This Order shall dispose of the present Appeal dated 18.7.2014 filed by the Appellant herein interalia challenging the Order dated 9.5.2014 passed by the Consumer Dispute Redressal Forum, South Goa, at Margaoin Complaint No. 10/2014, hereinafter referred to as the ‘impugned Order’.
Vide the impugned Order, the Ld. South Forum was pleased to partly allow the original complaint with the following directions:
“The complaint of the Complainant is partly allowed and the Opposite Party is directed to pay a sum of Rs. 80,124/- to the Complainant with 9% interest p.a. from the date of filing of this case till its realization. The Complainant is also entitled for a sum of Rs.10,000/- as compensation and a sum of Rs.5,000/- are also required to be paid by the Opposite Party to the Complainant towards the cost.”
Being aggrieved by the impugned Order, the Appellant has filed the present Appeal
The brief facts of the case can be stated as under:
I The Complainant in his original complaint alleged that he is a Silver Health Insurance Policy holder and is paying the annual premium amount regularly for last six years and has paid his last premium of Rs.12,587/- during the pendency of the complaint before the Forum. On 6.12.2013, the Complainant i.e. the Respondent herein was admitted in KLE Hospital, Belgaum for severe stomach and brain problem. Before admitting himself in the Hospital, the Hospital authorities had faxed the pre-authorization letter for cashless facility to the Opposite Party for approval of estimated expenses of Rs.95,000/-.
II The Opposite Party thereafter generated a query dated 6.12.2013 and accordingly the hospital authorities faxed the reply to the query. On 9.12.2013 the Complainant contacted the Customer Care Centre on phone and on inquiry he was informed that a sum of Rs.38,000/- was approved for the facility and the approval letter has been sent to the hospital by e-mail. On inquiry the hospital authorities informed the Complainant that they have not received the email and as such the Complainant again contacted the Customer Care Centre. Upon inquiry the official informed him that no approval has been granted and again a query has been generated.
III The Respondent herein further alleged in his complaint that the hospital authorities again replied to the query and accordingly the Customer Care Centre informed the Complainant that the facility is under process for approval. As there was no response from the Opposite Party inspite of repeated inquiries with them, the complaint was filed before the Lower Forum and accordingly the Lower Forum has partly allowed the complaint as said earlier.
On perusal of the Memorandum of Appeal and the case papers in the file received from the Learned Forum as well as the arguments advanced by both the parties, we now proceed to decide the fate of this Appeal as would contain hereinafter.
6. The Appellant has filed his written arguments on 8.1.2014 and the Respondent has filed his written submissions on 9.12.2014. The Appellant has argued before us that the Learned Forum has passed the impugned Order without applying its mind to the serious defences raised by the Appellant and in total violation of principles of natural justice. The Appellant has further argued that the Ld. Forum has erroneously ordered the Appellant herein to pay exorbitant compensation without giving any opportunity to the Appellant to lead the evidence.
7. The Appellant has further argued before us that the Ld. Forum committed an illegality while passing the impugned Order and the same is founded on unwarranted presumption and unsustainable interference. It was argued on their behalf that the Ld. Forum has failed to consider the willful concealment of facts and misrepresentation by the Respondent. Hence the Appellant prays that the present Appeal be allowed and the impugned Order be dismissed.
8. On the contrary, the Respondent has argued before us that he present Appeal is filed only with a view to harass the Respondents and deny the right of the policy holder. The Respondent has also contended that the Appellant before the Ld. Forum submitted that the Insurance Company wants to settle the claimed amount under the Medical bills paid to KLE Hospital by the policy holder. However such a talk of compromise before the Ld. Forum did not materialize at all as the Appellant did not attend the proceedings before the Forum on and after 9.5.2014. It was contended by the Respondent that the Ld. Forum has perused the case file minutely and in greater details and only thereafter has passed the impugned Order based on documents on record and merits of the case.
