JUDGEMENT

          Complainant by filing this complaint has submitted that complainant is holder of a Medicare Policy issued by op no.2 since 10.08.2010 without any break and the present policy issued by op no.2 is proved as Policy No. 030600/48/06/00002613 and is valid for the period from 12.08.2013 to 11.08.2014 which provides cashless facility at hospitals empanelled by the op no.2 and the policy is a floater policy providing coverage to the extent of Rs. 5,00,000/- and by that policy his entire family is covered.

          Fact remains that complainant’s son Master Anmol Saraogi, aged about 4 years covered under the above mentioned policy and has been suffering from stomach pain for two days  and was under the supervision of Dr. S.K. Khanna who is a child specialist and on 16.11.2013 it was noticed by the mother of Anmol Saraogi that there was swelling in his prostate area and he was taken to Dr. Khanna and doctor instructed the patient to undergo an Ultrasonography test immediately and Ultrasonography test was conducted in Bansal Diagnostics on the same day i.e. on 16.11.2013 and after collecting Ultrasonography report it was placed before the doctor who found that it was caused with torsion Testis (Left) with Scrotal and Prepuceal Edema and was then referred to Fr. Soumen Kumar Mitra by Dr. S.K. Khanna and Dr. Mitra after examining the boy asked for admission and advised that the patient should undergo an operation on an emergency basis. 

          Accordingly his son was admitted at Apollo Gleneagles Hospital then and there on 16.11.2013 and that was verbally informed that the total charges for surgery and stay will be approximately around Rs. 1,00,000/- and 80% of the payment i.e. Rs. 80,000/- has to be paid in advance for the treatment to commence and accordingly complainant paid the said amount and in order to get cashless facility under the policy, the hospital authority filled up the form and that was sent to TPA but no response was received.  But op/TPA did not release the same on the contrary asked for some queries.  Thereafter the operation was held up and patient was discharged.  Ultimately complainant’s son was re admitted on the ground of no approval of the hospital for hospital expenses from op nos. 2 to 4 and for which complainant was compelled to disburse the entire bill amount of Rs. 1,22,950/- from his own pocket.  But ultimately on 27.11.2013 TPA repudiated the claim which was reported/informed by SMS when complainant sent legal notice on 11.12.2013 for reconsidering the same.  But there is no response on behalf of op for which complainant is harassed by the op and in the above circumstances complainant has prayed for release of the said Medicare Policy amount and also for refund of Rs. 20,500/- as taken by Apollo Gleneagles Hospital for illegal collection of the same and for detaining the patient without any cause and also prayed for refund of the said Medicare Bill from op nos. 2 to 4 with interest and cost.

          On the other hand op no.2 by filing written statement submitted that the claim of the complainant was fully settled as per policy term and was repudiated on 27.11.2013 and there is no question of harassing or deficiency or negligence on the part of the op and as per policy condition clause-4.3 and 4.8 the case of the complainant is for the treatment expenditure which is under exclusion clause and there is no record to show that complainant intimated the fact by the deficiency of service by TPA or Insurance Company and it was repudiated illegally so, complainant has failed to prove any negligence, deficiency for which the complaint should be dismissed.

          On the other hand op Apollo Gleneagles Hospital by filing written statement submitted that op no.1 never detained the patient for any further period but he was released on 18.03.2013 and another factor is that complainant on the date of discharge also he did not lodge any complaint.  But op no.1 authority denied all other allegations and prayed for dismissal of this case.

                                                     Decision with reasons

          On in depth study of the complaint and written version and also considering the final bill issued by Apollo Gleneagles Hospital, it is clear that final bill was submitted for treatment period from 16.11.2013 to 19.11.2013 and total amount of bill was Rs. 1,22,660.85 paisa.  Details of the bill was submitted and from the letter of TPA reported to Sr. Divisional Manager of Insurance Company that cashless claim could not be processed due to incomplete query reply received though some queries were raised to the insured to provide OT/surgery and anesthesia notes along with previous policy copies as previous policy i.e. 030600/48/12/00002621 is not enrolled with TPA.  But due to non-receipt of query reply from the insured, the cashless claim filed as “No Claim”.  But it is reported to the TPA, however insured did not submit reimbursement claim and so he requested by the insurance company kindly advise the insured to lodge the reimbursement claim along with supporting documents i.e. Vipul Claim form, Discharge Summary, Final Bill with their numbered receipts, investigation reports, cash memos etc. along with documents asked during hospitalization to enable them to re-examine the claim and process it as per policy norms.

          But truth is that after that complainant did not submit any such bill along with such documents.  Complainant has failed to produce any such documents to show that he submitted that fresh claim for reimbursement to the insurance company.  Considering all the above fact and circumstances and also considering the claim of the complainant in respect of final bill of Rs. 1,22,660.85 paisa we are convinced to hold that the allegation against the op no.1 cannot be entertained in view of the fact that final bill was submitted for Rs. 1,22,660.85 paisa for the treatment period from 16.11.2013 to 19.11.2013 and for which complainant again cannot claim that op no.1 raised any exorbitant bill when cashless benefit claim as made by the complainant has been refused.

          But when that was not allowed, complainant did not file any fresh claim application for reimbursement of the said amount and from the TPA’s letter dated 19.12.2013 it is clear that TPA sent reply stating that no Vipul Claim Form, Discharge Sumary, Final Bill with their numbered receipts, investigation reports, cashless memos etc. along with documents during hospitalization to be filed by the complainant to enable them to re-examine the claim and process it as per policy norms. 

          In the above situation we find that practically after denial of the cashless facilities, complainant did not file any such claim.  So, the matter cannot be decided finally without giving the op a chance to reconsider the same after submission of such claim application form along with other documents for settlement of the Mediclaim as per Policy.  But peculiar factor is that complainant has brought the allegation against the ops.  But truth is that complainant has not complied the terms and conditions of the policy for which we are deciding this matter finally by directing the complainant to submit application claim form along with all materials to the op no.2 the insurance company for settlement of the claim and op nos. 2 to 4 shall have to dispose of the matter within one month from the date of receipt of the said claim application form and if any queiry is required then op nos. 2 to 4 shall have to verify the documents with Apollo Gleneagles Hospital without disturbing the complainant.   But in this regard complainant shall always cooperate with the op for disposing of the same.

          Hence, it is

                                                               ORDERED

          That the complaint be and the same is allowed on contest without any cost at this stage.

          Op nos. 2 to 4 are hereby directed to settle the mediclaim of the complainant after receipt of proper application form for claim including all papers and complainant is directed to submit the same to the op no.2 at once and on receipt of the same, op nos. 2 to 4  shall have to dispose of the claim of the complainant within 45 days from the date of this order and if any query is required, complainant shall have to give and if any documents is required, op nos. 2 to 4 to collect it from op no.1 and op no.1 shall have to supply all documents for the final bill to the op nos. 2 to 4 for settling mediclaim of the complainant as per direction of this order.

          Op nos. 2 to 4 are directed to comply the order very strictly.  But invariably complainant shall have to comply the order of this Forum and settled the matter within 45 days op no.1 and complainant shall have to cooperate in this regard in all respect.

          Accordingly this complaint is disposed of finally with such spirit of order.

          If op nos. 2 to 4 fail to comply the order and shall fail to dispose and settle the claim within 45 days in that case op no.2 the insurance company shall have to pay Rs. 1,00,000/- treating it as final medicalim settlement of the claim.  But invariably complainant shall have to file claim application form along with documents within 10 days from the date of this order.