Kerala

Idukki

CC/88/2021

sunny joseph - Complainant(s)

Versus

Stra helth allied insurance co ltd - Opp.Party(s)

07 Jul 2023

ORDER

DATE OF FILING : 16/07/2021

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 7^th day of July 2023

Present :

              SRI.C.SURESHKUMAR                                               PRESIDENT

              SMT.ASAMOL P.                                                          MEMBER

              SRI.AMPADY K.S.                                                        MEMBER

CC NO.88/2021

Between

Complainant                           :  Sunny Joseph,

                                                   Kolancheril House,

                                                   Vannappuram P.O., Thodupuzha.

                                                    (By Adv.K.M.Sanu)

                                                           And

Opposite Party                       :   The Manager,

                                                   Star Health and Allied Insurance Co.Ltd.,

                                                   Puthenpurackal Complex, MC Road,

                                                   Kodimatha, Kottayam – 686 013.

                                                             

O R D E R

SMT.ASAMOL P., MEMBER

 

Complainant filed this complaint under Sec.35 of Consumer Protection Act 2019.  Brief facts of this complaint are discussed hereunder:-  

1 . Complainant has been taking Mediclaim Policy since 2017 from opposite party.  This policy was renewed for a period from 31/03/2019 to 30/03/2020.  During the validity period of this policy, complainant had gone to VEIN MIRACLES Specialist Hospital at Palarivattom in Kochi on 18/09/2019 for the treatment of vein in his leg due to severe pain.  After medical examination, medicines were prescribed for some days and thereafter, it was recommended that he is to be admitted on 10/10/2019 for operation of varicose vein.

(Cont....2)

 

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2 . As per that, complainant was admitted on such date in the hospital and after the operation, he was discharged, because, the doctor advised that taking bed rest at home is sufficient, moreover, opposite party and his agent had assured that there is no problem to get claim.  Thus, complainant was in bed rest at his home.  He has incurred Rs.25,000/- as hospital expenses.

3 . Complainant had applied for claim amount with sufficient documents after he got a healthiest condition.  But opposite party has repudiated this claim application due to the reason that hospitalization is less than 24 hours.  Complainant was in bed rest for 15 days at home instead of that he was same as admitted in hospital.  During these periods, he had taken medicines and treatment with dressing, review to hospital in every 7 days.  At that time, he was not able to move without any help from others.  He was allowed by the doctor to take bed rest at home.  He had taken discharge only upon advice from opposite party about the claim.  So, repudiation of claim for baseless reasons amounts to unfair trade practice and deficiency in service on their part.  As per the policy, complainant is entitled to get claim amount.   Hence, complainant has prayed the following reliefs.

(a ) Opposite party may be directed to pay Rs.25,000/-  as hospital expenses.

(b ) Opposite party may be directed to pay Rs.20,000/- as compensation for deficiency in service and unfair trade practice.

(c ) Opposite party may be directed to pay Rs.10,000/- as litigation cost.

Upon notice from this Commission opposite party has entered for appearance.  Written version was filed.  Opposite party’s contentions are briefly discussed hereunder:-

(Cont....3)

 

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1 . Complainant has no bona fides in instituting the complaint and the same has been done with the ulterior motive of making illegal gains.

2 . Complainant had taken Medi Classic Individual Health Insurance Policy from the opposite party for the period from 31/03/2017 to 30/03/2018 and the same has been renewed upto  30/03/2020 for the Sum Insured of Rs.2,00,000/- vide Policy No.P/181113/01/2019/010099.  At the time of issuing the policy the complainant was supplied with the terms and conditions of the policy.  The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to complainant along with the policy schedule.  Moreover it is clearly stated in the policy schedule.

3 . Complainant was admitted on 10/10/2019 at Vein Miracles Clinic, Cochin for  treatment for Chronic Venous Disease and underwent Microfoam Sclerotheraphy and after the treatment he was discharged on the same day.  

4 . The certificate issued by the treating Dr.Kishore Kiran, Consultant Surgeon clearly mentioned that the complainant was suffering from Chronic Venous Disease of both the lower limbs since past 2 months.   He has undergone modified Microfoam Sclerotherapy on 10/10/2019 for the right leg in this institution.  This is an innovative surgical technique for treatment of varicose veins with excellent clinical results.  This procedure took about 2-3 hours and is done as day care.

