SMT. MOLYKUTTY MATHEW : MEMBER
This is a complaint filed by the complainant U/S 35 of Consumer Protection Act 2019 for an order directing the opposite parties to pay the balance medical charges for Rs.81,000/- to the complainant and Rs.10,000/- as compensation for mental agony caused to the complainant and Rs.10,000/- as deficiency of service on the part of opposite parties.
The case of the complainant in brief
The complainant had availed an individual health insurance policy from OP No.1 and he paid net premium Rs.12,032/- and other charges making at total of Rs.14,318/-. In the policy issued and hired the service of the Insurance being a gold plan and the same insured as Rs.2,00,000/- and for DOM hospital Rs.35,000/-. The complainant had a problem with prostate and was admitted to Metromed International Cardio Centre Pvt. Ltd., Kozhikode and his illness was diagnosed as “Benign Enlarged prostrate” for which a HOLEP (Holmium Laser Enucleation of Prostrate) was advised. Since he was aged and had other problems and it could lead to death. The complainant was admitted as an inpatient on 16/03/2020 and discharged on 20/03/2020. The surgery was done on 17/03/2020 to remove the prostate by laser procedure. The entire medical expenses including room rent, bills doctors charge, operation, hospital charges and other incidental expenses came to Rs.2,30,000/-. The total hospital charges alone came to Rs.1,83,493.25/- only. Accordingly the claim was made a claim No.2222 9497 for an amount of Rs.2,30,000/- but on 26/08/2020 it was informed to the complainant that the claim has been settled for an amount of Rs.1,02,491/- only. Then the complainant send a registered lawyer notice dated13/10/2020 to OP’s claiming the actual medical expenses Rs.1,83,493.25/- from the OPs. On receipt of the notice the OP send an e-mail reply stating that they are liable to pay only an amount of Rs.1,02,491/-. Denying the actual medical charges to the complainant by the OPs without any valid reason. The OPs violated the condition of insurance policy is not settling the entire medical expenses. The act of OPs the complainant caused much mental agony and financial loss. So there is deficiency of service and unfair trade practice on the part of OPs. Hence the complaint.
After filing the complaint notice issued to all OPs. OP 1 and 2 received the notice and appeared before the commission and filed their written version. OP No.3 received the notice and not appeared before the commission and not filed version also. So the commission had to hold that OP No.3 is set ex-parte. OP No.1 and 2 contended that the terms and condition of the policy stipulates the maximum limit of various head of treatment expenses payable by the insurer under the head ‘what we cover’ and it was according to maximum ceiling of various heads of expenses, the amount payable by the OPs assessed to Rs. 1,02,491/-. Moreover instead of undergoing normal surgery for removal of Benign enlarged prostate the complainant opted HOLEP (Holmium laser Enucleation of prostate) treatment which would cost excessive and unreasonable expense which is medically unnecessary for curing the disease. Since the complainant had accepted the sum of Rs.1,02,491/- is full and final satisfaction of his claim. He is not entitled to claim any more sum from the OPs. So there is no deficiency of service and unfair trade practice on the part of OPs and the complaint may be dismissed.
On the basis of the rival contentions by the pleadings the following issues were framed for consideration.
- Whether there is any deficiency of service on the part of OPs?
- Whether the complainant is entitled for any relief?
- Relief and cost?
The evidence consists of the oral testimony of Pw1 and Ext. A1 to A5 were marked. On OP’s side Ext. B1 and B2 were marked.
Issue No.1
The complainant adduced evidence before the commission by submitting his chief affidavit in lieu of his chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. He was cross examined as Pw1 by the OP No.1 and 2. The documents Ext.A1 to A5 were marked on his part to substantiate his case. According to the complainant as per Ext.A1 he availed an individual health insurance policy covering the period from 13/08/2019 to 12/08/2020. As per medical advise the complainant was admitted to Metro Med International Cardio centre Pvt. Ltd. at Kozhikode, and his illness was diagnosed as Benign Enlarged prostate for which a Holep (Holmium Laser Enucleation of prostate) was advised. The complainant was admitted as an IP on 16/03/2020 and discharged on 20/03/2020. The discharge summary as marked as Ext.A2. The surgery was done on 17/03/2020 and total medical expenses incurred as Rs.2,30,000/- and the medical charges as shown in Ext.A3 document ie, Rs.1,83,493/-. But the OP’s settled an amount of Rs.1,02,491/- only. The balance Rs.81,000/- is pending as medical bill alone. In the evidence of Pw1 who clearly stated that “സാധാരണ സർജറിയെക്കാളും കീഹോൾ സർജറിയെക്കാളും ചെലവ് കൂടിയതാണ് ലെയ്സർ സസർജറി? അതെ. എനിക്ക് അതേ ചെയ്യാൻ പറ്റൂ.” Since the OPs denied the reimbursement claim. In Ext.A4 is the registered lawyer notice send by the complainant to OP. In Ext. A5 is the Bank statement of the complainant. So there is deficiency of service on the part of OPs.
On OP’s side Ext.B1 and B2 documents produced to substantiate their defense. They stated that a calculation statement regarding the policy valuation for actual expenses payable to complainant. They paid Rs. 1,02,491/- is full and final satisfaction of his claim. But the OP’s are not ready to reimburse Rs.81,000/- as the balance medical charges. Therefore we hold that there is deficiency of service and unfair trade practice on the part of OPs. Hence the issue No.1 found in favour of the complainant and answered accordingly.
Issue No.2 & 3
As discussed above the complainant is treated on 16/03/2020 to 20/03/2020 and the surgery was conducted on 17/03/2020 within the policy coverage period ie. 13/08/2019 to 12/08/2020. So we hold that the OP’s are directly bound to redressal the grievance caused to the complainant. So the complainant is entitled to get the reimbursement claim for balance medical expenses of Rs.81,000/- to the complainant along with Rs.7,000/- as compensation for mental agony caused to the complainant and Rs.5,000/- as litigation cost. Thus the Issue No.2 & 3 are also answered accordingly.
In the result the complaint is allowed in part directing the opposite parties 1 to 3 are jointly and severally liable to reimburse the balance medical expense of Rs.81,000/- to the complainant along with Rs.7,000/- as compensation for mental agony caused to the complainant and Rs.5,000/- as litigation cost within 30 days of receipt of this order. In default the amount of Rs.81,000/- carries 12% interest per annum from the date of order till realization. Failing which, the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.
Exts.
A1 –Health insurance policy
A2-Discharge summary
A3- Inpatient invoice
A4-Copy of Registered lawyer notice
A5-Bank statement
B1-Certified copy of Insurance policy
B2-Reply send by OP to complainant
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
