THE DISTRICT CONSUMER DISPUTES REDRESSAL    

                 COMMISSION, AT MADIKERI ,KODAGU

             Dated this the 17^thday of September,2021

PRESENT

SRI .PRAKASHA K.                                    : HON’BLE PRESIDENT

SRI. B.NIRMAL KUMAR                            : HON’BLE MEMBER

ORDERS IN

CONSUMER COMPLAINT NO.63/2019

(Admitted on:20.09.2019)

1.Sri. R.Mahesh

S/o  R.B Rawal,

2. Smt.Vasanthi,

W/o . R.Mahesh

R/o. R.M  Road,

Kushallnagara,

Kodagu District.

(Advocate for the Complainant: M.A.N)

…..Complainants

VERSUS

1.The Branch Manager,

 The New  India  Assurance Co. Ltd.,

 1^st  Floor, Sri Lakshmi Complex,

College Road , Madikeri.

2.   The  Branch Manager,

 Medi Assist India TPA Pvt. Ltd.,

Tower  D, 4^th Floor, IBC knowledge park,

4/1, Bannerugatta Road.

Bangalore-560029.

(Opposite Party No.1 : P.T.G)

(Opposite Party No 2 : Representative) ……. Opposite  Parties

ORDER DELIVERED BY HON’BLE PRESIDENT

SRI .PRAKASHA K.

            1. This complaint is filed under section 12  of the Consumer Protection Act,1986 Act seeking direction  to the Opposite party  to pay the sum of Rs.49,561/- payable  under the policy with interest  at the rate of 18%p.a  and directing the  Opposite party to pay  a sum of Rs.25,000/- as  damages  for causing  mental   agony, loss and hardship  to the complainant, complainant  also prays for   the  cost of this  complaint.   

2.      The brief facts of the case are as under:

   The complainant  had  obtained  family group health  insurance policy  from the Opposite Party No.1 in the  year 2011. The Opposite Party No.2 is the third party administrator of the scheme.  The  complainant  have been renewing  the policy  every year  without fail.  The policy for the year  2018-19 was renewed  by  paying  the renewal premium of Rs.16,231/-on 15.03.2018. The said policy bearing  the No.67240234132500000189 was valid from 15.03.2018 to 14.03.2019.  The sum assured is Rs.8,00,000/-. The policy has been in force since2011.

        3. During the subsistence of the said policy the complainant   No.2 got admitted  at Apollo  BGS hospital / Mysore with the  complaint  of blurred vision and diagnosed as idiopathic intracranial Hypertension – Seizure disorder.  She was  admitted on 05.101.2018 and discharged  on 06.10.2018 after  necessary medical  expenses  for the  treatment  of second  complainant  was Rs.49,561/-(Rs.48,631/- hospital bill+ Rs .930 pharmacy bills).

         4. Thereafter  the  complainants  submitted duly filled claim from enclosing all the medical records and bills  for reimbursement  of their  claim.  The said  claim has been forwarded  by  the O.P.NO.1 to the O.P No.2 on 13.10.2018 for settlement  of the claim.  However  now more than  10 months  have  elapsed  but the claim of the  complainant  has not   yet been  settled.

        5.     The complainants got  issued legal notice to the  Opposite parties  on 01.08.2019 calling upon  them to settle  the lawful  claims of the complainants.  The  notice  has been served  on  the Opposite parties. The  Opposite parties have neither  replied to the  said  notice nor have  settled the claim.  Hence  this complaint.

    6.  After service of notice to opponents,  Opposite Party No.1  appeared through  his counsel  and Opposite party NO.2  representative  appeared.  Opposite Party No.1 filed version. However  Opposite party No.2 did not  file  version on their side.   In the  version  of Opposite Party No.1 contends that  Opposite Party No.2 after scrutiny  of the documents  subject  to the terms and  conditions  of  the policy  informed the Opposite Party No.1 that  the claim is  not  admissible  because  as per the  discharge  summary  the insured  is admitted  with complaints of  seizure disorder  since  15 years  now transient obscuration  of vision  and  flashes  of light  diagnosed  as idiopathic intracranial hypertension [MRI+], seizure disorder, migraine and  as per   records  it is  noticed that insured mainly admitted for  Evaluation –only investigation done without  any active line of  treatment  during  the period of hospitalization.  Opposite party No1 further contends that  all investigations are  day care procedure  can be done  on OPD basis  and only  oral  medications  are advised  during admission period as symptomatic treatment. Hence Opposite party further contends that  claim stand  repudiated under  clause 4.4.11 of the policy.

   7. Opposite party No.1  contends that  as per  clause4.4.11 charges  incurred  at hospital  primarily of 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  illness  or injury  for which  confinement  is required  at a hospital.

         8. Opposite party  further contends  that they  also  replied  to the  legal notice dated 01.08.2019 and   contends that  the  repudiation is proper and  there  is no deficiency of service  on their  the part.  They further contends that  the claim was  repudiated  after  proper  investigation  as per  the terms and conditions  of the policy. Therefore  Opposite Party-No.1 prays for dismissal  of the  above complaint.

9. Complainant  No.1  filed  his examination chief  by way of affidavit  and  he is examined as  PW-1. Complainant  also  furnished  8 documents which are respectively  marked as Ex.P-1 to Ex.P-8. Senior Branch Manager  for Opposite party No.1 company  is also filed  examination chief by way of affidavit  and he is  examined as  RW-1 they  also produced  4 documents which  are marked as Ex.R-1 to Ex.R-4.

