Kerala

Idukki

CC/188/2022

THOMAS FELICKS - Complainant(s)

Versus

Kerala state finance enterprises - Opp.Party(s)

27 Oct 2023

ORDER

DATE OF FILING : 17/09/2018

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 25^th day of October 2023

Present :

SRI.C.SURESHKUMAR PRESIDENT

SMT.ASAMOL P. MEMBER

SRI.AMPADY K.S. MEMBER

CC NO.167/2018

Between

Complainant : 1 . Mr.Benny K.A., S/o Antony,

Koonamparayil House, Karikode,

Thodupuzha East P.O., Pin – 685 585,

Idukki District, Kerala.

2 . Mrs. Manju Maria, W/o Benny K.A.,

Koonamparayil House, Karikode,

Thodupuzha East P.O., Pin – 685585,

Idukki District, Kerala.

3 . Miss. Bosvin Ben Bentrock, D/o Benny K.A.,

Koonamparayil House, Karikode,

Thodupuzha East P.O., Pin – 685585,

Idukki District, Kerala.

(All by Adv.K.M.Sanu)

And

Opposite Party : 1 . The Manager,

National Insurance Company Ltd.,

Thodupuzha Branch, Pulimoottil Shopping

Arcade, Thodupuzha P.O., Pin 685 584.

2 . The Manager,

Medi Assist Insurance TPA Private Ltd.,

(Formerly Known as Medi Assist India TPA

Private Ltd.), Chiccago Plaza, 4^th Floor,

Rajaji Road, Cochin – 682 035, Kerala.

(Both by Adv.Jolly James & Adv.Antony J.Marattil)

Additional Opposite party: 3 . The Director,

Jubilee Ayurveda Mission,

Hospital and Research, Institute,

Thrissur – 5.

(By Adv.Sajesh K.)

O R D E R

SRI.AMPADY K.S., MEMBER

 

This Complaint is filed under S.12 of Consumer Protection Act, 1986. Complaint averments are briefly discussed hereunder.

 

1 . The first complainant is husband of the 2^nd complainant and father of 3^rd complainant.

 

2 . 1^st opposite party provided a National Parivar Mediclaim Policy (family floater health insurance policy) to complainants by policy No.570801/48/17/8500000269 for the period valid from 13^th June 2017 to 12^th June 2018 for a total sum assured Rs.2,00,000/-. In this health insurance policy the primary beneficiary is the 1^st complainant and complainants 2 and 3 are secondary beneficiaries. The 2^nd complainant is a teacher and the 3^rd complainant is student.

 

3 . Due to chronic severe back pain and abnormality in breasts of complainants 2 and 3, they have opted to take Ayurveda treatment from Jubilee Mission Medical College Hospital, Thrissur which is a listed network hospital of the 1^st and 2^nd opposite parties, as inpatient from 11^th May 2018 to 25^th May 2018. Immediately after the discharge of complainants 2 and 3, 1^st complainant presented the claim form along with medical bills for Rs.50,520/- for the 2^nd applicant and Rs.38,894/- for the 3^rd applicant. Total Rs.89,414/- (Eighty Nine Thousand Four Hundred and Fourteen only) with all relevant documents for reimbursement of said treatment expenses to the 1^st opposite party through its TPA 2^nd opposite party by 28/05/2018. On submission of reimbursement claim the 2^nd opposite party on 30/05/2018, asked the 1^st complainant to provide his NEFT details and also to “provide the current year Ayrveda hospital registration certificate or renewal cash receipt from the treated hospital “ ie of Jubilee Mission Medical College Hospital, Thrissur. 1^st complainant collected said registration certificate and details from said treated hospital and sent to the TPA by courier without delay. But the said claims were denied by the 1^st opposite party by letter dated 23/06/2018, on the reason that “there is no Ayurveda registration for Jubilee Mission Medical College Hospital, Thrissur” where the complainants 2 and 3 received treatment.

 

4 . Complainants 2 and 3 availed Ayurveda treatment, from the Ayurveda Department of Jubilee Mission Medical College Hospital, which is one of the departments of the said hospital. 1^st complainant also collected certificate from Jubilee Mission Medical College Hospital, Thrissur stating that Jubilee Ayurveda is one of the departments of Jubilee Mission Medical College Hospital, Thrissur and there is no separate registration number for the same and the medical college already applied for renewal of existing registration certificate for the year 2018-19.

