DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  1^st  day of  October,  2024

Present      :   Sri. Vinay Menon V., President

                    :   Smt. Vidya A., Member                        

                   :   Sri. Krishnankutty N.K., Member                                        Date of Filing: 05/04/2023 

                                      CC/94/2023

 Rajamanikan P.,

16/417, Thottathilveedu,

Thekkeparambu,

Pudupariyaram Post,

Palakkad – 678 731                                                    -           Complainant

(By Adv. Jayan C. Thomas)

                                                                                                Vs

1. Adithya Birla Health Insurance Co. Ltd.,

10^th Floor, R-Park,

Nirlon Compound, Goregaon (E),

Mumbai – 400 063

2. Adithya Birla Health Insurance Co. Ltd.,

10^th Floor, R-Park,

Nirlon Compound, Goregaon (E),

Mumbai – 400 063

Rep. by Its MD, Manager / Authorised Signatory -          Opposite parties

      (By Adv. Saji Isaac K.J.)

O R D E R

By Sri. Vinay Menon V., President

1. Pleadings made and admitted by O.P.s are that the complainant is a beneficiary of a health insurance policy issued by the O.P.s The complainant was admitted in Palana Hospital and at the time of discharge, the complainant made enquiries regarding cashless treatment and his request was denied and he had to pay the entire amounts. Even after repeated requests, the O.P.s failed to indemnify him. It is aggrieved by the non-indemnification that this complaint is filed.
2. O.P.s justified non-indemnification claiming that the complainant had not informed the Company regarding hospitalization within 24 hours of hospitalization as warranted in the policy conditions and that the complainant had made enquiries only at the time of discharge. Hence cashless treatment was out of question. Thereafter, the complainant had not raised a claim before the O.P. Company. The allegation that the complainant had repeatedly contacted the O.P.  is false. Hence they sought for dismissal of complaint.
3. The following issues were framed for consideration:

1. Whether denial of cashless facility for treatment by the OP is as per the  terms and conditions of the Policy ?
2. Whether there is any deficiency in service or unfair trade practice on the part of OPs?
3.  Whether the complainant is entitled to any of the reliefs sought for?
4. Any other reliefs?

4.         (i)           Documentary evidence of complainant comprised of proof affidavit and Exhibits           

                          A1 to A6.    

(ii)            OP filed proof affidavit and marked Ext. B1.    

(iii)        Complainant also marked a certificate accompanied by a set of photocopies of some register allegedly maintained by Palana Hospital as Ext. A6. This certificate shows that the complainant had approached the hospital authorities on 25/10/2021. The hospital authorities had issued communication to the Insurer, but no reply was received from the O.P. This document was marked without any objection from the O.P.

But one confusing aspect herein is that the complainant himself had pleaded that he enquired about cashless facilities on the date of his discharge and not earlier. Now-where in the pleading has the complainant stated, till the time of hearing, that  he had caused filing of a communication before the O.P. or their associate TPA on 25/10/2021. It is not to be overlooked that the complainant is not appearing as a party -in-person/lay-man, but through a counsel who is well versed in the art of pleadings, practice and proceedings before a court of law.

Thus, we can see that a fresh pleading is raised in the proof affidavit objecting the version pleading. Proof affidavit does not explain the circumstances under which such a vital pleading was left out in the memorandum of complaint. In fact, such a pleading, by its very nature changes the course and nature of pleadings. It is a vital pleading that ought to have pleaded at the very first instance and such a pleading, by its very important nature as a game changer, cannot be accepted without having the memorandum of complaint amended at the first instance itself and affording an opportunity to the O.P.s to have in record their take on the matter. Thus, raising of such a plea at the evidence stage is nothing short of bridging the gap in pleadings.

Legal sanctity could have been afforded to Ext. A6, had the complainant taken steps through this court to have the documents produced after having the memorandum of complaint amended in accordance with practice and precedents. It is also vital to note that there exists a chance whereby the e-mail id of O.P., entered by the staff of Palana hospital, might have been wrong and the same was not delivered to the O.P. Contents in the sheet of paper showing the page number as 391 forming part of Ext. A6,  does not show the address in which it was issued or whether it was delivered or not. It merely shows that there is no reply.

