Andhra Pradesh

East Godwari-II at Rajahmundry

CC/51/2015

K. Vinod Kumar - Complainant(s)

Versus

E.Meditek (TPS) Services Ltd., - Opp.Party(s)

P.N.N. Tagore

11 Aug 2016

ORDER

                                                                                                                      Date of filing:   25.08.2015

                                                                                                                       Date of Order:  11.08.2016

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAMAHENDRAVARAM

 

                                   PRESENT:   Smt H.V. Ramana, B.Com., L.L.M.,   PRESIDENT(FAC)

                      Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

    

               Thursday, the 11^th day of August, 2016

 

C.C.No.51 /2015

Between:-

 

K. Vinod Kumar, S/o. Vastimal, Hindu, Business,

D.No.9-25-56, Gundivari Street, Rajahmundry.                                                             …  Complainant

 

                                    And

 

1)  E. Meditek (TPS) Services Ltd., Plot No.45,

      Union Bank of India Colony, Road, No.3,

      Banjara Hills, Hyderabad.

 

2)  E. Meditek (TPS) Services Ltd., Udyog Vihar,

      Phase V, Gurgaon-122 016.

 

3)  The Divisional Manager,

      The Oriental Insurance Co. Ltd., Jetty Towers,

      2^nd Floor, Innispeta, Rajahmundry.

      (3^rd opposite party is added as per orders in

       I.A.No.170/2015, dt.7.1.2016).                                                                             …  Opposite parties

 

 

            This case coming on 27.07.2016 for final hearing before this Forum in the presence of Sri P.N.N. Tagore, Advocate for the complainant and Sri M. Sambasiva Rao, Advocate for the opposite parties 1 to 3, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Smt.H.V. Ramana, President(FAC)] 

This is a complaint filed by the complainant U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties 1 to 3 jointly and severally liable to pay an amount of Rs.28,089/- to the complainant towards surgery and medicines of his wife; award Rs.10,000/- towards mental agony and award Rs.5,000/- towards costs of the complaint.

2.         The case of the complainant is that he obtained medi-claim policy bearing No.462800/48/2015/358 from the 1^st opposite party branch for his family consisting of himself, his wife and their children and the amount insured is Rs.2 lakhs and the insurance is in force and is effective from midnight of 24.8.2014 and midnight of 23.8.2015. While so, the complainant’s wife Kanta Devi developed sebaceous cyst and had undergone operation for removal of the cyst, which were discovered about 6 months prior to the date of operation. The complainant’s wife underwent operation at Medicare Hospitals, Rajahmundry and got cyst removed. For the purpose of operation of the wife of the complainant, the complainant spent Rs.28,089/- which is made up of Rs.22,000/- towards surgery and hospitalization charges and the remaining Rs.6,089/- is towards medicines. The complainant already made a claim for payment of the amount by submitting the claim application along with all the necessary documents in proof of the claim. But to the surprise and misfortune of the complainant, the complainant received a letter dt.2.1.2015, repudiating the claim under Section 10 of the coverage under the policy, stating that the expenses other than the expenses covered by the policy. But in fact the expenses which the complainant met are all covered by the policy and therefore, the complainant is entitled to seek for the reimbursement of expenses. The complainant got issued a regd. notice on 18.2.2015 to the 1^st and 2^nd opposite parties demanding them to pay the amount. The 1^st opposite party having acknowledged the said notice and they did not give any reply and kept quiet. Hence, the complaint. 

