DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 12th day of January, 2024.
Present : Sri Vinay Menon .V, President.
: Smt. Vidya.A., Member.
: Sri. Krishnankutty N .K, Member.
Date of filing:09.12.2021.
CC/224/2021
Haseena Ahammed, -Complainant
W/o Ahammed,
Vettathuthodi, Pampadi,
Thiruvilwamala,
Thrissur-680 588.
(By Adv.Vinod Kayanat)
Vs
United India Insurance Company Ltd., -Opposite Parties
Branch Office, 2nd Floor,
Prappurath Towers,
Main Road, Ottappalam,
Palakkad-679 101.
(By Adv. M.Krishnadas)
ORDER
By Sri. Krishnankutty N .K, Member.
1. Pleadings of the complainant.
The grievance of the complainant is the repudiation of insurance claim by the opposite party. The complainant had taken mediclaim policy for Rs.5,00,000/- each from M/s Star Health and Allied Insurance and the opposite party. The policy taken from the opposite party was for the period from 05.12.2018 to 04.12.2019. Initially, she took treatment from Kovai Medical Centre Hospital and subsequently at Lakeshore Hospital, Kochi for Breast Cancer. The expenditure at Kovai Medical Centre Hospital was claimed under the policy from M/s. Star Health and Allied Insurance and her claim for chemotherapy totalling Rs.11,48,966/- at Lakeshore Hospital was denied by the opposite party for the reason that there was no hospitalisation for 24 hours. Hence, this complaint is filed seeking settlement of claim to the extent of Rs.5,00,000/- apart from a compensation of Rs.2,00,000/- for Deficiency in Service and cost of litigation.
2. Notice was served to the opposite party. They entered appearance and filed version. According to them, the bills submitted pertains to treatments which do not require hospitalization for more than 24 hours which is the reason for repudiation.
3. Based on the pleadings of the complainant and the opposite party the following issues were framed;
(1) Whether the treatment/procedure undergone by the complainant forms part of the main hospitalisation or can be done as outpatient as alleged by the OP ?
(2) Whether the OP has repudiated the claim on genuine grounds and as per the terms and conditions of the policy ?
(3) Whether the repudiation of claim by OP amounts to Deficiency in Service on their part ?
(4) Whether the complainant is entitled to reliefs claimed ?
(5) Reliefs as to cost and compensation ?
4. The complainant’s evidence comprised of proof affidavit and Ext.A1 to Ext.A16. Ext.A1 is the inpatient bill summary from Lakeshore Hospital, Kochi, Ext.A2 (series) is the cash bill summary from Lakeshore Hospital & Exts.A3 to A10 are inpatient bill summary and IP bill breakup details issued by Lakeshore Hospital on various dates. Ext.A11 is the X-ray cash bill from Lakeshore Hospital, Exts.A12 to A14 are the discharge summaries issued from Kovai Medical Centre Hospital, Ext.A15 is the inpatient bill summary issued by Kovai Medical Centre Hospital and Ext.A16 is the IP bill breakup details issued by Kovai Medical Centre Hospital.
Exts.A1, A3, A4 to A10 and A13 were objected on the ground that they are duplicate bills and paid by Star Health & Allied Insurance. Ext.A1 was also objected on the ground that it is a credit bill. Ext.A14 was objected as it is a copy of the bill already paid by Star Health. Exts.A15 to A16 were objected as they are duplicate credit bills Ext.A2 was also objected for the reason that all pages except page 1 are duplicate copies.
The opposite party filed proof affidavit and marked Ext.B1 as evidence, which is the photocopy of the insurance policy issued by the opposite party to the complainant. It was also objected on the ground that it is a photocopy, but the objection was overruled as there was no allegation that it is a forged/concocted document.
Issues 1 and 2
5. The main contention raised by the opposite party for denying the insurance benefit to the complainant are;
(a) The treatment for which the claim has been preferred from the opposite party neither required 24 hour hospitalization nor included in the list for day care treatment. A detailed scrutiny of the insurance policy document (marked as Ext.B2) reveals that as per Clause No.3.10 of the terms and conditions, “Day Care treatment refers to medical treatment and or surgical procedure which is;
i) Undertaken under local/general anaesthesia in a hospital or day care centre in less than 24 hours because of technical advancements.
ii) Which would have otherwise required hospitalisation of more than 24 hours.
Treatment normally taken on an outpatient basis is not included in the scope of this definition”. Chemotherapy undergone by the complainant cannot be classified as “treatment normally taken on an outpatient basis.” without considering the condition of the complainant by the Doctor who treated the complainant, Neither this Commission nor the opposite party can sit in judgement on the seasoned judgment of a Doctor when it comes to rendering the mode of treatment. That studied decision cannot be overruled or set aside by a contractual term. The opposite party has failed to disprove the necessity of stay in hospital by adducing cogent evidence. Hence the argument of OP will not sustain and the decision will go in favour of the complainant.
