JUDGEMENT

By Sri. A.H. Malaghan, President:-

            The complaint has filed this complaint against the Op U/sec. 12 of C.P. Act 1986. The brief facts of the complaint are that, the complainant has taken a mediclaim policy bearing No.240200/481/11/97/00000612 with effect from 23-11-2011 to 22-11-2012 for a sum assured amount of Rs.75,000/- from Op’s Insurance Company. The complaint was admitted to one Sri Nursing Maternity Home in Raichur on 20-07-2012 and was discharged on 22-07-201. In the said hospital the complainant was diagnosed as right ureteric calculus and he underwent for right URS+ISWL+DJ stenting done. After discharging from the hospital. The complainant has submitted his claim form to the Op’s Insurance company for reimbursement of Rs.12,800/- incurred towards his medical expenses in the above said hospital. Accordingly he submitted bills and other necessary papers to Op’s Insurance Company for settlement of his claim. On receipt of said claim forms the Op’s Insurance Company has assured the complainant that the claim will be allowed soon.

2.         Further it is stated by the complainant that, the claim of the complainant was repudiated on 10-05-2013 stating that, “this has reference to above your claim the policy is serviced by the third party administrator who have sent recommendations to repudiate the claim on the ground that. “The hospital   where the patient availed treatment does not comply with minimum criteria of policy condition 2.1. In view of the above we are unable to admit the claim. It is further stated by the complainant the action of the Op’s Insurance Company on the above said ground is not only the legal but also against the cannons of the principles of policy, since the complainant has taken treatment and has been operated in a registered and qualified surgeon under the supervision of Dr.Shailesh Amarkhed,  Raichur.

3.         The complainant further urged that, after repudiation of the claim, he approached the Op’s Insurance Company and showed the documents for having granted claim by the Op’s Insurance Company in a case of one G.Mallikarjunareddy who has been treated in the same hospital in which the Op’s Insurance Company was allowed the claim. But at that time, the manager of the Op’s Insurance Company brought gundas and threatened the complainant saying that, should not disclose the very fact of one G.Mallikarjunreddy’s claim. Hence the complainant has not informed the same to anyone due to said threat. He further averred that, recently the complainant has met with his relative who is an advocate by name Sri. Govardhanreddy who suggested the complainant for filing this complaint, accordingly the complainant has filed this complaint. Saying that, looking to the above said facts, the same was constituting a deficiency of service on the part of the Op’s Insurance Company.  So he requested to allow the complaint.

4.         On the other hand, the Op’ Insurance company has represented this case through counsel and submitted his written version stating that, the complaint filed by the complainant is not maintainable either in law or on facts of the case. Further he stated that, the complainant has taken a Mediclaim policy from the Op’s Insurance Company and said policy contents various conditions & limitations that whenever claim is made the claim will be settled by third party administrator i.e, (TPA) who holds a valid license from IRDA.  It is further submitted by Op’s Insurance Company that, claim of Rs.12,800/- incurred towards the medical expenses by the complainant, as per the policy condition the said claim was sent to TPA Bangalore for settlement of claim and third party administrator has visited the hospital in which the complainant has taken treatment and then TPA has rejected the claim stating that, the hospital in which the complainant was treated is not a registered hospital as per condition No.2.1. As per the definition clause of 2.1 it reads as under:

2.1) Hospital/Nursing Home, means any institutions in India established for   

       indoor care and treatment of sickness and injuries and which

Either

1.  Has been registered as a hospital or nursing home with the local authorities and it is under the supervision of a registered and qualified medical practitioner.

Or

2. Should comply with minimum criteria as under:-

1.  It should have at least 15 in patient beds.
2. Fully equipped operation theater of its own wherever surgical operation is carried out.
3.  Fully qualified nursing staff under his employment round the clock.
4.  Fully qualified doctor(s) should be in-charge round the clock.
5. Maintenance daily records for each of its patients.

