O R D E R

Per Sri A. Hazarath Rao,  President:-

          The complainant filed this complaint u/s 12 of the Consumer Protection Act seeking a direction to the opposite parties to pay Rs.9,837/- together with interest @24p.a; Rs.50,000/- towards deficiency in service and Rs.40,000/- towards mental agony. 

2.      In nutshell the complainant’s case is hereunder:

          The complainant took a policy bearing No.060600/48/10/97/00017734 from the 3^rd opposite party at Guntur covering not only his risk but also his wife and son.  The complainant has renewed the policies from 2006 to 2012.  The complainant paid the premiums with the 1^st opposite party and obtained necessary receipts.  The complainant incurred Rs.9,837/- for medical treatment of his wife.  The complainant produced necessary bills along with claim form on 30-12-11.  The 2^nd opposite party has pre-repudiated claim on 23-04-14 on flimsy grounds.  Inspite of repeated requests and remainders the opposite parties failed to fulfill the complainant’s obligations.  The opposite party repudiating the claim on flimsy ground amounting to deficiency in service.  The complainant estimated the same @ Rs.50,000/- and his mental agony @ Rs.40,000/-.  The complaint therefore may be allowed.     

3.      One Kurra Srinivas representing the 1^st opposite party filed his version contending that it played role of facilitator and the insurance company is alone liable to pay the amount and sought for dismissal of complaint against him.  

4.      The 2^nd opposite party remained exparte. 

5.      The 3^rd opposite party filed counter and its contents in brief is thus:

          The complaint is not maintainable either in law or on facts.  The 3^rd opposite party did not commit any deficiency in service.  The complaint is barred by time. The 3^rd opposite party issued individual health insurance policy bearing No.060600/48/10/97/00017734 covering the period from          31-12-10 to 30-12-11 to the complainant and other persons named in schedule.  The complainant’s wife namely K.V.L.Kanyaka Parameswari obtained treatment for breast cancer.  The opposite party settled three claims under the said policy i.e., for Rs.16,200/- , for Rs.15,355/- and Rs.8,923/-.  The opposite party repudiated the 4^th claim for Rs.9,837/-.  The patient stayed in the hospital for 5 ½ hours and took oral treatment for the treatment of cancer i.e., radiotherapy and parental chemotherapy alone is permitted.  The opposite party rightly repudiated the claim.  The complaint therefore may be dismissed. 

6.   Exs.A-1 to A-11 on behalf of complainant were marked.  No documents were marked on behalf of 3^rd opposite party. 

7.  Now the points that arose for consideration in this case are these:

1.       Whether the complaint is barred by time?

2.       Whether the repudiation of claim by the opposite party is unjust and if so amounting to deficiency in service?

3.       Whether the complainant is entitled to damages as claimed?

4.       To what relief?

8.    POINT No.1:-         The 3^rd opposite party in para 9 of its version mentioned that it repudiated the 4^th claim of the complainant for Rs.9,837/-.  Ex.A-5 discloses that 3^rd opposite party through the 2^nd opposite party repudiated the claim on 23-04-14.  The complainant filed the complaint on 04-08-14 questioning the same and as such it is well in time as per Sec.24 (A) of the Consumer Protection Act.  We therefore answer this point infavour of the complainant.        

9.    POINT No.2:-  The 2^nd opposite party is the third party arbitrator appointed by the 3^rd opposite party to settle to settle the medical claims.  The relevant portion in Ex.A-5 is extracted below for better appreciation:-

  1.As per claim documents it has been observed that the patient was admittedfor less than 24 hrs and we note that patient had received oral chemotherapy but oral chemotherapy is not payable.  Hence claim is repudiated. 

  2. As per policy terms and conditions, claim is not payable, under clause No.2.3 (please refer to policy copy for details)

  3. CRS explanation As per claim documents it has been observed that the patient was admitted for less than 24 hrs.  Hence claim is not payable.           