3.         The 3^rd opposite party filed its written version and the same was adopted by the         opposite parties 1 & 2 and denied the allegations made by the complainant and the complaint is not maintainable either under law or on facts. This opposite party submits that the complainant obtained “Happy Family Floater Policy” bearing No.462800/48/2014/734, valid from 00.00 hours on 24.8.2014 to the midnight of 23.8.2015 from the 3^rd opposite party. Under the policy obtained by the complainant, the following family members are covered: (1) K. Vinod Kumar – complainant, (2) Kanta Devi – spouse employed, (3) Sweta – Dependent child, (4) Priyanka – Dependent child and (5) Labhesh – Dependent child. This opposite submits that the original insurance policy along with all the terms and conditions, exclusions and exceptions was given to the complainant. This opposite party submits that under the insurance policy obtained by the complainant, all the ailments/treatments are not covered. Suffice it to say, that in the insurance policy obtained by the complainant, the terms, conditions, exceptions, exclusions, limits etc. are clearly mentioned under the following heads: (1) Coverage under the policy, (2) Definitions, (3) Other definitions and interpretations, (4) Exclusions, (5) Conditions, (6) Period of policy, (7) Renewal of policy, (8) Product withdrawal clause, (9) Sum insured, (10) Authority to obtain records,               (11) Quality of Treatment, (12) ID Card, (13) Mediclaim with Overseas Mediclaim Policy and (14) IRDA Regulations No.5. This opposite party submits that as per the policy obtained by the complainant, the opposite parties 1 and 2 are “Third party Administrator” (TPA). TPA is only a facilitator for processing the claim, to advise the insurer about the admissibility or otherwise of a claim and inter act with the insured. For the convenience and quick settlement of the claims TPAs are accredited by IRDA and this opposite party appointed opposite parties 1 and 2 as one of its TPA. This opposite party submits that as per the terms and conditions of the insurance policy, the insured (complainant) has to submit the necessary documents, claim forms etc. to the opposite parties 1 and 2 (TPA). After such submission, the opposite parties 1 and 2 (TPA), process the claim and decide/advise the insurer, whether the claim is admissible or not. In the instant case also, the complainant submitted the claim intimation/claim form to the opposite parties 1 and 2 (TPA) regarding the treatment undergone by Smt. Kanta Devi – spouse of the complainant, in Medicare Hospital, Rajahmundry, under Dr. V. Ganga Kishore, Plastic Surgeon. This opposite party submits that the details of diagnosis, treatment etc. are clearly mentioned in the discharge summary given by Medicare Hospital, Rajahmundry. The opposite parties 1 and 2 (TPA) after careful scrutiny of the claim intimation/claim form/medical record (including the discharge summary) and the terms and conditions, particularly condition No.4, “EXCLUSIONS”, concluded that the ailment of Kanta Devi (spouse of the complainant) and the treatment undergone by her comes within the purview of Exclusion 4:10 and hence not admissible. This opposite party submits that the ailment of Kanta Devi, the treatment undergone and the expenses incurred by her are clearly excluded under clause 10:4 of exclusions and hence, they are not admissible and consequently the claim is rejected, for valid reasons and the complainant is not entitled any relief.  Hence, there is no deficiency of service on the part of this opposite party and the complaint is liable to be dismissed with costs.   

4.         The proof affidavit filed by the complainant and Exs.A1 to A8 have been marked for the complainant. The proof affidavit filed by the 3^rd opposite party and Exs.B1 & B2 have been marked for the opposite parties.

5.         Heard both sides.

6.         Points raised for consideration are:

 

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

            2. Whether the complainant is entitled for the reliefs asked for?

            3. To what relief?

 

7.  POINT Nos.1 & 2:  The admitted facts of the complaint are that the complainant obtained Medi-Claim Policy bearing No.462800/48/2015/358 for an amount of Rs.2,00,000/- for his family consists of himself, his wife Smt. Kanta Devi and their children from the 3^rd opposite party vide Ex.A5. The said policy was in effect from midnight of 24.8.2014 to midnight of 23.8.2015. The complainant wife Smt. Kanta Devi developed sebaceous cyst and had undergone operation for removal of the said cyst which was discovered about 6 months prior to the date of operation. The complainant’s wife underwent the operation at Medicare Hospital, Prakash Nagar, Rajahmundry and got the cyst removed and she was in the hospital from 11.00 AM on 16.12.2014 to the following day up to 4 PM on 17.12.2014.  To that extent, the complainant filed the discharge summary, consolidated bill and bill summary vide Exs.A2, A3 & A4. The complainant further submitted that he spend a total amount of Rs.28,089/- towards the surgery, hospitalization and medicines. The complainant also submitted that he made a claim and also made a representation to the 1^st opposite party vide Ex.A1. After receipt of the claim form, the 1^st opposite party sent a letter dt.2.1.2015 by repudiating the claim of the complainant. Later, the complainant got issued the legal notice vide Ex.A6 to the 1^st & 2^nd opposite parties demanding them to pay the claim amount, the opposite parties received the same and acknowledged vide Ex.A7 and kept quiet.

 The opposite parties also admitted that the complainant obtained the policy from them and filed the policy schedule and marked as Ex.B1. They also filed the terms and conditions of Happy Family Floater Policy vide Ex.B2. The 3rd opposite party submitted in his written version that the opposite parties 1 & 2 are the Third Party Administrators. They are only the facilitators for processing the claim and to advise the insurer about the admissibility of the claim. These TPAs are appointed for the convenience and quick settlement of claims in accordance with the IRDA. As per the terms and conditions of the insurance policy, the complainant has to submit the necessary documents to the opposite parties 1 & 2. After that, the opposite parties 1 & 2 advised the insurer whether the claim is admissible or not. In the present case, the complainant submitted the claim form to the opposite parties 1 and 2 regarding the treatment undergone by his wife and also submitted all the papers and also given the discharge summary. The opposite parties after the scrutiny of the medical record and terms and condition No.4 ‘Exclusions’ concluded that the ailment of Kanta Devi and the treatment undergone by her within the purview of Exclusion 4:10 and hence not admissible. The opposite parties also submitted that the treatment undergone by Smt. Kanta Devi and expenses incurred by her are clearly excluded under Clause 10:4 of Exclusions and hence, they are admissible and consequently the claim is rejected for the valid reasons. The complainant is not entitled for the claim of Rs.28,089/- towards medical expenses and Rs.10,000/- towards mental agony and Rs.5,000/- towards costs and there is no deficiency of service.

