DOF.7.3.2008 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 23rd day of June 2010 CC.43/2008 Lillykutty Joseph, Pushpagiri, Taliparamba Complainant 1. TTK Health care services Ltd., Jeevan Bhima Nagar, Main Road, HAL 3rd stage 560075. 2. TTK Health care Services P Ltd., Mareena Building, M.G.Road, Opposite parties Ernakulam. (Rep. by Adv.P.P.Sheena for Ops 1 & 2) 3. National Insurance co. Bank Road, Kannur. (Rep. byAdv.V.K.Rajeev) O R D E R Smt.K.P.Preethakumari, Member This is a complaint filed under section12 of consumer protection act for an order directing the opposite parties to pay the balance amount incurred for treatment along with Rs.25, 000/- as compensation. The case of the complainant is that she is the subscriber of the Medi claim insurance policy of 3rd opposite party from 2002 onwards and having valid policy certificate during 6.12.07 to 5.12.08. On 3.2.08, her son met with an accident at Bangalore and admitted to Apollo Hospital and is entitled to get cash less benefit. The complaint had shown the original policy to the hospital authorities at the time of admission and submitted the photo copy of the same to them. Even though both the complainant and the hospital authorities were contacted the 2nd opposite party no information was received from him. Even though the complainant is entitled to cashless benefit, they have paid Rs.70730/- at the time of discharge. The complainant has suffered lot of mental and physical agony due to the act of the opposite parties. At the time of discharge, the hospital authority had handed over the reimbursement form to the complainant and the complainant had issued the same along with a letter tothe3rd opposite party. The hospital authorities had given to the complainant a copy of the sanctioned letter for an amount of Rs.52, 500/- on 11.2.08, when they had gone to the hospital for check up. But on 27.2.09, the complainant had issued a sanctioned letter only for Rs.40, 500/-. In short the opposite arty has not given the cashless price and reduced the sanctioned amount from 52,500/- to 40,500/-. The reason stated for reducing the amount was that the room taken by the complainant was A/C and the room rent shown is high. She has received with protest the amount of Rs.40, 500/- due to financial stringency. So there is deficiency on the part of opposite parties and hence this complaint. Upon receiving notice from the forum, the 3rd opposite arty has appeared and fields their version and opposite parties 1 and 2 remains absent and hence they were called absent and set exparte. The 3rd opposite party filed version admitting the medi-claim insurance policy and the total sum insured as per the policy is Rs.50,000/- but denied their further liability to pay any further amount towards reimbursement claim of the complaint since they have already paid Rs.40,500/- to the complaint and she had accepted the same and that amount was paid to the complainant on the basis of medi-claim policy and its condition and hence the compliant is not entitled to claim for Rs.12,000/- as balance amount and Rs.25,000/- towards compensation. The complainant is well aware of the fact that she is entitled for the reimbursement claim up to a limit of Rs.50, 000/-. Since the sum insured in the policy was only Rs.50, 000/-and is evident from her letter dt.11.2.08 addressed to the 2nd opposite party requesting to sanction her claim for the eligible insured amount. If an offer is made for Rs.52, 500/-the same would have been made due to oversight without taking into account the limitation of liability of 3rd opposite party. The opposite party had settle the reimbursement claim of the complaint to the fullest extend of her entitlement as per the medi-claim policy, its condition and exclusion clauses. According to the opposite party , while computing the claim of the complainant on the basis of hospital bills for Rs.70729.98 for the various nature of expenditure incurred, the opposite parties had to disallow various amount since they were specifically excluded in the policy i.e., professions fee, consultation fee, etc. should not exceed 25% of sum insured the total amount as anesthesia, medicines, lab, O.T etc. maxim um limit per illness is 50% of sum insured ie.rs.25,000/-, MLC charges not payable and room rent, nursing restricted to 1% of sum insured ie.Rs.500 per day = 500 X 6 = 3000/-. So the complainant was reimbursed for the sum of Rs.40, 500/- which she is entitled for as per policy and its condition and hence there is no deficiency of service on the part of opposite party and hence the complaint is liable to be dismissed. Upon the above pleadings the following issues have been raised for consideration. 1. Whether there is any deficiency on the part of opposite parties? 2. Whehter the complainant is entitled to any relief? 