Kerala

Idukki

CC/15/2020

Noushad M S - Complainant(s)

Versus

Adithya Birla Health Insurance Co ltd - Opp.Party(s)

Adv: Vikraman Nair N G

31 Aug 2022

ORDER

DATE OF FILING : 14.1.2020 

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 31^st  day of   August,  2022

Present :

SRI. C. SURESHKUMAR                   PRESIDENT

SMT. ASAMOL P.                               MEMBER

SRI. AMPADY K.S.                            MEMBER

CC NO.15/2020

Between

Complainant                                            :     Noushad M.S.,

                                                                      New Manzil,

Rosappookandam, Kumili P.O.,

Idukki – 685 509.

          (By Adv: Vikraman Nair N.G.)

And

Opposite Parties                                       : 1. The Managing Director,

                                                                      Aditya Birla Health Insurance Co. Ltd, 

                                                                      Registered Office : 10^th Floor, R Tech Park,

                                                                      Nirlon Compound,

Off Western Express Highway,

Guregaon East, Mumbai – 400 063.

           (By Adv: Saji Isaac)

      2. The Branch Manager,

                                                                      Muthoot Finance,

                                                                      Muthoot George Group, Kumili P.O.,

                                                                      Idukki – 685 509.

                                                                              3.  Betsy Kurian,

                                                                      Branch Manager,  Muthoot Finance,

                                                                      Muthoot George Group, Kumili P.O.,

                                                                      Idukki – 685 509.

                                                                 4.  Arun Abraham,

                                                                      INS Sales Manager,

                                                                      Aditya Birla Health Insurance Co. Ltd.,

                                                                      Ernakulam.                                                                                                                (By Adv: Saji Isaac)

O R D E R

SRI. AMPADY K.S., MEMBER

 

 

          1. Complainant  filed this complaint raising the following allegations against the opposite parties.

                                                                                                              (cont….2)

• 2  -

          Complainant is a permanent resident in the above address and the principal insured. 1^st opposite party is a registered company having its registered office at Mumbai engaged in sales of health insurance policy.  2^nd opposite party is the intermediary of 1^st opposite party.  3^rd opposite party is the branch manager of 2^nd opposite party.  The fourth opposite party is the sales manager of 1^st opposite party who assist the intermediary to sell 1^st opposite party’s products among the general public.  The complainant had taken Aditya Birla Health Insurance policy bearing No.13-18-0064917-00, on 28.1.2019 for the protection of family health.  The policy is valid from 28.1.2019 to 27.1.2020 and the mode of premium payment rest with yearly.  The logo of the policy itself is cashless hospitalization.  On 10.4.2019, the Raashid Muhammed, 15 years, son of the principal insured met an accident while he was playing football and sustained injury to right knee.  He was taken to Anand Hospital at Cumbum and the doctor given treatment.  Thereafter found tenderness over joint line.  Complainant consulted doctor on 26.4.2019 at Matha Hospital, Kottayam and apprehension test for dislocation patella strongly positive in MRI Scan.  Dr. Dileep Isaac, Orthopedic Surgeon advised to undergo a keyhole surgery.  As such, Raashid Muhammed was admitted in the hospital on 5.5.2019 and on 6.5.2019, Arthroscopic MPFL Reconstruction using Hamstring Tendon, lateral Retinacular  Release was done.  After discharge from the hospital, the complainant approached 2^nd, 3^rd  and 4^th opposite parties for medi claim reimbursement and as per their advice submitted all the medical expenses bill along with Medi claim form.  But astonishing to the complainant received a letter from 1^st opposite party informing that 1^st opposite party is unable to approve and reimbursement claim, dated 18.10.2019.  Several times thereafter the complainant tried to contact the 4^th opposite party but he never took the phone.  Without providing proper reason repudiating a claim itself is an unfair trade practice and defect in service.  The 2^nd 3^rd and 4^th opposite parties are jointly and severally liable to compensate the complainant.  In section C of policy terms and conditions, clause (i), first 30 days waiting period clearly mentioned that company is only liable to pay claims arising due to an accident irrespective of 30 days waiting period.  Hence complainant is entitled to get reimbursement of claim number 19700293 for Rs.1,12,315/- and claim number 1121910016548 for Rs.19,629/- in total Rs.1,31,944/- along with interest.  As per section 45 of the Insurance At, complainant is eligible for the claim.  The insurance companies are misleading the innocent consumers by introducing such unconscionable and misleading terminologies.  Accidents are fatal error which cannot be avoided by.  1^st opposite party had denied the genuine claim of the complainant.  Complainant is entitled to the benefits as per the policy and he is also entitled to get costs and compensation.  The cause of action for the complaint arose on 28.1.2019 and continuously on 18.3.2017, when claim was repudiated by opposite party by letter dated 18.10.2019, directly at Kumily which is within the jurisdiction of this Forum.  Hence he prayed for the following reliefs :

a)  Direct the opposite party to pay the claim, an amount of Rs.1,31,944/- along with interest.                                                                                                    (cont…3)

-  3  -

b)  Direct the opposite party to pay Rs.1 lakh as compensation for mental pain sufferings.

c)  Direct the opposite party to pay Rs.10000/- as cost of this proceedings.

d)  Any other incidental charges as the Forum thinks to fit.

