Tamil Nadu

South Chennai

CC/393/2006

Radhasubramaniam - Complainant(s)

Versus

Family Health Plan Ltd., - Opp.Party(s)

V.Muthukumarasamy

09 Oct 2017

ORDER

                                                                        Date of Filing :   11.07.2006

                                                                        Date of Order :   08.11.2017

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

PRESENT: THIRU. M.MONY, B.Sc., L.L.B. M.L.,                     : PRESIDENT            

                  TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

             DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

 

C.C.NO.393/2006

  WEDNESAY THIS 8^TH DAY OF NOVEMBER 2017

Mrs. Radhasubramaniam,

W/o. Mr.R.H.Subramaniam,

F-4, Srividya Apartment,

No.9,  Bala Krishna Street,

West Mambalam,

Chennai 600 033.                                           .. Complainant

                                        ..Vs..

1. M/s. Family Health Plan Limited,

Rep. by its Authorized Signatory,

Aditya JR Towers,

8-2-120/86/9/A&B,

III Floor, Road No.2,

Banjara Hills,

Hyderabad 500 034.

 

2. M/s. Family Health Plan Limited,

Rep. by its Manager, First Floor,

Ali Towers,

No.55, Greams Road,

Chennai 600 006.                                           .. Opposite party.

 

Counsel for Complainant            :   M/s.V.Muthukumarasamy          

Counsel for opposite parties        :   appeared in person.     

ORDER

THIRU. M. MONY, PRESIDENT

This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act 1986 seeking direction  to pay a sum of Rs.2,00,000/-towards compensation for mental agony and damages for difficulties sustained in the Hospital authorities and also to pay Rs.1,000/- towards expenses by way of telephone and Rs.5,000/- towards cost of the complaint.

1. The averment of the complaint in brief are as follows:

           The complainant submit that  he is availed Family Health Insurance Policy with M/s. National Insurance Company Ltd., New Delhi for a period of 25.3.2006 to 24.3.2007, policy No.350601/48/05/8500000606.    Further the complainant state that on 22.5.2006 the complainant was admitted in the Hospital for depression / A typical chest pain for treatment and the complainant made a claim under Medi claim policy through M/s. Malar Hospital, Chennai,  by giving pre authorization form which is not processed till the date of discharge and the opposite party has not responded for the past three days.    The complainant further state that the doctors advised to discharge from the hospital on 25.5.2006  and the complainant ready to vacate the hospital but the pre authorization form is not cleared from the Family Health Plan Limited.      As such the act of  the opposite parties amounts to deficiency in service which caused mental agony and hardship to the complainant.  Hence this complaint is filed.

2.    The brief averments in Written Version of  the  opposite party is  as follows:

      The  opposite parties deny each and every allegations except those that are specifically admitted herein.    The opposite parties submit that the complainant admitted in the hospital on 22.5.2006 for depression /typical chest pain for treatment and the complainant make claim in the medi claim policy Card No.FHDU.0000587648, dated 24.4.2006 issued by Hyderabad Office through M/s. Malar Hospital, Chennai by giving pre authorization / admission request note which is not processed till the date of discharge is a false statement as such denied and the complainant is put to strict proof of the said contention.    The opposite party has not responded for the past three days is totally incorrect statement and as such denied.   On verification it is observed that, the UHID number mentioned in the authorization request note was relating to earlier policy period and the same is not found in the records.   Since the details were not found, on 23.5.2006 the opposite party has sent a request to Malar Hospitals seeking for the renewal details of the policy.   However on further verification after receiving the required information, it is observed that the identification number is not correct.    Accordingly on verification and finding the correct details, has issued authorization to the Hospital for providing cashless service to the member and guaranteeing to make the payments against the said treatment and allowing the members to discharge the patient from the Hospital without asking for the payments against the treatment taken.    A per the policy conditions, the insured member may admit into the hospital to take treatment under a prior intimation to the Insurance company and if it is case of emergency with an intimation within 24 hours of the hospitalization.   Hence there is no deficiency in service on the part of the opposite party and the complaint is liable to be dismissed.

