By Sri. MOHANDASAN.K, PRESIDENT
Case of the complaint is as follows:-
1. The complainant is part of medisep insurance scheme. As per the policy No.441200/48/2023/275 the complainant along with her husband Abdul Kalam Azad, Children Amal bin Azad and Aflah Azad and Adlan Azad are members in the scheme. The son of complainant Sri. Adlan Azad was admitted in the first opposite party hospital on 30/12/2023 due to ailment and he was discharged on 01/012024. During the hospitalization there was various clinical examination of the patient. At the time of discharge the first opposite party issued bill for 11,264/- rupees and asked to pay Rs.6, 000/- in advance. The complainant remitted 6,000/- rupees. It was assured to refund while the medisep insurance company approve the claim. But later two days it was informed insurance company denied the insurance claim. While the complainant enquired before the insurance company then it was advised to register a complaint and accordingly on 03/01/2024 a complaint was registered as ticket ID MG 15421.
2. Complainant submitted that subsequent to that there was no response from the insurance company. Hence the complainant prayed for the refund of 11,264/- rupees along with compensation of 50,000/-rupees and cost of Rs. 5,000/.
3. On admission of the complaint notice was issued to the opposite parties and on receipt of the notice the first opposite party entered appearance and filed version.
4. The first opposite party admitted that Sri. Adlan Azad M D was admitted to the first opposite party hospital with the diagnosis of lover respiratory tract infection (LRTI) on 30/12/2023 and after receiving appropriate treatment he was discharged on 01/01/2024.
5. The opposite party submitted that they submitted insurance claims on the behalf of the patient but they did not get approval from the oriental insurance company. It is submitted that they are acting merely as intermediaries between the insurance company and the patient. The first opposite party have no authority to approve or reject insurance claims independently. Instead they rely on decisions made by the insurance company after assessing the patient’s symptoms in consultation with the treating physician and obtaining the appropriate medisep package. The opposite party further submitted that despite excellent health care within their facility they have encountered instances where approval from the insurance company could not be obtained resultantly caused inconveniences to the patients and the complainant. It is submitted if the insurance company reconsider and approve the claim they are dedicated to promptly refunding the billed amount to the patient.
6. The complainant filed affidavit and documents. The opposite parties did not file affidavit and documents. The documents of the complainant marked as Ext. A1 to A4. Ext. A1 is copy of discharge card. Ext. A2 is copy of discharge bill. Ext. A3 is copy of medisep card. Ext. A4 is copy of complaint registered ticket ID MG 15421-CL.
7. Heard complainant, perused affidavit and documents. There is no contra evidence against the case of complainant.
8. The case of the complainant is that her son was admitted in the hospital on 30/12/202023 and discharged on 01/01/2024. Ext. A1 discharge care reveals the same. 9. The complainant submitted that she paid an advance amount of Rs. 6,000/- on 01/01/2024 which substantiated Ext.A2 discharge bill. The complainant submitted that a complaint was registered for the denial of the insurance benefit which is proved through Ext. A4. Ext. A4 reveals the claim of the complainant was rejected stating that IP care not justified and also the claim rejected. So the case of the complainant stands proved through Ext. A1 to A4. It is evident from Ext. A4 that the claim was denied due to admission was not justified according to the opposite party. But it is a fact that admission is not the desecration of the patient but the decision of the treating doctor. In this complainant it can be seen that the patient was admitted as per advice of the doctor. So there is no justification for denied of insurance benefit stating the admission is not justified. The Commission finds the act of the opposite party as deficiency in service and unfair trade practice. It appears the complainant is entitled refund of advance amount paid by the complainant. Ext. A2 shows the complainant paid an advance amount of 6,000 rupees to the first opposite party. Hence the Commission finds that the insurance company, the second opposite party is liable to pay Rs. 6,000/-, the advance amount paid towards the treatment. The complainant prayed compensation of Rs. 50,000/- and cost of Rs.5, 000/-. The commission allow Rs. 10,000/- towards compensation on account of deficiency in service and unfair trade practice and thereby caused inconvenience and hardship to the complainant. The complainant also entitled cost of Rs. 3,000/-.
In the light of above fact and circumstances the complaint stands allowed as follows:-
- The second opposite party is directed to pay Rs. 6,000/- (Rupees six thousand only) to the complainant on account of treatment expenses.
- The second opposite party is directed to pay Rs. 10,000/- (Rupees ten thousand only) to the complainant as compensation on account of deficiency in service and unfair trade practice and thereby caused inconvenience and hardship to the complainant.
- The second opposite party is directed to pay Rs. 3,000/- (Rupees three thousand only) to the complainant as cost of the proceedings.
The second opposite party shall comply this order within one month from the date of receipt of copy of this order, failing which the complainant is entitled interest at the rate of 9% per annum from the date of order to till date of payment.
Dated this 30th day of September, 2024.
Mohandasan. K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1 to A4
Ext.A1: Copy of discharge card.
Ext.A2: Copy of discharge bill.
Ext A3: Copy of medisep card.
Ext A4: Copy of complaint registered ticket ID MG 15421-CL.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Nil
Mohandasan. K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