(b) The complainant has not submitted original bills to the OP along with the claim application:
6. Having decided the eligibility, next issue to be decided is whether the complainant has submitted the original bills of such treatment to the opposite party for processing the claim. The complainant is having insurance coverage from the opposite party as well as from M/s. Star Health and Allied Insurance. From the document marked as evidence it can be seen that Ext.A1, A3, A4, A5, A6, A7, A8, A9, A10, A15 & A16 are the bills for which the complainant has taken the insurance benefit from M/s. Star Health & General Insurance and Ext.A11 to A14 and bills dated 22/08/2018 and 04/12/2018 (Page No.1 and 2 of Ext.A2 series) are the bills not pertaining to the period (05/12/2018 to 04/12/2019) of insurance coverage under the policy issued by the opposite party.
Hence, the bills marked under Ext.A2 eligible for insurance benefit from the opposite party are;
| Date | Details | Remarks |
a | 27/12/2018 | Rs.59,781.12 | Duplicate bill |
b | 05/02/2014 | Rs.1,19,562.24 | Duplicate bill |
c | 19/02/2019 | Rs.59,781.00 | Duplicate bill |
d | 09/04/2019 | Rs.59,781.00 | Duplicate bill |
e | 30/04/2019 | Rs.1,19,562.24 | Duplicate bill |
f | 13/06/2019 | Rs.59,781.00 | Duplicate bill |
g | 04/07/2019 | Rs.61,836.00 | Duplicate bill |
h | 04/07/2019 | Rs.59,781.00 | Duplicate bill |
i | 14/08/2019 | Rs.61,836.00 | Duplicate bill |
j | 26/09/2019 | Rs.1,26,372.00 | Duplicate bill |
It is pertinent to note that all these bills are duplicate copies. Hence, it is not clear whether the originals has been used to claim the insurance benefit from M/s. Star Health & Allied Insurance. The complaint as well as the proof affidavit are silent about the amount of claim settled by M/s. Star Health. However, if the complainant has not claimed the same from Star Health, it will not be just to deny the claim to the complainant by the opposite party. Hence, this Commission is of the view that the complainant should be given a chance to submit the original bills to the opposite party for processing the claim.
Issue No.3, 4 & 5
7. Though the opposite party’s main contention was about the eligibility of claim, they cannot process the claim without the original bills of the treatment. Since the complainant has not submitted the same so far, we cannot fix any Deficiency in Service to the opposite party. Hence, the complainant is not entitled to any relief claimed.
However, in the interest of ensuring justice to the complainant the following orders are passed;
(1) The complainant is directed submit the originals of bills scheduled in Paragraph 5 (supra) totalling to Rs.7,88,073/- to opposite party before 31.03.2024.
(2) The opposite party is directed to process the claim as per the terms and conditions of the policy within 30 days of receiving the originals from the complainant.
Pronounced in open court on this the 12th day of January, 2024.
Sd/-
Vinay Menon .V,
President.
Sd/-
Krishnankutty N .K,
Member
.
APPENDIX
Documents marked from the side of the complainant:
Ext.A1: Inpatient Bill Summary from Lakeshore, Hospital.
Ext.A2: Cash Bill Summary from Lakeshore, Hospital.
Ext.A3: Inpatient Bill Summary and IP Bill Break Details from Lakeshore Hospital, Kochi.
Ext.A4: Inpatient Bill Summary and IP Bill Breakup Details from Lakeshore Hospital, Kochi.
Ext.A5: Inpatient Bill Summary and IP Bill Breakup details from Lakeshore Hospital, Kochi.
Ext.A6: Inpatient Bill Summary and IP Bill Breakup details from Lakeshore Hospital, Kochi.
Ext.A7: Inpatient Bill Summary and IP Bill Breakup details from Lakeshore Hospital, Kochi.
Ext.A8: Inpatient Bill Summary and IP Bill Breakup details from Lakeshore Hospital, Kochi.
Ext.A9: Inpatient Bill Summary and IP Bill Breakup details from Lakeshore Hospital, Kochi.
Ext.A10: Inpatient Bill Summary and IP Bill Breakup details from Lakeshore Hospital, Kochi.
Ext.A11: X-Ray Cash Bill from Lakeshore Hospital, Kochi.
Ext.A12: Discharge summary from Kovai Medical Centre and Hospital.
Ext.A13: Discharge bill issued by Kovai Medical Centre and Hospital.
Ext.A14: Discharge bill issued by Kovai Medical Centre and Hospital.
Ext.A15: Inpatient Bill summary issued by Kovai Medical Centre and Hospital.
Ext.A16: IP Bill break up details issued by Kovai Medical Centre and Hospital.
Document marked from the side of Opposite party:
Ext.B1: Copy of Health Insurance policy issued by the opposite party.
Cost : Nil
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.