10.  The patient Smt.K.V.L.Kanyaka Parameswari took treatment as in patient in St.Joseph’s General Hospital on 29-12-11(subject claim).  The complainant has split up the claim as follows :

       1.         Medicine               :        Rs.7,937/-

       2.         Inpatient Bill                   :        Rs.   850/-

       3.         Admission Fee       :        Rs.   150/-

       4.         Oncologist Charges         :        Rs.   300/-

                             Total            :        Rs.9,237/-

11.  The 3^rd opposite party relied on clause 2 of terms and conditions of the policy and it 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

 Or any other surgeries/procedures agreed by the TPA/Company which require less than 24 hours hospitalization. 

Note :   Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours. 

1. DOMICILIARY HOSPITALISATION BENEFIT means:- Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital /nursing home but actually taken whilst confined at home in India under any of the following circumstances namely:-

          i).  The condition of the patient is such that he/she cannot be removed to the hospital /nursing home or

          ii).   The patient cannot be removed to Hospital/Nursing home for lack of accommodation therein

Subject however that domiciliary hospitalization benefit shall not cover:

I).  Expenses incurred for pre and post hospital treatment and

II). Expenses incurred for treatment for any of the following diseases:-

1.  Asthma

2. Bronchitis

3.Chronic Nephritis and Nephritic Syndrome

4.Diarrhoea and all type of Dysenteries including Gastroenteritis

5.Diabetes Mellitus

6.Epilepsy

7.Hypertention

8.Influenza, Cough and Cold

9.All psychiatric or psychosomatic disorders

10.Pyrexia of unknown origin for less than 10 days

11.Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharangitis.

12.Arthritis, Gout and Rheumatism. 

Liability of the company under this clause is restricted as stated in the schedule attached hereto.

3.0.  ANY ONE ILLNESS :-  Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of discharge from the hospital/nursing home where treatment has been taken.  Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.        

12.    In this case the patient took treatment for a day only i.e., less than 24 hours.  In order considered opinion hospitalization means bed charges, clinical charges and doctor charges.  In this case the complainant has paid Rs.850/- towards room charges and Rs.300/- to Oncologist visiting charges and Rs.150/- towards clinical investigation.  In this case the patient is suffering from carcinoma.  As per clause 2.3 of terms and conditions the time limit of 24 hours is not applicable for radio therapy and parenteral therapy.  No where it was mention that the insured is not entitled for oral therapy taken for carcinoma.  Under those circumstances we are of the considered opinion that the complainant is entitled for reimbursement of Rs.7,937/-(9,237-1,300).  We therefore answer this point accordingly infavour of the complainant.        

13.    POINT No.3:-  The opposite parties 1&2 being facilitator we are of the considered opinion that they have no obligation to settle the claim except to process the papers submitted by the complainant to the 3^rd opposite party.  Hence the claim against 1^st & 2^nd opposite parties are dismissed.  The complainant claimed Rs.50,000/- towards deficiency in service and Rs.40,000/- towards mental agony.  Considering the conduct of the opposite party in settling other claims awarding a sum of Rs.2,000/- as damages in our considered opinion will meet ends of justice.  We therefore answer this point accordingly infavour of complainant.   

14.    POINT NO. 4:-  In view of our above findings in the result the complaint is partly allowed as indicated below : 

1.       The 3^rd opposite party is directed to pay Rs.7,937/- (Rupees seven thousand nine hundred and thirty seven only) together with interest @9% p.a. from 23-04-14 till payment. 

2.       The 3^rd opposite party is directed to pay a sum of Rs.2,000/- (Rupees two thousand as damages and Rs.2,000/- (Rupees Two thousand) towards costs of the complaint to the complainant.

3.       The claim against 1^st & 2^nd opposite party is dismissed without costs. 

4.       The above order shall be complied within a period of six weeks from the date of receipt of copy of this order. 

Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 27^th day of February, 2015.

MEMBER                                  MEMBER                                PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite party:  NIL

                                                                                                                         PRESIDENT

NB:   The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise the extra sets shall be weeded out.