Date of Filing      : 08.01.2021

                                                                                                                 Date of Disposal: 29.11.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                  .…. PRESIDENT

                 THIRU.P.MURUGAN,.MCom., ICWA(Inter)., B.L.,                                    ....MEMBER-II

  

CC. No.03/2021

THIS TUESDAY, THE 29th DAY OF NOVEMBER 2022

 

Mr.S.Anand, S/o.S.K.Shanmugham,

No.1, Pillaiyar Koil Street,

Siruvanur Village, Thirupachur Post,

Thiruvallur Taluk & District.                                                            .........Complainant. 

                                                                          //Vs//

 

1.HDFC ERGO General Insurance Company Limited,

   Old No.319, New No.4,

   Valluvar Kottam High Road,

   Nungambakkam, Chennai -600 034.

 

2.HDFC ERGO General Insurance Company Limited,

   Apollo Hospitals Complex,

   Hubliee Hills, Hybera bad -500 033.

   Telungana.

 

3.The Medical Superintendant,

   Metha Multispecialty Hospitals India Private Limited,

   No.2, Mc, Nichols Road, 3rd Lane,

   Chetpet, Chennai 600 031.                                                        ...Opposite parties.

 

Counsel for the complainant                              :   Mr.A.R.Poovannan, Advocate.

Counsel for the opposite parties 1&2               :   Mr.T.V.Suresh, Advocate.

Counsel for the 3rd opposite party                     :   M/s.V.Shankar, Advocate.

                         

This complaint is coming before us on various dates and finally on 21.11.2022 in the presence of Mr.A.R.Poovannan Advocate,  counsel for the complainant, Mr.T.V.Suresh Advocate, counsel for the opposite parties 1& 2 and M/s.V.Shankar Advocate counsel for the 3rd opposite party and upon perusing the documents and evidences of both sides, this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI,   PRESIDENT.

 

This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service in repudiation of medical insurance claim of the complainant along with a prayer to direct the opposite parties  to pay the complainant’s claim in policy No.140100/11121/AA00287792 with 12% interest and to pay  a sum of Rs.1,00,000/- towards compensation for the mental agony and hardship caused to the complainant due to the deficiency in service on the part of the opposite parties and to pay a sum of Rs.5,000/- as cost of the complaint. 

Summary of facts culminating into complaint:-

 

It was submitted by the complainant that he took a policy for himself and his family with the 2nd opposite party for a sum of Rs.5,00,000/- on 11.09.2015 by paying an Annual premium of Rs.14,346.90/-.  The policy document was issued to the complainant on 13.09.2015 vide policy No.140100/11121/AA00287792 for a period commencing from 11.09.2015 to 10.09.2016. The policy was periodically renewed by the complainant and during the last week of September 2019 the complainant fell sick, consulted his doctor and got admitted on 06.10.2019 with the 3rd opposite party hospital in IP No.47977.  The complainant was in hospital till 10.10.2019 until that date no queries were raised about the Medical Insurance Policy by the 2nd opposite party.  However, all of sudden on 06,00pm on 10.10.2019 it was informed that the Insurance Company had declined the complainant’s claim.  The complainant sent Discharge Summary and the Medical Bills to the 1st opposite party to process his claim but there was no reply from the opposite party. The complainant paid Rs.48,736/- and got discharged from the 3rd opposite party.  The repudiation of insurance claim by the 2nd opposite party on the ground that the complainant had same ailment 12 years back is not correct as he had only decrease in WBC counts before 12years.  Further the complainant is not having any proof of the treatment he had 12 years back, thus the 3rd opposite party’s action in not furnishing the correct details and also not forwarding the claim in time and the 2nd opposite party in repudiating the claim on vague reasons amounts to gross deficiency in service. Thus aggrieved by the act of the opposite parties the present complaint was filed for the following reliefs as mentioned below;

To direct the opposite parties to pay the complainant’s claim in policy No.140100/11121/AA00287792 with 12% interest; 

To pay  a sum of Rs.1,00,000/- towards compensation for the mental agony and hardship caused to the complainant due to the deficiency in service on the part of the opposite parties;

 To pay a sum of Rs.5,000/- as cost of the complaint. 

