party relies on clause 2(1) of the policy conditions. Policy 2(1) reads as follows :

 “2.1 – Expenses on hospitalization for minimum period of 24 hours are admissible. However this time limit is not applied to specific treatments such as ………………”

The above heading is followed by a list of 34 instances. Then clause 2.1 continues :

“This condition will also not apply in case of stay in hospital of less than 24 hours provided –

1. The treatment is undertaken under General or Local Anesthesia in a hospital / day care centre in less than 24 hours because of technological advancement and
2. Which would have otherwise required a hospitalization of more than 24 hours.

Procedures / treatments usually done on outpatient basis are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in Day Care Centres.”

9.(a)     It would be appropriate to dissect clause 2(1) to understand the nature, ambit and spirit of the clause.

            This clause (2) has three  parts.

1)The first line which states the minimum period requirement for admissibility; 

2) Rest which deals with exclusion; and

3) Proviso

9.(b)     i)          First line  deals with expenses on hospitalization for minimum period of 24 hours.  That is,  the beneficiary should have spent at least 24 hours in the hospital. 

ii)         But, if the patient or the beneficiary is suffering from any of the 34  conditions stated in the schedule, the beneficiary need not spent 24 hours in the hospital.  

iii)        The necessity to stay in the hospital for a minimum of 24 hours will not apply also where  the treatment is undertaken under GA or LA due to advancement in technology.

iv)        It also follows that, if in the normal course,  the hospitalization requirement was more than 24 hours but took only lesser time, indemnification is possible even if stay in the hospital was for less than 24 hours.   

10.       Spending of over 24 hours in the hospital by the complainant is not disputed. Hence, the question that is to be answered is whether the procedure carried out on  the beneficiary is a Day procedure not requiring hospitalization  for a period of over 24 hours. The opposite party relies exclusively on clause (2)(1) (b) to hold their ground.  The said clause is repeated herein below for easy reference.

2. Procedures / treatments usually done on outpatient basis are not payable under  the policy even if converted as an inpatient in the hospital for more than 24 hours or carried out in Day Care Centres.”

The procedures and treatment done on outpatient basis are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours. But this statement is qualified by insertion of the word “Usually”. What transpires from a reading of this clause is even though the contract excludes many procedures as stated in 2(1)(b), it is not an outright exclusion. The word “usually” waters down the blanket exclusion and brings in situations where  a deviation from  usual, customary, established  or frequent usage is contemplated. Had the intention of the framers of Ext.B1 been to put in place and iron clad clause denying  any benefits in its entirety, the word “usually” would not have found place. 

The fact that the beneficiary suffers from various other ailments is undisputed and  admitted by opposite party.   The beneficiary,  an aged women, who suffers from various ailments had to undergo painful treatment for even more  painful conditions.  We would have appreciated the resort of the opposite party to clause 2(1)(b) in  Ext.B1, had the patient been young, healthy and afebrile. But applying the same conditions to another person of ill health and of advanced age  as like the beneficiary herein,  will not serve justice.  We are of the opinion that the opposite party has resorted to one-size-fits-all attitude while applying the terms and conditions to the  beneficiary herein.  The spirit behind insertion of “usually” was given a blatant go-by without any application of mind.

11.       While the opposite party made a pleading that in the condition of the beneficiary, she required only lesser than 24 hours of hospitalization, it was incumbent  upon the opposite party to prove the same with proper evidence.  The opposite party should have adduced evidence like deposition by the Doctor who treated the beneficiary to prove that she did not require more than 24 hours of treatment. 

12.       Rejection of the claim without looking into the facts and circumstances and the underlying  conditions of the beneficiary in a mechanical manner without application of mind, as had happened herein, in our opinion, tantamount to deficiency in service.

Issue No.2

13.       In view of the discussion above, we hold that there is deficiency in service on the part of opposite party in rejecting the claim of the complainant.

Issue Nos.3 & 4

14.       In the facts and circumstances of the case, we hold that the complainant is entitled to  indemnification of the amount expended for the treatment incurred in hospitalization and medical treatment as admissible as per the terms and conditions of Ext.B1 policy schedule.  The complainant is entitled to an interest of 9% per annum on the said amount from 2/8/2018 till date of actual realization of the full and final amount. The complainant is also entitled to a compensation of Rs.10,000/- (Rupees Ten thousand only) as sought for by him. The complainant is further entitled to a cost of Rs.15,000/- (Rupees Fifteen thousand only)

Comply with the aforesaid order within 45 days of receipt of this Order failing which  the complainant will be entitled to a solatium of Rs.250/- per month or part thereof from the date of this Order till   full and final settlement of the amounts ordered above.  

            Pronounced in open court on this the 15^th  day of June, 2022.

Sd/-

                                                                                                             Vinay Menon V

                                                      President

                                                              Sd/-

    Vidya.A

                        Member     

                               Sd/-

                                                                                               Krishnankutty N.K.

                                                                                                      Member

APPENDIX

Exhibits marked on the side of the complainant

 Nil

Exhibits marked on the side of the opposite party

Ext.B1 – Copy of the  Policy document

Witness examined on the side of the complainant

NIL

Witness examined on the side of the opposite party

NIL

Cost : Rs.15,000/- allowed as cost     

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.