9. The Respondent has submitted in his written arguments that the said hospital authorities have replied all the queries except one which they could not have replied. The Appellant/Opposite Party had asked in their query – “All previous consultation paper for gastric ulcer since 5-6 years as per consultation on 24.5.2011.” The Respondent has drawn our attention to the fact that when the Policy holder had not consulted the said Hospital prior to 24.5.2011, then it would have been difficult for the hospital authorities to provide consultation papers of 5-6 years back. In our considered opinion the Respondent has rightly pointed out that he had contacted the Customer Care Centre several times after admitted into the said Hospital as also on 12.12.2013 and the telephonic conversation in a CD and the copy of the query report have already formed part of the record of the Lower Forum.
10. On going through the original file of the Lower Forum, we find that the Appellant/the Opposite Party, after receiving the notice from the Forum has filed therein written version on 21.3.2014. The Opposite Party has failed to file their Affidavit-in-evidence thereafter. In the absence of the Affidavitory evidence, it is difficult for this commission to accept the defences of the Opposite Party.
11. We have gone through the Policy document i.e. C1, the pre-authorization for cashless facility document i.e. C4, the medical documents at C7, C9 Colly, additional information request form at C19, C20 Colly, the bill receipts issued by the authorities on different dates as well as other related documents enclosed to the original complaint.
12. In our considered opinion, there is considerable substance in the contention of the Respondent that the Opposite Party had absolutely no reason to deny the cashless facility to the Complainant. It is pertinent to note that the Ld. Forum has rightly gone through in greater details as regards condition No. E(3) of Silver Health Policy document which incorporates claim procedure. We have no hesitation to hold that the Ld. Forum has rightly come to the inference that once the formalities that are required to be completed by the Complainant and the hospital, are completed, the Opposite Party is duty bound to pay the bills raised by the Hospital.
13. In this regard we hold that The Cashless Facility is usually obtained by the policy holders to save themselves from the financial problems which they might face on admitting themselves in the hospital. If this facility for which the cashless policy is obtained by the policy holder is denied, then the very purpose of obtaining the cashless facility is frustrated. Hence, we take the view that the Ld. Forum has rightly applied its mind to the evidence on record and has carefully drawn the conclusion that once the preauthorization letter and the ID along with the policy is submitted, the Opposite Party is duty bound to provide cashless facility to the Complainant especially when preauthorization letter in Annexure B is duly filled by the Hospital authorities and sent to the Opposite Party.
14. It is pertinent to note that the Respondent herein has produced on record the CD and the contents thereof are also placed by the Respondent in separate writing which are taken on record. We have gone through the contents of the said CD and find that the same is in conformity with the case of the Complainant/the Respondent. The extract of the conversation recorded on the said CD during the period from 9.12.2013 to 12.12.2013 throw enough light on the case of the Complainant as set before the Learned Forum, especially the following conversation between the parties:
CC Official - “Your cashless hospitalization is not yet approved and it is under process and it will take 2 to 3 hours”.
The Complainant: “We have sent an Application for cashless hospitalization but not yet approved”.
CC Official – “So many queries have been generated that is why it is delaying and it is under process”.
15. In our considered opinion, the Ld. Forum was justified in accepting the averments made in the complaint and has arrived at a just and fair decision while passing the impugned Order after evaluating the evidence on record.
16. In view of our aforesaid findings, we are duty bound to hold that the Ld. Forum was justified in accepting the case and the cause of the Complainant on merits of the case in terms of the evidence on record and holding that the Opposite Party is certainly guilty of ‘deficiency in service’ as defined under the Consumer Protection Act, 1986. Since we do not find any illegality, absurdity or irregularity in the impugned Order passed by the Ld. Forum, we are not inclined to interfere with the same. Also we do not find any merit in the argument of the Appellant that the present matter deserves to be remanded back to the Forum, in the particular/peculiar facts and circumstances of this case.
17. In view of our aforesaid findings, we do hereby pass the following:
O R D E R
It is hereby ordered that the present Appeal is hereby dismissed. The impugned Order dated 9.5.2014 passed by Ld. Forum, South Goa, at Margao in Complaint No. 10/2014 is hereby upheld. The Appellant herein is hereby directed to comply with the impugned Order passed by the Lower Forum and also to pay to the Respondent herein the amount of Rs. 7,000/- (Rupees Seven Thousand only) towards the costs of the present Appeal within 30 (thirty) days from the date of this Order.