Crux of the defence put forth by the opposite parties 1& 2:-

It is admitted by the 1st and 2nd opposite parties with respect to taking of policy by the complainant and existence of policy at the time of incident.  Further availing cashless claim request for an estimated amount of Rs. 2,27,050/- for the hospitalization of the complainant with the 3rd opposite party is also not disputed.  However, on evaluation of initial documents submitted by the complainant it was noted that the complainant had history of Anemia 12 years back and a query letter was sent to the complainant to provide the treating Doctor Certificate for past history duration diagnosis and Treatment details of Anemia underwent 12 years back for the proper assessment of the claim.  As the said information was not provided by the complainant the claim was rejected vide letter dated 10.10.2019 and the reason was given as follows; Cash less facility cannot be granted as the required information/documents has not been provided by the Insured to decide admissibility.  However, insured can file the claim for reimbursement post completion of the treatment with all medical reimbursement post completion of the treatment with all medical & financial records.  The admissibility of the claim would be decided past review of the documents and policy conditions.  Kindly provide treating Doctor Certificate for post history duration diagnosis & treatment details of Anemia underwent 12 years back. (As per preauth patient had history of Anemia 12 years back). Hence it was submitted that the cash less facility was denied only accordance with the terms and conditions of the policy.  Without taking efforts to provide the said documents the complainant had preferred the present complaint and therefore contended that there is no deficiency in service on the part of the opposite parties 1 & 2 and they sought for the complaint to be dismissed.

Crux of the defence put forth by the 3rd opposite party :-

The 3rd opposite party filed version stating that seeking direction against them is a mala fide action sought for dismissal of complaint contending inter alia that the complainant visited the 3rd opposite party hospital on 06.10.2019 with complaint of breathlessness of exertion for one week, pain in shoulders and back and informed the 3rd opposite party that he had similar complaints before 12 years and was treated in Billroth Hospital.  It was also informed that the complainant had taken medical claim policy with the 1st opposite party but when asked to submit the documents the complainant did not submitted any documents.  The 3rd opposite party’s role was limited to the extent of facilitating between the complainant and the 1st opposite party as the matter of propriety and not supposed to disclose the result of the claim to the patients unless and until the 1st opposite party informs the 3rd opposite party about the result of the claim. As the 1st opposite party denied the medical claim of the complainant the 3rd opposite party received the payment directly from the complainant.  The 3rd opposite party was not aware about the complainant submitting his claim to the 1st opposite party nor its outcome.  Thus submitting that there is no cause of action for the complaint they sought for the dismissal of the complaint. 

The complainant has filed proof affidavit and documents Ex.A1 to Ex.12 were marked on their side.  On the side of opposite parties 1 & 2 proof affidavit was filed and documents Ex.B1to Ex.B4 were filed by them.  Though proof affidavit was filed by the opposite parties 1 & 2 they did not file any written arguments and adduce oral arguments on their side.  The 3rd opposite party filed proof affidavit but no documents were filed. 

Point for consideration:-

Whether the act repudiation of claim by the opposite parties 1& 2 on the ground of non submission of treatment summary relating to complainant’s ailment 12 years back amounts to deficiency in service and whether the deficiency in service against the opposite parties 1 to 3 has been successfully proved by the complainant with admissible evidence?

If so to what relief the complainant is entitled?

Point:1

On the side of the complainant the following documents were filed in support of the complaint allegations;

Request Form dated 09.10.2019 was marked as Ex.A1;

Letter of Denial of Cashless service dated 10.10.2019 was marked as Ex.A2;

Discharge Summary dated 10.10.2019 was marked as Ex.A3;

Cash bills & Receipts dated 10.10.2019 was marked as Ex.A4;

Certificate of Insurance was marked as Ex.A5;

Legal notice issued by the complainant to the opposite parties dated 04.11.2019 was marked as Ex.A6;

 Reply from the 3rd opposite party dated 12.11.2019 was marked as Ex.A7;

Reply from the 2nd opposite party dated 14.12.2019 was marked as Ex.A8;