After perusing the material on record, it is observed that as per the instructions of the opposite parties, the complainant sent the claim form along with other necessary documents such as the discharge summary, bill summary and other receipts to the 1^st opposite party. As per the terms and conditions and written version, the 1^st & 2^nd opposite party are only the Third Party Administrators and they are only the facilitators for processing the claim and to advise the insurer about the admissibility or otherwise of the claim and to inter act with the insured. These Third party administrators are appointed for the convenience and quick settlement. Here, in this case, it is the duty of the 1^st & 2^nd opposite parties to send their advise to the insurer after going through the claim form and other material documents, but in this case, they have not sent any information to the 3^rd opposite party and they directly sent a letter by denying the claim of the complainant vide Ex.A8. In this case, the 1^st & 2^nd opposite parties failed to do their duty as prescribed to them. It is also observed that the 3^rd opposite party was not having the knowledge of the claim process done by the opposite parties 1 & 2.  This amounts to deficiency in service on the part of all the opposite parties as the 3^rd opposite party is vicariously liable for the acts of their Third Party Administrators ie. Opposite parties 1 and 2, who are appointed by them only.   

As per our observation and going through the terms and conditions

Clause 10: Reasonable and Necessary Expenses:-

1. For a networked hospital means the rate pre-agreed between Network Hospital and the TPA/Company, for surgical/medical treatment that is necessary for treating the insured person who was hospitalized.
2. For any other hospital it shall mean the cost of surgical/medical treatment that is necessary and reasonable for treating the condition for which insured person was hospitalized.

NOTE: Any expenses other than the above have to be borne by the insured person himself.    

Basing on the above clause, we opined that the surgery and the expenses which are incurred by the complainant’s wife are reasonable and necessary. Therefore, the complainant is entitled for the claim amount as per the claim form. The complainant also entitled for damages for not informing the claim details of the complainant by the opposite parties 1 & 2 to the 3^rd opposite party and not settling the claim by the 3^rd opposite party amounts to deficiency in service and causing mental agony to the complainant even inspite of taking a valid medical policy which is within the time span of the policy. The opposite parties also directed to pay the costs to the complainant as he has to approach the Forum because of not settling the claim. Hence, the complaint is allowed in part.

               

8.   POINT No.3:  In the result, the complaint is allowed in part, directing the opposite parties to pay the claim amount of Rs.28,089/-, and to pay Rs.2,000/- towards damages for mental agony and to pay Rs.1,000/- towards costs of the complaint to the complainant. Time for compliance is two months from the date of this order.

 

Typed to dictation, corrected and pronounced by us in open Forum, on this the  11^th day of August, 2016.

    

                   Sd/-                                                                                             Sd/-

              MEMBER                                                                              PRESIDENT(FAC)

         

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANT: None.                                         FOR OPPOSITE PARTIES: None.

 

DOCUMENTS MARKED

 

FOR COMPLAINANT:

 

Ex.A1    Photostat copy of claim form.

Ex.A2    Photostat copy of Discharge summary.

Ex.A3    Photostat copy of the receipt dt.17.12.2014 for Rs.22,000/-.

Ex.A4    Photostat copy of the billing summary for Rs.22,000/-.

Ex.A5    Photostat copy of insurance policy.

Ex.A6    Office copy of the registered notice got issued by the complainant to the opposite

              parties 1 and 2 along with postal receipts.

Ex.A7    Postal acknowledgement.

Ex.A8    Letter dt.2.1.2015 from E Meditek.

 

FOR OPPOSITE PARTIES:-  

 

Ex.B1    True copy of the Insurance policy issued by the 3^rd opposite party to the complainant

              under Happy Family Floater Policy schedule – Policy No.462800/48/2015/358

              valid from 00:00 on 24.8.2014 to midnight of 23.8.2015.

Ex.B2    Terms and conditions of Happy Family Floater Policy of the Oriental Insurance

              Company Limited.

 

                    Sd/-                                                                                            Sd/-

              MEMBER                                                                              PRESIDENT(FAC)