This Order shall dispose of the present Appeal dated 18.7.2014 filed by the Appellant herein interalia challenging the Order dated 9.5.2014 passed by the Consumer Dispute Redressal Forum, South Goa, at Margaoin Complaint No. 10/2014, hereinafter referred to as the ‘impugned Order’.
Vide the impugned Order, the Ld. South Forum was pleased to partly allow the original complaint with the following directions:
“The complaint of the Complainant is partly allowed and the Opposite Party is directed to pay a sum of Rs. 80,124/- to the Complainant with 9% interest p.a. from the date of filing of this case till its realization. The Complainant is also entitled for a sum of Rs.10,000/- as compensation and a sum of Rs.5,000/- are also required to be paid by the Opposite Party to the Complainant towards the cost.”
Being aggrieved by the impugned Order, the Appellant has filed the present Appeal
The brief facts of the case can be stated as under:
I The Complainant in his original complaint alleged that he is a Silver Health Insurance Policy holder and is paying the annual premium amount regularly for last six years and has paid his last premium of Rs.12,587/- during the pendency of the complaint before the Forum. On 6.12.2013, the Complainant i.e. the Respondent herein was admitted in KLE Hospital, Belgaum for severe stomach and brain problem. Before admitting himself in the Hospital, the Hospital authorities had faxed the pre-authorization letter for cashless facility to the Opposite Party for approval of estimated expenses of Rs.95,000/-.
II The Opposite Party thereafter generated a query dated 6.12.2013 and accordingly the hospital authorities faxed the reply to the query. On 9.12.2013 the Complainant contacted the Customer Care Centre on phone and on inquiry he was informed that a sum of Rs.38,000/- was approved for the facility and the approval letter has been sent to the hospital by e-mail. On inquiry the hospital authorities informed the Complainant that they have not received the email and as such the Complainant again contacted the Customer Care Centre. Upon inquiry the official informed him that no approval has been granted and again a query has been generated.
III The Respondent herein further alleged in his complaint that the hospital authorities again replied to the query and accordingly the Customer Care Centre informed the Complainant that the facility is under process for approval. As there was no response from the Opposite Party inspite of repeated inquiries with them, the complaint was filed before the Lower Forum and accordingly the Lower Forum has partly allowed the complaint as said earlier.
On perusal of the Memorandum of Appeal and the case papers in the file received from the Learned Forum as well as the arguments advanced by both the parties, we now proceed to decide the fate of this Appeal as would contain hereinafter.
6. The Appellant has filed his written arguments on 8.1.2014 and the Respondent has filed his written submissions on 9.12.2014. The Appellant has argued before us that the Learned Forum has passed the impugned Order without applying its mind to the serious defences raised by the Appellant and in total violation of principles of natural justice. The Appellant has further argued that the Ld. Forum has erroneously ordered the Appellant herein to pay exorbitant compensation without giving any opportunity to the Appellant to lead the evidence.
7. The Appellant has further argued before us that the Ld. Forum committed an illegality while passing the impugned Order and the same is founded on unwarranted presumption and unsustainable interference. It was argued on their behalf that the Ld. Forum has failed to consider the willful concealment of facts and misrepresentation by the Respondent. Hence the Appellant prays that the present Appeal be allowed and the impugned Order be dismissed.
8. On the contrary, the Respondent has argued before us that he present Appeal is filed only with a view to harass the Respondents and deny the right of the policy holder. The Respondent has also contended that the Appellant before the Ld. Forum submitted that the Insurance Company wants to settle the claimed amount under the Medical bills paid to KLE Hospital by the policy holder. However such a talk of compromise before the Ld. Forum did not materialize at all as the Appellant did not attend the proceedings before the Forum on and after 9.5.2014. It was contended by the Respondent that the Ld. Forum has perused the case file minutely and in greater details and only thereafter has passed the impugned Order based on documents on record and merits of the case.
