By Jayasree Kallat, Member The case of the complainant is that complainant’s daughter Bini had a fall in the bath room at 10 P.M. on 31-7-06. She fell unconscious after a few minutes she retained her consciousness, but she felt that her vision going dim and felt discomforts. So she was taken to National Hospital, Kozhikode where the complainant could claim cashless treatment as per the medi claim insurance policy taken by the complainant. Complainant’s daughter Bini was admitted in the opposite party-2 hospital from where C.T. Scan, E.C.G., E.E.G.and Ultra Sound scanning were done. She was examined by several Doctors and found that there was no serious matter concerning the patient. Hence she was discharged on the 3rd day. Complainant had taken necessary steps to contact the first opposite party, Paramount Health Services to make available cashless treatment as per the medi claim policy taken by the complainant with the 3rd opposite party. But even after the 3rd day the complainant did not receive any information regarding the permission for attaining cashless treatment and such connected rules and regulations. The complainant had to face many hardships, because 3rd opposite party, United India Insurance Company and its agent, first opposite party, Paramount Health care did not take any steps. Complainant had to pay the hospital bills by taking loan. The company is getting extra premium of 6% from the policy holders for the facility of being treated in the hospitals without paying cash. The Insurance company had appointed first opposite party for their third party administration. Both the first and 3rd opposite party have given the name of National Hospital in their list of hospitals where the policy holder can attain cashless treatment. Complainant had taken this particular policy giving extra 6% premium to avail this particular service of opposite party-1 and 3 but because of the deficiency of service of opposite party-1 and 3 the complainant had to suffer mental agony and pain and financial loss as well. The company has not reimbursed the amount due to the complainant till this date. Hence this petition is filed by the complainant alleging deficiency of service on the part of opposite parties. Opposite party-1, the Paramount Health Service has not appeared in court nor filed version. Opposite party-2 filed a version denying the averments contained in the complaint except those that are expressly admitted. There is no specific allegation against the opposite party-2, as to the treatment availed by the complainant for her daughter. The patient was examined by the duty Doctor and referred to the Senior consultant. After necessary investigations and thorough check up, the patient was admitted in the hospital for further check up and observation. She remained in the hospital till 2-8-06. Since the complainant had informed that the patient has Medi Claim Insurance with the first opposite party Paramount Health Service, the second opposite party hospital submitted a report of the consultant to the first opposite party on 1-8-06. On receiving the report the T P A ( Paramount Health Service) vide their Fax No.777370 dated 2-8-06 denied cashless treatment to the patient and advised the patient to go for reimbursement. The patient was informed accordingly. The second opposite party had no other way but to collect the hospital bill directly from the patient. The bill amount was collected from the patient, as they did not get the permission from the first opposite party for cashless treatment. There was no procedural lapse or deficiency of service on the part of second opposite party hospital. The second opposite party is not liable to pay any amount or reimbursement or compensation. The second opposite party prays to dismiss the complaint as against the second opposite party. Opposite party-3, Unit India Insurance Company filed a version denying all the material allegations except those matters, which are expressly admitted. The 3rd opposite party states that the claim for Rs.4175/- was not settled as the complainant failed to produce the necessary particulars before the 3rd party administrator. The refusal of the cashless service was within the exclusive knowledge of opposite party-2 hospital. Hence they have to explain regarding this matter. Third opposite party had collected the premium as per the rules of tariff administration. The complainant has not submitted the necessary details requested by the 3rd opposite party. Hence there is no cause of action for this complaint. The points for consideration is (1) whether there was any deficiency in service on the part of opposite parties? (2) Whether the complainant is entitled to get any relief? PW1 was examined and Exts.A1 to A17 were marked on complainant’s side. There was no oral evidence from any of the opposite parties. Ext.B1 and B2 were marked on the side of opposite party-2. Point No.1: It is an admitted fact that the complainant was having a medi claim policy with the United India Insurance Company. Ext. A3 is the individual medi claim policy of Mrs. Sreemathy.P., the complainant. The period of insurance is from 11-1-06 to Midnight of 10-1-07. The complainant’s daughter had a fall in the bathroom and became unconscious on 31-7-06 she was taken to opposite party-2 hospital which is included in the list of Network Provider of Kerala of Paramount Health Services. Ext. A2 is the document to the proof this fact. Exts. A4 to A9 shows that complainant’s daughter was admitted in Opposite party-2 hospital, had undergone several tests and checkups and was given medicines as well she was there in the hospital for three days. As per the medi claim policy the complainant was to give cashless treatment. But in this case she was denied of cashless treatment. The complainant had to pay all the bills in the hospital before discharge. So she had claimed the expenses incurred in the hospital for the treatment. A perusal of Exts.A12 to A14 will show that the complainant had forwarded the papers claiming for the expenses. Ext.A15 shows that certain documents in addition were sought from the complainant. Ext.A16 is the copy of the registered letter sent to the first opposite party regarding the details which were submitted before the opposite parties for reimbursement. Ext.A17 is the acknowledgement from first opposite party. On a perusal of the documents submitted by the complainant the Forum has come to the conclusion that the first and second opposite party were negligent and deficient in their service imparted to the complainant. They have not taken necessary steps to make available the claim amount to the complainant on time, even though the complainant was a valid medi claim policyholder and the opposite parties were collecting premium from the complainant during this period. Collecting premium and not making available proper service is deficiency in a gross level. Thus the point No.1 is proved. Point No.2:- As the Forum has come to the conclusion that the first and third opposite party were negligent and deficient in their service. The complainant is entitled for the relief sought. In the result the petition is allowed and the complainant is entitled to get an amount of Rs.4175/- along with a compensation of Rs.1000/-(Rupees One thousand only) and a cost of Rs.500/-. Opposite party-1 ( Paramount Health Services) and opposite party-3 (United India Insurance Company) are jointly and severally liable to pay the amount to the complainant. Pronounced in the open court this the 20th day of December 2008. Sd/-PRESIDENT Sd/-MEMBER APPENDIX Documents exhibited for the Complainant: A1 Affidavit filed by the complainant. A2 List of Network provider of Kerala. A3 Individual Mediclaim Policy of United India Insurance Co. A4 Photocopy of the Clinical Suimmary Report of National Scan & Research Centre. A5 Photocopy of E.E.G. Report of National Hospital. A6 Photocopy of USG/Abdomen Report of National Scan & Research Centre. A7 Photocopy of Clinical Pathology Report of National Hospital. A8 Photocopy of the cash bill of New National E.E.G.Centre. A9 Photocopy of Discharge Summary of National Hospital. A10 Photocopy of letter from the complainant to the M.D., National Hospital. A11 Photocopy of the details of treatment of Kum. Bini P., D/o. Sreemathi. A12 Photocopy of Medical Certificate issued by Dr. Vinod Krishnan., National Hospital. A13 Photocopy of filled up Mediclaim Insurance Policy claim form. A14 Copy of letter from United India Insurance Co. Ltd., to the complainant. A15 Photocopy of Deficiency Letter from Paramount Health Services Pvt. Ltd. A16 Photocopy of letter from the complainant to the Branch Manager, Paramount Health Services (P) Ltd. A17 Postal acknowledgement card. Documents exhibited for the Opposite parties: B1 Photocopy of Admission Request Note. B2 Photocopy of reply dated 2.8.06 from Paramount Health Services. Witness examined for the Complainant: PW1 Sreemathi, D/o. Krishnan kutty Nair – Complainant. Witness examined for the Opposite parties: None. -/True copy/- Sd/-President (Forwarded/By Order) Senior Superintendent.
......................G Yadunadhan B.A.
......................Jayasree Kallat M.A. | | 
