Orissa

Sambalpur

CC/37/2018

Saswat Kumar Panda - Complainant(s)

Versus

1-Branch Manager, Star health Insurance - Opp.Party(s)

10 Aug 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Case No-37/2018

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

 

Saswat Kumar Panda,

S/O-Nrusingh Charan Panda

R/o-H.L.O. Colony, Sambalpur, PS-Town,

Dist- Sambalpur, Odisha.                                              ………….Complainant

Vrs.

1. Branch Manager, Star Health Insurance Co. Ltd.

Nuapadh, Sambalpur-768001.

2. Star Health Insurance Co. Ltd.
3.  

New Delhi-11001

3. Max Superspeciality Hospital(Managing Director)..….Opp. Parties

Counsels:-

1. For the Complainant      :-Self
2. For the O.P.s                    :- Sri. B.K.Purohit.

 

DATE OF HEARING :29.06.2022, DATE OF JUDGEMENT :10.08.2022

Presented by Dr. Ramakanta Satapathy, PRESIDENT.

1. The case of the Complainant is that the Complainant made a Health Insurance Policy from the O.P. No.1 & 2 bearing Policy No. P/191214/01/2018/000459. The Complainant got an injury in his knee. Consulted Dr. Gautam Satapathy and also star Health who advised to go to Max Hospital, Shalimar Bag, New Delhi where cashless surgery in available and is an empanelled hospital. The Complainant consulted Dr. Raju Iswaran in Max Health care. New Delhi submitted the details of injury but the date of incident on the date of M.R.I. The O.Ps rejected the claim on 06.03.2018 as the details are not correct. Dr.Raju again wrote a letter correcting the date and to consider the case. The O.Ps again rejected the claim. The Complainant sent mail to the O.Ps and waited for four days in New Delhi but no response came from O.Ps. The Complainant consulted Bhubaneswar and local office at Sambalpur where they denied for any help. The Complainant came to Sambalpur without any surgery. As the Complainant is a lawyer due to the problem unable to earn and suffering a lot.

Being agrived the complaint was filed.

2. The O.P. No.1 & 2 in their version submitted that one star comprehensive Insurance Policy bearing No. P/191214/01/2018/000459 was issued to the Complainant covering the period 22.06.2017 to 21.06.2018 MN for an amount of Rs. 5.00lakhs for cashless treatment the condition are:

1. 24 hour helpline for assistance which is 1800-2255/1800-102-4477.
2. Inform the ID for easy reference.
3. On admission in the hospital, produce the ID card issued by the hospital. Produce the ID card issued by the company at the Hospital Help desk.
4. Obtain pre-authorisation form Hospital Help Desk.
5. The treating Doctor will complete hospitalization/treatment information and the hospital will fill up expected cost of treatment.
6. Form is submitted to company.
7. Company will process and request for additional documents.
8. Once the details are furnished then the company will process.
9. In case of emergency hospitalization information to be given within 24 hours after hospitalization.
10. Cashless facility is available only in network hospital.

The Complainant admitted in Max Super Specialty Hospital O.P. No.3 and raised a cashless facility for ACE TEAR on left knee. The documents submitted by treating hospital and the O.Ps raised querry to submit the documents vide letter dated 05.03.2018. The required documents were:

1. MCL/FIR/AR Copy
2. First aid treatment taken immediately after injury
3. Follow up consultation papers & treatment
4. Clear MRI left knee report/image.
5. Letter from treating doctor regarding alcohol influence at the time of injury.
6. Referral doctor letter for MRI knee.

The O.Ps came to know that the Complainant received injury on 23.07.2017, discrepancy, found in date and circumstances of  injury as not ascertained, on 06.03.2018 cashless authorization was denied.

The Complainant was advised to come for reimbursement with claim form vide letter dated 13.03.2018 with required documents:

1. Discharge summary
2. Investigation report with x-ray film
3. Main Hospital bills, payment receipts with break up.
4. Prescriptions
5. Medical bills, receipts etc.
6. Earlier treatment record etc.

The O.Ps issued three reminders letter dated 28.03.2018, 12.04.2018 and 27.04.2018 but no response received from complaint, for the insured not approached for reimbursement of medical expenses. It was presumed that the insured not interested in preferring the claim and was rejected.

The mistake is by the empanelled hospital and treating doctor.

The Complainant has not fulfilled the terms and condition of the policy, accordingly rejection of claim is proper.

