Sri Rama Chandra Das, President : - This complainant filed this complaint under section 12 of C.P Act to direct the O.P for payment of Rs.18,311/- under health insurance, Rs.50000/- as compensation for mental agony and Rs.10,000/- for litigation cost.
The complainant case is that he opened a Medi-claim policy bearing no.163203/48/12/8500000381 on 30.10.2012 for sum assured Rs.30,000/- for the period from 30.10.12 to 29.10.2013 on payment of net premium of Rs.600/- covering him, his wife Laxmipriya Sahoo, Son Saikrishna and mother Banalata Sahoo and obtained Insurance Bond . While the policy is in force , on 23.1.2013 his wife due to sickness get checked in SUM HOSPITAL with various test and the Dr. B. Padhy opined Fibroadonoma in Right Breast so she was admitted in the said hospital for operation and treatment from 3.2.2013 to 7.2.2013. During the treatment the complainant requested the O.P for grant of Madi claim but the O.P did not listen. During. During hospitalization he spent Rs.8311/- and other expenditure of Rs.10,000//- totaling Rs.18,311/-. After discharge on 07.02.2013 his wife was under treatment and bed rest in his residence on the advise of the doctor. After her improvement the complainant on 20.3. 2013 applied for Mediclaim with all medical documents but his claim not allowed . On 19..11.2013 he requested the O.P through Registered Post but in vein Hence he filed this complainant with the prayer as mentioned above.
The O.P filed the written version stating that the complaint is bad for non- joinder of Third party Administrator (TPA Pvt Ltd ) who is the necessary party the complainant has obtained the policy by suppressing the disease of his wife. There was no cause of action to file this complaint. The complainant never visited to O.P office for payment towards treatment of his wife while at SUM Hospital. Only on 20.3.2013 the complainant collected the Hospitalization benefit policy claim and submitted the filed up form which was forwarded to Dedicated Health Services TPA (India) Pvt Ltd to process the claim. The DHS, TPA (India) Pvt Ltd issued a letter on 24.10.13 to clarify the delay information regarding treatment of his wife Laxmipriya Sahoo but no reply received. Again 2nd reminder was sent on 25.11.2013 regarding late submission of claim documents but the complainant did not co-operate. Lastly the claim of the complainant was closed on 02.1.2014. The wife of the complainant was admitted in the Hospital on 03.2.2013 and was discharged on 07.02.2013 but intimated to the office on 20.3.20123 violating the policy condition as per rule 5.3 of universal Health insurance policy . The O.P ha no deficiency in rendering service to the complainant and is no way liable to pay the compensation and litigation expenses as well as for the treatment expenditure . On the above facts the complainant may be dismissed with cost.
On the above averments of the parties the following issues needs for consideration in adjudicating of the case.
1. Whether the complainant has no cause of action to file the complaint and it is bad for non-joinder of TPA (India) Pvt Ltd
2. Whether the complainant has violated the condition as per Universal Health Insurance Policy ?
3. Whether the complainant is entitled for the medical expenditure of Rs.18,311/-, compensation Rs.50,000/- and litigation cost 10,000/- due to deficiency of service of the O.P ?
The complainant filed his evidence on affidavit land relied upon the xerox copies of the documents filed with the complaint as per Annexure -1 to 34. The B.M Bramhananda Barik the O.p filedlhis evidence on affidavit and relied upon the xerox copies of the documents and policy schedule filed as per the list dated 04.04.2014.
DECISIONS
Issue No.2 to 3 : - It is admitted by the O.P in his evidence that the complainant, his wife, son and mother have been issued with Universal Health Insurance policy Bond for the period form 30.10.2012 to 29.10 2013 The dedicated Health care Services is licensed by the Insurance Regulatory and Development Authority as Third party Administrator to decide the claims on behalf of the company airsing out of the Universal health Insurance policy. In the event of any claim become admissible under the scheme the company will pay through TPA to the Hospital or the insured person. The complainant did not give information during period of illness of Laxmipriya Sahoo at SUM Hospital , Bhubaneswsar to the Dedicated Health Insurance Service within the stipulated period and did not submit suitable reason for delay. The xerox copy of the claim form filed by the O.P shows that it is submitted in its office on 20.3.13 and was forwarded to Dedicated Health care Services TPA (I) Pvt Ltd received on 26.9.2013. The DHS TPA (India) Pvt Ltd issued a deficiency letter dated 24.10.13 confirming that they have received claim documents forwarded by you pertaining the captioned claim and made querry regarding reason for late submission of claim form above 30 days from the date of discharge i.e. 07.2.2013.
As per the complainant in his complaint at para -6 mentioned that on 19.11.2013 sent a letter to the O.P through Registered post to allow this claim. The said letter has been annexed as Annexure – 4 and the postal receipt as Annexure-1. In the said letter at page -2 para-2 the complainant has explained that his wife was discharged on 07.2.2013 from Medical and was under the treatment in his residence as per the advice of the doctor and when her condition developed he applied for the Medi-claim on 20.3.2013. Since this letter was addressed to the O.P and sent to him by Regd. Post the O.P be must have received that letter and it was his duty to forward the same to Dedicated health care Services as he had already forwarded the medi-claim form. Since this letter was not forwarded to the Dedicated Health care Services, the said organisation issued 2nd reminder on 25.11.13, deficiency letter on 26.11.13 and closure letter on 02.1.2014. The deficiency letter dated 24.10.2013, 2nd reminder on 25.11.2013 deficiency letter on 26.11.13 and closure letter on 02.1.2014 are not received by the complainant. No documents is produced to show that these letter were received by the complainant. The complainant sou-moto has submitted his explanation on 19.11.2013 by Regd. Post to the O.P who did not forwarded the same to the Dedicated Health care Services. Had it been sent to this organisation the medi-claim could have been allowed in favour of the complainant. As per Rule 5.5.(NOTE) of Universal Health insurance policy it envisage that “ waiver of this condition may be considered in extreme cases of hardship. Where it is proved to the satisfaction of the TPA/ company that under the circumstances which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time limit ” The reason of delay mentioned in the letter dated 19.11.2013 of the complainant has not been considered by the O.P nor forwarded to Dedicated Health care Services which proves deficiency of service on his part towards the complainant and the O.P is liable to pay the medical expenditure,compensation and litigation cost to the complainant.
Issue No.1 : - The complainant was issued with the policy bond under Annexure-2 which does not show that the terms and condition of Health Insurance policy schedule will apply nor a copy of it was attached with the insurance bond. Therefore the complainant is not obliged to follow the instruction as mentioned in the policy schedule. Since the claim, of the complaint was not materialized there was cause of action for him to file the complaint. The complainant made contract with the O.P while getting the insurance Bond but has no privity with Dedicated Health care Services so the Dedicate Health care Service TPA (I) Pvt Ltd is not a necessary party.
Hence we order
ORDER
The complaint is allowed on contest . The O.P is directed to pay the Medical expenditure of Rs.18,311/- , compensation of Rs.5,000/- and litigation cost of Rs.1000/- to the complainant within one month from the date of this order failing which the complainant may adhere to the procedure under section 27 of C. P. Act.
The final order is prepared by us, corrected,
signed, sealed and pronounced in the open
Forum on this 25th April, 2014.
