By. Sri. Jose. V. Thannikode, President:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get the entitled mediclaim which is refused by the opposite parties and to get cost and compensation.
2. Brief of the complaint:- The 1st opposite party approached the complainant and introduced him as a agent of 2nd opposite party and introduced one mediclaim policy. On believing the words of 1st opposite party complainant took the mediclaim policy on 06.08.2012 and it was renewed up to date 12.08.2015 and the last policy number was P-181315-01-2015-001433. While so the complainant admitted in Vinayaka Hospital, Sulthan Bathery on 16.10.2014 to 23.10.2014 for severe acute low back ache and was under the treatment of Dr. Randheer Krishnan and spent Rs.7,000/- as treatment expenses. All these treatment details and admission was reported to opposite parties and they have not opposed and no objection was reported but delayed in processing the claim. On enquiry the 1st opposite party told the complainant that before discharge the bills will be paid by the 2nd opposite party. Hence the complainant not arranged any money. But the opposite party has denied the claim stating that “denial of pre-authorization for cashless treatment”. On 17.10.2014 and 18.10.2014 the denial letter was given to the complainant. Hence the complainant and her husband caused much difficulty to arrange the money to pay the treatment expenses. Thereafter the complainant approached somany time to the opposite party No.1 and opposite party No.1 to take steps to set the claim stated that he is helpless and opposite party No.2 is the responsible person for sanction of policy claims. The complainant further says that she is admitted as inpatient in the hospital as per the advice of the doctor who treated the complainant. But the opposite party has denied the claim stating the this disease and treatment does not require the admission in the hospital. The complainant further says that the Doctor is the authority to say whether the treatment is required admission in the hospital or not and further says that the opposite party has denied the treatment expenses of the complainant for getting abnormal gain and the denial of the eligible treatment expense is a clear deficiency of service and unfair trade practice from the side of opposite parties. Hence the complainant prayed before the Forum to direct the opposite parties to pay Rs.7,000/- which is paid as treatment expenses by the complainant and to pay Rs.1,00,000/- as compensation and cost of the proceedings.
3. Notices were served to opposite parties on 22.12.2014 and opposite party No.1 not appeared before the Forum and he is set ex-parte on 31.01.2015 and opposite party No.2 filed version stating that the complainant is not entitled to get any reliefs as prayed for. There is no deficiency of service from the side of this Opposite party and the alleged treatment and complaint is created for the purpose of the case. This opposite party admits that the complainant had taken Star True Value Insurance Policy from this opposite party for the period from 06.08.2012 to 05.08.2013 covering 5 persons for a insured sum of Rs.80,000/- for each person and the same Policy was renewed up to 07.08.2014 covering 4 person, It is further submitted that, again on 13.08.2014 the insured has converted the earlier Policy to medi-classic Insurance for the period up to 11.08.2015, covering Smt. Mary Thomas for a insured sum of Rs.1,50,000/- vide Policy No. P 181315/01/2015/001433. It is submitted that during the existence of the said Policy the insured was admitted on 16.10.2014 at Vinayaka Hospital, for IVDP. The 2nd opposite party received a pre-authorisation request from the said Hospital in which the Provisional diagnosis was recorded as IVDP.
4. Since the submitted records from the hospital were insufficient to rule out any possibility of pre-existing illness, this opposite party denied the cashless request and intimated the hospital on 18.10.2014 and it has been noted in the denial letter that the claim will be processed on receipt of duly, completed claim form and other documents, as per the term & conditions of the policy. At the same time a claim form was sent to the complainant for getting a reimbursement from the opposite party, as per policy terms. But the complainant has not submitted any documents to the opposite party. The complainant had submitted a letter issued by his Doctor dated 18.10.2014 to this 0pposite party which is in no way helpful for the complainant. The letter speaks about nothing more than the treatment taken by the complainant in that hospital which the opposite party has no dispute. It i submitted that Cashless settlement/facility is not a part of contractual obligation as per the terms and conditions of the Insurance policy. It was more than the commitment given under the contract of insurance and meant for extra-comfort level for the customer insured. It is a facility extended to those cases where the liability of the insurance company under the policy is established beyond any doubt. In all other cases, the insured has to submit a completed Claim Form with all supporting treatment documents, to enable this opposite party to understand and process the claim on its merit. It is very pertinent to note that the complainant has miserably failed to submit such documents so as to process the claim by this opposite party. It is further submitted that there is clear violation of condition No.3&4 in this regard by the complainant. As per condition No.3 the Claim must be filed within 15 days from the date of discharge from the hospital which is a condition precedent to admission of liability.
