IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 15th day of July, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 204/2020 (filed on 17/12/2020)
Petitioners : 1. Mr. Antony Mathew,
S/o. C.J. Mathew,
Srampickal House,
Koorali P.O. Kottayam.
2. Asha Jacob (Asha Antony)
W/o. Antony Mathew,
Srampickal House,
Koorali P.O. Kottayam.
(For ptrs. 1 and 2, Adv. Sreekala K. Mohan)
Vs.
Opposite Party : Divisional Manager,
United India Insurance Co. Ltd.
Kottayam.
(Adv. P.G. Girija)
O R D E R
Sri. Manulal V.S. President
Crux of the complaint is as follows:
Complainant is a Family Mediclaim policy holder vide policy number 1005002818P114541780 issued by the opposite party for a period from 12-2-19 to 11-12-2020. As per the policy complainants and their children Aleena Antony and Ann Liza Antony are also the insured persons. The second complainant got admitted in Carithas Hospital on 3-5-2019 due to severe back pain, head ache and pain on her breast. Several lab tests, scanning and all possible tests were done to diagnose the reason behind the severe pain. After primary tests and scanning the doctor advised to admit her for further treatment as she was suffering from severe pain in different parts of the body. So she had undergone inpatient treatment up to 8-5-2019 and the doctors recommended her to take six months rest and medicine intake. The second petitioner is allergic to the pencilin and hence antibiotics were orally administered without giving any injections.
On 8-5-2019, the second petitioner was discharged from the hospital and the first petitioner claimed medical benefit as per the policy as he and his family were entitled for cashless treatment. The second petitioner was discharged in the morning and they waited till 7.00 p.m. as per the information from the insurance office under the expectation that the claim would be settled, out of amount which would be sanctioned from the policy. But at 7.00pm opposite party rejected the claim as there is no treatment, but only regular checkups and the admission was
only for evaluation.
It is averred in the complaint that the doctors treated the second petitioner advised her to undergo inpatient treatment for administering the medicines under their supervision. According to the second petitioner she was admitted in the hospital as she had terrible pain on the breast, she did not know that the procedures underwent by her could have been done even by undergoing outpatient treatment and no doctors advised like that to the petitioners. The petitioners had incurred Rs.30,118/- towards expenses and the original bills were submitted to the opposite party. The repudiation done by the opposite party is baseless and amounts to deficiency in service and unfair trade practice on the part of the opposite party. Hence this complaint is filed by the complainant praying for an order to direct the opposite party to pay Rs.5,00,000/- as compensation to the complainants and to pay Rs.30,118/- which is the expenses incurred by the complainant for the treatment of the second complainant.
Upon notice opposite party appeared before the Commission and filed version contending as follows:
The complainants availed a Family Medicare policy 2014 for a period from 12-2-2019 to 11-2-2020. Complainant’s claim was repudiated for the reason that the admission was only for checkups and not for any treatment. No medicine was
administered in the hospital which required hospitalization. She was treated with only oral supportive which could have been done on OPD basis and the admission was only for evaluation. As per the policy condition ,procedures/treatments usually done in outpatient departments 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 centre. The Insurance Ombudsman dismissed the complaint accepting the contentions of the opposite party. It is averred in the version that the inpatient treatment is done at the option of the complainants as they wanted to get the bills of the regular checkups honoured by the opposite party. The complainants have not sustained any loss due to any act of the opposite party and not entitled for any amount as compensation from the opposite party. There is no negligence or unreasonable repudiation of the complainant’s claim by the opposite party.
Complainant filed proof affidavit in lieu of chief examination and exhibit A1 to A7 were marked from the side of the complainant. M.R. Sureshkumar, who is the divisional manger of the opposite party filed proof affidavit and marked exhibit B1 from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
- Whether there is any deficiency in service on the part of the opposite party?
- If so what are the reliefs and costs
Point number one and 2 together.
There is no dispute on the fact that Complainants availed Family Mediclaim policy vide policy number 1005002818P114541780 from the opposite party for a period from 12-2-2019 to 11-12-2020. Exhibit A1 is the insurance policy issued by the opposite party. As per the policy, the complainants and their daughters namely Aleena Antony and Anna Liza Antony are the insured persons and the sum assured was Rs.3,00,000/-.
The second complainant who is a teacher got admitted Carithas Hospital on 3-5-2019 due to severe back pain, head ache and pain on her breast and treated there as inpatient and got discharged on 8-5-2019. It is proved by exhibit A3 discharge summary issued from the Carithas hospital that the second petitioner had treated as inpatient there from 3-5-2019 to 8-5-2019. Second complainant had paid Rs.25,618/- towards the treatment expenses vide exhibit A2 discharge bill issued by the hospital authorities.