3.     In order to prove the averments of the complaint, the complainant has filed proof affidavit as her evidence and documents Ex.A1 to Ex.A10 marked.  Proof affidavit of opposite party filed and no documents marked on the side of the  opposite party.

4.   The points for the consideration is: 

1. Whether the complainant is entitled to a sum of Rs.2,00,000/-towards compensation for mental agony and damages for difficulties sustained in the Hospital authorities as prayed for?

2. Whether the complainant is entitled to a sum of Rs.1,000/- towards expenses by way of telephone with cost of Rs.5,000/- as prayed for?

 

5.  POINTS 1 & 2:

        Both parties has not turned up to advance any oral arguments for long time after filing written arguments.   Admittedly the complainant availed Family Health Insurance Policy with M/s. National Insurance Company Ltd., New Delhi for a period of 25.3.2006 to 24.3.2007, Policy No.350601/48/05/8500000606.   The complainant pleaded and contended that on 22.5.2006 the complainant was admitted in the Hospital for depression / A typical chest pain for treatment and the complainant made a claim under Medi claim policy through M/s. Malar Hospital, Chennai, after obtaining pre authorization as per Ex.A5.   After treatment when the complainant was at the stage of discharge from the hospital neither the opposite party nor the insurance company has not responded properly, hence the complainant paid the balance bill raised by the Malar Hospital, towards the treatment.   But the complainant has not produced any bill issued by the Malar Hospital, after deducting the pre approved amount claimed.   Further the complainant contended that such deficiency in service of the opposite party caused great mental agony and defame in the eye of the public and the hospital.   But on a careful perusal of the records it is apparently seen that the complainant has not produced any document to prove the payment made to the Malar Hospital, Chennai.  Equally  the contention of the opposite parties is that the Malar Hospital has not given the correct UHID number for the current policy.  Even after repeated requests by the complainant the said number was not supplied to the opposite parties. 

6.     The contention of the opposite parties is that there is no deficiency in service caused by the opposite parties to the complainant in this case.   Admittedly the complainant availed medi claim policy with National Insurance Company under Corporate policy.    The opposite party extended a benefit of cash less treatment to such medi claim policy holder.  When the complainant approached the opposite party through Malar Hospital in which he is to take treatment, this opposite party rightly processed the request and sanctioned pre authorization approval.  Accordingly a sum of Rs.20,000/- was granted.   The complainant also undergone due treatment after availing such facility.   Thereafter the complainant has not given correct UHID number to the opposite party through Malar Hospital.   Even after repeated requests and demands no correct particulars supplied.   Hence the opposite parties was not able to settle the claim.  The complainant also discharged from the hospital; there is no record available in this case to prove whether the complainant paid any amount at the time of discharge from the hospital.  The complainant also has not produced any discharge summary and final bills.  Therefore the claim towards deficiency of service which caused mental agony; defame in hte eye of the public does not arise.   The complainant the claim towards telephone expenses is unsustainable without any proof. Considering the facts and circumstances of the case this forum is of the considered view that the  complainant is not entitled for any relief as prayed for in the complaint and the point is answered accordingly. 

            In the result the complaint is dismissed.  No cost

            Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 8^th day  of  November  2017.  

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainant’s side documents:

Ex.A1- 16.3.2005  - Copy of National Insurance Company Policy.

Ex.A2- 24.4.2006  - Copy of Covering letter.

Ex.A3- 25.3.2006  - Copy of policy card of Mr.R.H.Subramaniam & Mrs. Radha

                              Subramanian.

 

Ex.A4- 22.5.2006  - Copy of Pre Authorization Form.

Ex.A5- 25.5.2006  - Copy of additional information request form.

Ex.A6- 25.5.2006  - Copy of authorization letter to the spital.

Ex.A7- 22.5.2006  - Copy of pre authorization.

Ex.A8- 20.5.2006  - Copy of covering letter.

Ex.A9- 29.5.2006  - Copy of covering letter.

Ex.A10- 20.5.2006         - Copy of Policy UHID No. details.

Opposite parties’ side document: -   

..Nil..   

 

MEMBER-I                        MEMBER-II                             PRESIDENT.