 

          2.  Notice issued to opposite parties.  Eventhough opposite parties 2 and 3 sought time for filing vakalath and written version, thereafter, they were absent.  Hence opposite parties 2 and 3 were called absent and set exparte on 20.4.2021.  Though notice to 4^th opposite party is unclaimed and returned, joint written version was filed for 1^st and 4^th opposite parties, in the following lines.

 

          Save those which are expressly admitted here under all the allegations in the above complaint are hereby denied.  The above complaint is an abuse of the process of law and the complainant has not approached the Forum with clean hands.  The above complaint is not maintainable before this Forum.  1^st opposite party had received a claim from complainant with registration number 1121910016548 for admission in Matha Hospital for Raashid Muhammed for viral fever.  The claim of complainant was initially repudiated by letter dated 18.10.2019.  On reviewing the claim of complainant, the claim was settled for an amount of Rs.13,138/- and the said amount was sent to complainant by NEFT to his account number 67004293278 in State Bank of India on 10.1.2020.  The allegation in the complaint regarding the key hole surgery and hospitalization is not known to this opposite party and is denied.  The allegation in the complaint regarding claim number 19700293 is not known to this opposite party and is denied.  Complainant has not submitted claim number 19700293 to 1^st opposite party.  1^st opposite party has received only one claim from complainant with number 1121910016548 which has already been paid by 1^st opposite party.  Contract of insurance is a contract based on the policy and this opposite party is liable only according to the terms and conditions of the policy.  According to the conditions of policy, for reimbursement claims a written notice of the claim shall be submitted within 48 hours of admission to the hospital or before discharge from the hospital.  If the claim is not notified within such time interval then the company shall be provided with reasons for the delay in writing.  All required claim documents shall be submitted with 30 days of the insured person’s discharge from the hospital.  Complainant had not submitted the claim for the hospitalization on 5.5.2019 as stated in the complaint.  According to the conditions of the policy, for all claims for which cashless facilities have not been pre-authorised or for which treatment has not been taken at a Network Provider, we shall be given written notice of the claim along with the following details within 48 hours of admission to the hospital or before discharge from the hospital, which ever is earlier.  (1) Policyholder Number (2) Name of the Policyholder.  (3)  Name and address of the Insured Person in respect of whom the request is being made.  (4)  Health card, photo ID, KYC documents. (5)  Nature of                                                                                                                   (cont….4)

• 4  -

illness or injury and the treatment/surgery taken.  (6)  Name and address of the attending medical practitioner. (7) Hospital where treatment/surgery was taken.  (8) Date of admission and date of discharge.  (9)  Any other information that may be relevant to the illness/injury/hospitalization.  The complainant had not submitted any claim to complainant with regard to hospitalization on 5.5.2019 as stated in the complaint.  The said claim does not pertain to 1^st opposite party.  Hence this opposite party is not liable to compensate the complainant.  The allegation in para 6 of the complaint that as per Section 45 of the Insurance Act, the complainant is eligible for the claim is false and hence denied.  The cause of action as stated in para 7 of the complaint is non existent.  There is no cause of action for above complaint.  The complainant is not entitled to any of the reliefs claimed.  The complainant is not entitled to the amount of Rs.1,31,944/- or for Rs.1 lakh as compensation or for incidental charges.  The above complaint is a frivolous litigation and hence ought to be dismissed with compensatory cost.  Therefore the complaint may be dismissed with cost.

 

          3.  Evidence in this case includes oral evidence of complainant and Exts.P1 to P5 marked for complainant and Exts.R1 and R2 for opposite parties 1 and 4.  No oral evidence was adduced for opposite parties 1 and 4.  Documents produced for complainant are as under, which were marked as Exts.P1 to P5 respectively.

1)  Ext.P1 – photocopy of claim rejection letter dated 18.10.2019, issued by 1^st opposite party.

2)  Ext.P2 – photocopy of  “Activ Assure” policy schedule having No.13-18-0064917-00 for the period from 28.1.2019 to 27.1.2020 for an amount of Rs.3 lakhs.

3)  Ext.P3 – Discharge Summary from Matha Hospital, Kottayam in respect of Raashid Muhammed.

4) Ext.P4 – e-mail print out of acknowledgment of claims raised dated 19.7.2019, 2.8.2019 and 31.8.2019, issued to complainant’s e-mail.

