The Court of Appeal has ordered for a trial in a suit brought by a private hospital to claim about RM40,000 from a patient who underwent surgery for a hernia.
The dispute arose after the patient’s insurer, AIA Bhd, declined to cover the cost of the procedure, citing concerns of alleged misrepresentation regarding the cause of the hernia.
The patient, M Kamala Manuel, in turn challenged Pantai Medical Centre’s claim for payment submitted by Dr Luqman Mazlan, and commenced third-party proceedings against Luqman, AIA Health Services Sdn Bhd, and AIA Bhd.
“Clearly, if the appellant (Kamala) was told that her operational cost would not be covered as the cause was ectopic pregnancy, she may not have gone through with it,” said Justice M Nantha Balan in allowing her appeal yesterday.
Nantha Balan, who sat with justices Zaini Mazlan and Ahmad Kamal Shahid, said the question was whether Kamala truly had an ovarian cyst surgery and if this was the cause of the incisional hernia.
“We are satisfied that there are triable issues with regard to Luqman’s actions in facilitating the insurance claim, and if when he did so, he did it as the plaintiff’s agent,” he said.
He said it had to be determined at the trial if there was any falsification in the forms that were filled up by Luqman.
The bench also awarded Kamala RM10,000 in costs.
A magistrates’ court previously allowed Pantai Medical Centre’s claim against Kamala through a summary judgment, and ordered her to pay RM40,017.85 after AIA Health Services declined to cover the medical costs.
Her appeal to the High Court was subsequently dismissed.
According to the facts of the case, Luqman facilitated Pantai Medical Centre’s submission of a request to AIA Health Services for a guarantee of insurance coverage for Kamala’s surgery.
AIA Health Services then sought clarification, to which Luqman said Kamala’s incisional hernia was the result of an ectopic pregnancy.
When the insurer replied that her policy did not cover such a condition, a subsequent request was submitted, this time stating that the hernia was caused by an ovarian cyst surgery.
Based on this information, AIA Health Services issued a guarantee of coverage for Kamala’s surgery. However, it later suspected something was amiss and declined to honour the claim.
Pantai Medical Centre then filed a suit to recover the operation cost from Kamala.
The case will now proceed before the sessions court, following an application by Luqman to transfer the matter from the magistrates’ court.
Lawyers Gurbinder Singh Gill, Chen Qin Zi, T Sailaja and Au Ching Yi represented Kamala while M Mishand Patmanathan appeared for the hospital.