 

(Cont....4)

 

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5 . Based on the available medical records, it is evident that the complainant had taken treatment for Chronic Venous Disease as day care basis and the complainant stayed at the hospital less than 24 hours.  In policy conditions issued to the complainant  list of day care procedure is clearly mentioned.  The present treatment and its procedure are not mentioned in the list of day care procedure as per policy terms and conditions.  Hence the opposite party had repudiated the claim for the reason Hospitalization less than 24 hours not covered under the policy and the same was informed to the complainant on 06/11/2019.

6 . According to opposite party, there has been no deficiency of service to complainant.  The opposite party had acted only as per the terms and conditions of the policy.  The complainant has absolutely no cause of action for the petition and not entitled for any damage, cost and compensation.  The procedure undergone by the complainant not comes under the list of day care treatments as per policy terms and conditions.

7 . It submitted that the claim is not payable as per policy terms and conditions.  The complainant had submitted claim form for an amount of Rs.25,000/-.  Therefore it is  humbly submitted that even though the claim is not payable as per policy terms and conditions, if this Hon’ble Commission finds any liability upon this insurer, then the liability of the insurer may be limited to Rs.21,780/-.  Hence, complaint may be dismissed with compensatory costs to the opposite party.

Complainant has produced 3 documents.  These were marked as Exts.P1 to P3.  Ext.P1 is copy of claim form, Ext.P2 is copy of treatment summary issued from VEIN MIRACLES hospital and Ext.P3 is copy of bill. 

 

(Cont....5)

 

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No oral evidence adduced on the part of complainant.  Opposite party has also not adduced oral evidence.  Seven documents were produced and marked as Exts.R1 to R7 on the part of opposite party.  Heard the counsels for both parties.  Thereafter it was taken for orders.  Now the points which arise for consideration are:-

1 . Whether there is any deficiency in service on the part of opposite party?

2 . If so, what reliefs the complainant is entitled for?

Points are considered together

We have perused the complaint and evidence on record.  Complainant states that as per the policy, he is entitled to get claim amount from opposite party.  Complainant was under the treatment for varicose vein during the validity period of this policy.  He was admitted in hospital for the treatment of varicose vein on 10/10/2019, but after the treatment, he was discharged on the dame day.  On the perusal of Ext.P2 ie, treatment summary, it is seen that Chronic Venous Disease diagnosed and modified Microfoam Sclerotherapy done on right leg of him on 10/10/2019 and thereafter he was discharged on the same day because post procedure period was uneventful and stable vitals.  Moreover, complainant was advised on discharge that he keeps foot end elevated, medicines were prescribed and Review after one week.  Thereafter, complainant has applied for claim amount as per the insurance policy.  The copy of claim form was produced and marked as Ext.P1. However, opposite party had repudiated the claim due to the reason of hospitalization is less than 24 hours.  According to opposite party, the insured patient was admitted on 10/10/2019 and discharged on the same day itself and his stay at the hospital is  less   than  24  hours,  that  is  not  covered  under  the  policy  terms  and

(Cont....6)

 

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conditions.  Opposite party has produced policy terms and conditions ie, marked as Ext.R2.  We have carefully perused this document.  It is mentioned in this Ext.R2 document that inpatient treatment covers hospitalization expenses for period more than 24 hours.  However, we are of considered view that in this case, complainant deserves the consideration of same as that of inpatient treatment in the hospital for more than 24 hours, because he was diagnosed Chronic Venous Disease and thereafter, modified Microfoam Sclerotherapy   done on his right leg and he was discharged on the advice that to take bed rest at home and keep foot end elevation.   Moreover, complainant was prescribed medicines and review after one week.  Complainant had taken bed rest at his home.  According to opposite party, there is an exclusion clause in the policy conditions, hence repudiated the claim.  But in Texco Marketing Pvt Ltd., V/s Tata AIG General Insurance Company Ltd., and others case, the Honourable Supreme Court emphasised that exception clause must be interpreted to the benefit of the insured when the exception clauses are too wide and not consistent with the main purpose or object of the insurance policy.  ie, an exclusion must be understood on the prism of main contract.  The Honourable Supreme Court also noted in this case that the insurance contracts belong to a category of adhesion contracts, ie, these contracts are prepared by the insurer having a standard format in which the consumer has very little option or choice to negotiate the terms of the contract, except to sign on the dotted lines.

