Oriental Insurance Co. Ltd. vs Mahendra Kumar Saraf

THIS appeal is directed against the order dated 3.1.2000 passed in Case No. 185-A/99 by the District Consumer Disputes Redressal Forum, Durg ((for short the ''District Forum'').

FACTS giving rise to this appeal are thus : The respondent obtained Mediclaim (Hospitalisation and Domiciliary Hospitalisation Benefit) Policy No. 48/99/00110 dated 12.5.1998 covering the period from 13.5.1998 to 12.5.1999. The respondent had gone with his wife and other family members for a holiday trip to Chennai where he suffered from Hematuria/(passing of blood in urine) and Strangurie/(painful micturation) with fever and vomiting. He approached Apollo Hospital for diagnosis and treatment by expert Urologist of Apollo Hospital Dr. S. Duraiswamy M.S. M.Ch. (Uro) Consultant Urologist who advised for investigations under observation for administering the treatmnet. Investigations of blood Biochemistry, Microbiology, Radio Imaging Techniques and E.C.G. were done on 6.10.1998. As the condition was not improving, he was advised for special endoscopic procedure (Cystoscopy and Biopsy) under General Anaesthesia and for that he remained in hospital from 9 a.m. to 6 p.m. The Biopsy report was also not conclusive. He was also advised 4-5 days admission for further observation investigation and treatment. According to the respondent no bed was available, hence he was advised for domiciliary treatment as he was accompanied by his wife who is a Doctor who administered treatment as directed by Urologist Dr. Duraiswamy. Thereafter Dr. Duraiswamy advised to take further treatment at Durg under guidance of senior consultant. The respondent and his wife came back from Chennai on 16.10.1998, at Durg where respondent was examined by Dr. P.N. Vijayvargiya on 17.10.1998. The treatment as advised by Urologist continued by Dr. P.N. Vijayvargiya at the residence of the respondent till 29.11.1998, who granted medical fitness certificate on 30.11.1998. The mediclaim of Rs. 13,937.94 was lodged on 2.12.1998. The admission slip registration No. 593037 of Apollo Hospital, reports, receipts and cash memo prescription of Apollo Hospital were sent to Insurance Company on 26.3.1999. The Insurance Company disallowed the claim as respondent was treated as an outdoor patient. The respondent filed a complaint to claim the amount of Rs. 13,937.94 paise of the expenses incurred with its interest of Rs. 4,500/- and Rs. 1,50,000/- for mental pain and sufferings, Rs. 500/- miscellaneous expenses in all Rs. 1,68,937.94 paise. The complaint was resisted. The District Forum held that non-payment of the claim was not justified as respondent for lack of accommodation (Bed) in hospital took treatment at home with the approval of attending Medical Practitioner and thereafter with the approval of Dr. P.N. Vijayavargiya at Durg, hence, ordered to pay Rs. 13,937.94 paise with interest thereon at the rate of 18% p.a. from 17.5.1999 and Rs. 4,500/- of interest till the date of filing of the complaint, Rs. 2,000/- as compensation for mental pain and inconvenience and Rs. 200/- as costs of the proceedings.

Having heard learned Counsel for parties and on reappraisal of evidence on record we are of the opinion that for the lack of accommodation and with the approval of attending Medical Practitioner of Apollo Hospital, the respondent was advised to continue treatment at home at Chennai. He remained in hospital on 12.10.1998 throughout the day under observation when Cystoscopy and Biopsy under General Anaesthesis was performed as bed was not available inspite of admission card as Dr. S. Duraiswamy advised for admission as indoor patient of probable stay of 4 days for observation and treatment. The respondent and his wife Dr. (Mrs.) Urmila Saraf by their affidavits have asserted that the respondent could not be admitted due to non-availability of accommodation, hence, the respondent was treated at home during the period of stay at Chennai with the approval of attending Medical Practitioner and the treatment was administered under advice by respondent''s wife. On return to Durg on the advice of Dr. S. Duraiswamy, respondent was treated at home by senior consultant Dr. P.N. Vijayvargiya which is also amply proved.

