BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD                                        :  PRESIDENT

SMT. R. SATHI                                         :  MEMBER

SMT. LIJU B. NAIR                                  : MEMBER

C.C. No. 344/2011 Filed on 04.11.2011

Dated: 31.07.2014

Complainant:

 

Anil. S, Asha Nikethan, Punnavoor, Koovalassery P.O, Thiruvananthapuram

 

                               (By adv. Sreeja Thulasi)

Opposite parties:

 

1. Bajaj Allianz Life Insurance Company Ltd., G.E. Plaza, Airport Road, Yerawada, Pune, Maharashtra-411 006.

         

2. The Branch Manager, Bajaj Allianz, Life Insurance Company Ltd., Arun Krishna Building, Near Sree Krishna Swamy Temple, Neyyattinkara, Thiruvananthapuram.

   (By adv. Sreevaraham G. Satheesh)

This C.C having been heard on 21.07.2014, the Forum on 31.07.2014 delivered the following:

ORDER

SRI. G. SIVAPRASAD:  PRESIDENT

The facts leading to filing of the complaint are that complainant was a medi-claim policy holder of the opposite party Bajaj Allianz Life Insurance Co. Ltd., vide policy No. 115246812 named ‘Family Care First’, that as per the terms all his family members are the beneficiaries of the cashless service facility across many hospitals under the coverage one lakh rupees, that the policy period was 05.12.2008 to 05.12.2011, that on 07.11.2009 complainant’s elder son Abhiram, aged 8 years was admitted in the NIMS Hospital, Neyyattinkara, due to severe fever, that complainant informed the office of the hospital regarding the mediclaim policy and gave his medicard, that from there the child was referred to KIMS Hospital for expert treatment on 10.11.2009, that before the discharge from NIMS the office of the hospital insisted for payment of bill amount of Rs. 3,642/- which the complainant was forced to give, that at KIMS the child was treated for 4 days, that though medicard was given to KIMS, opposite parties denied the cashless service and complainant was forced to pay an amount of Rs. 16,819.22.  Opposite parties denied the cashless service without any legally sustainable grounds.  There is clear violation of policy coverage which amounts to deficiency in service on the part of the opposite parties.  Hence this complaint to direct opposite parties to pay an amount of Rs. 20,461/- being the bill amount along with Rs. 1,00,000/- as compensation. 

The opposite parties, on being served, entered appearance and filed their version contending interalia that the complaint is premature since no formal claim has been lodged by the complainant before filing the complaint, that mere rejection of cashless request should not be construed as rejection of claim and opposite party had not provided with documents and claim form for medical reimbursement, that the cashless service lodged by the complainant through NIMS hospital was rejected by M/s Medicare, the third party administrators approved by IRDA.  The reason for rejection was that “it is apparent from the documents that the patient started having acute exacerbation of wheeze since 3 years of age and was on seroflo inhaler.  Hence the disease is pre-existing and the cashless is not approved”.  It is evident from the preliminary findings of the TPA that Master Abhiram was suffering from pre-existing disease which was not disclosed and hence claim was rejected at the time of cashless stage itself.  Complainant had approached this Forum with unclean hands by suppressing the truth and hence opposite party prayed for dismissal of the complaint with cost.        

The points that arise for consideration are:-

1. Whether the repudiation of claim is justifiable?

2. Whether there is deficiency in service on the part of opposite parties?

3. Whether the complainant is entitled to the reliefs as prayed for?

In support of the complaint, complainant has filed proof affidavit in lieu of chief examination as PW1 and has marked Exts. P1 to P9.  In rebuttal, the Deputy Manager (Operations) of the opposite party Divisional Office, Thiruvananthapuram has filed proof affidavit as DW1. 

