Ttk health care services
CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM
KATHRUKKADAVU, KALOOR, KOCHI - 17
consumer case(CC) No. CC/08/222
UNITED INSURANCE COMPANY
TTK HEALTH CARE SERVICES PVT.LTD.
NATIONAL INSURANCE CO.LTD.
3. PROF:PAUL GOMEZ
O R D E R
A. Rajesh, President.
1. Very briefly, the facts as brought out in the complaint are :-
The complainant is a mediclaim policy holder of the 3rd opposite party. In August 2007, he underwent treatment for rheumatic complaint in a local hospital. Thereafter on 20-08-07, he approached Government Ayurveda Hospital, Aluva for expert management. He got admitted in the hospital on 24-08-07 and discharged after treatment on 30-09-07. He incurred Rs. 5,373/- for his medical expenses. His claim for insurance claim was repudiated by the 3rd opposite party. Hence the complainant approaches this Forum for reimbursing the medical expenses from the opposite party with its interest.
2. The 3rd opposite party filed the following reply refuting the claim of the complainant:
i) The mediclaim insurance policy issued in favour of the complainant was active during the period of hospitalization of the complainant.
ii) The complainant was admitted in the hospital for the treatment of numbness of the left arm and shoulder pain, these ailments can be treated as an out patient. Since the complainant was suffering from pain and numbness on the left arm and shoulder the treatment could have been undergone as an out patient.
iii) It is clearly stated in the policy condition that treatments usually done in out patient department are not payable under the policy even if converted to day care procedure or as inpatient in hospital for more than 24 hours.
iv) The 3rd opposite party has no liability to admit the claim of the complainant and requests to dismiss with their cost.
3. The 1st opposite party was deleted from the party array as per the order in I.A. No. 198/08 dated 24-09-08. Despite service of notice from this Forum, the 2nd opposite party abstained from the proceedings. The complainant was examined as PW1 and Exts. A1 to A5 were marked from his side. No oral evidence was adduced by the 3rd opposite party, Ext. B1 was marked from their side. The complainant appeared in person and the learned counsel for 3rd opposite party was heard.
4. The only point that came up for our determination is whether the complainant is entitled for mediclaim insurance from the 3rd opposite party. It is not in dispute that the complainant had undergone treatment for shoulder pain at Government Ayurveda Hospital, Aluva as inpatient from 25-08-2007 to 30-09-2007. It is also not in dispute that the above period is within the validity of insurance policy. The reason for the repudiation of the claim as per Ext. A3 rejection letter is as follows:
“Since pain and numbness manifested on left arm shoulder only, the procedure could have been undergone as an out patient without the need for confinement in the hospital.”
The relevant clause which lead the 3rd opposite party to repudiate the claim of the complainant as per Ext. B1 policy (Clause 2.6) is as follows:
“Procedures/treatments usually done in Out patient/Department (OPD) are not payable under the policy even if converted to Day Care Surgery Procedure or as inpatient in hospital for more than 24 hours”
5. The complainant had underwent treatment in a Government Ayurveda Hospital at Aluva. As per Ext. A5, he has undergone the following treatment.
We think that the doctor, who treated the patient is to decide whether the treatment of the patient is to be continued as inpatient or outpatient. In the instant case, the doctor prescribed inpatient treatment for the complainant. Apart from the submission by the learned counsel, there is no other reason before us to disbelieve Ext. B5 the discharge summary issued by the attending doctor. The 3rd opposite party ought to have taken steps to adduce medical evidence to contradict the prescription of the doctor. Hence the 3rd opposite party is liable to indemnify the complainant and to pay the mediclaim insurance with its interest Ext. A4 series medical bills.
6. In the above circumstances, we allow the complaint and direct that the 3rd opposite party shall pay mediclaim insurance claim of Rs. 5,373/- to the complainant with interest at the rate of 12% p.a. from the date of complaint till realisation.
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