IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Tuesday, the 30th day of May, 2017.
Filed on 28-11-2015
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt. Jasmine D (Member)
in
C.C.No.347/2015
between
Complainants:- Opposite parties:-
Suresh.S Senior Divisional Manager
Suresh Nivas United India Insurance Company
North Aryad PO Divisional Office,
Alappuzha. Sarada Shopping Complex
Mullackal, Alappuzha.
(By Adv. Hemalatha R)
O R D E R
SMT. ELIZABETH GEORGE(PRESIDENT)
The case of the complainant is as follows:-
Complainant took a medical insurance policy from the opposite party. He was admitted at PVS Hospital Ernakulam on 25/7/14 and discharged on 26/7/14. He filed insurance claim for the reimbursement of expenses. But it was repudiated by the insurance company on 28/8/15 on the plea that as per clause 4(11) of the policy the claim was not payable. Being aggrieved of the repudiation of the claim the complaint is filed.
2. Version of the opposite party is as follows:-
The opposite party had issued a MEDI CLAIM Policy to the complainant under Policy No.1015002813P142836437. The allegation is that the complainant was treated at P.V.S. Memorial Hospital, Ernakulam on 25/07/2014. The complainant approached the opposite party and claimed the bill amount for policy benefits. The opposite party rejected the claim as per the exclusion clause of the policy. This was duly informed by the opposite party to the complainant. The complainant was treated in the P.V.S. Hospital Ernakulam on 25/7/14 and discharged on 26/7/14. In the policy, Exclusion No.4(11), it is specifically stated that “charges incurred at hospital or nursing home primarily for diagnosis, X ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital / nursing home”. So the complainant is not eligible to get the claim amount as per the exclusion clause. There is no deficiency in service on the part of the opposite party.
3.The complainant was examined as PW1. The documents produced were marked as Exts. A1 to A14. Opposite party was examined as RW1 and documents produced were marked as Exts. B1 and B2.
4. Points for considerations are:
1) Whether there is any deficiency in service on the part of opposite party?
2) If so reliefs and costs?
5. It is an admitted fact that the opposite party had issued a Medi Claim Policy to the complainant. According to the complainant he was treated at P.V.S. Hospital Ernakulam on 25/7/14 and discharged on 26/7/14, but his claim for reimbursement of the medical bill was rejected by the opposite party. Opposite party filed version stating that in the policy exclusion No.4(11), it is specifically stated that “charges incurred at hospital or nursing home primarily for diagnosis, Xray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital / nursing home”. Complainant produced discharge summary and it marked as Ext.A6. In the Ext.A6 discharge summary under title the MRI Abdomen it is stated that “ Pelvis showed midline posterior prostatic utricle cyst, left epidydimal cyst”. Ext.A14 dtd 6/3/17 issued by Public Relations Officer shows that complainant was admitted in the hospital on 25/7/16 went for MRI-Pelvis and Genitalia at VITA Diagnostics on 25/7/16 after the admission as per their advice. On reading clause 4(11) of the policy it is clear that charges incurred by the insured at hospital / nursing home primarily for diagnosis, Xray or laboratory examinations are excluded from insurance cover unless diagnostic Xray or laboratory examinations is consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital / nursing home”. Ext.A14 shows that complainant during the admission period at the hospital underwent MRI –Pelvis and Genitalia at VITA Diagnostics as per their advice. As per the test conducted he was treated with medicine. From the discharge summary it is also clear that the complainant was discharged from the hospital and he was given medicines and advised to review in Urology OP after three months. Therefore the contention of opposite party that the charge incurred by the complainant is not consistent with or incidental to the diagnosis and treatment of the complainant, is not sustainable. Hence we are of opinion that complainant is eligible for reimburse the medical bill amount under the policy.
In the result complaint is allowed.
The opposite party is directed to reimburse the treatment expenses claimed by the complainant. The opposite party is further directed to pay Rs. 1000/- towards compensation and Rs.1000/- towards cost.
The order shall be complied within one month from the date of receipt of this order
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in the Open Forum on this the 30th day of May, 2017
Sd/- Smt. Elizabeth George (President)
Sd/- Sri. Antony Xavier(Member)
Sd/- Smt. Jasmine.D. (Member)
Appendix:
Evidence of the complainant
PW1 - S.Suresh(Witness)
Ext.A1 - Copy of letter dtd14/10/15
Ext.A2 - Copy of letter dtd 18/11/15
Ext.A3 - Copy of reply letter RTI dtd 16/12/15
Ext.A4 - Copy of letter dtd 20/8/15 issued by Sr.Divisional Manager
Ext.A5 - Copy of Individual Health Insurance Policy Schedule
Ext.A6 - Copy of discharge summary
Ext.A7 - Copy of Health insurance policy claim form
Ext.A8 - Prescription dtd 26/7/14 by Dr.George P.Abraham
Ext.A9 - News Paper cutting
Ext.A10 - Copy of Receipt No.VVM/633 E dtd 25/7/14
Ext.A11 - Prescription dtd 9/1/14 by Dr. George P. Abraham
Ext.A12 - Copy of letter dtd 20/8/15
Ext.A13 - Copy of letter
Ext.A14 - Certificate issued by Public Relations Officer dtd 6/3/17
Evidence of the opposite parties
RW1- - Bindu B(Witness)
Ext.B1 - Copy of Policy
Ext.B2 - Copy of letter dtd 20/8/15
//True Copy//
By Order
Senior Superintendent.
To
Complainant/Opposite party/S.F