5. As per Condition No.4 the complainant must submit to the Company all original bills, receipts and other documents along with duly completed claim form upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim. The complainant has violated condition No.4 by not submitting the relevant documents regarding her claim to this opposite party. It is submitted that on receipt of court notice from this Honorable Forum the opposite party investigated the claim and collected records/case sheets from the hospital which revealed that the complainant was suffering from low back ache from 2008 and was on treatment. Since the records confirmed the pre-existence of the ailment & the same was suppressed by her at the time of inception policy which amounts to suppression of material facts, the claim falls under exclusion clause No.1 of the policy ie, pre-existing disease.
6. 1t is submitted that insurance contracts are “contracts of uberime-fide". The opposite party issued the aforesaid policy on good faith based on the declaration made by the proposer/insured in the proposal form. Proposal from is the basis and integral part of the insurance contract on which the policy is issued. As per the contract of insurance the insured has to furnish true and correct facts in the proposal form for issuing the policy . The policy is issued strictly according to the terms and conditions of the policy. The complainant herein had admitted the terms conditions and exclusion set in the policy and thereafter had signed in the proposal from of the policy. The policy issued to the complainant being a health policy, the complainant is bound to give the proper information regarding her, present and past health status at the time of filing the proposal which are material for proper underwriting of the proposal. The policy is issued alter accepting the facts in the proposal from on utmost good faith.
7. The complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the opposite parties with the intention for getting unlawful enrichment from the opposite parties who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trust the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. The averment that she had spent Rs.7,000/- for the treatment that she had informed all developments to this opposite party, that she was persuaded by the agent of the opposite party for taking the policy, that she was assured by phone of payment in advance in the hospital etc.. are all, mere imaginations and there is no iota of truth in such statements. The opposite party did not get any bills/ documents to process a claim with respect to her treatment. The denial of pre-authorization cashless treatment made by this opposite party was genuine and nothing is there to be flabbergasted. The complainant is not entitled to get any compensation from this opposite party. Hence prayed to dismiss the complaint.
8. Complainant filed proof affidavit and stated as stated in the complaint and she is examined as PW1 and PW2 is also examined. Ext.A1 to A8 documents were also marked. Ext.A1 is the customer identity card issued by the opposite party Ext.A2 is the policy certificate issued by opposite party No.2. Ext.A3 is the discharge summary issued by Vinayaka Hospital, Sulthan Bathery, wherein it shows the complainant admitted on 16.10.2014 and discharged on 23.10.2014. Ext.A4 series is the Bill issued by Vinayaka Hospital to the complainant for Rs.4,650/- on 23.10.2014. Ext.A5 is the denial of pre-authorization of cashless treatment dated 17.10.2014 stating that “as per the policy terms and conditions. This ailment does not require admission or IP treatment. This ailment could have been treated on OPD basis. Hence your request for authorization for cashless treatment of the above insured patient is denied”. Ext.A6 is the Denial of pre-authorization for cashless treatment, wherein also it is stated that pre-existence could not be ruled out. Hence your request for authorization for cashless treatment of the above insured-patient is denied. Ext.A7 is the Certificate issued by Dr. Randheer Krishnan, Vinanyaka Hospital, wherein it is stated that “because of the present condition she need IP care (inpatient)”. Ext.A8 series 1 to 17 are the bills issued by the Hospital to the complainant for Rs.2,178/-. Opposite party also filed proof affidavit and stated as stated in the version and he is examined as OPW1 and Ext.B1 to B6 marked. Ext.B1 is the authorization letter. Ext.B2 is the pre-authorization request claim form issued by complainant to opposite party No.2. Ext.B3 is the copy of pre-authorization request form. Ext.B4 is the same as Ext.A5. Ext.B5 is the same as Ext.A7. Ext.B6 is the case diary of the complainant issued by Vinayaka Hospital, Sulthan Bathery.