Legal notice to the opposite party dated 14.02.2020 was marked as Ex.A9;

Acknowledgement card for proof of delivery was marked as Ex.A10;

Discharge Summary from Aravind Hospital dated 05.08.2020 was marked as Ex.A11;

Final Bill from Aravind Hospital dated 05.08.202020 was marked as Ex.A12;

On the side of opposite parties 1 & 2 the following documents were filed in support of their defence;

The copy of the certificate of incorporation issued by the Registrar of Companies, Mumbai mentioning the change of name of the opposite party company was marked as Ex.B1;

Copy of proposal form was marked as Ex.B2;

Copy of policy schedule along with policy bond was marked as Ex.B3;

Copy of claim form, medical document and claim rejection letter was marked as Ex.B4;

  Heard the oral arguments of learned counsels appearing for both the parties and perused the pleadings and material evidences submitted by them.  The crux of the oral arguments is that the complainant had not made any claim till the year 2019 and that the complainant was admitted by the 3rd opposite party hospital from 06.10.2019 to 10.10.2019.  In the interregnum period the 3rd opposite party did not ask for any payment apart from the advance payment of Rs.10,000/- made at the time of admission.  Only at the time of discharge all of a sudden the hospital authorities started saying that the insurance claim was not cleared and that they are waiting.  Hence with great difficulty the complainant paid Rs.48,736/-and got discharged from 3rd opposite party.  When a legal notice was issued to the opposite parties 2 & 3, the complainant insisted to approach the local Branch for reimbursement and the complainant sent the Discharge Summary and Medical Bills to the 1st opposite party to process the claim.  However, there was no reply till date. Further the repudiation of Medi claim by the 2nd opposite party on the ground that the complainant had similar ailment 12 years is not correct and also that the complainant underwent LE-ARSPLANA VITRECTOMY (PPV) surgery on 04.08.2020 and the pre operative sanction for the same was denied by the opposite parties 1 & 2.  Thus for the subsequent surgery the complainant had spent Rs.30,600/- in spite of having insurance. It was further argued that before 12 years he took treatment in Billroth Hospital and that the 3rd opposite party did not give the details of the said treatment.  Thus it was argued that all the opposite parties had committed deficiency in service in honouring the claim and in not taking effective steps for the medical insurance reimbursement.

On the other hand it was argued by the opposite parties 1 & 2 that the claim of the complainant itself is a pre matured claim.  The claim was not repudiated by them till today, it was kept pending for want of certain additional documents. Only when the documents were produced they could process the claim and thus the opposite parties sought for the complaint to be dismissed.

On the other hand the 3rd opposite party submitted that the pleadings by the complainant that the 3rd opposite party Doctor had not furnished the correct details of treatment was false.  Further the complaint averments that the 3rd opposite party did not forwarded the claim in time and hence the 2nd opposite party did not honour the claim could not be accepted as the 3rd opposite party is a person acting between the insurer and the insured.  He relied upon Ex.A2 and submitted that they were no way responsible for the repudiation of the claim.  He also relied upon Ex.A3 the Discharge Summary issued by them and stated that for similar complaint complainant was treated 12 years ago in Billroth Hospital.  Further he also relied upon Ex.B4 the letter dated 10.10.2019 and contended that they have already informed to the insurance department that the past records for similar complaints were not available with them and thus sought for the dismissal of the complaint.

On appreciation of the available documents and pleadings it is seen that taking of policy by the complainant with the opposite parties 1 & 2 is not disputed.  Further the treatment taken by the complainant is also not disputed. Only issue to be decided by this commission is that whether the complainant is entitled for reimbursement of the medi claim.  It is seen that the opposite parties 1 & 2 had rejected the claim for non production of documents relating to the treatment taken by the complainant 12 years back with Billroth Hospital.  When the document is sought by the insurance company, it is submitted by the 3rd opposite party that they were not in a possession of any past records of similar complaint with them. Further the complainant also submitted that 12 years ago he took treatment only for lack of WBC and not for any similar aliment of treatment taken at present by having admitted for five days with the 3rd opposite party.  Thus the non-reimbursement of the claim by the opposite parties 1 & 2 terming the claim as pre matured claim is a clear deficiency in service and unfair trade practice as it is evident that the required documents is of nature which could not be or unable to be produced by the complainant.  Hence the complainant cannot made to suffer for no reason.  Hence we are of the view that the non reimbursement of the insurance claim by the opposite parties 1 & 2 clearly amounted to deficiency in service. 