 

5 . Against the denial of the claim, 1^st applicant approached the 1^st opposite party’s Grievance Cell but they also denied the claim of the applicants on the same reasons. Opposite parties have denied the eligible reimbursement of treatment bills according to the terms of policy issued by them. Moreover amount claimed for reimbursement is also within the policy limits.

 

6 . Non consideration of the claim for reimbursement is a gross deficiency in service on the part of the opposite parties. Hence the complainants suffered severe loss both financially and mentally. Hence the opposite parties are liable to compensate the complainants.

 

7 . Opposite parties are jointly and severally liable to compensate the complainants for the gross deficiency in service to complainants. Hence complainants prayed for allowing Rs.1,24,414/- under following heads.

 

a . Medical claims of complainants 2 and 3, Rs.50,520+38,894-Rs.89,414/-.

 

b . Compensation for deficiency in service – Rs.20,000/-.

 

c . Compensation for mental agony and inconvenience caused to complainants – Rs.10,000/-.

 

d . Costs – Rs.5,000/-

 

Total – Rs.1,24,414/-

 

Opposite parties 1 to 3 filed separate written version as shown below.

 

1^st opposite party’s contentions are as follows.

 

1 . The complaint is not maintainable either under law or on facts against this opposite party.

 

2 . 1^st opposite party admits the existence of the Mediclaim Policy No.570801/48/17/8500000269 for the period from 13/06/2017 to 12/06/2018 in which the first complainant is the primary beneficiary and second and third complainants are the secondary beneficiaries and the total sum assured is Rs.2,00,000/-.

 

3 . 1^st opposite party admits that it denied the claims of an amount of Rs.50,520/- and Rs.38,894/- of the second and third complainants respectively. It is admitted by the complainants that they underwent Ayurveda treatment in the Jubilee Mission Medical College Hospital, Thrissur. The definite stand of 1^st opposite party is that, the said hospital is not recognised for Ayurveda treatment and hence as per the norms of the policy the claimants are not entitled for re-imbursement. The claim for reimbursement was repudiated under clause No.3.9 of the policy.

 

4 . In spite of repeated requests the complainants failed to produce any document showing that Ayurveda recognition is obtained by the said hospital which is mandatory for the claim for re-imbursement.

 

5 . Statement in para 3 of the complaint that requisite certificate for Ayurveda treatment is obtained by the 1^st complainant is not true. The Jubilee Mission Medical College Hospital, Thrissur has not secured certificate so far.

 

6 . Averments in clause 4 of the complaint is not true and hence denied. No deficiency in service is occurred from the part of 1^st opposite party. The claim made by the complainants in each head must be proved before the Forum with supporting evidence. Complainants have not produced any evidence in support of their claims.

 

7 . 1^st opposite party is not liable to compensate the complainants and pay interest and costs.

 

So, it prayed for dismissal of complaint with costs.

 

2^nd opposite party’s contentions are:-

 

1 . Complaint is devoid of any merit. There is no cause of action for the complaint. All the averments and allegations in the complaint in so far as they are contrary to or inconsistent to the facts admitted hereunder are denied. Above complaint is absolutely misconceived, frivolous and vexatious in nature, unsustainable in law and liable to be dismissed at the threshold.

 

2 . This opposite party admits that the claims of the 2^nd and 3^rd complainants for Rs.50,520/- and Rs.38,894/- respectively are denied. As per the case of the complainants they underwent Ayurveda treatment in Jubilee Mission Medical College Hospital, Thrissur. It is admitted that the claim of the complainants were processed by 2^nd opposite party as per the norms of the policy and was recommended for denial as the aforementioned hospital was not recognized for Ayurveda treatment.

 

3 . In spite of repeated requests, complainants failed to produce any documents showing that Ayurveda recognition is obtained by the said hospital which is mandatory for the claim for re-imbursement. As per the policy issued by the first opposite party “hospital means any institution established for inpatient care and day care treatment of illness and /or injuries and which has been registered as a hospital with the local authorities under the clinical establishments(registration and regulation ) Act, 2010 or under the enactments specified under the schedule of section 56(1) of the said Act.

 

4 . Statement in paragraph 3 of the complaint that requisite certificate for Ayurveda treatment is obtained by the 1^st complainant and sent the same to 2^nd opposite party is not true. The Jubilee Mission Medical College Hospital, Thrissur had no such certificate at the time of treatment given to the 2^nd and 3^rd complainants.

