State Consumer Disputes Redressal Commission
V.N.Dixit vs Vipul Medi Corporation on 11 October, 2018
Daily Order M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO. 1886 OF 2012 (Arising out of order dated 16.08.2012 passed in C. C. No. 266/2010 by District Forum, Indore) V. N. DIXIT, S/O LATE SHRI NARMADA PRASAD DIXIT, R/O 26, GREATER TIRUPATI COLONY, INDORE (M.P.) .... APPELLANT. Versus 1. VIPUL MEDI CORPORATION, TPA PRIVATE LTD. 306, THIRD FLOOR, SHRIVARDHAN COMPLEX, RNT MARG, INDORE (M.P.) 2. THE ORIENTAL INSURANCE CO.LTD, RATLAM KOTHI, GEETA BHAWAN CHOURAHA, INDORE (M.P.). .... RESPONDENTS. BEFORE : HON'BLE SHRI S. D. AGARWAL : PRESIDING MEMBER
HON'BLE DR. (MRS) MONIKA MALIK : MEMBER COUNSEL FOR PARTIES : Shri Rajesh Yadav, learned counsel for the appellant.
None for the respondent no.1 though service is presumed and despite intimation through SPC.
Shri Kartikeya Tiwari, learned counsel for respondent no.2.
O R D E R (Passed On 11.10.2018) The following order of the Commission was delivered by Dr. (Mrs) Monika Malik, Member:
This appeal is by the complainant/appellant, against the order dated 16.08.2012 passed by the District Consumer Disputes Redressal Forum, Indore in C.C.No. 266/2010, whereby the complaint filed by him, has been dismissed.
2. Briefly put, the case of the complainant is such that the complainant had obtained a mediclaim policy for himself and his wife from the opposite party no.2/respondent no.2. During the currency of the policy for the period from 10.09.2008 to 09.09.2009, the complainant and his wife got admitted in Kottakkal Arya Vaidyasala, Ayurvedic Hospital & Research Centre, Kottakkal, Kerala for treatment and had filed a claim with the opposite parties, which they disallowed. However, the opposite parties had earlier allowed the claim which was filed by him in the year 2004, for similar treatment. Further, the opposite parties did not give any mention of his wife's claim in their repudiation letter, in which they denied -2- the complainant's claim. The complainant therefore, filed a complaint before the District Forum, alleging deficiency in service on the part of the opposite parties.
3. The opposite parties resisted the complaint on the ground that the complainant's claim was repudiated on the basis of clause 2.3, 4.2 and 4.8 of the mediclaim policy. The Ayurvedic Centre, where the complainant was treated does not fall under the category of hospital, as referred in the policy schedule. Furthermore, the complainant received treatment for general debility condition, and there was no need for hospitalization for a period of 30 days. Moreover, the complainant had filed only one claim with them and the opposite parties did not receive his wife's claim.
4. Learned District Forum held that the complainant has not been able to establish that he was suffering from a condition, which requires hospitalization for a period of 30 days. It is held that out of the 3 illnesses, none appears as a serious ailnment which would require admission in the hospital for 30 days. No evidence has been put forward by the complainant that the hospital in which he was treated, falls in the category in the network hospitals of the opposite parties. There is no proof of illness of the complainant's wife, for which she had received treatment. The District Forum dismissed the complaint. Hence this appeal.
5. Heard learned counsels for appellant and respondent no.2. None appeared for the respondent no.1. Perused the record.
6. Learned counsel for complainant/appellant argued that complainant/appellant is insured under the opposite parties' policy since last 20 years. It is argued that the complainant along with his wife was admitted in Kottakkal Arya Vaidyasala, Ayurvedic Hospital & Research Centre, Kottakkal, Kerala for treatment of Vatha Vyadhi, regarding which they both had informed the opposite party no.1/respondent no.1. The treatment expenses for the complainant and his wife were Rs.46,659/- and Rs.48,143/- respectively. The complainant/appellant was diagnosed with stiffness of right foot, occasional jerking of hands and less memory, however, the opposite party/respondent rejected the claim on the basis that the complainant/appellant received treatment for less memory (considering it as general debility condition), whereas as apparent, the complainant/appellant was treated for 2 other conditions as well. Moreover, there is no mention of condition no. 4.24 in the policy schedule, which has been referred to in the repudiation letter issued by the opposite party -3- no.1/respondent no.1. He argued that the claim filed earlier for same treatment was paid by another TPA-Paramount Health Services. Moreover, Naturopathy treatment falls under the exclusion clause of the policy schedule but the complainant had taken Ayurvedic treatment which is not excluded from the policy cover. He also referred that the hospital is a recognized hospital for treatment of Central Government Employees. The policy conditions- clause 2.3, 4.2 and 4.8 referred by the opposite party no.2 in their repudiation letter are not applicable in the instant matter. It is further argued that the claim of his wife has not even been considered by the opposite party no.1/respondent no.1.
7. Learned counsel for opposite party no.2 argued that the complainant's/appellant's claim was repudiated because Ayurvedic treatment does not fall within the scope of the policy. The complainant/appellant was not suffering from any serious illness. He was admitted in the hospital only to improve/enhance his health condition. Further the concerned hospital does not fall under the category of hospital, as referred to in the policy schedule and is not in list of network hospitals of the opposite parties/respondents. The complainant/appellant obtained treatment for general debility due to which his claim is not payable. The complainant's/appellant's claim was repudiated on the basis of clause 2.3, 4.2 & 4.8 of the policy schedule. The complainant/appellant did not lodge his wife's claim with the opposite parties/respondents and therefore her claim was not considered. Further, no discharge summary of the complainant's wife has been placed on record by him, which could be the evidence of her illness and the treatment received by her.
8. The repudiation letter mentions that the complainant's/appellant's claim is not payable because there was no acute indication for admission and he was admitted for an age related illness and general debility condition. We do not find there two reasons adequate enough, to be ground for repudiation. The patient requires to get admitted in the hospital or not can be decided by the treating doctor only and the loss of memory (referred to as age related illness) is not always necessarily age related. It cannot be ignored that the complainant/appellant had complaints of stiffness of foot and occasional jerking of hands too besides loss of memory. The opposite parties/respondents have taken another ground that, the Ayurvedic treatment expenses are not covered under the policy schedule. We observe that, Hospital/Nursing Home (as defined in the policy schedule) is an institution which is under the supervision of a registered and qualified Medical Practitioner (a person -4- who holds a degree/diploma of a recognized institution and is registered by Medical Council of any State of India). Therefore, since the treatment was sought by the complainant/appellant in the Ayurvedic Hospital, his claim is not payable, on this very basis.
9. As regards the complainant's wife claim, we observe that there is no discharge summary/certificate on record, which could indicate the treatment received by her. The complainant/appellant has placed on record, the payment voucher given to him by the insurance company in the year 2004. There is no specific mention of the treatment covered by this payment voucher. The opposite parties/respondents cannot be held accountable on this basis only for not paying the claim now which as per the complainant/appellant was earlier allowed by them, since there is no substantial evidence.
10. Therefore, to summarize the entire matter, we reach a conclusion that the complainant's claim was not payable for the reasons stated as aforesaid. This appeal is therefore dismissed. However, no order as to costs of this appeal.
(S. D. AGARWAL) (DR. MRS MONIKA MALIK) PRESIDING MEMBER MEMBER