BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 20TH DAY OF DECEMBER 2022

ORDER

SRI.M.SHOBHA, PRESIDENT

1. This  complainant  filed this complaint against the Opposite parties  for reliefs

1. To Direct the OP to refund Rs.28,656-66Ps along with interest at the rate of 18% per annum from 15.12.2016 and Rs.50,000/- as compensation towards mental agony along with Rs.15,000/- towards litigation costs.

2.  The case of the complainant is that:

It is case of the complainant that he took health insurance policy from OP on 04.05.2016. He developed low back pain radiating to both his lower limbs in the 2^nd week of May 2016. When the pain got worst, he got admitted to Aster CMI hospital on 14.12.2017. He was administered heavy doses of pain killers along with MRI investigation of the spine. Since the pain got reduced, he was discharged on 15.12.2017. As his requisition for cashless treatment was rejected by OP by assigning the reason that his illness was pre-existing. The complainant has paid hospital bill of Rs.24,326.66p from his pocket.

It is further case of the complainant that he applied for reimbursement  to the TPA of OP, since there was no response. He also sent legal notice to the OP to refund the money which he spent, there was no response.

It  is further grievance of the complainant that the inception date of the policy is 04.03.2016. The first symptoms of the illness started on 2^nd week of May 2016 after more than two months of inception of the policy.

It is further grievance of the complainant that  OP itself  after studying his previous policy of National Insurance Co. Ltd., and accordance with its own terms and conditions has issued endorsement letter stating that in his case for any claim, the date 05.03.2009 should be taken as date of inception for illness started  after 05.03.2009 is not pre-existing according to the endorsement.  Thus by rejecting the claim OP has put the complainant a lot of mental agony.

It is further grievance of the complainant that he has spent Rs.630/- for pre-hospitalization treatment and Rs.3,700/- for post-hospitalization treatment apart from hospital bill of Rs.24,326-66P.  When the OP has not responded to the legal notice, the complainant has filed this complaint.

3. After service of notice, OP has appeared before this commission through their counsel. OP not filed version within 45 days. Hence, this commission has rejected IA filed by the OP seeking permission to file the version. Hence, version was rejected.

4. It is pertinent to note here that the OP has preferred Revision Petition before the Hon’ble State Commission in Rev.Pet.128/2018. The Hon’ble State commission has also granted interim  stay order. This commission also granted time for await of the order from the Hon’ble State Commission till 13.07.2022 from 06.09.2018. The OP neither produced stay order nor the order passed by the Hon’ble State Commission. Hence, this Commission has posted the mater for arguments of both sides. In spite of giving sufficient opportunity, the OP have not submitted any arguments.

5. The complainant in order to prove his contention had filed his affidavit evidence and also relied on documents annexure no.1 to 6. On the other hand OP  has neither filed affidavit evidence nor submitted any arguments.

6. We have perused the evidence of the complainant and the documents.

7. We heard the arguments of the complainant.

8. The following points do arise for our consideration are as under:-

1. Whether the complainant has proved deficiency of service and negligence on the part of the OP?
2. Whether the complainant is entitled for the reliefs as sought for?
3. What order?

9. Our answer to the above points are as under:

       Point No.1:-Affirmative

      Point no.2:- Affirmative in part.

      Point No.3:-As per the final order.

REASONS

10. Point Nos.1 and 2: Perused the complaint, affidavit evidence of the complainant and documents annexure no.1 to 6. The affidavit evidence of the complainant and the allegations made in the complaint and documents relied by the complainant are not at all disputed by the OP. Even though the OP have appeared before this commission and have failed to file version within 45 days. At  this stage version was rejected by this commission.

11. It is clear from the evidence of the complainant that he has taken the health insurance policy from the OP on 04.03.2016. As he developed back ache pain radiating to both his lower limbs  in the 2^nd week of May 2016. He was admitted to the Aster CMI hospital on 14.12.2017 and he was administered heavy doses of painkillers along with MRI Investigation  of his spine. The pain got reduced, he was discharged on 15.12.2017. He has paid hospital charges of Rs.28,656.66p from his pocket. He applied for reimbursement to the TPA of OP, since there was no response he sent legal notice to refund the amount. There was no response from them. He has totally paid Rs.28,656.66p.  Out of which he has spend Rs.600/- for pre-hospitalization treatment and Rs.3,700/- for post hospitalization treatment apart from the hospital bill of Rs.24,326.66p.

12. It is clear from the evidence of the complainant that the symptoms of illness started in the 2^nd week of May 2016 and the policy inception is 04.03.2016.The OP itself after studying the previous policy of National Insurance Co. Ltd.,  and in accordance with its own terms and conditions has issued endorsement letter stating that in his case for any claim the  date 05.03.2009 should be taken as the date of inception, any illness which started  after 05.03.2009 is not pre-existing according to the endorsement.

