Adv. For the Complainant: - Self
Adv. For O.P. No. 1 & 2 :- Sri Gobinda Chandra Behera
Date of filing of the Case :- 27.03.2023
Date of Order :-26.02.2024
JUDGMENT
Smt. Jyotsna Rani Mishra , Member
Fact of the case-
Complainant opened a health policy scheme for a whole family member in the year 2010. The agent was Sri Puskara Kharsel. The policy number is H059/593708192/01. UHID number of Nirupama Rath is FHPL0000116154 claim ID7400. The said policy covers the insurance of complainant wife and two children and complainant is the Principal insured.
Complainant wife Smt Nirupama Rath underwent a surgery for LAPAROSCOPIC HYSTERECTORMY. She was admitted to M/s Jeevan jyoti Nursing Home, Titilagarh on dt.05.08.2022 and discharged on dt. 10.08.2022 after the surgery. Complainant spent total amount as Rs.73,570/- paid to Nursing Home (Rs,55,300/- nursing home charges +rest medical bills). Some other expenses were also made by complainant like food , transport charges from home to nursing home.
Then that complainant sent a letter of claim with all details along with the medical documents to OP through Agent on dt.24.08.2022. The same was filed duly acknowledged by OP No.1 and submitted the application before the Op .
However on dt.06.12.2022 complainant received a letter from manager (HI), L.I.C of India ,Divisional Office , Sambalpur vide letter No.3479 dt 02.12.2022 where it is stated that complainant claim was rejected on the ground that
“ Claim forms not received with all Mandatory documents of treatments taken despite repeated reminders by TPA after 45 days’’ complainant got surprised to receive such a letter since he has not receive a single letter properly communicated from any TPA at any time.
That , complainant have submitted all the relevant papers like claim application , copy of policy bond, report from Jivan Jyoti Nursing Home, medical prescriptions , medicine bills etc.
After some days complainant received an another letter from the Division Office, Sambalpur vide letter No. 4221 dt. 13.01.2023 whereby requested for submit letter note of treating doctor having H/O HTN, Hypothyroidism, T2DM, with Date/ Month or duration since when this ailment was first time diagnosed.
That requirement of such document was not necessary for proper adjudication of the claim since complainant wife has undergone for operation for another cause. Thyroid, blood pressure are a common phenomena which gets control within time .Further, blood pressure, sugar level gets fluctuated for different reasons. By seeing one or two blood report that a person suffering from diabetic/pre-diabetic, which is never possible to get on the part of the complainant. And complainant wife is only having blood pressure problem from 2014 as well as thyroid. she was never a diabetic or pre-diabetic patient till the date of operation.
To Substantiates his case the complainant relies on following document:-
- Claim application form with all medical documents.
- Acknowledgement receipt made by OP1.
- Pathology Re3port.
- Rejection letter.
- Another letter which shall be read as a part of evidence.
Having gone through the complainant its accompanied and hearing the complainant Prima Facie, it seemed to be a genuine case hence admitted and notice to the OPS were served and in response they appear through their advocate and filed their written version.
To counter the charge in rival contention OPS not admitted that
- It is true that letter dt.13.01.2023 was sent by the OP , request him to submit the required document for further processing on health insurance claim.
- Health Insurance claim relate to medical document and are administered for medical scrutiny and opinion by TPA as an arrangement of LIC. Prognosis and diagnosis is carried out by TPA on the basis of pathological and discharge summerised submitted and their recommendation is obtained on this case the process is underway and is still pending for a decision in wasn’t of the required documents for which follow up is being made from our side. The communication from TPA is only a part of claim process and not the end result.
- The allegations made by the complainant which are not specifically admitted in this show-cause are deemed to have been denied.
Heard the complainant perused the material is on record with submission and vehement denials of the learned advocate for OP with arguments. After going through the pleading of both the parties, I observed that.
- An insurance claim is a formal request by a policy holder to an insurance company for coverage or compensation for a covered loss or policy event. The insurance company validates the claim and once proved , issues payment to the insured or an approved interest party on behalf of the insured.
Insurance company liable for deficiency in service for failure to disburse full insurance amount claimed after presenting sufficient document submitted by complainant. Complainant is under coverage period, deposit premium in time. Health insurance policy helps in having protocols in place can help in prevent human error and poor communication around medical decisions And also insurance contract is a contract of utmost good faith, This duty is reciprocal is duty not any requires insured to present their claims in good faith but also insurers to respond to and investigates claims in good faith. Thus no any reason for which OP denied on technical ground.
- TPA is the agent of health insurance Corporation it acts as a mediator between insurance provider and the insured individual. Its primary role is to address all case less and insurance claims linked to hospitalization and medical expenses.
In this case TPA sent repeated reminder to the complainant but complainant not received any single letter properly communicated on the requirement of any document.
And also here OPS are admitted that TPA is only a part of claim process not the end result. So how can OPS rejected the Insurance claim base on the letter send by TPA which is communication with complainant and send letter (Annex-2) to complainant.
- Reminder letter send by OP through TPA, which was not received by complainant and this copy of reminder letter was not submitted by OP , So I presume that no proof of any sending letter. So complainant is not liable for it.
- Complainant was requested to submit the letter note of treating doctor having H/O HIN, Hypothyroidism, T2DM which details information. But such documents are not necessary because these are the common phenomena which get control within time. Blood pressure sugar level gets fluctuated for different reason and complaint’s wife never a diabetic or pre-diabetic patient till the dt of operation.
- OPS are in their rival contention mentioned that health insurance claim is still under process and compliance of claimant is awaited. The claim is not yet rejected or repudiated by LIC but In (annexure-2) which is submitted by complainant , the letter from manager LIC of India clearly mention that Denial/repudiation clauses with description as claims for not received with within all mandatory documents of treatments taken despite repeted reminders by TPA after 45 days. So due to restrictive trade practice the OPS are amount to deficiency in service, which create sustained mental agony to the complainant.
Sequel to the above discussion, I pleased to consider in favour of the complainant with following direction. Hence order.
ORDER
OPS are directed to pay a sum of Rs. 76,570/- total amount of expenditure.
I further directed to pay Rs.20,000 towards mental agony and harassment. And Rs.2000/- towards litigation Expenses should be paid by the OPS within one month from the dt. Of Order. Failing which the entire amount should be paid by the OPS @12% interest per annum from the dt. Of filing of the case till realization.
No award as to cost.
PRONOUNCED IN THE OPEN COMMISSION TO-DAY 26th day of February‘ 2024.
