DOF.14.1.2009 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 7th day of April 2010 CC.16/2009 Philip Parekattu, Parekattu House, Thirumeni.P.O. (Rep. by Adv.A.S.Thomas Smith) Complainant 1. Branch Manger, M/s.National Insurance Company Ltd., Branch office, P.B.No.32, 1st floor, Perumal Buildings, Opposite parties Perumba, Payyannur (Rep. by Adv.V.K.Rajeev) 2. M/s.Assit India Pvt.Ltd., No.406, Chandralayam Kursupally Road, Temple Lane, Ravipuram, Kochi 682 015. O R D E R Sri.K.Gopalan, President This is a complaint filed under section 12 of consumer protection Act for an order directing the opposite party to pay Rs.14, 988/- with interest @12% from 10.11.08 till date of payment and a sum of Rs.50, 000/- as compensation with cost of these proceedings. The case of the complainant in brief is as follows: The complainant is having a medi claim policy with 1st opposite party which has validity up to 7.5.09. 2nd opposite party is the 3rd party Administrator of 1st opposite party. The sum insured is Rs.1, 50,000/-. He has paid an amount of Rs.4, 656/- as premium. The complainant was admitted in the KMC Hospital on 4.11.08 for his treatment of wrist strain with cellulites and discharged on 10.11.08. The hospital is a network hospital, in which the insured persons, who are opted third party Administrators services of the 1st opposite party, can avail cash less facility by showing the identity card issued by the opposite party. Hospital authorities obtained copies of the relevant documents on showing the identity card and forwarded an estimated bill for Rs.14, 000/- to the 2nd opposite party. It was informed to complainant also. After the submission of the claim by the hospital authorities the treatment has been done. But at the time of discharge complainant was informed that the claim has been ejected without any reason and they did not give cash less facility. Complainant paid the bill and thereafter, submitted a claim of Rs.14, 988/- along with interest at the rate of 12% and a sum of Rs.50, 000/- as compensation. It was sent through registered letter dt.11.12.08 before 1st opposite party. The same also was not considered. It is against policy conditions. The main reason to choose the KMC hospital is that they are included in the list of the net work hospital from where the policy holder can avail cashless facility. Due to rejection of claim he suffered much trouble to arrange required amount to pay the bill. The complainant could only clear the bill only after arriving the relatives from Cherupuzha by vehicle. The rejection of cashless facility is illegal and without any reason. Complainant there by sustained huge loss. There is clear deficiency of service on the part of opposite parties. Hence this complaint. Pursuant to the notice 1st opposite party entered appearance and 2nd opposite party remained absent through out. 1st opposite party filed version contending that the complaint is not maintainable. The 2nd opposite party had already satisfied the claim of the complainant by reimbursing him the medical expenses by paying him Rs.14, 403/- on the basis of medical records and the bills and receipts furnished by the complainant to 2nd opposite party. It is true that the 1st opposite party had issued a Hospitalization benefit policy to the complainant and 2nd opposite party is the 3rd party Administrator. But 1st opposite party cannot be liable since the complainant had not complied with the conditions under clause 10 of Insurance policy. According to clause 10” pre authorization for cashless secure service in net work hospital/nursing home is within the authority of the T.P.A and will be given after verification of the required documents pertaining to treatment of the insured to the satisfaction of the T.P.A. Complainant had not properly understood the nature and pre-requisites for claiming the cashless Access service provided in the policy. Complainant is under the impression that by showing identity card in the net work hospital by itself is sufficient to claim the cashless service from T.P.A. It is not correct. Clause 10 says that the claim has to be through the list net work hospital and is subjected to a pre-admission authorization from the T.P.A and only if the T.P.A itself is satisfied they need to issue a pre authorization letter/guarantee of payment to the hospital mentioning the sum guaranteed as payable. It is understood that T.P.A in the above case had not granted pre-authorization to the complainant since neither the insured nor the hospital had furnished the related medical records to them. Hence the T.P.A had initially rejected the claim and informed the insured through the hospital to pay the amount to the hospital and then to submit the medical records and bills so as to enable the T.P.A to make them possible to reimburse the same. T.P.A can disallow the claim initially as per the clause 10 of the policy conditions. The T.P.A has already reimbursed the amount Rs.14, 403/- to the complainant. Therefore, complainant is neither entitled for interest nor for compensation. Hence to dismiss the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency in service on the part of opposite parties? 2. Whether the complainant is entitled for the relief as prayed for? 3. Relief and cost. The evidence consist of the oral evidence of Pw1 and documentary evidence Exts.A1 to A6 on the side of the complainant and oral evidence of DW1 and documentary evidence B1 and B2 marked on the side of the opposite parties. Issues1 to 3 Admittedly complainant is a Medi claim policy holder having the validity of policy up to 7.5.09. 