SMT. RAVI SUSHA: PRESIDENT

Complainant filed this consumer complaint U/S 12 of Consumer Protection Act 1986 against OP seeking to get an order directing OP to reimburse the balance amount of Rs.12,645/- with Rs.25,000/- towards compensation

            Facts of the case are that the complainant had purchased a Janatha Medi claim policy from the 1^st OP.  Policy period is from 28/03/2017 to 27/03/2018.  2^nd OP is the third party Administrator of the 1^st OP.  Complainant sustained injuries on his face on 20/08/2017  So had taken to Anamaya Medical Institute, Payannur as OP and then on that day itself he was referred to Medical college hospital, Pariyarm  due to the seriousness of injury and taken treatment as IP from 20/08/2017 to 25/08/2017.  Due to the fracture of the bone on face surgery was done at MCH Pariyaram.  He had incurred Rs.29,660/- as total Medical expense including room rent, treatment surgery and for medicine.  So he preferred a claim of Rs.29,660/- before the Insurance company with medical bill and other records.  Insurance company made reimbursement Rs.17,015/-  with explanation that the balance amount was not covered under the Insurance policy purchased by the complainant.  So complainant filed this complaint.

            After receiving notice 1^st OP Insurance company filed written version admitted the policy of complainant.  Contention of OP is that 2^nd OP is the 3^rd party administrators to process Health Insurance claims arising out of medi-claim policies issued by 1^st OP.  It is further submitted that though the complainant preferred a claim of Rs.29,650/-, OP  had approved an amount of Rs.17,015 after deducting non-medical expenses and also applying sub limits as per the policy.  It is also stated that the amount of Rs.17,015/-has been finally approved to the complainant after taking into account the sublimit specified for minor surgeries and also deducting Non-medical amount as per terms and conditions No.2(10) of the policy.  According to OP complainant is not entitled to get any further amount than Rs.17,015 and there is no deficiency in service on their part.

            The learned counsel OP NO.1 and the learned counsel for complainant filed written argument note.  We have considered the evidence and submissions of both parties and perused the record brought before us.

            The learned counsel for OOP submits that the amount paid to the complainant is the maximum amount under the policy conditions 2(10) by applying sub limits.  OP’s version is that the surgery conducted on the complainant was a minor one so, he is eligible to get claim benefit   as per condition No.2.10 for minor surgery.

            Complainant contended that he had undergone major surgery on his face due to broken of bone on the face.  For proving the injury and treatment complainant had produced wound certificate from Anamaya Medical Institute (A2), outpatient card Ext.A1 and discharge summary from MCH Pariyaram.  On going through  wound certificate and OP card of Anamaya Medical Institute, it is revealed that c/o swelling over ® edge, bleeding from nose since the incident., foreign body sensation in ® eye and pain over ® check and Teenderness+ in ® ihaxillary region.  The patient was then referred to higher centre MCH  Pariyaram for detailed evaluation and management. Further Ext.A4 is the discharge card from MCH Pariyaram which shows that the patient was aged 64 years admitted on 20/08/2017 and discharged on 25/08/2017.  The diagnosis was  “Right Zygoma TIC complex Fracture and Fracture of Anterior and Lateral wall of Maxilla, Hea MOsinus IRT Right Maxillary Sinus.  Treatment don was Right Zygoma TIC complex elevation done through through Gillies.  Temporal approach under General Anastasia.

            As far as the policy conditions in the Janata Medi claim policy, condition No.1 says that any insured person who renewed policy shall contract any disease or sustain any bodily injury through accident and if such injury shall require up on the advise of qualified physician or Medical surgeon to incur hospitalization Expenses for Medical/surgical treatment at Hospital, as an impatient company will pay to the hospital or reimburse the insured person the expenses that are necessary incurred in the treatment of such injury as 2.0 cost of treatment taken in the hospital 2.2 surgeon, Anesthetist Medical practitioner, consultant/ specialist  2.3 Anesthesia operation theatre charges, medicines and drugs, Diagnostic test/Relevant Laboratory test, x-ray etc.

            So as far as policy condition 1.0,2.0,2.1,2.2,2.3 are concerned the expenses which have been enumerated in this conditions are not required to be given narrow meaning.  Further from the Medical records Ext.A4 discharge summary, the surgery conducted on the patient comes under the category of major surgery due to fracture of bone on the face.  Here OP failed to substantiate their contention that there was only minor surgery was done on the patient, by examining medical experts or treated doctor.  In view of the aforesaid facts, the list given in sub-clause major surgery are required to be considered for calculating treatment expenses.

            Therefore, after taking into consideration the terms of the policy, we are of the view that complainant is entitled to get the entire treatment expenses incurred to him including major surgery expenses. Here complainant has claimed Rs.29660/- as treatment expenses incurred to him and OPs reimbursed only Rs.17,015/-.  So the balance amount Rs.12,645/- is required to be reimbursed by the Insurance company under the terms of the policy.

            In the result complaint is allowed in part.  Opposite parties 1 and 2 are directed to pay Rs.12,645/- to the complainant and also directed to pay Rs.10,000/- as compensation for causing mental agony to the complainant aged 64 years.  OPs shall comply the order within one month from the date of receipt of this order.  Failing which the amount Rs.12,645/- carries interest @12% per annum from the date of order till realization.  Complainant can realize the awarded amount from OPs by filing execution application against them as per the provision of Consumer Protection Act 2019.

Exts.

A1       - Copy of OP record issued by Anamaya Medical Institute dated 20/08/2017

A2       - Copy of wound certificate issued by Anamaya Medical Institute dated 20/08/2017

A3       - Photo copy of cash bill dated 20/08/2017

A4       - Copy of discharge card issued by Pariyaram Medical College dated 25/08/2017

A5       Photo copy of medical bills issued by Pariyaram Medical College

A6       - Copy of Railway ticket (7 Numbers)

A7       - Insurance Policy issued by New India  Insurance Company Ltd.

A8       - Reimbursement claim approval letter dated 19/10/2017

A9       - Medi-claim computation sheet.

B1       - Policy

Pw1    - Complainant

Dw1    - Suresh Babu R

      Sd/                                                                          Sd/                                                     Sd/

PRESIDENT                                                                   MEMBER                                                   MEMBER

Ravi Susha                                                               Molykutty Mathew                                     Sajeesh K.P

(mnp)

/Forward by order/

                                                          Assistant Registrar