9. The Respondent has submitted in his written arguments that the said hospital authorities have replied all the queries except one which they could not have replied. The Appellant/Opposite Party had asked in their query – “All previous consultation paper for gastric ulcer since 5-6 years as per consultation on 24.5.2011.” The Respondent has drawn our attention to the fact that when the Policy holder had not consulted the said Hospital prior to 24.5.2011, then it would have been difficult for the hospital authorities to provide consultation papers of 5-6 years back. In our considered opinion the Respondent has rightly pointed out that he had contacted the Customer Care Centre several times after admitted into the said Hospital as also on 12.12.2013 and the telephonic conversation in a CD and the copy of the query report have already formed part of the record of the Lower Forum.
10. On going through the original file of the Lower Forum, we find that the Appellant/the Opposite Party, after receiving the notice from the Forum has filed therein written version on 21.3.2014. The Opposite Party has failed to file their Affidavit-in-evidence thereafter. In the absence of the Affidavitory evidence, it is difficult for this commission to accept the defences of the Opposite Party.
11. We have gone through the Policy document i.e. C1, the pre-authorization for cashless facility document i.e. C4, the medical documents at C7, C9 Colly, additional information request form at C19, C20 Colly, the bill receipts issued by the authorities on different dates as well as other related documents enclosed to the original complaint.
12. In our considered opinion, there is considerable substance in the contention of the Respondent that the Opposite Party had absolutely no reason to deny the cashless facility to the Complainant. It is pertinent to note that the Ld. Forum has rightly gone through in greater details as regards condition No. E(3) of Silver Health Policy document which incorporates claim procedure. We have no hesitation to hold that the Ld. Forum has rightly come to the inference that once the formalities that are required to be completed by the Complainant and the hospital, are completed, the Opposite Party is duty bound to pay the bills raised by the Hospital.
13. In this regard we hold that The Cashless Facility is usually obtained by the policy holders to save themselves from the financial problems which they might face on admitting themselves in the hospital. If this facility for which the cashless policy is obtained by the policy holder is denied, then the very purpose of obtaining the cashless facility is frustrated. Hence, we take the view that the Ld. Forum has rightly applied its mind to the evidence on record and has carefully drawn the conclusion that once the preauthorization letter and the ID along with the policy is submitted, the Opposite Party is duty bound to provide cashless facility to the Complainant especially when preauthorization letter in Annexure B is duly filled by the Hospital authorities and sent to the Opposite Party.
14. It is pertinent to note that the Respondent herein has produced on record the CD and the contents thereof are also placed by the Respondent in separate writing which are taken on record. We have gone through the contents of the said CD and find that the same is in conformity with the case of the Complainant/the Respondent. The extract of the conversation recorded on the said CD during the period from 9.12.2013 to 12.12.2013 throw enough light on the case of the Complainant as set before the Learned Forum, especially the following conversation between the parties:
CC Official - “Your cashless hospitalization is not yet approved and it is under process and it will take 2 to 3 hours”.
The Complainant: “We have sent an Application for cashless hospitalization but not yet approved”.
CC Official – “So many queries have been generated that is why it is delaying and it is under process”.
15. In our considered opinion, the Ld. Forum was justified in accepting the averments made in the complaint and has arrived at a just and fair decision while passing the impugned Order after evaluating the evidence on record.
16. In view of our aforesaid findings, we are duty bound to hold that the Ld. Forum was justified in accepting the case and the cause of the Complainant on merits of the case in terms of the evidence on record and holding that the Opposite Party is certainly guilty of ‘deficiency in service’ as defined under the Consumer Protection Act, 1986. Since we do not find any illegality, absurdity or irregularity in the impugned Order passed by the Ld. Forum, we are not inclined to interfere with the same. Also we do not find any merit in the argument of the Appellant that the present matter deserves to be remanded back to the Forum, in the particular/peculiar facts and circumstances of this case.
17. In view of our aforesaid findings, we do hereby pass the following:
O R D E R
It is hereby ordered that the present Appeal is hereby dismissed. The impugned Order dated 9.5.2014 passed by Ld. Forum, South Goa, at Margao in Complaint No. 10/2014 is hereby upheld. The Appellant herein is hereby directed to comply with the impugned Order passed by the Lower Forum and also to pay to the Respondent herein the amount of Rs. 7,000/- (Rupees Seven Thousand only) towards the costs of the present Appeal within 30 (thirty) days from the date of this Order.