5)  Ext.P5 – e-mail print out dated 25.8.2019 issued by MediAssist Insurance TPA (P) Ltd. to complainant’s e-mail, stating that claim for reimbursement of Rs.1,12,315/- is under process.  (Exts.P4 and P5  were marked subject to proof).

 

          Opposite parties 1 and 4 filed 2 documents and marked as Exts.R1 and R2 respectively.

1)  Ext.R1 – consisting of copy of policy schedule, letter addressed to complainant welcoming him to the world of Aditya Birla Capital Policy terms and conditions etc.

2)  Ext.R2 – copy of letter dated 10.1.2020 issued 1^st opposite party to complainant stating that they have allowed Rs.13,138/- against the claim registration No.1121910016548 for Rs.14,266/- for the treatment done from 29.6.2019 to 1.7.2019.

 

 

                                                                                                              (cont…5)

-  5  -

          4.  Opposite parties 1 and 4 filed argument notes and both counsels were heard.

 

          We have examined the rival contentions raised by both sides, oral testimony of complainant and perused records.  On a careful examination of the same, following points arise for consideration.

1)  Whether the complainant is entitled to re-imbursement of medical expenses claimed Rs.1,31,944/- with interest ?

2) Whether there is any deficiency in service and unfair trade practice on the part of opposite parties ?

3)  Whether the complainant is entitled to Rs.1 lakh as compensation ?

4)  Costs of the complainant ?

 

5.  Point No.1  & 2 considered together

 

          In this case, complainant has taken Family Floater Medical Insurance Policy from 1^st opposite party through the intermediary opposite parties 2 and 3, for an insured amount of Rs.3 lakhs, by paying Rs.18,509/- including IGST.  Complainant’s specific case is that eventhough he has preferred claim, opposite parties have not reimbursed the amount.  On the other hand, 1^st and 4^th opposite parties contended that they have paid the amount Rs.13,138/- against the claim raised by complainant for the treatment of his son.  But on a perusal of Ext.R2, it is seen that it relates to treatment done between 29.6.2019 to 1.7.2019.  But the complainant claimed an amount of Rs.1,31,944/- with interest for the treatment of his son for which claim Nos.19700293 and 1121910016548 as discernible from Ext.P5 and Ext.R2.  Eventhough complainant has claimed this amount, copy of hospital bills were not produced before us.  At the same time, from Ext.P5, it is seen that TPA (Third Party Administrator) issued e-mail to complainant acknowledging receipt of physical documents in respect of claim No.19700293 for an amount of Rs.1,12,315/-. But opposite parties 1 and 4 denied in written version that no such claim was received by them.  Eventhough they have objected to marking of Ext.P4 and P5, no action was taken by them to disprove the same.  They have no allegation that those documents are not genuine.  In these circumstances, there is no room for any doubt regarding the genuineness of those documents.  From this, it is clear that above claim was raised by complainant but amount was not paid in respect of claim No.19700293.  Ext.P5 negates contention of opposite parties 1 and 4.  But Rs.13,138/- was paid subsequently in respect of treatment done on a different occasion for which claim No.1121910016548 was raised.  Hence Ext.P1 has no relevance.   So the contention of opposite parties 1 and 4 on this score are overruled.  Another important aspect is that name, address and phone number of TPA is not mentioned in the policy schedule.  Without furnishing such details and terms and conditions of concerned policy, details of network hospitals, procedure to be followed etc., policy holder would not get an idea of                                                                                                       (cont….6)

• 6  -

the same.  Opposite parties have no case that they have furnished those to complainant.  After receiving huge amount towards premium, it is the duty of insurer to supply all connected documents to policyholder.  Not supplying those documents creates lot of difficulties to policy holders, especially illiterate persons.  The contention that complainant has not adduced evidence to show that he had submitted claim No.19700293 to opposite party is unsustainable in the light of Ext.P5.  Opposite parties cannot absolve from liability blaming policy holder.  There is grave violation of the assurance given by 1^st opposite party in not honouring the claim and not even taking a decision thereon.  It is very serious to note the following conditions laid down in the policy terms and conditions.   Conditions specified for reimbursement of claims under clause (d)(i) in page 29 of Ext.R1 is found to be impossible to perform by a patient who is hospitalized.  In this, it is stated that “for all claim for which cashless facilities have not been pre-authorised or for which treatment has not been taken at a network provider, we shall be given written notice of the claim along with following details (8 details were shown there) within 48 hours of admission to the hospital or before discharge from the hospital, whichever is earlier”.  One of the details is “date of admission and date of discharge”.  How the date of discharge can be given before discharge from the hospital ?  Claim forms can be prepared only after discharge and when the patient attains good health.  In the case of network hospitals, on getting information about the existence of policy, policy help desk in the hospital would do all necessary documentation for cashless facility.  It is the right of policyholder to claim the genuine medical expenses under a policy and not a bounty of the insurer.  Date of cause of action shown in the complaint as 18.3.2017 as against 18.10.2019 seems to be a clerical mistake. From the evidences available on record, it is abundantly clear that contending opposite parties have not honoured the claim of complainant in respect of claim No.19700293 for Rs.112315/-.  As opposite parties 2 and 3 are intermediaries and agents of 1^st and 4^th opposite parties, they are duty bound to take necessary steps with opposite parties 1 and 4, for reimbursement of the claim of complainant. Due to failure on their part, all of them are jointly and severally liable for deficiency in service and unfair trade practice.  Abstinence from appearance and non-filing of written version shows that they have nothing to object to the allegations of complainant.  Rulings relied on by opposite parties 1 and 4 have no application to the facts of this case.  Hence we are unable to accept the contention.  It is the prime duty of insurer to pay the genuine insurance claim.