In this case, complainant had taken treatment of Chronic  Venous Disease in the hospital on a day care basis.  As per Ext.P1, it is an innovative surgical technique for treatment of varicose vein.  This new method, probably, came to be adopted in hospital only from recent time.  Policy conditions were drafted and proposed earlier.  Under Ext.P2, after this treatment Elastocrepe bandage applied to complainant and he was shifted to observation room.  Thereafter post OP instructions were given to complainant

(Cont....7)

 

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that foot end elevation, creep bandage application and calf muscle exercise etc.   We are of the opinion that this is not a simple procedure for treatment of complainant, same as that of an outpatient consultation.  Ordinarily, if a patient has consulted a doctor with the particular time in a day for some silly things in which further treatment is not necessary, such patient need not be considered to get the benefit of hospitalization less than 24 hours as per the insurance policy.  But, in this case, complainant had taken a day time treatment which more expensive.  According to insured persons, the main purpose of taking insurance policy is to get a relief from huge hospital expenses.  Here, even though complainant was in a day time treatment, he has incurred Rs.25,000/- for such treatment.  Ext.P3 ie, the bill was marked.  Opposite party has not adduced evidence against the Ext.P3 bill.  Under the decision of Hon’ble Supreme Court in the above quoted case, complainant deserves to get insurance claim from opposite party here also. 

The main purpose of insurance policy is that the insured persons should be getting the claim benefits in their unexpected hospital expenses.  The repudiation of such claim upon outdated policy conditions cannot be taken as binding in view of Apex Courts Judgement cited supra.  Opposite party does not have a case that, complainant has not taken treatment for varicose vein or paid as hospital expenses of amount shown in Ext.P3 bill.  Moreover, opposite party has not tendered any evidence against the hospital bill.  Opposite party has produced copy of claim repudiation letter ie, Ext.R6.  On the basis of above discussions, we find that reason for repudiation of claim is not justifiable.  Hence, opposite party is liable to compensate the complainant for deficiency in service on their part.  Complainant is entitled to get the reliefs as prayed for.  In the light of the above said circumstances, the complaint is allowed  in part as hereunder.

(Cont....8)

 

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1 . Opposite party is directed to pay Rs.25,000/- as hospital expenses to complainant with interest @ 12% per annum from 06/11/2019 (Date of R6) till realization.

2 . Considering the claim amount and other circumstances, opposite party is directed to pay Rs.5,000/- as compensation and Rs.3,000/- as cost of litigation to complainant within 45 days from the date of receipt of  copy of this order, failing which, compensation amount shall carry 12% interest from the date of order till its realization.

Parties shall take back extra copies without delay.

Pronounced by this Commission on this the 7^th  day of July 2023.

                                                                                                                                                                                                                            

                                                                                                Sd/-                                                           

                                                                         SMT.ASAMOL P., MEMBER

                                                                                                Sd/-

                                                                   SRI.C.SURESHKUMAR, PRESIDENT

                                                                                                Sd/-

                                                                           SRI.AMPADY K.S., MEMBER

 

 

 

 

 

 

 

 

 

 

 

 

(Cont....9)

 

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APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1  -  Copy of claim form

Ext.P2  -  Copy of treatment summary issued from VEIN MIRACLES  

                 Hospital

Ext.P3  -  Copy of bill. 

On the side of the Opposite Party :

Ext.R1 -  Mediclassic Insurance Policy (individual) Schedule, Unique

                Identification No.IRDA/NL-HLT/SHAI/P-H/V.II/400/13-14,  

                 Renewal Endorsement No.P/181113/01/2019/010099.

Ext.R2 -   Star Health and Allied Insurance Company Limited – Customer

                 Information Sheet – Mediclassic Insurance Policy (Individual)

Ext.R3 -  Copy of Treatment Summary dated 10/10/2019,  Vein Miracles,

                The Speciality Center for Venous Diseases 

Ext.R4 -  Copy of  ‘To whomsoever it may concern’

Ext.R5 -  Copy of Cash Bill dated 10/10/2019, Vein Miracles,

                The Speciality Center for Venous Diseases.

Ext.R6  -  Copy of Repudiation of Claim dated 06/11/2019.

Ext.R7  -  Copy of letter from Star Health and Allied Insurance

                Company Ltd., to complainant  dated 14/12/2019.

 

 

                                                                                                   Forwarded by Order  

 

 

                                                                                        ASSISTANT REGISTRAR