Points (i) to (iii):- Admittedly, the complainant was a mediclaim policy holder of the opposite party vide policy No. 115246812.  Ext. P1 is the copy of the policy.  As per Ext. P1 the policy is named as Bajaj Alliance Family Care First.  The basic sum assured is Rs. 1,00,000/-.  The said policy is valid from 05.12.2008 to 05.12.2011 and the policy covers dependent members also.  The case of the complainant is that on 07.11.2009 his elder son Abhiram. A was admitted in the NIMS Hospital, Neyyattinkara due to severe fever, that complainant informed the office of the hospital regarding his mediclaim policy and gave his medicard.  Hospital authorities did not take any steps for payment under the coverage of the said policy rather they insisted for payment for bill amount of Rs. 3,642/-.  The patient was referred to KIMS hospital for expert treatment on 10.11.2009, that at the time of admission in the KIMS hospital also complainant submitted his medicard that the hospital officials reported the matter to the opposite party and opposite parties’ official came to the hospital for verification, that on 14.11.2011 the patient was discharged from KIMS hospital.  Since the opposite party denied the cashless service, complainant was forced to pay an amount of Rs. 16,819.22.  The very case of the complainant is that opposite parties denied the policy coverage on the ground that the child had been suffering from acute wheezing.  According to complainant the stand of the opposite party was strictly different from the medical report of the hospital that the child was treated for Bronchopneumonia.  Ext. P2 is the copy of the discharge summary issued by NIMS Hospital.  As per Ext. P2 8 years old child was admitted with:fever-6 days, vomiting – 1 day, no significant cough, tiredness (+) and known wheeze with good control.  As per Ext. P2 the diagnosis is viral fever.  Ext. P3 is the copy of the discharge summary issued by KIMS Hospital.  As per Ext. P3 discharge diagnosis: Acute exacerbation of wheeze (+) and Bronchopneumonia.  Ext. P4 is the copy of discharge bill for Rs. 3,642/- issued by NIMS.  Ext. P5 is the copies of cash receipts dated 10.11.2009, 06.12.2009 and 09.12.2009 for Rs. 3,000/-, Rs. 5,000/- and Rs. 2,085.29.  Ext. P8 series include the copies of the cash receipts dated 10.11.2009 for Rs. 250/-, cash receipt dated 13.11.2009 for Rs. 124.95, receipt dated 06.12.2009 for Rs. 100/-, bill dated 14.11.2009 for Rs. 13,177.22.  Complainant has claimed an amount of Rs. 3,642/- by Ext. P4 and an amount of Rs. 16,819.22 by Ext. P5 & P8.  Total amount claimed comes to Rs. 20,461/-.  Ext. P6 is the copy of the notice sent by the complainant to opposite parties.  Ext. P7 is the copy of the acknowledgement card.  Ext. P9 is the copy of the denial of cashless access dated 14.11.2009.  Complainant has been cross examined as PW1 by the opposite party.  During cross examination PW1 has deposed that he received e-mail from the opposite party, filled it and sent it to the opposite party.  PW1 deposed as required by the opposite party, he sent copy of the treatment records and bills to opposite party.  PW1 denied the suggestion put forward by the opposite party that PW1 never sent claim form and relevant treatment bills.  PW1 has added that he had given complaint against denial of cashless and sent claim form after discharge from the hospital.  When asked whether your son had wheezing, PW1 deposed that his son had wheezing at infant stage, but his son was admitted in NIMS Hospital with fever, without wheezing.  PW1 admitted that as per Ext. P3 diagnosis is acute exacerbation of wheeze.  PW1 deposed that soon after discharge from NIMS his son was admitted in KIMS, with high fever and pediatrician admitted his son in IC Unit, naturally in A/C, allergy-stricken patient would develop wheeze due to cold.  According to PW1 in Ext. P3 discharge summary bronchopneumonia is recorded, but bronchopneumonia is not pre-existing one.  It is a symptom of some disease.  Opposite party has led evidence by the oral testimony of DW1.  Opposite party has not produced any documents.  When asked about cashless facility, DW1 deposed, the insured need not pay any money at the time of admission or at the time of discharge, if approved by the TPA.  DW1 admitted that the policy in this complaint comes under a cashless facility.  DW1 admitted that only on intimation of a claim by the insured, TPA would visit the hospital and put forward the claim.  DW1 deposed that opposite parties have not received any documents.  Asked on what ground TPA denied the claim, DW1 said it was denied on pre-existing disease, on verification of documents. 

