FINAL ORDER/JUDGEMENT
SHRI REYAZUDDIN KHAN,MEMBER
This is a complaint case filed u/s.12 read with sections 11 & 13 of the C.P. Act, 1986.
The case of the complainant in brief is that the complainant is a house wife and for the purpose to avail cashless benefit for her medical treatments the complainant purchased a mediclaim insurance policy no.H0211611 for the period from 15th June 2017 to 14th June 2018 from Future Health Suraksha Individual “Health Suraksha Individual”having its IRDA Registration No.132,Corporate identity No.(CIN) U66030MH2006PLC165287 by paying the premium at the Branch office of the Future Generali Insurance Company Limited at 3rd Floor,Chitrakut Building,230 A, A.J.C Bose Road Kolkata 700106 through cheque No.964409 dated 23/05/2017 amount Rs.5682.00 drawn on S.B.I.That as per the information embodied in the customer information sheet the it is committed to provide cashless medical facilities subject to treatment by any network hospital of the OPs 1& 2 and the OP 3 is within the network hospital.Due to acute fever and sudden physical problem the complainant was admitted at UMA Medical Related Institute Private Limited on 9th March 2018 under Dr Jayanta Datta.After admission the complainant was examined by the concerned doctor through various Pathological examination for better medical treatment till the complainant felt fit and comfort.Immediatly after the admission the complainant’s son informed the office of the OPs No.1& 2 to docket the claim in the nursing home of the OP no.3 which was registered as Pre-authorization with No.382898 dated 10th March 2018 claim no.A0059952 .The OP No.3 also contacted the OPs 1& 2 for confirmation of cashless medical assistance and at the same time all the photocopy of the documents were sent to the office of the OPs no.1 & 2.The representative of the OPs attended the complainant to get the factum of the admission of the complainant in the hospital of the OP3 and verbally gave assurance to approve the amount for the cashless medical insurance facility.But inspite of all the efforts made by the complainant’s son to avail such cashless benefit ,the OPs 1& 2 failed to comply their assurance as per the terms and conditions of the policy deliberately and consequently the son of the complainant compelled to pay the total bill amount of Rs,56,184 to OP3.
The act of negligence on the part OP 1 & 2 has put the family of the complainant in serious problem due to insufficient amount of money lying with them as well as believing to get cashless benefit from the OPs.Thereafter the complainant’s son contacted several times to office of the OPs 1 & 2 but failed to get in written assurance.
On 17th March 2018 the OPs issued a letter (Cashless denial Letter FGH/CLM/CAS/06/02) to Mr Prithviraj PRO /Insurance Co-ordinator of the OPs to OP3 and expressed their inability to render the cashless benefit to the complainant with the reason that after verified the coverage terms and conditions of the insurance plan they are unable to issue authorization letter to OP3 with the caption “Liability of the insured can not be ascertained at this juncture” and cashless stand denied.Without informing the complainant about the denial of cashless insurance money. Finding no alternative the complainant has approached the Commission seeking justice with relief as detailed in the complaint petition.
Due to such defiant and deliberate negligent act the complainant also states that the OPs failed and neglected to perform its part of contract as stated hereinbefore for her wrongful gain for that the OPs are liable to compensate the complainant for her mental trauma and retardation along with her family members.The OPs 1& 2 have to pay Rs.56,184/- with interest and compensation of Rs,2,00000/- ( Two Lakh) only.
The OPs have contested the case by filing W/V contending inter alia that the present complaint is misconceived and is a flagrant abuse of law and is not maintainable and has no cause of action against the opposite parties as alleged in the complainant petition. It is admitted by the OPs that the complainant had taken a Health Suraksha individual policy from the OPs being no.H0211611 for the period from 15/06/2017 to14/06/2018.It is also stated by the OPs that the complainant admitted in UMA Medical Related Institute Private Limited due to fever and other health related issues. The claim of cashless benefit of Rs.56,184/- was lodged with the OPs which was however denied by the OPs vide letter dated 17.03.2018 on the ground that “Liability of the insured can not be ascertained at this juncture”.It is also mentioned by the OPs that cashless facility is a privilege given to some distinguished customers by the insurance company,however it is never a legal right of a customer.After scrutiny and verification of documents it has been found by the insurance company that there are certain discrepancies which required detailed clarification from the complainant as Dr.Dutta and Dr.Pandey refused to give any written statement regarding exact duration duration of CKD and medical certificate, all first and past consultation of UMA Medical Related Institute with referance to hospital ID 20174740,all first and past consultation and investigation reports related to chronic kidney disease issued by the treating doctors.The complainant was asked to submit the mentioned discrepancies within 30 days from the date of request but complainant failed to provide any clarification within the stipulated time. OPs further stated that on 31.10.2018 the OPs insurance company had no option but to repudiate the claim of the insured by letter FGH/CLM/RIM /05/02.The complainant violated the terms and conditions of the insurance company.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OP is deficient in rendering proper service to the Complainant?