THE Insurance Company did not allow the claim in view of 1.3 of definitions. It would be appropriate to reproduce definition from 1.1 to 1.3. 1.0 Definitions 1.1 Hospital/Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner. 1.1.1 THE term "Hospital"shall not include an establishment which is a place of rest a place for the aged a place for drug addicts or place of alcoholics, a hotel or a similar place. 1.2 Surgical Operation Means-Manual and operative procedures for correction of deformities and defects, repairs of injuries diagnosis and cure of diseases, relief of suffering and prolongation of life. 1.3 Domiciliary Hospitalisation Benefit-Medical treatment for a period exceeding three days for such illnes/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 circumstance namely : (i) the condition of the patient is such that he/she cannot be removed to the hospital/nursing home; or (ii) the patient cannot be removed to hospital/nursing home for lack of accommodation therein; or (iii) the patient to be confined at home for treatment with the approval of the attending Medical Practitioner. Subject however that domiciliary hospitalisation benefits shall not cover. Expenses incurred for pre and post hospital treatment and Expenses incurred for treatment for any of the following diseases. (1) Asthma (2) Bronchitis (3) Chronic Nephritis and Nephrostic Syndrome (4) Diarrhoear and all types of Dysenteries including Gastro Entries (5) Diabetes Mellitus and insipidus (6) Epilepsy (7) Hypertension (8) Influenza Cough and cold (9) All Pscychratic or Psychosomatic Disorders (10) Pyrexia of unknown origin for less than 10 days. (11) Tonsillitis and Upper Respiratory Tract infection including laryngitis and phrainfitis (12) Arthritis Goul and Rheumatism Note-When treatment such as Dialysis, Chemothreapy, Radiotheraphy is taken in the Hospital/Nursing Home and the insured is discharged on the same day, the treatment will be considered to be taken under Hospitalisation Benefit Section.

From a bare look of the definition No. 1.3(ii) it is clear that benefit of Domiciliary Hospitalisation would be available, if the patient cannot be removed to hospital/nursing home for lack of accommodation therein or in view of 1.3(iii) the patient can be confined at home for treatment with the approval of the attending Medical Practitioner. From the documents adduced, it is evident that respondent took treatment for more than 3 days at home at Chennai for lack of accommodation in Apollo Hospital at Chennai as required by No. 1.3 with the approval of attending Medical Practitioner and Dr. S. Duraiswamy at Chennai who also advised to take treatment under the advice of Senior Consultant Dr. P.N. Vijayvergiya. Therefore, in view of the definition No. 1.3(ii) and (iii) the respondent was entitled to benefit under Mediclaim (Hospitalisation and Domiciliary Hospitalisation Benefit) Policy.

IN similar circumstances the question came up for consideration before this Commission in Appeal No. 454/94, United INdia INsurance Company Limited, Guna v. Dr. Vijay Kumar Jain, Guna, decided on 8.6.1999 wherein after referring to the condition No. 2.3 which is pari materia to definition 1.3(ii) and (iii) in para 4 it was observed thus : "4. From a bare reading of the condition No. 2.3 it is clear that an insured is entitled of medical benefit under the policy if such person gets medical treatment exceeding for a period three days for such illness/injury/disease in the normal course required, care and treatment at hospital/nursing home but actually confined for the treatment taken by the attending Medical Practitioner at home is INdia."

In the circumstances, the claim of the respondent is based on circumstances (ii) and (iii) i.e. where the patient cannot be removed to hospital/nursing home for lack of acco-mmodation therein or the patient to be confined at home for treatment with the approval of the attending Medical Practitioner which has been proved by the respondent. The disease which the respondent had suffered also does not fall within any of the disease for which domiciliary hospitalisation, benefit is not covered. In the circumstances the District Forum rightly ordered that the respondent was entitled to be reimbursed of the expenses incurred by him in medical treatment of Chennai and Durg. In view of the above we direct the Insurance Company to pay Rs. 13,937.94 paise the expenses incurred in treatment with interest thereon at the rate of 9% p.a. in view of the recent pronouncement of the Supreme Court in case of S. Kaushnuma Begum & Ors. v. The New India Assurance Company Ltd. & Ors., AIR 2001 SC 85. This interest has been ordered to be paid in the shape of compensation and damages, therefore, the respondent would not be entitled to compensation of Rs. 2,000/- nor respondent would be entitled to the amount of interest of Rs. 4,500/- claimed by the respondent till the date of filing of the complaint. However, the respondent would be entitled to Rs. 500/- the costs of the proceedings as ordered by the District Forum. The Insurance Company shall pay the amount within a period of two months from receipt of certified copy of this order failing which the amount shall carry interest at the rate of 12% p.a.

IN the result, appeal is partly allowed. The order of the District Forum shall stand modified as indicated hereinabove. IN the circumstances, parties to bear their own costs of this appeal. A copy of this order be conveyed to the parties and a copy be sent to the District Forum along with the record of the case. Appeal partly allowed.