          (1) Whether the Complainant proves that           

                there  is deficiency in service on the  

                part  of Opposite Party No.1 and 2?

 (2)  If so, whether the Complainant is  

        entitled to get reliefs as prayed for?

 (3)  What order?

11.    We have considered the arguments submitted by the party and  also considered the materials that, placed before the Commission and answered the points are as follows:

        Point No.(1) :  In the  affirmative

        Point No.(2) :  In the affirmative    

        Point No.(3) :  As per the final order.

REASONS

12.    Point No. 1&2

   For the sake of convenience  Point No.1 and Point No.2  are taken up together for discussion. Examination-in-chief  by way of affidavit  filed by the parties  are replica  of their pleadings. In this case Opposite party admitted  the existence of  policy but  they raised  specific contention that  as per records it is  noticed  that  insured  mainly admitted for  evaluation  only investigation done without any  active line of treatment  during the period of  hospitalisation. They further   specifically contends that  day care  procedure can done on   OPD basis and only oral medication are advised    during  admission period as symptomatic  treatment.  Thus they  repudiated the claim under clause  4.4.11 of the policy.

    13.   In this case complainant  produced  insurance policy and it  is marked as  Ex.P-1. Opposite party No.1 also  furnished  insurance policy   with terms and conditions  and said documents  is marked as  Ex.R-4.  On perusal of Ex.R-4 as per clauses  4.4.11 which read as under:-

“Charges incurred at hospital 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 illness or injury for which  confinement  is required at a Hospital.”

Thus  as per clauses  4.4.11 charges  incurred at hospital primarily of 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 illness or injury for which  confinement  is required at a Hospital. Thus  Opposite party No.1  contends that   in this case  all investigations  are day care procedure     can be done  on OPD basis .

        14. In this case complainant  also produced one certificate  issued by Dr.Somanth vasudeva consultant neurologist Apollo BGS Hospital Mysore. The said latter  is marked  as Ex.P-8.

The contents of ExP-8  which read as under :-

“This is to certify that  Mrs. Vasanti Rawal, aged 35 years(Hospital no :303475) was seen by me on 05/10/2018 and advised admission for evaluation of headache with  visual disturbances.  Since she needed  a lumbar puncture for measurement  of  intracranial pressure she  was admitted  here as this  procedure  cannot  be done  on an outpatient  basis.  She was  diagnosed  to have  Idiopathic intracranial hypertension, started  on medications  and  discharged  on 06/10/2028 after  the diagnostic procedure.”

   Thus the treated Dr specifically stated that complainant  No.2  needed  lumbar puncture for measurement  of  intracranial pressure she  was admitted  in their hospital  as this  procedure  cannot  be done  on an outpatient  basis.  Thus  in this case burden  now shifted  to Opposite party No.1 and 2  show that  in the present  case all investigation day care  procedure done on OPD basis. However in this case no effort made by Opposite parties to show that all investigation are  day care    procedures can be done   on OPD  basis.  Thus in this case except oral evidence of Opposite Party No.1 no other expert evidence produced by  Opposite party No.1 to show that investigation can be done   only on  OPD  Basis.  Therefore  we are of the considered   that on  the basis of oral  evidence coupled with the documentary evidence produced by the complainant that is Ex.P-8 clearly goes to show that Complainant  No.2 needed  a lumber puncture for measurement of intracranial pressure  cannot  be done  on an  outpatient  basis. Even though  complainant  issued  a legal notice to Opposite party No.1& 2 they  failed to settle  the lawful claim to  the complainants.  Thus there is clearly deficiency in service on the part of Opposite Party NO.1 &2.  Accordingly, Point No.1 answered in the  affirmative. In this case complainant also produced  discharge summary  final bill with  receipt and  Pharmacy  bills,  the said  document  marked as  Ex.P-2 to Ex.P-4. On perusal of Ex.P-2 to Ex.P-4 it appears that  the  complainant  spent  the medical expenses for the treatment of 2^nd complainant  was Rs.49,561/-(48,631Hospital Bill +930 Pharmacy Bill) As per policy Opposite Party No.1 collected the premium from complainant side. There by Opposite party No.1 liable to pay sum of 49,561/- to the complainant  with interest.  Further Opposite party No.1are also  liable to pay compensation  and cost of Rs.5,000/- to the complainant. Accordingly  point no.2 also answered in the affirmative.        

 15.  Point No.3

          In the result, we proceed to pass the following:

ORDER

          The complaint filed by the Complainant under section 12 of Consumer Protection Act 1986 is allowed.  Opposite party No.1 is directed to pay the complainant a sum of Rs.49,561/- with  interest  at 6%p.a from the date of complaint  till realisation.  Opposite Party No1 is also  directed to pay sum of Rs.5,000/- as compensation and cost.

        Opposite Party No.1 is directed to comply with the aforesaid relief within 30 days from the date of receipt of this order.

Copy of this order as per statutory requirements, be

forwarded to the parties free of cost and file shall be consigned to record room.

(Page No.1 to 12 dictated to the Stenographer typed by him, revised and pronounced in the open Commission on this the 17^th day of September, 2021)

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 – Sri. R.Mahesh.    (Complainant)

Documents marked on behalf of the complainant   

Ex.P-8: Certificate  issued by Dr.Somanth vasudeva consultant neurologist Apollo BGS Hospital Mysore.

Witnesses examined on behalf of the Opposite Party:

RW-1:   Suresh kumar B.S ,Senior Branch Manager 

Documents marked on behalf of the Opposite Party:-

Dated:17.09.2021                                                  PRESIDENT