Negligence against 3rd opposite party:-

 Further the contention of the complainant that he was not approached for any information with regard to payment until the date discharge on 10.10.2019 by the 3rd opposite party also has to be taken in to account.  If at all the 3rd opposite party had initiated and sought for the insurance claim approval at the time of admission of the complainant, the complainant ought not have suffered at the last moment by rejection of the medi claim by the opposite parties 1 & 2.  In such circumstances when no proof was submitted by the 3rd opposite party to show that they had initiated steps appropriately even before 10.10.2019 for getting the approval of the insurance claim of the complainant.  Thus we hold that the 3rd opposite party has also committed deficiency in service on their part.  Thus we answer the point accordingly in favour of the complainant and as against the opposite parties 1 to 3.

Point No.2:-

With regard to the relief to be granted to the complainant as we have held above that the opposite parties 1 to 3 had committed deficiency in service in non reimbursement of the medi claim to the complainant, we direct the 3rd opposite party to provide the available necessary details to the opposite parties 1 & 2 and to direct the opposite parties 1 & 2 to process the claim of the complainant within four weeks from the date of receipt of copy of this order on the available documents.  We also direct the opposite parties 1 & 2 not to seek for any other unrelated/unavailable documents from the complainant for processing the claim.  Further we direct the opposite parties 1 to 3 jointly to pay a sum of Rs.25,000/- towards compensation for the mental agony and hardship caused to the complainant and we also award Rs.5,000/- towards cost of the proceedings to the complainant.

In the result the complaint is partly allowed against the opposite parties 1 to 3 directing them

a) Direct the 3rd opposite party to provide the available required details to the opposite parties 1 & 2 and opposite parties 1 & 2 to process the claim of complainant within six weeks from the date of receipt of copy of this order;

b) To pay a sum of Rs.25,000/- towards compensation for the mental agony and hardship caused to the complainant;

c) To pay a sum of Rs.5,000/- towards litigation expenses to the complainant.  

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 29th day of November 2022.

 

    Sd/-                                                                                                                  Sd/-

MEMBER-II                                                                                                    PRESIDENT

 

List of document filed by the complainant:-

 

Ex.A1 09.10.2019 Request form. Xerox

Ex.A2 10.10.2019 Letter of Denial for Cash less Service. Xerox

Ex.A3 10.10.2019 Discharge Summary. Xerox

Ex.A4 10.10.2019 Cash Bills & Receipts. Xerox

Ex.A5 ............... Certificate of Insurance. Xerox

Ex.A6 04.11.2019 Legal notice to the oppostie party. Xerox

Ex.A7 12.11.2019 Reply from 3rd opposite party. Xerox

Ex.A8 14.12.2020 Reply from the 2nd opposite party. Xerox

Ex.A9 14.02.2020 Legal notice to opposite party. Xerox

Ex.A10 .............. Acknowledgement card. Xerox

Ex.A11 05.08.2020 Discharge Summary form Aravind Hospital. Xerox

Ex.A12 05.08.2020 Final Bill from Aravind Hospital. Xerox

 

List of documents filed by the opposite parties 1& 2:-

 

Ex.B1 ............... The copy of the certificate of incorporation issued by the Registrar of Companies, Mumbai mentioning the change of name of the opposite party company. Xerox

Ex.B2 ................. Copy of proposal form. Xerox

Ex.B3 ............... Copy of policy schedule along with policy bond. Xerox

Ex.B4 ............ ... Copy of claim form, medical document and claim rejection letter. Xerox

 

List of documents filed by the 3rd opposite party:-

 

-Nil-

 

  Sd/-                                                                                                                      Sd/-

MEMBER-II                                                                                                    PRESIDENT