KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No. 528/2018

JUDGMENT DATED: 17.10.2018

(Against the order in C.C. 116/2015 of CDRF, Thiruvananthapuram)

PRESENT : 

HON’BLE JUSTICE SRI.S.S. SATHEESACHANDRAN  : PRESIDENT

SMT. BEENA KUMARY. A                                                 : MEMBER

APPELLANTS:

1. N. Gopinathan, Ambadi, Vadasserikonam P.O, Varkala, Thiruvananthapuram-695 143.

2. G. Sarojam, Ambadi, Vadasserikonam P.O, Varkala, Thiruvananthapuram-695 143.

 (Party in person)

                                                Vs.

RESPONDENT:

The National Insurance Company Ltd., Vazhuthacaud, Thiruvananthapuram represented by the Manager.        

JUDGMENT

HON’BLE JUSTICE SRI.S.S. SATHEESACHANDRAN  : PRESIDENT

Appeal is filed by the complainants challenging the disposal of their complaint numbered as C. C No. 116/2015 by Order dated 30.05.2018 by the Consumer Disputes Redressal Forum, Thiruvananthapuram. 

2.  Complainants who are spouses filed the complaint alleging deficiency in service by the opposite party insurance company, from which their son had taken a beneficiary policy for him and his family.  The 2^nd complainant underwent cataract surgery in a hospital covered by the policy and in connection with that surgery she was treated as inpatient, was the case of complainants.   The claim made for reimbursement of the medical expenses from the opposite party was allowed by them deducting room rent of Rs. 975/- stating that for cataract surgery the amount towards room rent is not reimbursable.  According to the insurance company cataract surgery requires only day care treatment.  In fact the claim was settled excluding the sum spent for room rent.  Complainants filed the complaint asserting that they are entitled to get room rent also with 10% interest thereon.  That claim was resisted by opposite parties reiterating their objection for denying refund of the sum spent for room rent.  The lower forum taking note of the policy conditions covered by Ext. D1 accepted the contention of the insurance company and dismissed the complaint.  Aggrieved by that Order, complainants have preferred this appeal.

3.  We heard the 1^st appellant who appeared in person and also the learned counsel appearing for the respondent.  Ext. D1 policy, no doubt, states that where treatment can be had even if it includes surgery by day care alone and the period of treatment is less than 24 hours, no room rent is realizable.  But the larger question is who is the competent person to determine whether hospitalization over and above day care treatment is required for a patient or not.  No doubt, it is the doctor who treats the patient.  There cannot be a generalized view that in a cataract surgery no hospitalization is needed.  That definitely will depend upon health condition of the patient who undergone cataract surgery and also on various factors which are to be taken to avoid complications arising from surgery.  Merely because the policy contains a clause to the effect that surgery which is taken under general or local anesthesia may require only 24 hours day care in view of technological advancement it cannot be stated that all patients undergoing cataract surgery do not require hospital treatment for more than a day.  The forum below has not looked into that aspect while dismissing the complaint accepting the condition incorporated in th