2) Whether the OP has indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3 :-
The above mentioned points are taken up together for the sake of convenience and brevity in discussion.
We have travelled over the documents placed on record. The complainant and the OPs have filed their Evidences supported by affidavit.. Both parties have submitted their BNAs.
The fact of the case in brief is that the complainant is the beneficiary of the subject Mediclaim Policy No. H0211611 for the period from 15th June 2017 to 14th June 2018 from Future Health Suraksha Individual “Health Suraksha Individual”having its IRDA Registration No.132,Corporate identity No.(CIN) U66030MH2006PLC165287 by paying the premium at the Branch office of the Future Generali Insurance Company Limited at 3rd Floor,Chitrakut Building,230 A, A.J.C Bose Road Kolkata 700106 through cheque No.964409 dated 23/05/2017 amount Rs.5682.00 drawn on S.B.I Due to acute fever and sudden physical problem the complainant was admitted at UMA Medical Related Institute Private Limited on 9th March 2018 under Dr Jayanta Datta.After admission the complainant was examined by the concerned doctor through various Pathological examination for better medical treatment till the complainant felt fit and comfort.The complainant was discharged on 17th March 2018 at about 0.55 pm. On perusal of the Discharge Summary issued to the complainant it is observed in the final diagnosis was AKI on CKD,Anaemia,LRTI and clinincal summary mentioned that patient was admitted with complaints of fever & cough ,vomiting and passage of Black stool. In the said Discharge Summary we do not find any other observation of the Hospital. The said observation of the Hospital has been found mentioned in the repudiation letter dated 31.10.2018 issued by the Insurer. The subject mentioned in the repudiation letter is as follows.
1.Our authorized verification officer tried to request to Dr.Dutta and Dr.Panday but they refused to give any written statement regarding the exact duration of CKD ..please provide medical certificate from both DR.Dutta and Dr.Panday.
2.Please provide all first and past consultations of UMA medical Related Institute with reference to hospital ID 20174740.
3.Please provide all first and past consultations and investigation report related to chronic Kidney disease .
The relevant clause of the policy that defines the exclusion …
The insured person shall immediately file the claim and in any case within 30 days of discharge from the hospital provide the company with written details of the quantum of any claim along with all the original bills,receipts and other documents upon which a claim is based and shall give the company such additional information and assistance as the company may require in dealing with the claim.
Now,the question arises firstly, that to issue claim repudiation letter the insurance company took more then seven months ie,17th March 2018 the date of discharge to 31st October2018 …..
Secondly,in the claim repudiation letter the company mentioned that “kindly note that we have sent an intimation dated 30.10.2018 and subsequent 2 reminders dated 03.08.2018 and ……..? for submission the deficient documents but the company was failed to submit those intimation letters.No documents has been filed for the OPs in the WV as well as in the evidence in support of their contention.
Thirdly,in the policy letter no.2017-H0211611-FHI dated 19/06/2017 it is clearly mentioned that “Cashless facility can be availed on producing the FGH-Health ID card along with a photo identification proof.whereas it is not mentioned anywhere that cashless facility is a privilege given to some distinguished customers it is not a legal right.so, it is a matter of misleading of facts to the customers.
Having heard the parties present and the evidence as filed by them we are opined that both the complainant and OPs are not performed their part on time and their left certain lacunas on both the sides.
So,The complainant is directed to submit the documents as mentioned afore in the claim repudiation letter dated 31.10.2018 to the OPs within 30 days from the date of passing of the order and thereafter OPs shall settle the claim of the complainant within 45 days from the date of the receiving of the aforesaid documents
DCDRC Unit II CC No 494/2018 is thus disposed of
Copy of the judgment be delivered to the parties free of cost as per the C.P. Act and Judgment be uploaded in the website of the Commission for perusal of the parties