3. Notices were issued to the O.Ps on 05.07.2018 by the Forum/Commission, the O.P. No.1 & 2 appeared and filed version. The O.P. No.3 not appeared. Accordingly, it is presumed that the O.P. No.3 set ex-parte. Till the final argument the O.P. No.3 did not turn up.
4. Perused the documents filed by the Complainant and O.P. No.1 & 2. It is the admitted case both the parties that the Complainant was having a policy No. P/191214/01/2018/000459 with the O.P. No.1 &2 after initial treatment from Dr. Goutam Satapathy contacted the O.P. No.3 and Dr. Raju Easwaran, Senior Consultant planned for admission in Hospital (O.P. No.3) and the Complainant declared his fall on 23.07.2017 but the treating doctor mentioned as ‘August 2017’. In this connection Dr. Raju Easwaran also made a clarification to the O.P. No.1 & 2 and after clarification the O.P. No.1 & 2 advised the complainant to submit certain documents. The Complainant submitted the documents but further querry was made by O.P. No.1 & 2. The denial of pre-authorisation for cashless treatment letter issued on 07.03.2018. No doubt on 13.03.2018, 28.03.2018& 12.04.2018 reminder letter have been issued by the O.P. No.1 & 2 and ultimately on 27.04.2018 the rejection letter was issued.

In the present case the Health policy was valid, within the period the Complainant sustained injury in his left knee, approached the O.P. No.1 & 2 for cashless service but with procedural wrangles the complainant was denied the service of O.P. No.3. Thereby the Complainant not only burden the pain but also due to physical deformity unable to earn his livelihood, moved to Delhi, Spent in journey and being harassed returned un operated and till date shouldering the pain.

5. Taking in to consideration circumstances of the case pleading of the parties the following issues are framed:
103606587.  

1. Whether the Complainant denied with cashless service due to his fault?
2. Whether the Complainant denied with cashless service due to his fault?
3. What relief the Complainant is entitled to get?

Issue No. 1 Whether the Complainant denied with cashless service due to his fault?

          In the policy bond cashless service defined as “A facility extended by the insurer to the insured where the payments of the cost of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the net work provided by the insurer to the extent pre-authorisation approved.”

          The Complainant made an application for his cashless treatment but the O.P. No.1 & 2 vide letter dated 06.03.2018 rejected the claim on the ground that discrepany found in date and circumstances of injury. The querry on pre-authorisation was made on 05.03.2018 against claim, intimation No. CLI/2018/191214/0632273. At that time the patient was admitted in FC-50 C& D Block of O.P. No.3 hospital. The estimated cost of treatment was as under:

1. ACL reconciliation (TPA)package              -        Rs.1,17,000.00
2. Medical Supervision fees                            -        Rs.       1800.00
3. Implant                                                         -        Rs.     65,000.00
4. 3 days ICV stays                                          -        Rs.       8,000.00
5.                                                                      Total Rs. 1,91,800.00

          After reply of Dr. Raju Eswaran of the O.P. No.3 hospital also the O.P. No.1 & 2 not taken care of the claim of the Complainant, although there was no any fault of the Complainant. The Complainant gave a mail to O.P. No.1 & 2, waiting for 4 days in Delhi since 07.03.2022 but no any reply received. The Complainant returned back to his native place.

          From the aforesaid circumstances it is clear that the O.P. No.1 & 2 should have consider the clarification of Dr. Raju Easwaran but the O.Ps remained silent, which debarred the Complainant to get his legitimate service from O.P. No.1 & 2.

          In the other hand due to fault of Dr. Raju Eswran the O.P. No1 & 2 denied the service. Accordingly I am of the opinion that the O.Ps are jointly and severally liable for the un-operated knee of the Complainant and pain sustained, humiliation made by the O.Ps.

          Accordingly, issue No.1 is answered.

Issue No.2 Whether the Complainant denied with cashless service due to his fault?

          The O.Ps are deficient in their service for which the Complainant returned to his native place un-operated, sustained pain and humiliation & lost his livelihood.

          The issue is answered against the O.Ps.

Issue No.3 What relief the Complainant is entitled to get?

          From the supra facts and circumstances the Complainant is entitled for the relief. It is ordered:

ORDER

The Complaint is allowed partly against the O.Ps. The O.Ps are jointly and severally liable to pay the estimated cost of operation Rs. 1,91,800/-  and to-wards financial & mental suffering Rs. 2,50,000/- with 9% P.A. interest w.e.f. 06.03.2018 within one month, failing which the amount will carry 12% interest P.A. till realisation.

          Further the O.Ps are directed to make special arrangement of ACL (L) knee operation of the complainant in the hospital of O.P. No.3 within one month from the day of order and incase of successful operation the amount of Rs. 1,91,800/- with 9% interest shall be exempted and adjusted to-wards charges of operation.

          Order pronounced in open court on this 10^th day of August, 2022.

          Supply free copies to the parties.