DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOZHIKODE
PRESENT : Sri. P.C. PAULACHEN, M.Com, LLB : PRESIDENT
Smt. PRIYA.S, BAL, LLB, MBA (HRM) : MEMBER
Sri.V. BALAKRISHNAN, M Tech, MBA, LL.B, FIE: MEMBER
Thursday the 20th day of October 2022
C.C. 601/2013
Complainant
K. Fathima,
W/o V. Veeran,
Mangalthaliyil House,
Feroke amsom and Nallur desom,
Kozhikode Taluk and District.
(By Adv. Sri. K. K. Krishna Kumar)
Opposite Party
United India Insurance Company Limited,
Divisional Office No.II, PB. No. 192,
Seema Tower, Mavoor Road,
Kozhikode – 673 001.
(By Adv. Sri. T.V. Hari)
ORDER
By Sri. P.C. PAULACHEN – PRESIDENT.
This is a complaint filed under Section 12 of the Consumer Protection Act, 1986.
2. The case of the complainant, in brief, is as follows:
The complainant had availed a Health Insurance Policy of the opposite party. The policy covered the time period of 15/06/2011 to 14/06/2012. The policy was availed through Third Party Administrator (TPA) engaged by the opposite party to provide the health services. It was assured that the hospitalisation of the insured for a minimum period of 24 hours upon written advice of a medical practitioner would make him entitled to claim the expenses of hospitalisation undergone. The complainant, who is a senior citizen, has been availing the mediclaim/health policy offered by the opposite party since 2000. During the second week of April 2012, the complainant had difficulty in walking and low back pain. She was advised to be hospitalized by the medial practitioners at Baby Memorial Hospital, Kozhikode. She was diagnosed LUMBAR SPONDYLOSIS along with other life style diseases. She was admitted in the hospital for conducting physiotherapy and other treatments. It was diagnosed that she was experiencing pain due to disk bulges. She was admitted on 16/04/2012 and discharged on 20/04/2012 with advice to continue medication.
3. She had incurred an expense of Rs. 32,295 in the hospital for treatment. She preferred a claim on 20/04/2012 along with necessary documents. She submitted her claim for medical expenses to the third party administrator namely Paramount Health Services. But on 13/07/2012 the complainant was informed by the opposite party that their third party administrator had informed that the treatment availed by the complainant did not necessitate hospitalization and hence the claim was not admissible. On 20/12/2012 the complainant sent a detailed letter to the Grievance Cell. They sent a written response expressing their inability to entertain the claim. There is no legal justification in denying the claim. She is entitled to full claim. There was negligence and deficiency of service on the part of the opposite party which caused inconvenience and hardship to her. Hence the complaint to direct the opposite party to pay the claim along with compensation of Rs. 25,000/-.
4. The opposite party resisted the complaint by filing written version. According to the opposite party, the complaint has been filed vexatiously for getting unlawful enrichment. The policy is subject to terms, conditions, exclusions and definitions. The hospitalisation of the complainant comes within the exclusion clause 4.11 and the claim was validly repudiated as per the terms and conditions of the policy. The claim also falls within the exclusion clause 4.9. The opposite party has not caused any mental agony or suffering to the complainant at any point of time. The opposite party has not committed any deficiency in service. The relief sought for is not allowable. With the above contentions, the opposite party prays for dismissal of the complaint.
5. The points that arise for determination in this complaint are;
(1). whether there was any deficiency of service on the part of the opposite party, as alleged?
(2). Reliefs and costs.
6. Evidence in this complaint was recorded by our learned predecessors – in-office. The complainant has filed proof affidavit in terms of the averments in the complaint and in support of the claim. The opposite party has filed counter affidavit. CW1 and PW1 were examined. Exts A1 to A5 were marked on the side of the complainant. Ext B1 was marked on the side of the opposite party. The case sheet of the complainant produced from the Baby Memorial Hospital, Kozhikode was marked as Ext C1.
7. Heard.
8. Point No.1 : The complainant, who is a senior citizen, has approached this Commission with a grievance that the claim put in by her in connection with her treatment was repudiated by the opposite party without any valid reason.
9. The complainant is the holder of Ext A1 Individual Health Insurance Policy – 2010 issued by the opposite party. The period of insurance was from 15/06/2011 to 14/06/2012. The sum insured is 3,75,000/-. The policy is admitted by the opposite party. On 16/04/2012 the insured was admitted in Baby Memorial Hospital, Kozhikode with the history of difficulty in walking and to get up from squatting position. She was diagnosed Lumbar spondylosis, morbid obesity, type II diabetes mellitus, hyper tension and coronary artery disease. She was admitted for physiotherapy. She was discharged on 20/04/2012. Ext A2 is the copy of the discharge summary. The medical and treatment expenses amounted to Rs. 32,295/-. She preferred a claim before the insurer with necessary documents. The claim was repudiated as per Ext A3 letter dated 13/07/2012 for the reason that treatment availed did not necessitate hospitalization and consequent expenses are primarily for investigation and evaluation purpose. Thereafter she approached the Grievance Cell of the opposite party as per Ext- A4 letter dated 20/12/2012. They also expressed their inability to entertain the claim as per Ext A5 letter dated 15/03/2013. There is no serious dispute on the above aspects.