The specific case of the complainants is that though the opposite party offered cashless treatment as per terms of the policy, but the opposite party illegally repudiated the claim of the second complainant at 7.pm. on 8-5-2019. The opposite party resisted the complaint on the ground that the second complainant was treated with only oral supportive which could have been done on OPD basis and the admission was only for evaluation. The opposite party relied upon clause 1.2 note-1 of the terms and conditions of the policy to repudiate the claim. Exhibit A5 is the denial letter dated 8-5-2019 issued by the opposite party stating that they were unable to sanction cashless benefit for the hospitalization. Thereafter the opposite party repudiated the claim of the complainants vide exhibit A6 stating the reason that the need for IP treatment care not justified, treated with oral supportive, which could possibly done in OPD basis. Admission found mainly for evaluation purpose. On perusal of clause 1.2 note. 1 of the terms and conditions of the policy we can see that it is stated as “ Note 1. The amount payable under 1.2C &D above shall be at the rate applicable to the entitled room category. In case the insured person opts for a room with rent higher than the entitled category as in 1.2A above, the charges payable under 1.2C &D shall be limited to the charges applicable to the entitled category. This will not be applicable in respect of medicines and drugs and implants.”
However neither in version nor in the proof affidavit the opposite party have a case that any amount which is claimed by the second complainant will fall in the purview of the Note.1. of clause 1.2 of policy terms and conditions. They did not disclose how much amount is deducted from the amount claimed by the insured as per the said clause of the policy.
In Exhibit A6 it is further stated that the clause under which claim was rejected. “It is stated that procedures /treatment usually done in outpatient department 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 procedure. On perusal of Exhibit B1 we can see a similar clause under clause 1.2I which says as
” Expenses on hospitalization for minimum period of 24 hours are admissible , however this time is not applicable to specific treatments such as
1.Adenoidctomy
*************
*************
34. Varicose Vein Ligation”
This condition will also not apply in case of stay in hospital of less than 24 hours provided-
a). the treatment is under taken under general anesthesia in hospital /day care centre in less than 24 hours because of technology advancement and which would have otherwise required a hospitalization of more than 24 hours.
b) procedures /treatment usually done in 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 centers.”
Referring to the Exhibit A3 Discharge summary of the hospital and the sworn statement of the complainant, we find that only after definite and conclusive diagnosis of left sided mastalgia and 2nd degree uterine prolapse, complainant was admitted for evaluation and for treatment of her ailment and all the diagnostic tests were performed. Therefore exclusion clause to which a reference is made supra, is clearly not attracted in the instant case. Thus, finding the repudiation arbitrary, the deficiency on the part of Insurance Company is well established.
As discussed above it is proved by exhibit A2 that the second complainant had spent Rs.25618 for her treatment in the Caritas hospital. Exhibit A5 proves that the opposite party denied cashless benefit for the hospitalization of the complainant. No doubt the act of the opposite party caused much hardship and mental agony to the complainants for which the opposite party is liable to compensate.
It is further observed that the Consumer Protection Act, 2019 is a benevolent social legislation as held by the Hon’ble Apex Court in their judgments from time to time and is aimed at providing for better protection of the interests of the consumers as defined in the preamble to the Act itself.
In these circumstances we allow the complaint and pass the following order
- We hereby direct the opposite party to pay Rs.25618/- to the second complainant which is the amount incurred by her for the treatment.
- We hereby direct the opposite party to pay Rs.10,000/- to the second complainant as compensation for the hardship and mental agony suffered by her due to the deficiency in service on the part of the opposite party.
- We hereby direct the opposite party to pay Rs.5000/- to the second complainant as coat of this litigation.
The Order shall be complied within 30 days from the date of receipt of this Order. If not complied as directed, the compensation amount will carry 9% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 15th day of July, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of family medicare policy 2014
A2 – Copy of medical bills for Rs.30,118/- issued by Carithas Hospital
A3 –Discharge summary dtd.08-05-19 issued by Caritas Hospital
A4- Copy of certificate issued by Dr. Reji D. MD, DGO
A5-Copy of Denial Letter
A6 – Repudiation letter dtd.08-07-19 issued by opposite party to 1st
complainant
A7 – Award dtd.23-01-2020 from the Insurance Ombudsman
Exhibits marked from the side of opposite party
B1 –Copy of policy with terms and conditions issued by opposite party to 1st complainant
By Order
Assistant Registrar
