United India Insurance Co. Ltd vs Rajesh Katiyar

V.K.Jain, J.

This is a very old revision petition which was dismissed for non-prosecution on 19.10.2005 but was restored vide order dated 04.06.2018. The revision petition is directed against the order of the State Commission dated 24.03.2004 whereby the petitioner was directed to pay a sum of Rs.80,000/- to the complainant alongwith interest @ 6% per annum.

The complainant/respondent obtained a medi-claim policy from the petitioner for Rs.1,00,000/- for the period from 25.05.1998 to 24.05.1999 and got the same renewed for the period from 25.05.1999 to 24.05.2000. He allegedly suffered with Jaundice and got admitted in Suyash Hospital, Bhopal, where he was treated under one Dr. Manish Jain. He submitted a claim for re-imbursement to the extent of Rs.88,526.88p. On receipt of the claim, a Surveyor was appointed to scrutinize the same. The surveyor inter-alia reported that the claim was not admissible since Suyash Hospital was not a 15 bedded hospital as was required for re-imbursement under the mediclaim policy and the complainant had taken treatment as a day care patient and not as an indoor patient. The claim was therefore, repudiated vide letter dated 09.02.2001 which to the extent it is relevant, reads as under:

"After perusal of your medi-claim application form dated 12.08.99 and treatment papers produced by you, I am informing you as under:-

That, you have submitted a mediclaim on dated 12.08.99 against your mediclaim insurance policy alongwith treatment papers.

That, as per the discharge summary which is produced by you of Suyash Hospital Jehangirabad Bhopal you were hospitalized from 10.7.99 to 12.7.99 for the treatment of Jaundice off and on but according to hospitalization records of the Suyash Hospital and statement of Dr. Manish Jain, you were taking treatment under the supervision of Dr. Manish Jain.On 10.7.99 you were a day-care patient in the said hospital and not be admitted as regular patient in Suyash Hospital Jehangirabad, Bhopal from 10.7.99 to 12.7.99.And as per the mediclaim insurance policy terms and conditions "insurance should be hospitalized for a minimum period of 24 hours.

That, as per the statements of Dr. Manish Jain, Suyash Hospital having total no. of beds is only 13 but as per the terms and conditions of the mediclaim insurance policy the hospital should have at least 15 in-patient beds.

In view of the above facts, your mediclaim application dated 12.8.99 does not fall within the purvies of the terms and conditions of mediclaim insurance policy which was obtained by you. So your mediclaim application dated 12.8.99 is not maintainable and it is rejected as "NO CLAIM".

Being aggrieved from the rejection of the claim, the complainant approached the concerned District Forum by way of a Consumer Complaint. The complaint was resisted by the petitioner primarily on the grounds on which the claim had been repudiated.

The District Forum having dismissed the complaint, the complainant approached the concerned State Commission by way of an appeal. Vide impugned order dated 24.03.2004, the State Commission partly allowed the appeal by directing payment of Rs.80,000/- to the complainant alongwith interest, on the ground that though Suyash Hospital was not a 15 bedded hospital as was required under the policy and the complainant had failed to prove hospitalization for at least 24 hours, the cost of the medicines should be paid to him, the cost of medicines was Rs.87,230/-. After deducting Rs.20,000/- under the head 'Hospitalization', the State Commission directed payment of the balance amount of Rs.80,000/-.

Though the medi-claim policy issued to the complainant has not been filed, the petitioner has placed on record a Standard Hospitalization and Domiciliary Hospitalization Benefit Policy and its counsel submits that the policy issued to the complainant was identical to the aforesaid standard policy. The standard policy, obligated the petitioner to re-imburse the policy holder in respect of Hospitalization/ Domiciliary Hospitalization expenses for illness or disease or injuries sustained. Under the policy, the hospital/nursing home was defined to mean an institution having at least 15 in-patient beds. It has come in the report of the surveyor and the statement of Dr. Manish Jain, supplied today in the Court, that Suyash Hospital was a 13 bedded hospital and not a 15 or more bedded hospital. Therefore, the complainant was not entitled to any re-imbursement in respect of the treatment taken in the aforesaid hospital.

Moreover, there is no evidence of the complainant having been admitted in the aforesaid hospital for at least 24 hours. The statement of Dr. Manish Jain obtained by the surveyor would show that after discharge on 06.05.1999, the complainant came out infected with HBV Chronic Liver Disease and therefore, the Interferon Therapy was started on him for a period of four months from 10.07.1999. The certificate of Dr. Manish Jain also shows that since the said therapy has a very incidence of side-effects, the complainant was kept under observation as a day-care patient on first and second day of injections. The complainant therefore, did not get admitted as an indoor patient while taking Interferon Therapy and was given the said therapy as a day-care patient. Therefore, he was not entitled to re-imbursement of the treatment taken during the aforesaid period, the said treatment having not been taken as an indoor patient.

Though the standard policy filed by the petitioner also provides for Domiciliary Hospitalization Benefit, there is no evidence of the said benefit being available to the complainant. The conditions for Domiciliary Hospitalization Benefit, as given in the insurance policy are as under:

DOMICILIARY HOSPITALISATION BENEFIT means:

Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing home but actually taken whilst confined at home in India under any of the following circumstances namely:-

The condition of the patient is such that he/she cannot be removed to the hospital/nursing home or

The patient cannot be removed to the hospital/nursing home for lack of accommodation therein.

Subject however that domiciliary hospitalization benefits shall not cover:-

expenses incurred for pre and post hospital treatment and

expenses incurred for treatment for any of the following diseases

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Chronic Nephritis and Nephritic Syndrome

Diarrhoea and all type of Dysenteries including Gastro-enteritis

Diabetes Mellitus and Insipidus

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Influenza, Cough and Cold

All Psychiatric or Psychosomatic Disorders

Pyrexia of unknown Origin for less than 10 days

Tonsillitis and Upper Respiratory Tract Infection includingLaryngitis and Pharingitis

Arthritis, Gout and Rheumatism

Since there is not even an allegation that the condition of the complainant was such that he could not be removed to hospital for lack of accommodation, he is not entitled to any re-imbursement even under the Domiciliary Hospitalization Benefit of the policy.

The State Commission despite having held that the hospital was not a 15 bedded hospital and that the complainant was not admitted to the said hospital for 24 hours or more, proceeded to direct re-imbursement of the cost of medicines. The aforesaid direction of the State Commission is faulty since the cost of the medicines could have been paid only in case of hospitalization of the patient for at least 24 hours or in case he was covered under the Domiciliary Hospitalization Benefit of the medi-claim policy.

For the reasons stated hereinabove, the impugned order is set aside and the complaint is consequently dismissed with no order as to costs. The revision petition stands disposed of.