 

5 . Averments in paragraph 4 of the complaint is not true and hence denied. No deficiency in service is occurred from the part of this opposite party. The claim made by the complainants in each head must be proved before the Forum with supporting evidence. The complainants have not produced any evidence in support of their claims.

 

6 . Complainants are not entitled to get any amount from this opposite party by way of reimbursement, cost or compensation as claimed in the complaint.

 

So, it prayed for dismissal of complaint with compensatory costs.

 

3^rd opposite party filed written version as under:-

 

1 . Complaint filed is vexatious, baseless and is more of an abuse process of law. It has been made to injure the interest and reputation of the opposite party herein and therefore the same is liable to be dismissed.

 

2 . It is submitted that this be treated as a specific denial of complaint.

 

3 . 3^rd opposite party admits that 2^nd and 3^rdcomplainants were admitted in the Ayurveda Department of Jubilee Mission Medical College Hospital. This opposite party provided all the documents as requested by the complainants. There was no latches in providing documents from the side of this respondent. The Ayurveda Department of Jubilee Mission Medical College was properly registered and the copies of said documents already supplied to the complainants.

 

4 . As per records, 2^nd and 3^rd complainants were satisfactorily completed the treatment with this opposite party and entire amount was also paid by them. There was no deficiency in service from the side of this opposite party.

 

5 . Though the Consumer Protection Act 1986 is a beneficial legislation, the same cannot be misused to arm twist companies to heed to the unreasonable demands of the customers if the present complaint is allowed, which has been filed only with an intention of making wrongful gain and tarnishing reputation of answering opposite party.

 

It also prayed for dismissal of complaint with costs.

 

Documents filed by complainants were marked as Exts.P1 to P4 series (2 in Nos), Ext.P5 series (9 in Nos), Ext.P6 to Ext.P12, Ext.P13 series (13 in Nos) and Ext.P14 to Ext.P22. No oral evidence tendered by complainant. Though 1^st and 2^nd opposite parties and additional 3^rd opposite party filed written version and represented on certain postings, no documents were produced and no oral evidence was also tendered by them.

 

Heard.

 

We have examined the pleadings of both sides and documents produced by complainant. On a careful analysis of the same, following points arise for consideration.

 

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

 

2 . If so, for what reliefs complainants are entitled to?

 

3 . Reliefs and costs?

 

Point Nos.1 and 2 considered together

 

From the pleadings of both sides, it is seen that treatment at Jubilee Medical Mission Hospital, Trissur is an admitted fact. Reason stated by 1^st opposite party for repudiation as per exhibit P15 is that above hospital is not recognised. As per Ext.P18, it is stated that in the light of clause 3.12 “ as there is no Ayurveda Registration for the hospital, this claim needs denial”. Clause 3.12 is reproduced in above exhibit as “hospital means any institution established for inpatient care and day care treatment of illness and/ or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the schedule of section 56(1) of the said Act. Similar is the reason mentioned in Ext.P23. As per Ext.P14, 2^nd opposite party called for from the 3^rd complainant current year Ayurveda hospital registration certificate or renewal cash receipt from the treated hospital. Similar request was also given to 2^nd complainant as per Ext.P19. 1^st opposite party as per Ext.P15 issued letter to 1^st complainant regarding claim made for 2^nd and 3^rd complainants stating that “they have called for the mediclaim file scrutinized it and also had a discussion with the doctor of the TPA, it is stated therein that as per the certificate provided this hospital is registered for Allopathic system of treatment”. They also stated that relevant pages of IRDA Health Regulation 2013 is attached. As per the same “Ayush Coverage-Insurers may provide coverage to non-Allopathic treatment provided the treatment has been undergone in a Government Hospital, in any institute recognised by Government and / or accredited by quality control of India/NABH or any other suitable institutions”. They also stating guidelines for reimbursement/settlement of Ayurveda treatment expenditure claims under insurance coverage by government of India, Ministry of Ayush, which states that the eligible hospital for Ayurveda treatment.

 

1. Central or State Government Hospital.

 

2. NABH Accredited Ayurveda Hospital.

 

3. Teaching hospital attached to Ayurveda Colleges recognized by Central Government/ Central Council of Indian Medicine.

 

(d) Ayurveda Hospital having registration with the Government Authority under appropriate act in a State/ Union territory etc. Jubilee Mission Medical College Hospital which does not qualify under the Regulation/Guidelines stated above.

