Order No. 20 dt. 11/10/2017
The case of the complainant in brief is that the complainant is a bona fide health insurance policy holder under the o.p. In terms of the policy the complainant paid a sum of Rs.1,57,648/- yearly on 4.12.10. The complainant paid the policy premium regularly. The father of the complainant became ill and he was admitted to hospital on 14.5.14 for the purpose of treatment of prostate disease and was released on 16.5.14. The complainant claimed the amount for medical reimbursement of Rs.9336/-. Thereafter the father of the complainant was admitted at Apollo Gleneagles Hospital on 13.6.14 after chest related problem. The complainant asked the TPA for getting cashless treatment and as per the message sent by o.p. the complainant complied all the requirements as sought for by TPA, but his prayer for cashless treatment was rejected. The complainant thereafter paid the hospital bill of Rs.1,71,962.23 and for realization of the said amount the complainant made claim to o.p. but o.p. did not settle the claim of the complainant for which the complainant filed this case praying for direction upon the o.p. for releasing the amount of Rs.1,71,962.23 along with compensation of Rs.3 lakhs.
The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant had duly signed and filled up the proposal form bearing no.1100842483 and on the basis of the declaration a policy was issued to the complainant on 24.12.10. By entering into such insurance policy with o.p. the complainant agreed / acknowledged and accepted the terms and conditions provided in such insurance policy. On 2.6.14 the complainant had filed a claim with date of admission on 13.5.14 to 15.5.14 and final amount of Rs.12,302/-. Upon scrutiny of the medical documents an additional information was called from the treating hospital to evaluate the admissibility of the claim by stating that the previous treatment record prior to hospitalization including first consultation letter treating doctor’s certificate for the past history duration asthma, prostate diseases when diagnosed for the first time, but the complainant despite receiving such letter failed to provide the mandatory documents. The complainant was repeatedly requested to furnish the documents, but failed to comply the request. The complainant only interested for cashless benefit as required in due process for approval of such reimbursement. The complainant did not provide those documents for which the cashless benefit was not provided. On the basis of the said fact o.p. insurance company prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy at the relevant point of time?
- Whether the complainant’s father was admitted to the hospital for his treatment?
- Whether the complainant will be entitled to get the cashless benefit / the complainanat can pray for reimbursement of the medical bills subsequently?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant paid premium as per the terms and conditions of the policy and the policy was valid at the relevant point of time and during the subsistence of the said policy the father of the complainant became ill and he was admitted to Apollo Gleneagles Hospital. The complainant asked the TPA for allowing the claim of the complainant for cashless benefit, but the said prayer was not entertained for which the complainant had to bear the expenses of Rs.1,71,962.23. Since the claim of the complainant for cashless benefit was not provided by o.p. the complainant filed this case praying for direction upon the o.p. for reimbursement of the medical bill as well as compensation.
Ld. lawyer for the o.p. argued that the complainant while informed the fat of the admission of the father of the complainant made some queries regarding the treatment rendered to the patient and whether the patient was suffering from any illness and if that be the so, for how many years he was suffering from, all these necessary queries were made by TPA, but the complainant did not provide those information for which the cashless benefit was not provided. The complainant after payment of the amount could have filed the documents along with the application form for medical reimbursement of the bills. But instead of taking such procedure the complainant by making false allegation against the o.p. filed this case praying for reliefs which are not at all maintainable. Accordingly o.p. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant had the policy with o.p. at the relevant point of time and the policy was valid while the father of the complainant took admission in the hospital. It is also an admitted fact that the complainant opted for cashless benefit as provided in the policy documents, but o.p. after receiving the information regarding the admission of the father of the complainant made some queries from the complainant. The complainant instead of providing the answers to those queries the cashless benefit was not provided. It is also an admitted fact that the complainant paid the amount of Rs.1,71,962.23 for the treatment of his father. The complainant filed this case with the allegation that since the cashless benefit was not provided which caused mental agony and harassment for which the complainant filed this case. the complainant could not file any document to show that o.p. insurance company repudiated the claim of the complainant. In view of such background of the case we hold that the complainant could have opted for reimbursement of the medical bills after the recovery of the patient. Since the complainant did not take such measure and only made allegation against the o.p. that the denial of the cashless benefit itself was the deficiency in service cannot be accepted. it is also found from the materials on record that the complainant after getting information from o.p. to fulfill some queries, but those queries were not answered by the complainant, as such, the cashless benefit was not provided to the complainant’s father. Since there was no repudiation on the part of o.p. insurance company regarding the claim of the complainant, therefore though the schedule is over, but the complainant is given opportunity to place the further claim to o.p. for realization of the medical bills regarding the treatment of his father. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.635/2014 is allowed on contest without cost against the o.p. The complainant will be entitled to get the claim, if established properly to the o.p. insurance company and the o.p. should consider the claim of the complainant after following necessary norms as envisaged in case of disposal of the claim of the policy holder.
Supply certified copy of this order to the parties free of cost.