3. Relief and cost. The evidence in this case consists of the oral testimony of PW1, DW1 and Exts.A1 to A9 and exts.B1 to B8. Issue Nos. 1 to 3 The case of the complaint is that she has a valid medi claim policy and hence she is entitled to get the entire amount incurred by her for the treatment of her son during the validity period of the policy. She has received Rs.40, 500/- and hence she is entitled to get Rs.30229.88/- and in order to prove her case she had produced documents such as photocopy of policy (Ext.A1).Photo copy of preauthorization request form(A2), certificates of hospitalization from Apollo hospital(A3), approval letter (A 4), bill receipt (A 5), medico legd registers(A 6) , mediclaim computer form(A7 ) , copy of cheque issued by 3rd opposite party(A8 ) , discharge voucher(A 9) . In order to disprove the case the 3rd opposite party has produced (B1) policy certificate with conditions (B2), letter by the complainant dt.11.2.08 (B3), letter from TTK dated 14.3.08 , (B4) mediclaim computer form, (B5) letter dt.1.3.08, (B6) preauthorization Performa, (B7) discharge summary and (B8) final cash bills. According to opposite party, they had already sanctioned and disbursed the eligible amount to the complainant as per the clause 1(A) (B) and (C) of mediclaim insurance policy and hence they have no liability to pay the amount. As per the clause 1 (A), (B) and (C) of the Medi - claim policy “It is stated that the company will pay to the insured person the amount of such expense as would fall under different heads mentioned below and are reason ably and necessarily incurred thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate mentioned in the schedule. A. Room, boarding, Nursing expenses as provided by the hospital/Nursing home. (Room rent limit 1% of sum insured per day subject to maximum of Rs.5000/-. If admitted in I.C unit 2% sum insured per day subject to maximum of Rs.10,000/-. Overall limit under thishead, 25% of sum insured per illness) B. Surgeon, Anesthetist, medical practitioner, consultants, special fees, maximum limit per illness – 25% of sum insured. C. Anesthesia, blood, oxygen, OT charges, surgical appliances, medicines, drugs, diagnostic material and X-ray, Dialysis, chemotherapy, radiotherapy, cost of pacemaker, artificial limb, and cost of stunt and implant maximum limit per illness - 50% of sum insured. But in Ext.A7 and B4, i.e. the medic claim computation, it is very clearly stated the way of computing the amount as per conditions of the policy. As per ext. B4 the amount sanctioned by opposite party is as follows. SL no | Item | Amount incurred | Amount paid | Maximum limit as per policy | 1 | Consultation | 2540 | 12500 | 12500 ie.25%of Sum insured | 2 | Total amount on anesthesia, medicine, lab OT etc. | 34581.13 | 25000 | 50% SI | 3 | Room and boarding expenses | 8250 | 3000 | 3000(1%of sum insured per day (500 x 6) |
So it is seen that the opposite party computed the amount as per the ceiling limit as per the policy. But for the room and boarding expenses, the opposite party has calculated only Rs.3000/-. But the patient was in ICU for one day for which the complainant is entitled to get 2% of sum is insured per day. So the complainant is entitled to get Rs.500/- more towards room and boarding. In all other heads the opposite party has calculated correctly. So we are of the opinion that there is deficiency on the art of 3rd opposite party in calculating the room rent and hence the complainant is entitled to receive this amount of Rs.500/- along with Rs.1000/- as cost of the proceedings and order passed accordingly. In the result, the complaint is allowed partly directing the 3rd opposite party to pay Rs.500/- (Rupees Five hundred only) along with Rs.1000/- (Rupees One thousand only) as cost of the proceedings to the complainant within one month from the date of receipt of this order. Otherwise the complaint is at liberty to execute the order against 3rd opposite party under the provisions of consumer protection Act. Sd/- Sd- Sd/- President Member Member APPENDIX Exhibits for the complainant (Ext.A1)Copy of the policy (Ext.A2).Photo copy of preauthorization request form (A3), Certificates of hospitalization from Apollo hospital (A4), Approval letter (A 5), Bill receipt (A 6), Medico legd registers (A 7) , Mediclaim computer form (A8 ) , Copy of cheque issued by 3rd opposite party (A9 ) , Discharge voucher Exhibits for the opposite parties (B1) policy certificate with conditions (B2), letter by the complainant dt.11.2.08 (B3), letter from TTK dated 14.3.08 , (B4) mediclaim computer form, (B5) letter dt.1.3.08, (B6) Preauthorization Performa, (B7) Discharge summary (B8) Final cash bills. Witness examined for the complainant PW1.Complainant Witness examined for the opposite parties DW1.T.A.Sankarankutty /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur
| | [HONORABLE PREETHAKUMARI.K.P] Member[HONORABLE MR. GOPALAN.K] PRESIDENT[HONORABLE JESSY.M.D] Member | | 