 

On going through the contents that Ext.P18 and Ext.P23 with that of Ext.P15, it is seen that additional conditions were mentioned therein that of Ext.P18 and Ext.P23. As per Ext.P24, complainant has produced copy of application dated 05/02/2018 for renewal of registration of the above hospital. Above hospital is renowned hospital established long back. It is a medical college also. Without taking registration from local authority and necessary registration from government departments, no such hospital can be functioned. The reasoning stated in Ext.P15 is found to be not to give medical expense incurred by the 2^nd and 3^rd complainants. A major hospital having hundreds of doctors, nurses, paramedical staff, beds etc., would have various departments like Ayurveda, Homeo, Naturopathy etc. For certain diseases both combined Allopathic and Ayurveda treatments are needed. 1^st and 2^nd opposite parties have not produced copies of Guidelines and Regulation mentioned in Ext.P15 before this Commission. As per clause 3.12 stated by the 1^st opposite party in Ext.P18 and Ext.P23, said hospital cannot be regarded as not having registered as a hospital with local authority. It is stated in clause 1.1 of Ext.P17 that policy covers expenses in respect of inpatient treatment (Allopathic, Ayurveda & Homeopathy) domiciliary hospitalisation etc.,. In clause 1.2.6, it is stated that the company shall pay to the hospital the medical expenses or reimburse the insured the medical expenses pre and post hospitalization expenses upto the sum insured, incurred for Ayurveda and Homeopathy treatment upto the sum insured, provided the treatment is undergone in a government hospital or in an institute recognized by the government and / or accredited by quality control of India / NABH. Insurer cannot go beyond the terms of explicit contract entered with insured. They cannot add any further condition also. Nothing could be brought out by 1^st and 2^nd opposite parties to prove that said hospital is not having any registration under provisions of relevant acts. On going through the pleadings of additional 3^rd opposite party, it is seen that said hospital is a major centre for various treatments and it is known to the public also. So, we find that additional 3^rd opposite party has no liability in the instant case as contract is between complainants and 1^st opposite party. In these circumstances we exonerate additional 3^rd opposite party. On the contrary, insurance company is under an obligation to honour the genuine claims of insured. 1^st and 2^nd opposite parties have not produced the reasoning behind the repudiation of claim before this Commission. TPA is an agent appointed by the insurance company for perusal and determination of claims received and to recommend for payment or rejection. So, both these opposite parties are in a principal and agent relationship. So they are vicariously liable to the insured. Rejection of claims stating flimsy reasons would definitely cause mental agony and hardship to an insured. In the instant case, we find that inaction on the part of 1^st and 2^nd opposite parties resulted in filing this complaint before this Commission. On an analysis of entire facts and circumstances and evidence of the case, we find that there is deficiency in

 

 

service on the part of 1^st and 2^nd opposite parties in not honouring the claim in time for which complainants are entitled to compensation. They are also entitled to compensation for mental agony and hardship caused to them. In this case complainants have claimed total hospital expenses of Rs.89,414/- for which they are eligible to get from 1^st and 2^nd opposite parties. Similarly complainants are entitled to compensation of Rs.20,000/- for deficiency in service of 1^st and 2^nd opposite parties and mental agony and hardship caused to complainants. They are also entitled to litigation costs of Rs.5,000/-. Hence point Nos.1 and 2 are answered as above.

 

In the result this complaint is allowed in part by giving direction to 1^st and 2^nd opposite parties as follows:-

 

(a ) 1^st and 2^nd opposite parties are directed to pay complainants hospital expenses of Rs.89,414 (Rs.50,520 for 2^nd complainant and Rs.38,894/- for 3^rd complainant) with 9% per annum interest from the date of complaint ie, 17/09/2018 till full realisation.

 

(b ) They are directed to pay complainants Rs.20,000/- with 9% per annum interest from 17/09/2018 till realisation for deficiency in service and mental agony and hardship caused to complainants by 1^st and 2^nd opposite parties.

 

(c ) They are also entitled to complainants litigation costs of Rs.5,000/- to complainants.

 

Above amounts should be paid within 30 days of receipt of this order failing which 1^st and 2^nd opposite parties are liable to pay further interest @ 9% per annum mentioned above except on litigation costs till realisation and

 

 

 

 

 

 

the complainants are entitled to proceed against them in accordance with law.