It is pertinent to point out that the patient was admitted in NIMS Hospital with high fever -6 days, that at that time, there was no wheezing problem.  According to complainant wheeze is not a disease, it is a symptom for many diseases.  When fever increased, the patient was referred to KIMS and at KIMS the doctor admitted the patient in ICU and naturally in A/C the allergy-stricken child would develop wheeze due to cold.  According to complainant wheeze is a symptom of several diseases.  There is no connection between wheeze and pneumonia.  Opposite party had denied the claim on the ground of pre-existing diseases.  It is the duty of the opposite party to seek expert opinion to show that bronchopneumonia is a pre-existing disease.  Opposite party has not taken any expert opinion to establish that the denial of cashless facility was on the ground of pre-existing disease.  The burden of proof would lay on the insurers (opposite party) to show that the patient was suffering pre-existing disease and justify grounds for denial of claim.  Opposite party has not produced any document to corroborate their stand.  Opinion of panel doctors was obtained.  It is pertinent to point that there is no whisper regarding bronchopneumonia in Ext. P2 discharge summary issued by NIMS.  Initially the patient was admitted in NIMS on 08.11.2009.  Later the patient was discharged and referred to KIMS.  As per Ext. P3 discharge summary bronchopneumonia is discharge diagnosis.  Complainant has produced electronic version of Starship Children’s Health Clinical Guidelines, wherein it has been mentioned that “pneumonia, bronchiolitis and asthma are all common illness that result in children presenting with acute lower respiratory symptoms and signs.  Antibiotics should be given to children with bacterial pneumonia but not to children with bronchiolitis or asthma”.  Complainant has also relied on the decisions of National Commission III (2010) CPJ 276 (NC) and I (2011) CPJ 216 (NC).  In both cases it was held that the onus to prove the facts to the contrary was on the insurer.  Herein insurer has not produced any documents, nor has insurer established that the disease is pre-existing.  Even Ext. P9, the copy of the denial of cashless access is illegible.  It is the duty of the opposite party to establish that there is connection between wheeze and pneumonia and the disease is pre-existing.  Opposite party failed to establish it.  Taking into consideration of all, we are of the view that denial of cashless facility is devoid of merits.  Repudiation of claim is not justifiable to the extent of which we find deficiency in service on the part of opposite parties.  Complainant is entitled to get Rs. 20,461/- as mediclaim amount with interest at the rate of 8% per annum from the date of complaint that is from 04.11.2011.

In the result, complaint is allowed in part.  Opposite parties are directed to pay to the complainant Rs. 20,461/- with interest at the rate of 8% per annum from 04.11.2011.  In facts and circumstances of the case, there will be no order as to compensation and cost.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room. 

          Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 31^st day of July 2014.

 

 

Sd/-

G. SIVAPRASAD                   : PRESIDENT

 

          Sd/-

R. SATHI                      : MEMBER

 

          Sd/-

                                                                        LIJU B. NAIR                : MEMBER

 

 

jb

 

 

 

 

 

C.C. No. 344/2011

APPENDIX

 

  I      COMPLAINANT’S WITNESS:

          PW1  - Anil. S

 II      COMPLAINANT’S DOCUMENTS:

          P1     - Copy of the policy

P2     - copy of discharge summary issued by NIMS Hospital

P3     - Copy of discharge summary issued by KIMS Hospital

P4     - Copy of discharge bill for Rs. 3,642/- issued by NIMS

P5     - Copies of cash receipt dated 10.11.2009, 06.12.2009 & 09.12.2009

P6     - Copy of letter dated 25.11.2009 issued by complainant

P7     - Copy of acknowledgement card

P8     - Copies of cash receipts dtd 10.11.09, 13.11.09, 06.12.09 & 14.11.09

P9     - Copy of denial of cashless access dated 14.11.2009.

III      OPPOSITE PARTY’S WITNESS:

          DW1 - Mallikarjuna Rao Borra

 IV     OPPOSITE PARTY’S DOCUMENTS:

NIL

 

                                                                                                     Sd/-

PRESIDENT

jb