2nd opposite party is the 3rd party administrator of 1st opposite party, National Insurance company Ltd. 1st opposite arty has admitted that hospitalization benefit policy had been issued to complainant by them. Complainant’s case is that while admitting in the hospital he has requested for cashless facility by showing his identity card and other documents. The hospital authorities obtained relevant documents from him and forwarded an estimated bill for Rs.14, 000/- to 2nd opposite party along with the medical details on 5.11.08. It was informed to the insured also. After subs\mission of the estimated claim the treatment has been started. These facts were not denied by 1st opposite party. The further case of complainant is that at the time of discharge hospital authorities handed over a photo copy of the letter dt.10.11.08 addressed to hospital authorities by 2nd opposite party wherein it was informed that the claim submitted by them has been rejected. Complainant thus compelled to pay the bill. The case of the opposite party on the other hand is that the TPA had initially rejected the claim since the complainant had not complied with the conditions under clause 10 of the insurance policy. Exts.B2 is the Medi claim Insurance policy. Clause 10 of the policy under the sub heading ‘procedure for awaiting cashless Access services in Net work Hospital/Nursing home” reads thus: “ Claims in respect of cashless Access services will be through the list of the net work of Hospitals/Nursing Homes and is subjected to pre admission authorisation. The TPA shall upon getting the related medical information from the insured persons/Net work provide, verify that the person is eligible to claim under the policy and after satisfying itself will issue a pre authorization letter/guarantee of payment letter to the Hospital/Nursing Home mentioning the sum guaranteed as payable, also the ailment for which the person is seeking to be admitted as a patient”. The next stage says that “The TPA reserves the right to deny pre-authorization in case the insured person is unable to provide the relevant medical details as required by the TPA. The last stanza under the same heading is also important to take in to account. It reads thus; “pre authorization for cashless access services in Net work hospital/Nursing home is within the authority of TPA and will be given after verification of required documents pertaining treatment of the insured to the satisfaction of TPA”. Hence it is clear by clause 10 that 2nd opposite arty TPA have the right to deny the pre authorization in case the insured is unable to provide the relevant medical records as required by TPA. Hence deficiency in service on the part of opposite parties can only be proved by the evidence showing that relevant medical records has been provided to TPA or else complainant should explain with supporting evidence that the complainant had taken sufficient measures to obtain a preauthorization letter to undergo the treatment and avail cashless benefit from the hospital. Complainant pleaded that while admitting in the hospital he requested the hospital authority’s cashless facility by showing his identity card. Here arose the question what more he has done over and above showing identity card. Complainant says that hospital authorities obtained documents and forwarded an estimated bill to 2nd opposite party. The burden lies upon the complainant to show that he has taken sufficient measures to make assure that the entire relevant document made available to 2nd opposite party. In chief affidavit he has repeated the same thing what he has pleaded in complaint. What all documents hospital authorities had forwarded to2nd opposite party is not clear. The specific case of 2nd opposite party is that the complainant failed to place relevant documents before them. Then it is his burden to prove that the entire relevant document has made available to 2nd opposite party. Complainant deposed in his cross examination that “ Rm³ t\cn«v 2 nd opposite party ¡v cashless benefit\p {]tX-y-In-¨v- A-t]£ sImSp-¯n-«n-Ã. “There is no evidence to show that the complainant has taken sufficient measures to place required relevant documents before 2nd opposite party. What has done by the hospital authorities is also not clear. Without taking pre admission authorization complainant is not entitled to get cash less facility. It can be seen that the complaint ;had not taken a pre admission authorisation from 2nd opposite party which is a mandatory condition of the insurance policy provided in clause 10 of the terms and conditions. The case of the opposite parties is that neither the hospital nor the complainant had furnished documents to the satisfaction of the third party administrators so as to enable them to issue a pre-admission authorisation letter to complainant. Complainant is not able to place any evidence to show that he had furnished required documents to 2nd opposite party under such situation it is difficult to find fault with 2nd opposite party in disallowing the claims initially. Anyhow it can be seen that TPOA had already reimbursed the medical expenses as per the terms of the policy by paying the complainant Rs.14, 403/-. Thus the grievances of the complaint are not that of medical expenses but of cashless facility. Since the complainant has failed to prove that the has done necessary prerequisites to make available that required relevant document of treatment to 2nd opposite party as per the clause 10 of the policy, opposite parties cannot be charged with deficiency in service. Hence we are of opening that complainant is not succeeded in establishing his case entitling him for any relief. The issues 1 to 3 are found against complainant. In the result, the complaint is dismissed. No cost. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.Copy of the policy certificate issued by OP A2.Copy of discharge summary issued from KMC Hospital A3.copyh of the letter issued by2nd OP to the hospital authorities A4.copyh of the registered letter sent to 1st OP A5.Copy of the settlement advice issued by 2nd oP A6.Copy of the cash bill issued from KMC,Mangalore Exhibits for the opposite parties B1.Copy of the claim form submitted by complainant B2.Copy of the medi claim policy with conditions Witness examined for the complainant PW1.Complainannt Witness examined for the opposite parties DW1.t.A.Sankarankutty /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur
| | HONORABLE PREETHAKUMARI.K.P, Member | HONORABLE GOPALAN.K, PRESIDENT | HONORABLE JESSY.M.D, Member | | 