Consequently, we are not in a position to accept the contents of Ext. A6. Ext. A6 will not be relied upon.

   Issue No.1

5.         Complainant’s unambiguous pleading in paragraph 4 of the memorandum of complaint is as below:

“4.        After treatment, at the time of discharge, when the complainant approached the staff with his claim and requested for cashless discharge by submitting the policy details, the hospital authorities informed the complainant that he should make the payment then only he will be discharged, as there is no cashless treatment available as per the policy issued by the opp. parties”

6.         In paragraph 11 of the memorandum of version, the O.P.s stated that “According to the policy conditions, “We or the associated TPA must be contacted to pre-authorize Cashless Facility within 24 hours of the Insured Person’s Hospitalisation if the Insured Person has been Hospitalised in an Emergency. Each request………………  directly to the Network Provider”.

7.         O.P. marked Ext. B1 in support of their pleadings. Ext. B1 is the Policy terms and conditions as applicable to the Group Activ Health Insurance Policy. Clause VI(1)(c) deals with Claims procedure and process to be followed for availing cashless facilities in emergency. Contents therein is in harmony with the pleadings raised.

8.         Ext. A4 is the discharge summary issued from Palana Institute of Medical Sciences. Date of admission and discharge are 24/10/2021 and 28/10/2021 respectively.

9.         Admittedly, per pleadings, the complainant had enquired about cashless treatment only on 28/10/2021. He had not contacted or intimated the O.P.s or associated TPAs within 24 hours of admission. Therefore, the complainant had not acted in accordance with the policy conditions.

10.       Thus, denial of cashless facility for treatment by the OP is as per the terms and conditions of the Policy. 

            Issue No.2

11.       Next question is whether the O.P.s have failed to allow the claim of the complaint. It is the clear case of the O.P. that post discharge the complainant had not raised a claim before the O.P. in accordance with the policy conditions.

12.       Complaint pleadings is vague as regard this issue. There is no case that the complainant had filed a claim before the O.P. Eventhough there are pleadings to the effect that the complainant had made continuous requests, these pleadings are not substantiated by evidence. Even after the O.P.s denying the said pleadings, the complainant had not taken any steps like calling for records to prove that the complainant had filed claim before the O.P. Denial of O.P. is not seen objected to in the proof affidavit either.

13.       Therefore, complainant has failed to prove that he had filed a claim before the O.P.s.

14.       Resultant to discussions and observations made in Issues 1 and 2, we hold that  there is no deficiency in service or unfair trade practice on the part of OPs.

            Issue No.3

15.       Complainant is not entitled to any of the reliefs claimed.

            Issue No.4

16.       Based on the discussions and findings above, we dismiss the complaint.

17.       But in the interest of justice, we direct the O.P.s to consider the claim of the complainant, provided the complainant file a claim with necessary documents within 45 days of receipt of a copy of this Order and dispose off the claim in accordance with the terms and conditions of the policy within 30 days thereon.

                        Pronounced in open court on this the 1^st  day of October, 2024.     

                             Sd/-                                                                                                                       

                                                                                                                Vinay Menon V

                                                                         President

                                                                               Sd/-

                      Vidya.A

                                              Member         

                         Sd/-

                Krishnankutty N.K.

                                                                                                                               Member      

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1   -  Copy of certificate of insurance.  

Ext.A2  – Original requisition slip and bystander card

Ext.A3 series   - Original cash bills   

Ext.A4   - Original discharge summary

Ext.A5 series   - Copy of lawyer’s notice, Original postal receipt and Original AD card  

Ext.A6   - Original certificate issued from Palana Hospital   

Exhibits marked on the side of the opposite party:

Ext.B1 – Copy of policy terms and conditions

 Court Exhibit:  Nil  

Third party documents:  Nil

 Witness examined on the side of the complainant:  Nil

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.