N.B1) In class “C” towns condition 2.1b(i) in respect of number of beds be reduced to 10.

5.         Hence as per the policy conditions the same are not fulfilled by the hospital in which the complainant has taken treatment, such being the facts the TPA has rejected mediclaim of the complainant. In this regard the doctor who treated the complainant has given a certificate dt. 10-10-2012 stating that, the hospital in which the complainant was treated is not a registered one and the registration is pending. As such there is no deficiency of service on the part of Op and it is not illegal to repudiate the claim of the complainant. It is further averred by the Op’s Insurance Company regarding the claim of one G.Mallikarjunreddy and the said claim is admitted by the TPA wrongly though the said Mallikarjunreddy has taken treatment in the same hospital. Hence this Op’s Insurance Company to initiate recovery proceedings against G.Malllikarjunreddy and recover the amount given by TPA.  It is further stated by Op that, as per the policy condition No.5.3 when claim is rejected then the claim must be made within 12 calendar months from the date of receipt of notice of repudiation. The letter of repudiation made on 10-05-2013 and the present claim is filed in the month of September-2014 which is barred by limitation as per the policy condition. Hence the TPA repudiated the claim legally based on policy conditions & limitations, as such there is no deficiency of services on the part of the Op’ company. Hence he requested to dismiss the complaint with cost.

6.         On perusal of the above said facts, the point for consideration arose are:

1.         Whether the complainant proves that, there is a deficiency of service on the part of the Op’s company in settling the medicalim of the complainant under mediclaim policy bearing  No.240200/481/11/9700000612.?

2.         What order?

 Answer to the Point No:1 is—Affirmative

 Answer to Point No:2- As per final order.

REASONS

POINT NO.1:-

7.         The complainant-himself has examined as PW-1 and reiterated his complaint averment on sworn affidavit and has produced four documents in support of his case which are marked as Ex.P-1 to Ex.P-4 and he prayed for allowing his complaint. On the other hand, the Op’s company has examined his local manager as RW-1 and got marked his two documents as Ex.R-1 & R-2. He also reiterated the written version averments on his sworn affidavit and prayed for dismissal of the complaint.

8.         The advocate for complainant has argued that, the complainant was taken treatment in a recognized & registered hospital and was operated by qualified doctors in the said hospital under the supervision of Dr. Shailesh Amarkhed at Raichur. Further he argued that, one patient by name G.Mallikarjun Reddy has also taken from the said hospital, but his mediclaim was allowed by Op or TPA. Hence the complainant has also took treatments in the said hospital but his claim was repudiated illegally on a baseless & falsely grounds. So there is no any violation of policy conditions as the facts of the complainant’s case and one G.Mallikarjun Reddy’s case are one and the same hospital records. As such the reputation complainant’s claim amounts to deficiency of services on the part of Op. So the complainant’s claim is legal and thereby he is entitled the reimbursement of his mediclaim from Op as his above said Mediclaim Insurance Policy was valid and effective as on the date of hospital treatments. Hence Op is liable to pay the said claim under the above said policy.

9.         Further he drawn the attention of this Forum on Ex.P-2 at Remarks column which reads as under:

2.1: HOSPITAL/NURSING HOME means any institution in India established for indoor care and treatment of sickness and injuries and which

Either

1. has been registered as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner.

Or

2. Should comply with minimum criteria as under:

1. It should have at least 15 inpatient beds.

(ii) Fully equipped operation theater or its own wherever surgical operations are carried out.

(iii) Fully qualified Nursing Staff under its employment round the clock.

(iv) Fully qualified Doctor(s) should be in-charge round the clock.

(v) Maintains a daily record for each of its patient.

