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Judgment
Sudip Ahluwalia, Member
The present Revision Petition under Section 21(b) of Consumer Protection Act, 1986 has been filed by Petitioner against the impugned Order dated 09.04.2015 passed by the State Consumer Disputes Redressal Commission, Punjab, in First Appeal No. 19 of 2013 vide which the Appeal filed by the Respondent No. 1/Insurance Company Appeal was allowed.
Brief facts of the case are that the Complainant purchased a Mediclaim Policy bearing No. 360701/34/10/11/00000314 from the Insurance Company for the period from 10.11.2010 to 09.11.2011 and Respondent No. 2/TPA was appointed as Third Party Administrator for verification of the treatments. On 02.02.2011, the Complainant suddenly lost vision in his left eye and he immediately rushed to Dr. Som Nath Singla at Singla Nursing and Eye Hospital, Kotkapura, where he was admitted as an indoor patient on the same day. He was examined by the said Doctor and was diagnosed as suffering from ‘vitreous haemorrhage’ in the left eye. He was further told that some blood clot had affected the vision of the left eye. He was prescribed some medicines and was discharged on 03.02.2011, having spent Rs. 3,880/- during the treatment at Hospital. Thereafter he went to Amritsar on 04.02.2011 for further treatment at Sri Guru Ram Dass Institute of Medical and Research, Amritsar. The Doctors there examined his eyes and informed that the blood clot had badly damaged his left eye, and prescribed certain medicines. He was referred to Dr. Khurana for further treatment; After seeing the Test Reports he was prescribed some more medicines and was advised to re-visit after 15/20 days. He spent Rs. 3,424/- on medicines. On 23.02.2011, when he revisited Amritsar, the Doctors added some more medicines and he had to spend another amount of Rs. 2,925/-. On 28.02.2011, he fell down unconscious and was taken to Dr. Pirthipal Memorial Hospital, Kotkapura, for treatment. He incurred additional expenses of Rs. 1,698/- for medicines. On 01.03.2011, he visited the CMC Hospital, Ludhiana where necessary tests were conducted and medicines were prescribed, and he spent Rs. 21,382/- during the treatment there. On 27.03.2011, he visited Singla Nursing and Eye Hospital for further consultations where he was informed that he needed laser treatment and he spent another amount of Rs. 2,000/-. On 29.03.2011, he visited Dr. Sohan Singh Eye Hospital, Amritsar for further consultation where he was informed that there was no need for laser treatment. However, he was prescribed some medicines which cost him Rs. 2,196/-. On 26.04.2011, he visited GGS Medical College and Hospital, Faridkot where he was advised Homocysteine Test and he spent Rs. 2,377/- on the Test and other medicines. Thus in total, he spent Rs. 40,000/- for the treatment of his left eye and thereafter submitted all the original bills along with necessary documents to the Insurance Company who sent the same for verification to the TPA. Thereafter, he received a letter dated 07.06.2011 from Respondent No. 2/TPA informing him that his claim has been refused. Aggrieved by the act of the Insurance Company and the TPA, he filed Complaint before District Forum, Faridkot.
The District Forum vide its Order dated 23.10.2012 allowed the Complaint. The relevant extracts of the Order of the District Forum are set out as below –
“10. ….So, the main objection of the OP-1 was that the complainant never remained indoor patient during his treatment is not correct and the same is rejected. On 28.02.2011, the complainant became unconscious and fell down and he was admitted at Dr Pirthi Pal Memorial Hospital, Kotkapura for one day. There Dr. Manvir Gupta referred the complainant for further treatment of CMC, Ludhiana. All necessary tests and investigations were done by the Doctor which they think is compulsory for the treatment. So, the complainant remained under the active management of the qualified doctors and eye surgeons.
The complainant has been regularly insured with the OP-1 since long time. So, the main objection of the OP-1 that complainant never remained an indoor patient and he was never under the active management of qualified doctors cannot be accepted due to above mentioned reason. In the present case, complainant remained under the medical treatment of so many doctors at Kotkapura, Amritsar and Ludhiana and the bills submitted by the complainant are quite reasonable so, we direct the OPs to pay to the complainant a sum of Rs. 40,000/- as cost of medical treatment at the rate of 9% interest from the date of filing his complaint and OPs are further directed to pay an amount of Rs. 5,000/- as cost of litigation expenses…”
Aggrieved by the Order of the District Forum, the Insurance Company filed Appeal before the State Commission. The State Commission allowed the Appeal and dismissed the Complaint vide impugned Order dated 09.04.2015. The relevant extracts of the impugned Order are set out as below –
“10. Though in the discharge summary Ex. C-31, Dr. Somnath Singla has certified that the complainant was admitted on 02.02.2011 and discharged on 03.02.2011 for the treatment of Vitreous HGS in his L/E, but there is no written advise by the said doctor for getting the patient admitted in the hospital nor any procedure was carried out during the admission. In fact, no active management of ailment was done, except conducting some laboratory tests. Where after, only medicines were prescribed. The complainant has himself proved on record the OPD Slip No. 101735 dated 2.2.2011 as Ex.C-29, in which it is mentioned that ‘injection Tricosa’ was given and doctor prescribed certain medicines. There is no recommendation for admission of the complainant as indoor patient. It is abundantly clear that the complainant was shown as admitted in the Singla Eye Hospital only to make him eligible for the claim under the policy. As such, complainant was not hospitalized as per condition No. 3,4 for which time limit of 24 hours is not applicable. The complainant has not even pleaded that the obtained the treatment as indoor patient from other hospitals. As such, the same was also not covered as per the policy terms and conditions
In view of the above discussion, the appeal filed by the appellant is allowed and impugned order of the District Forum is set aside. Consequently, the complaint filed by the complainant is dismissed. No order as to costs…
Aggrieved by the Order of the State Commission, the Petitioner filed the present Revision Petition raising the following key issues –
a. That the State Commission ignored the fact that the Clause 3.4 of the said Policy is fully applicable to the facts of the present case;
b. That the State Commission has wrongly held that Dr. Som Nath Singla of Singla Nursing and Eye Hospital has not given the Discharge Summary in proper format. The said Discharge Summary has been produced in the Annexure as Ex-C31 dated 03.02.2011 issued by Dr. Som Nath Singla, which is on the letter pad of the said Hospital. The State Commission has wrongly ignored it;
c. That the State Commission did not look closely into Clause 3.4, which clearly states the illnesses for which the minimum period limit of 24 hours is not considered. “Eye Surgery” comes within the scope of this clause, on account of which, the Order of the State Commission is faulty and thus needs to be struck down;
d.That the State Commission did not go through the Mediclaim Policy thoroughly. As Clause 1.0 of the said Policy mentions the terms, “any insured person shall contract any disease or suffer from any illness”, further also mentions, “as an in-patient”. The present case of the Petitioner fulfils the clause completely as an eye-illness falls under the broad scope of “any illness or disease”, also the Petitioner was admitted before the Singla Nursing and Eye Hospital for a day for the said operation, thus fulfilling the necessary conditions.