 

In these circumstances, we have no hesitation to hold that opposite parties 1 and 4 are jointly and severally liable to pay the hospital expenses incurred by the complainant for the treatment of his son for which claim No.19700293 was preferred. Point Nos.1&2 are answered as above.

 

 

                                                                                                                    (cont….7)

 

• 7  -

 

6.  Point No.3 :

 

          In the light of discussions made in respect of Point No.1,  it is manifestly clear that non-payment of medical treatment expenses and the above acts of opposite parties is a deficiency in service and unfair trade practice on their part.  In first page of policy terms and conditions under the head “key notes”, it is stated that “the policy schedule specify which of the following covers are in force and available for the insured persons under the policy period”.  As per Ext.P2, no such details are seen.  As the opposite parties have no case that they have supplied all the documents in respect of policy, that also is an unfair trade practice for which opposite parties are jointly and severally liable under the Consumer Protection Act, 1986.  Hence we find that opposite parties are liable to pay compensation to the complainant.  So we direct the opposite parties 1&4 to pay Rs.25,000/- (Twentyfive thousand) and opposite parties 2&3 to pay Rs.10,000/- (Ten thousand) as compensation which would meet the ends of justice.  Point No.3 is answered as above.

 

7.  Point No.4 :

 

          Considering the entire aspects of the case, we allow litigation cost of Rs.5000/- to complainant and this should be paid by opposite parties.

 

          In the result, complaint is allowed in part as follows :

 

1)  Opposite parties 1&4 are directed to pay to the complainant, medical treatment expenses Rs.1,12,315/- incurred by the complainant for the treatment of his son, with interest at the rate of 9% per annum from 14.1.2020 (date of complaint), till full realization.

 

2) Opposite parties 1&4 are directed to pay  Rs.25,000/- (twentyfive thousand) as compensation to the complainant and 2^nd and 3^rd opposite parties to pay Rs.10,000/- (Ten thousand) for deficiency in service and unfair trade practice.

 

3)  Opposite parties1 & 4 are directed to pay Rs.5,000/- (five thousand) as litigation costs to the complainant.

 

         

 

 

                                                                                                              (cont…8)

 

• 8  -

 

Above amounts shall be paid within 30 days of receipt of a copy of this Order, failing which complainant will be entitled to recover the amounts ordered as per Clause 1 to 3 in accordance with the procedure outlined in the Act.

 

                 Pronounced by this Commission on this the  31^st    day of August, 2022

                                                                                                    Sd/-

      SRI. AMPADY K.S., MEMBER

                                                                                                    Sd/-

SRI. C. SURESHKUMAR, PRESIDENT

                              Sd/-

         SMT. ASAMOL P., MEMBER

 

 

APPENDIX

Depositions :

On the side of the Complainant :

PW1        -  Noushad M.S.

On the side of the Opposite Party :

Nil.

Exhibits :

On the side of the Complainant :

Ext.P1   -   photocopy of claim rejection letter dated 18.10.2019, issued by 1^st OP.

Ext.P2 –   photocopy of  “Activ Assure” policy schedule

Ext.P3 –   Discharge Summary from Matha Hospital, Kottayam

Ext.P4 –  e-mail print out of acknowledgment of claims raised dated 19.7.2019, 2.8.2019

                and 31.8.2019, issued to complainant’s e-mail.

Ext.P5 –  e-mail print out dated 25.8.2019 issued by MediAssist Insurance TPA (P) Ltd.

                to complainant’s e-mail.

On the side of the Opposite Party :

Ext.R1  -  Insurance policy & terms and conditions.

Ext.R2  -  letter from opposite party to complainant dated 10.1.2020.

 

                                                                                          Forwarded by Order,

 

 

 

                                                                                       ASSISTANT REGISTRAR