10.     So he further argued that the above said conditions are wrongly interpreted by the Op for repudiation of this claim. As per the above conditions 2.1 Hospital/Nursing Home means any institution which is Either: it has been registered as hospital or Nursing Home with local authorities and is under the supervision of a registered and qualified Medical Practitioner OR (b) should comply with minimum criteria as under:

1. The hospital should have at least 15 inpatient beds.

(ii) Fully equipped operation theater or its own wherever surgical operations are carried out.

(iii) Fully qualified Nursing Staff under its employment round the clock.

(iv) Fully qualified Doctor/s should be in-charge round the clock.

(v) Maintains a daily record of each of its patient.

So meaning thereby the complainant’s hospital should comply Either condition No.2.1(a) OR (b) above but not both conditions. Hence he argued that, the hospital in which the complainant has taken treatment is complied with above all conditions without any violations and as such Op has to reimburse the Mediclaim of the complainant.

11.     On the other hand, the counsel for Op has argued that, document Ex.P-1 clearly discloses that, the hospital wherein the complainant has availed his treatments is not a registered hospital and same is under process only. So that itself is sufficient for Op to repudiate the claim of the complainant, as the TPA has collected the above documents Ex.P-1 and rightly repudiated the claim. Saying that it is clear violation of the conditions of Mediclaim Policy. Further the counsel for Op argued that, the claim in respect of a G.Mallikarjun Reddy has been wrongly allowed but his office is preceded for recovery of the amount paid to him. Further he pointed out that complaint is barred by limitation.

12.     After considering the said arguments & all the records, and after careful reading of Ex.P-2 repudiation letter at Remarks column of conditions No. 2.1 (a) & (b), the hospitals should comply with Either condition No.2.1 (a) or (b) but not both conditions together. Hence as per Ex.P-2, amongst condition 2.1(a) or 2.1 (b) (i) to (v), condition either one is complied, then Op has to allow the claim of the complainant. But in this case, the Op has not proved the violations of other conditions mentioned in clause 2.1 (b) (i) to (v) of repudiation letter. It is admitted by Op in his written version and in his evidence affidavit that “In class “c” towns condition No.2.1(b) (i) in respect of number of beds be reduced to 10. Meaning thereby the hospital should have less than 15 beds in “c” class city like Raichur but not “15” as contained in his repudiation letter. Hence the Op has not considered this aspect while repudiating the claim of complainant.  But simply based on letter Ex.R-1 the Op has repudiated the claim which is illegal. The duty cast upon the Op to prove his entire allegations including the treated hospital is having less than 10 beds by producing documentary evidence regarding violation of conditions 2.1(b)(i) also. Further he has not produced any documents to show that hospital where the complainant took treatments was not complied with other requirements of law. In the absence of the same Op cannot be discharged from the liabilities. So action of Op is illegal in repudiating the claim of the complainant in the absence of any material documents. The Ex.R-1 alone will not help the Op for repudiation of claim of complainant. On the other hand, in respect of one G.Mallikarjun Reddy’s case he has not produced any documents regarding recovery proceeding is initiated against him for wrong payments made by Op. In the absence of such documents there is no weight in the submission of his counsel. Hence the Op’s action in repudiating the claim of the complainant is amounts to deficiency in his service towards complainant. And as such he is under obligation to reimburse the mediclaim of the complainant Rs.12,800/- as per his mediclaim Insurance Policy issued in favour of complainant. No doubt the complainant might have suffered pain & other sufferings after dis-allowing his claim by Op and has incurred litigation charges. So in addition to above claim the complainant is entitled to Rs.3,000/- towards pain & suffering and Rs.2,000/- towards litigation charges. Hence in all the complainant is entitled Rs.17,800/- from Op. Hence we proceed to pass the following order:

ORDER

            The complaint filed by the complainant is allowed partly with cost.

            Consequently the Op is liable to make payment of Rs.12800+3000+2000=total Rs.17,800/- to complainant with 8% interest from the date of complaint till realization of entire amount, within two months from the date of this order.

Free copy of this order be supplied to all the parties.

(Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 07-10-2015)