| Final Order / Judgement | CONSUMER DISPUTES REDRESSAL COMMISSION – X GOVERNMENT OF N.C.T. OF DELHI Udyog Sadan, C – 22 & 23, Institutional Area (Behind Qutub Hotel) New Delhi – 110016 Case No.127/2016 Mr. SUNIL KUMAR DAWAR S/O LATE SH. AMARNATH DAWAR R/O K-33, PUNJABI BAJAR, KOTLA MUBRAKPUR, NEW DELHI-110003 …..COMPLAINANT Vs. - NATIONAL INSURANCE COMPANY
SAHYOG BUILDING 54, 302-304, NEHRU PLACE, NEW DELHI-110019..…..RESPONDENTNo.1/ OP - FOCUS HEALTH SERVICES (T.P.A) PVT. LTD.
AB-16, COMMUNITY CENTRE, SAFDARJUNG ENCLAVE, NEW DELHI-110029..…..RESPONDENTNo.2/ OP Date of Institution-19/04/2016 Date of Order- 13/05/2022 O R D E R RASHMI BANSAL– Member - The present complaint is filed by complainant against the repudiation of his Mediclaim by OP and praying for settlement of account with all OPs.
- The facts of the complaint filed by the complainant against OP are that he had availed a Mediclaim policy, from the OP1 valid for the period 25.07.2013 to 24.07.2014. OP2 is the third-party agent of OP1. Due to severe pain in abdomen, the complainant was admitted in emergency ward to Phoenix Hospital GK- II New Delhi on 04.12.2013 at about 3:30 AM with problem of severe pain while passing urine since night and he was admitted to emergency ward of the hospital and diagnosed for B/L renal stones, as per discharge summary dated 06.12.2013 and took treatment as inpatient from 04.12.2013 to 06.12.2013.
- The complainant had cashless facility but had to pay hospital charges and made a claim for reimbursement of Rs. 32,753/-, from the OP1, but his claim was repudiated by OP1 vide repudiation letter dated 25.04.2014, by invoking exclusion clause 4.10 of the policy document, on the ground that the hospitalization is only for investigation and evaluation purpose, and it was not followed with active treatment. By this complaint, complainant has prayed for a direction to the OP1 to reimburse his medical expenditure.
- OP filed his written statement and evidence by way of affidavit, admitting issue of policy in favor of the complainant. It is contended by OP that treatment undergone by the complainant is only for primary evaluation / diagnosis purpose, which was not followed by active treatment and discharge summary revealed that patient was given only conservative treatment and that the ailment mentioned in the discharge summary shows that no active treatment was necessary nor it was given to patient. Therefore, justified the repudiation of the claim of the complainant by invoking exclusion clause 4.10 of the conditions of the policy.
- We have heard the counsel for the complainant and OP and perused the records. The complainant in the affidavit evidence and written argument filed has claimed for the reimbursement of Rs. 52,753/-, with interest at 18% per annum from the date of filing claim till actual realization, however the claim form, Exhibit CW 1/D shows a claim for reimbursement of Rs. 32,753/- made by complainant .
On the above contentions, following points for determination arise. - Whether the complainant proved that the OP has caused deficiency in service by repudiating the claim of the complainant to reimburse the medical expenditure, he has incurred?
- To what relief is, the complainant entitled to?
- On consideration for point 1, this what emerges is the complainant had availed a Mediclaim insurance policy exhibit CW 1/A from the OP1, which was valid from 25.07.2013 to 24.07.2014 and that he underwent treatment for the severe pain while passing urine since night and he was diagnosed for B/L renal stones, as per discharge summary dated 06.12.2013, exhibit CW 1/C, and took treatment as in patient from 04.12.2013 to 06.12.2013 and hospitalized took treatment as in patient from 04.12.2013 to 06.12.2013 is not in dispute between the parties.
- The claim intimation was sent to OP1 and OP2 by the hospital vide email dated 04.03.2013, exhibit CW 1/B. But the claim of the complainant for reimbursement of his medical expenditure amounting to Rs. 32,753/- exhibit CW 1/D, was repudiated by OP through the repudiation letter dated 25.04.2014, exhibit CW 1/E by invoking exclusion clause 4.10 of the policy document, on the ground that the hospitalization is only for investigation and evaluation purpose. Hence claim falls under exclusion clause 4.10 of the policy, of the terms and conditions of the policy which OP has filed as Ex. OP-2W/1.