10. Ext A3 shows that the claim was repudiated for the reason that the treatment did not necessitate hospitalization and consequent expenses are primarily for investigation and evaluation purpose. Exclusion clause 4.9 in Ext A1 provides that convalescence, general debility, run down condition or rest cure, obesity treatment and its complications including morbid obesity, congenial external disease /defects or anomalies, treatment relating to psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, intentional self-injury and use of intoxication drugs/alcohol are excluded. In the written version it is averred that the hospitalization of the complainant comes within the exclusion clause 4.11 of Ext A1. Exclusion clause 4.11 reads as follows. “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 presents of any ailment, sickness or injury, for which confinement is required at a hospital/ nursing home”.
11. In this context, it is worthwhile to have a glance at the evidence tendered by PW1 and CW1. PW1 is the doctor who treated the insured in Baby Memorial Hospital, Kozhikode and Ext C1 is the case sheet. PW1 has categorically deposed that the insured was admitted in the hospital since she had acute back pain and difficulty in walking. The reason for backache was Lumbar spondylosis and in some cases it may be necessary to admit the patient for conducting physiotherapy. PW1 has stated that the diagnosis was after necessary tests. CW1 is the Associate Professor and HOD in charge of the Orthopaedics Department, Govt. Medical College, Kozhikode. CW1 has opined that the tests conducted were necessary since it was a case of Lumbar Spondylosis. CW1 has further opined that physiotherapy is advised for some patients with spondylosis and in some cases admission would be necessary. Eventhough PW1 and CW1 were cross-examined at length, nothing has been brought out to discredit their version. Their evidence clearly establishes that the tests and admission were absolutely necessary in the case of the complainant herein.
12. It is for the treating doctor to decide whether a patient should be admitted or not and that what all investigations/ tests are to be conducted. The opposite party cannot dictate that for a particular treatment, the patient should not be admitted in the hospital. It is the doctor who is aware of the patient’s condition and decide whether he should be treated as an inpatient or outpatient. It was only upon the advice of the doctor that the insured was admitted for necessary treatment for acute back pain she was undergoing. If the condition of the patient did not warrant admission, normally the doctor would not have advised admission. The hospitalization of the insured was on the advice of a qualified doctor and not out of her own accord. The complainant was diagnosed of having the specific condition named Lumbar Spondylosis and due to that complication she had severe low back pain and difficulty in walking. She was admitted and treated for that. She was not admitted for treatment for lifestyle diseases. So exclusion 4.9 is not attracted. Exclusion 4.11 is also not applicable in view of the diagnosis and the treatment undergone and also in the light of the evidence tendered by PW1 and CW1. The complainant was diagnosed of a condition which is as such not excluded and was treated for the same and after recovery from the same, she was discharged with advice to continue medication. Therefore, we are of the view that the repudiation of the claim by the opposite party only upon the advice of Third Party Administrator (TPA) that the said condition of the complainant did not require hospitalization and the expenses are primarily for investigation and evaluation purpose is totally unjustified.
13. From the above discussion, what emerges is that the claim was wrongly repudiated by the insurance company. The conduct and attitude of the opposite party in wrongly repudiating the claim and thereby denying the legitimate claim amount to gross deficiency of service. The complainant is entitled to get the claim amount. It goes without saying that the act of the opposite party has caused mental agony and hardship to the complainant, who is a senior citizen. She is entitled to be compensated adequately. The claim for compensation is Rs.25,000/-. The claim appears to be a bit excessive. However, she is entitled to get a reasonable amount as compensation. Considering the entire facts and circumstances, we are of the view that a sum of Rs. 5000/- will be reasonable compensation in this case. She is also entitled to get Rs. 5000/- as cost of the proceedings.
14. Point No.2: In the light of the finding on the above point, the complaint is disposed of as follows;
a) CC- 601/2013 is allowed in part.
b) The opposite party is hereby directed to pay the complainant the claim amount of Rs. 32,295/- (Rupees thirty two thousand two hundred and ninety five only) with interest at the rate of 6%p.a from the date of complaint ie 18/12/2013 till actual payment.
c) The opposite party is directed to pay a sum of Rs. 5000/- (Rupees five thousand only) to the complainant as compensation for mental agony and hardship suffered.
d) The opposite party is directed to pay a sum of Rs. 5000/- (Rupees five thousand only) as cost of proceedings to the complainant.
e) The order shall be complied with within 30 days of the receipt of copy of this order.
Pronounced in open Commission on this, the 20th day of October, 2022.
Date of Filing: 18/12/2013.
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PRESIDENT
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MEMBER
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MEMBER
APPENDIX
Exhibits for the Complainant :
Ext. A1 – Individual Health Insurance Policy – 2010 issued by the opposite party.
Ext. A2 – Copy of the discharge summary.
Ext. A3 – Letter dated 13/07/2012.
Ext. A4 - Letter dated 20/12/2012.
Ext. A5 - Letter dated 15/03/2013.
Exhibits for the Opposite Party
Ext. B1 – Individual Health Insurance policy - 2010.
Witnesses for the Complainant
PW1 – Dr. Mohan Leslie Noone MD, DM (Neuro).
Witnesses for the opposite parties
Nil.
Commission witness
CW1 – Dr. Rajesh Purushothaman
Commission Exhibits
Ext. C1 - Case sheet of the complainant produced from the Baby Memorial Hospital,
Kozhikode.
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PRESIDENT
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MEMBER
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MEMBER
Forwarded/By Order
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Assistant Registrar