13. The complainant has relied on 06 documents i.e. annexure-1 Denial of cashless facility  for  hospitalization issued by the OP. Annexure-2 is the copy of the policy. Annexure-3 is the discharge summary and it clearly discloses that the complainant was admitted to the Aster CMI hospital on 14.12.2017 and he was discharged on 15.12.2017. The complainant was diagnosed as L-45IVDP. It is clear from the discharge summary that  the complainant got low back ache with pain radiating to both lower limbs  in the 2^nd week of May 2016 and the pain was severe and hence, he was admitted to hospital. But the complainant underwent surgery for spinal stenosis at Manipal hospital on 05.05.2016. No co morbidity. It is clear from the discharge summary that the hospital authorities have done MRI Lumber Spine shows moderate diffuse disc bulge with neural foreman extension L4-5 level causing moderate impingement on the thecal sac and adjacent traversing nerve roots. Mild disc bulge L5-S1 level causing minimal impingement on the thecal sac. There is no significant nerve root compression. The complainant was treated with analgesics round the clock, gradually pain reduced and patient was comfortable and he was also advised the possible need for surgical management of the disc prolapse and he was discharged with advise to take analgesics on 15.12.2017.

14.  The complainant was also produced bill as per annexure-4 and he has paid Rs.24,326.66p to the hospital. The complainant has also produced copy of the notice issued to the OP. As per directions of this commission the complainant also produced copy of the insurance policy documents. As per the policy document the sum assured is Rs.5,00,000/- and the policy valid from 09.06.2017 to 08.06.2018. The OP have repudiated the claim made by the complainant stating that pre-existing diseases cannot ruled out from provided documents. Hence, cashless denied. It is clear from the document placed on the file that the inception of the policy is on 04.03.2016 and the complainant  has got the pain in the low  back in the 2^nd week of May 2016 after lapse of two months of the inception of the policy. When the complainant has got pain only 2^nd week of May 2016 that cannot be taken as pre-existing disease.

15. The complainant himself  is a Doctor and he  clearly stated in the written arguments that meaning of the procedure and the definition of the Day care center and also Round the Clock treatment. As per medical parlance a procedure means an act done on a patient like dressing-a-wound, kidney dialysis etc. No act which comes under this category was carried out on the complainant. He was never admitted to the OPD then shifted to inpatient ward. If transferred from OPD to inpatient ward there will be remark by the treating Doctor “Shift the patient to In-patient Ward”. Such a remark is not there in the case sheet.  The name Day care Centre implies a treatment facility which works in a day time only. This complainant was admitted to the Aster CMI hospital, which is not day care centre, but a full fledged speciality hospital. There is no evidence  to show that the complainant was initially admitted for a period less than 24 hours then extended beyond 24 hours.  As he was suffering from agonizing pain and hence he was directly admitted to inpatient ward of Aster CMI Hospital as his condition required Round the clock treatment as mentioned in the discharge summary. Round the clock treatment is not possible in a OPD or Day care centre as they do not work in night. Neither they are staffed sufficiently with man-power like doctors and nurses. In fact he was to stay in the hospital ward for more than a week as he was advised surgery for his disease.  He got discharged early as he did not have to bear the expenses.  

16.  The evidence and the documents produced by the complainant clearly discloses that he was not at all suffering from pre-existing diseases. He got pain only after lapse of 03 months after inception of the policy. This complainant was not treated as out patient and he was not shifted from OPD. He was directly admitted to the hospital  as inpatient due to severe pain as he needs treatment round the clock. He was kept in the inpatient ward. It is also clear from the evidence of the complainant that he was advised for surgery for the disease. As he has not having money to bear the surgery expenses he was discharged from the hospital. The evidence and  the documents of the complainant are  not at all disputed by the OP. It is clear from the documents that OP have repudiated the claim even though the complainant was not suffering from any pre-existing diseases and policy was in force on the date of treatment and there was need for the complainant for admission in the hospital as inpatient as he was in need of round the clock treatment. In spite of that the OP have simply repudiated the claim on the Doctors note pre-existing disease cannot be ruled out from provided document. Hence, cashless denied. Therefore, the complainant clearly established the negligence and deficiency of service on the part of the OP. Even though the complainant has sent notice to the OP, they have neither complied nor replied to the notice. The treatment taken by the complainant is not excluded in the policy. Under these circumstances, the complainant is entitled for refund of the amount.

17.  Even though the complainant being the Doctor and he has clearly stated about the conditions  and his disease and   also about treatment taken by him, the OP have without considering the documents produced by the complainant have rejected the claim of the complainant and there by causing mental agony and financial loss to the complainant. Therefore, the complainant is entitled for compensation. The complainant has claimed total compensation of Rs.25,000/- and the amount claimed by the complainant is high. Hence, compensation is restricted to Rs.15,000/- with litigation expenses of Rs.10,000/-.  Hence, we answer point no.1 in the affirmative and Point No.2 affirmative in part.  

18. Point no.3:-.  In view of the above discussions, the complaint is liable to be allowed in part and complainant is entitled for Rs.28,656/- towards medical expenses. The complainant is also entitled for compensation of Rs.15,000/- for the financial loss and also mental agony suffered by him. The complainant is also entitled for litigation expenses of Rs.10,000/-. Accordingly, we proceed to pass the following 

O R D E R

1. The complaint is allowed in part.
2. The OP is directed to refund Rs.28,656/- with interest at 10% p.a. from the date complaint  till realization.
3. The OP is further directed to pay compensation of Rs.15,000/- and  Rs.10,000/- towards litigation expenses.
4. The OP is further directed to pay entire amount within 60 days from the date of this order, if the OP failed to refund the amount, the amount of Rs.28,656/- will carry additional  interest at 12% p.a. after expiry of 60 days till realization of the amount.
5. Furnish the copy of this order to both the parties, and return the spare pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 20^th  day of December, 2022)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1 :  Nil