9. On considering the complaint, version, documents and evidences we raised the following points for consideration:-
1. Whether there is any deficiency of service from the side of opposite parties?;
2. Relief and Cost.
10. Point No.1:- Anyway the policy is admitted by the opposite party and the claim application is also admitted by the opposite party and opposite party No.2 has denied the claim stating that “this ailment does not require admission as IP treatment. The ailment could have been treated on OPD basis”. On this aspect the Forum of the opinion that the treating doctor is the person who is the authority to say that whether the inpatient treatment is required or not. Here in this case as per Ext.A7, the treating doctor stated that “because of the present condition of the patient she needs inpatient care”. On other contention of the opposite party No.2 that the complainant suppressed the pre-existence of the ailments. It is also not proved by the opposite parties beyond doubt that she has treated for IVDP before.
11. On the other contention of the opposite party No.2 that the complainant has not produced the bills and other details to the opposite party is also not believable since the opposite party has already denied the claim after getting the claim application and since the statement of the complainant that she has submitted all the bills and connected records to opposite party No.2's Bathery Branch office but they were not ready to accept the same stating that this claim is already denied by the opposite party No2. Hence the Forum is of the opinion that denial of claim stating untenable reason is a clear case of deficiency of service and unfair trade practice. Hence the Point No.1 found accordingly.
12. Point No.2:- Since the Point No.2 is found against the opposite party No.2, he is liable to pay medical expenses already incurred by the complainant and also liable to pay cost and compensation to the complainant and the complainant is entitled for the same. Hence the Point No.2 is decided accordingly.
In the result, the complaint is partly allowed and opposite party No.2 is directed to pay Rs.7,000/- (Rupees Seven Thousand) which is spent by the complainant as treatment expenses and also directed to pay Rs.5,000/- (Rupees Five Thousand) as compensation and Rs.3,000/- (Rupees Three Thousand) as cost of the proceedings to the complainant within 30 days from the date of receipt of this Order, failing which the complainant is entitled for interest at the rate of 12% per annum for the whole amount till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 15th day of September 2015.
Date of Filing: 14.11.2014. PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
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PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Mary Thomas. Complainant.
PW2. M. P. Thomas. Agriculture.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Executive Claims, Star Health, Trivandrum.
Exhibits for the complainant:
A1. Copy of Customer Identity Card.
A2. Copy of Policy Certificate.
A3. Discharge Summary.
A4(Series). Medical Bills (2 Nos).
A5. Copy of Denial of Pre-Authorization for cashless treatment. Dt:17.10.2014.
A6. Copy of Denial of Pre-Authorization for cashless treatment. Dt:18.10.2014.
A7. Copy of Certificate issued by Dr. Randheer Krishnan. K. dt:18.10.2014.
A8(Series). Medical Bills (17 Nos).
Exhibits for the opposite parties:-
B1. Authorization Letter. Dt:12.08.2015.
B2. Medi-Classic Insurance Policy (Individual).
B3. Copy of Pre-Authorization Request Form.
B4. Copy of Denial of Pre-Authorization for cashless treatment. Dt:17.10.2014.
B5. Copy of Certificate issued by Dr. Randheer Krishnan. K. dt:18.10.2014.
B6. Case Diary of complainant issued by Vinayaka Hospital, Sulthan Bathery.
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PRESIDENT, CDRF, WAYANAD.
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