Ld. Counsel for Respondent No. 1 has argued that on receipt of the claim of the Petitioner, it was referred to TPA who after thorough probing found that the claim of the Petitioner was outside the scope of the Policy and therefore not payable under the terms and conditions of the Insurance Policy and so vide letter dated 07.06.2011 the same was repudiated; Further, the Complainant had received the entire treatment as an outdoor patient and never remained admitted in the Hospital for one day for active management of his ailment, and so as per the terms and conditions of the Insurance Policy, the claim was not payable; That on 02.02.2011, the Petitioner approached the Singla Hospital for loss of his vision in the left eye where he was examined by Dr. Som Nath Singla. There, the Petitioner was subjected to certain medical tests, investigations and some other blood tests from Dr. Archna Gupta, Diagnostic Centre, Kotkapura. The said Doctor diagnosed that the Petitioner has suffered from vitreous haemorrhage in the left eye and some blood clot has affected the left eye. The Petitioner was administered some medicines for treatment and was discharged on 03.02.2011. Thus, the admission of the Petitioner was purely for diagnostic purposes and no treatment was given during the said admission; That the Petitioner was not hospitalized as per Clause 3.4 of the Policy and the ailment ‘vitreous haemorrhage’ is not included in the list of ailments mentioned in Clause 3.4 of Policy, for which time limit of 24 hours is not applicable.
This Commission has heard both the Ld. Counsel of the Petitioner and the Respondent; Perused the material available on record.
Copy of the Mediclaim Policy is on record as filed on behalf of the Respondent/Insurance Company. Perusal of Clause 1.0 of the same goes to show that its coverage extends to incurring “Hospitalization Expenses (herein defined) for medical/surgical treatment at a Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL/NURSING HOME/ DAY CARE CENTRE) as an in-patient, the Company will pay to the Hospital/ Nursing Home/ Day Care Centre or reimburse the insured person,…….” In addition, according to Clause 2.6, the Insured is also entitled to “Post hospitalization medical charges up to 60 days period immediately after the insured’s discharge from the hospital for that illness or injury.”
In the present case, however, the Petitioner/Complainant had claimed to have been admitted as an Indoor Patient in “Singla Nursing Home and Eye Hospital, Kotkapura” as mentioned in Para 2 of his original complaint. He was diagnosed to be suffering from “Vitreous Hemorrhage in the left eye”, was prescribed some medicines and discharged on the next day. It was nowhere his case that he had undergone any actual surgery or surgical procedure during such “Hospitalization”.
Now, according to Clause 3.4 of the concerned Mediclaim Policy-
“HOSPITALISATION means admission in any Hospital/Nursing Home in India upon the written advice of a Medical Practitioner for a minimum period of 24 consecutive hours. The time limit of 24 hours will not be applicable for following surgeries/procedures.”
Consequently, “written advise of a Medical Practitioner” is a sine qua non to constitute “Hospitalisation” as defined in the aforesaid Clause. But no such written advise was actually given by any Medical Practitioner before allegedly admitting the Petitioner/Complainant in Singla Nursing and Eye Hospital, Kotkapura, on 2.2.2011. The Ld. State Commission therefore was right in concluding that in the absence of any such written advice, and the fact that even the Discharge Summary of the Complainant was not in the proper format normally used by Hospitals and Nursing Homes in case of indoor patients, and it did not even explain what treatment was given during such hospitalisation and what procedure, if any, was conducted upon the Complainant on account of which, “It is abundantly clear that the Complainant was shown admitted in the Singla Nursing and Eye Hospital, Kotkapura, only to make him eligible for the claim under the Policy.”
Needless to mention, it is well settled that a contract of Insurance is to be honoured strictly in terms of the conditions specified in the Policy without making any alteration in the words used therein. When written advise by a Medical Practitioner was necessary to constitute Hospitalisation in terms of the specific Clause 3.4 of the Policy, failure to secure such written advise prior to the admission would consequently have the effect of exempting the Insurance Company from any liability to satisfy the Insurance claim.
Rest of the Complainant’s treatment during the following days was admittedly as an “Outdoor Patient” which was palpably outside the scope of insurance coverage except in the situation where he would have had to incur any “Hospitalization Expenses” for medical/surgical treatment.
For the aforesaid reasons, this Commission finds no grounds to interfere with the well-reasoned order passed by the Ld. State Commission. The Revision Petition is therefore dismissed. Parties to bear their own costs.
Pending application(s), if any, also stand disposed off as having been rendered infructuous.