 

Parties shall take back extra copies without delay.

Pronounced by this Commission on this the 25^th day of October 2023.

 

SRI.AMPADY K.S., MEMBER

 

 

SRI.C.SURESHKUMAR, PRESIDENT

 

 

SMT.ASAMOL P., MEMBER

 

APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1 –Photocopy of Ultra Sound Scan Report of Abdomen & Pelvis of 2^nd

complainant done at Jubilee Medical Mission Hospital, MCH,

Thrissur, dated 10/05/2018.

Ext.P2 – Photocopy of Bilateral Mammogram with USG Correlation of

2^nd complainant

Ext.P3 – Photocopy of Discharge summary treatments of 2^nd complainant

Ext.P4 – Photocopy of Medical prescriptions 2 Nos of 2^nd complainant

Ext.P5seires (9 in nos.) – Photocopy of Reimbursement Claim form 2^nd

complainant of Rs.50,520.00 with bills from Jubilee Mission

Medical College Hospital, Thrissur, submitted to 1^st opposite party

through 2^nd opposite party TPA. Original claim form and bills are

already with the opposite parties.

Ext.P6 – Photocopy of MRI – Lumbosacral Spine report of 3^rd complainant

done at Jubilee Mediscan, Jubilee Medical Mission Hospital,

MCH,Thrissur dated 21/05/2018.

 

Ext.P7 – Photocopy of Ultra Sound Scan Report of Abdomen & Pelvis of 3^rd

complainant.

Ext.P8 – Photocopy of Ultra Sonogram of Both Breasts & Axillae of 3^rd

complainant

Ext.P9 – Photocopy of Laboratory investigation – clinical pathology of 3^rd

complainant.

Ext.P10 - Photocopy of Laboratory investigation – clinical chemistry

of 3^rd complainant.

Ext.P11 - Photocopy of Discharge Summary treatments of 3^rd complainant.

Ext.P12 - Photocopy of Medical prescriptions 2 Nos of 3^rd complainant

Ext.P13 series (13 in Nos) - Photocopy of Reimbursement claim form

3^rd complainant, for Rs.38,894.00 with bills from Jubilee Mission

Medical College Hospital, Thrissur submitted to 1^st opposite party

through 2^nd opposite party TPA. Original claim form and bills are

already with the opposite parties..

Ext.P14 - Photocopy of letter dated 30/05/2018, issued by 2^nd opposite party

seeking information and documents of hospital registration

certificate to 2^nd complainant.

Ext.P15 - Photocopy of claim denial letter dated 03/08/2018, issued by

1^st opposite party to 2^nd and 3^rd complainants

Ext.P16 - Photocopy of Registration Certificate issued by Thrissur Municipal

Corporation to Jubilee Mission Medical College Hospital, Thrissur

for the period 2016/2017.

Ext.P17 - Photocopy of policy prospectus issued by 1^st opposite party along

with said medical insurance policy.

Ext.P18 - Photocopy of claim denial letter dated 23/06/2018, issued by

1^st opposite party to 2^nd complainant.

Ext.P19 - Photocopy of letter dated 30/05/2018, issued by 2^nd opposite party

seeking information and documents of hospital registration

certificate to 3^rd complainant

Ext.P20 - Photocopy of the reminder letter dated 22/03/2018, issued by the

Director Jubilee Mission Medical College Hospital, Trissur to

Municipal Corporation, Thrissur.

Ext.P21 - Photocopy of certificate dated 06/06/2018, issued by Jubilee

Mission Medical College Hospital, Thrissur stating that Jubilee

Ayurveda is one of the departments of Jubilee Mission Medical

College Hospital, Thrissur and there is no separate registration

number and they already applied for renewal of registration

certificate for the year 2018-2019.

Ext.P22 - Photocopy of hand book issued by the 2^nd opposite party including

list of network hospitals from where the policy holder can avail

treatment in Kerala.

Ext.P23 - Photocopy of claim denial letter dated 23/06/2018, issued by

1^st opposite party to 3^rd complainant.

Ext.P24 - Photocopy of Registration certificate application dated

05/02/2018, submitted Thrissur Municipal Corporation by Jubilee

Mission Medical College Hospital, Thrissur for the period

2018-2019 and its receipt copy.

On the side of the Opposite Party :

Nil

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Forwarded by Order

 

ASSISTANT REGISTRAR