- Exclusion clause 4.10 the condition of the policy, reads as under;
“4- Exclusions 4.10 – expenses incurred primarily for evaluation / diagnostic purposes not followed by active treatment during hospitalization”. At the same time, we are considering the other clause of the policy, i.e. the Clause 3.10 which states that: - “3.10- in-patient: an insured person who is admitted to the hospital and stays for at least 24 hours for the sole purpose of receiving the treatment for suffered ailment/illness/disease/injury/accident during the currency of the policy.” - The plain reading of both the clauses shows that they are not in sync with each other. On one side, the exclusion clause 4.10 says that expenses incurred at hospital or nursing home primarily for diagnostic purposes, which is not followed by active treatment, is excluded, which goes to show that if the insured has only undergone a process of diagnostic purpose not followed by treatment, such expenditure is excluded under the policy. On the other hand, as per clause 3.10, complainant is an in-patient as he is admitted in hospital and stayed there for more than 24 hours, for the sole purpose of receiving the treatment for suffered ailment, i.e. severe pain which obviously implies that for the treatment of this ailment, proper and detailed investigations are required before treatment, which later diagnosed as B/L renal stone. Both the clauses are independent on each other and should be construed as it is without having bearing upon each other. If complainant is covered under any clause, he should be treated accordingly, unaffected by the other clause.
- We do not think it is for the OP to see whether the particular ailment or patient required hospitalization or not, when a patient, the insured, is suffering from any particular ailment or disease. It is for the treating doctor to decide whether patient is required to be admitted to get himself diagnosed at first place and treated, may that be medication or surgery. In case on hand, it was decided by doctors that without proper test and diagnosis treatment could not be administered upon patient. Ongoing through the contents of discharge summary dated 06.12.2013 and hospital records, it is revealed that the complainant diagnosis mentioned B/L Renal stones by doctors after assessing the severity of the ailment of the complainant. It is only thereafter, when all the investigations were done, doctors at hospital decided their line of action and in this case, they chose for conservative treatment and started treating him by administering medicines and other supportive measures along with the follow-up treatment for complainant who was found stable after 2 days and was discharged on 06.12.2013.
- In medical terminology, ‘conservative treatment’ implies for avoidance of surgery or invasive surgery and to keep body parts intact. Merriam – webstar dictionary giving medical definition as not extreme or drastic. Especially: designed to preserve parts or restore or preserve function.
- Therefore, it is not that the complainant had only got his ailment investigated through tests and was discharged from the hospital. He after getting his ailment diagnosed was under treatment as per his doctor’s advice by follow-up administering tablets and then he was discharged. The doctors have treated him as per their best of wisdom, understanding and decided line of action that they thought appropriate for the complainant at that crucial point of time. Before making all the necessary test and consultations, it is impossible for the doctor to reach to any conclusion and to decide the line of action for the treatment. Therefore, this cannot be said that the active treatment has not been given. In fact, the active treatment started at the very point of time when the complainant entered into the hospital for his diagnosis of the pain he was suffering. Considering this fact born out of the discharge summary, contention of the OP that diagnosis did not follow the active treatment for that ailment cannot be accepted. Thus, in the instant case this Commission finds that the complainant after getting his ailment diagnosed took treatment for subsiding that ailment as in-patient and therefore, clause 4.10 of the exclusion clause is not applicable to the facts of the case. Thus, we are of considerate opinion that repudiation of the claim of the complainant by OP amounts to deficiency in services. Therefore, complainant is entitled for reimbursement of that money. OP is directed to reimburse Rs. 32,753/- ( Third two thousand, seven hundred, fifty three ), the claim amount, equivalent to full insured value with interest at the rate of 6% per annum from the date of the claim presented before this commission till actual realization, Rs. 10,000/- towards compensation for deficiency in services and 10,000/- towards litigation cost to the complainant within three months from the date of order failing which the entire amount shall carry an interest @9% p.a. till the amount is actually paid to complainant.
- The file be consigned to the record room after providing copy of the order to the parties free of cost.
- The consumer complaint could not be decided within the statutory period due to heavy pendency of Court cases. The order be uploaded on the website www.confonet.nic.in
- The order contains 7 pages and bears my signature on each page.
(Dr. RAJENDER DHAR) (RASHMI BANSAL) (MONIKA SRIVASTAVA) MEMBER MEMBER PRESIDENT | |
