Sri. Aswini Kumar Patra, President

1. The captioned consumer complaint is filed by the complainant named above inter alia alleging deficiency in service & unfair trade practice on the part of the Ops for denial of insurance benefits/cashless treatment & for repudiation of insurance claim under the health insurance policy.
2. The complainant seeks for the following reliefs:- (i) An order Directing the O.Ps. No.1 & 2 to release the insurance benefit of Rs.87,695/- under policy No.P0024300004/6115/100434,  MHDI50611765 vide  Claim No.24050300540. or to direct the O.P 3 to return back the said amount of Rs.87,695/- with interest @18 % P.A. (ii) Directing the  O.Ps to pay compensation of Rs 1,00,000/ with litigation cost of  Rs.50,000/-and to award punitive damages of Rs.2,00,000/- payable to the complainant, (iii) And further prays to award any other relief /reliefs as the learned Commission may deem fit and proper in the interest of justice.
3.  The factual matrix leading to the case of the complainant as emerged from the case record is that, the Complainant is one of the employee of SYSTAL Technology Solution Pvt. Ltd..434 bearing employee ID : SYS-IND-3182 and  got insured with Magma HDI GIC Ltd/O.P 1(one) vide Policy No.P0024300004/6115/100434 for the period of    01.01.2024 to 31.12.2024 . The parent, children and spouse are beneficiary under this policy. Suryakanti Panda is the mother of the complainant. She got admitted in the Andhra Hospital /OP3 on 02.05.2024 due to her illness and undergone treatment as indoor patient and discharged on 10.05.2024 .(Discharge summary and details of the bill paid is filed as - Annexure 1 series of the complaint petition.)The complainant is entitle for cashless treatment of her mother under subject insurance policy and have avail initial cashless authorization letter dt.03.05.2024 vide claim No.24050300540 vide  Annexure 2 series of the complaint petition. Accordingly, the Op1&2 /insure has made Preauth Query to the Op 3/Hospital on dt. 5/9/2024 at 7: 11 PM vide  Annexure 3 series of the complaint petition accordingly the Op3/Hospital has respond the said Query immediately on 5/9/24 at about 7:20PM to the satisfaction of the insurer op1&2 vide  Annexure 4 series of the complaint petition. However, the cashless service for treatment of the insured mother of the complainant is arbitrarily denied by the Insurer/OP1&2   vide letter dt. 09/05/2024 stating there in that:-“As per our medical opinion and submitted documents, the present hospitalization is for the (not required), can be investigation and evaluation only .The investigation could have been done on outpatient basis without necessity of admission for the same. Hence we regret to inform that your claim is repudiated under section 3.E” vide Annexure -5 of the complaint petition. On receiving of said repudiation letter a clarification was made by Dr, L.R.GIRINADH (MD.DM) of OP 3/Hospital, the treating physician  of the mother of the complainant, and justified necessity of treatment of the mother of the complainant as indoor patient vide Annexure -5 of the complaint petition .So also, the  Andhra Hospital authority /O.P 3 has again requested to  reconsider cashless approval of patient Suryakanti Panda under  claim No.MHD156611765 certified therewith that, there was sufficient reason for treatment of Suryakanti panda/mother of the complainant as indoor patient but the O.P 1 &2 have  arbitrarily & illegally denied the cashless treatment service and arbitrarily rejected the claim of the complainant vide letter dt.10.05.2024 stating  therein that: “Cashless facility is denied as claim, as there is no active line of treatment and need for admission is not justified” vide Annexure -7 of the complainant petition. The request for consideration cashless approval vide  Annexure -9 series of the complainant petition is not responded. Hence this complaint.
4. The complaint further contents  that, no one, even the complainant or his mother got pleasure to stay in any hospital as indoor patient rather, the mother of the complainant was under active supervision of physicians Dr.K Santosh Kumar MD, General medicine, Dr. LRS Girinath , MD,DM Gastro ENT Rology , Dr. Bhaskar MD, Nephrology of Andhra Hospital/op3 and as per their  advise the mother of the complainant undergone treatment as indoor patient form 02.05.2024 to 10.05.2024 in theOP3/Hospital and that, denial of service of cashless treatment  for the treatment of the mother of the complainant during the policy period is arbitral & illegal which clearly proof the unfair trade practice and deficient service there in the part of O.P 1&2 for which the complainant was compel to pay the entire bill amount of Rs.87,695/- to the O.P 3/Andhra Hospital and suffered  financial loss  & mental agony need to be  indemnify by the O.P 1(one) & 2(two).
5. The complainant further submits that, it shall be a matter of great concern that, if honorable Commission will found that , the doctors of  O.P 3/Andhra hospital has given wrong advise and unnecessarily admitted the patient /mother of the complainant as indoor patient only for abstraction  of huge money dishonestly from the innocent patient   causing  financial loss, physical pain & mental agony then it shall be clearly prove deficient service and unfair trade practice there in the part of O.P 3./Andhra Hospital for which the O.P 3/Andhra Hospital shall be liable to refund the entire money of Rs.87,695/- taken  from the complainant and further liable to compensate the complainant sufferings of financial loss and mental agony and again liable to be punished by awarding punitive  damages .
6. To substantiate his claim,  the complainant has relied on following documents and filed the self attested true copy of the following documents:-

1. Discharge Summary and details of the bill paid, Annexure -1 series.
2. Initial cashless authorization letter dt.03/05/2024. Annexure 2 series.
3. Preauth Query dt.09.05.2024.Annexure-3 series.
4. Query response dt.09.05.2024. Annexure- 4 series.
5. Letter of Denial of cashless service dt.09.05.2024 . Annexure 5 series .
6. Request letter for reconsider cashless approval of the patient Surya Kanti panda, MHDI50611765 to op 2 from OP 3 Annexure 6.
7. Letter of denial of cashless service dt.10.05.2024. Annexure 7.
8.  Money receipt dt.10.05.2024, 4 number of money receipt towards payment of Rs.87,695/-. Annexure 8 series.
9. Letter of request dt.03.06.2024 for consider cashless approval of the patient Suryakanti Panda vide card No. MHDI50611765, Claim No.24050300540 and details of communication with Ops. Annexure 9 series
10. Aadhar Card of the Complainant Annexure- 10.
11. Affidavit of complainant declaring that, the averment of the complainant petition & documents are true & correct.

7. On being notice the Op 1(one) appeared through their learned counsel Shri. D.R. Bohidar and filed their written version denying complaint allegation and challenging the maintainability of this complaint stating therein that, there is no cause of action to bring this complaint against the Ops and further contended that, the alleged complaint is barred by the principles of estoppels waiver, acquiescence, limitation, non-joinder and mis-joinder of necessary parties. However, the Op 1 /Insurance Company   have not disputed the valid insurance policy as on the date of medical treatment under gone by the mother of the complainant. The Op/insurance Company also not disputed the treatment of the mother of the complainant as well as expenditure incurred in this respect. 

8. The Op1/Insurance Company submits that, there is no active line of treatment of the mother of complainant as such there was any need for admission of the mother of the complainant as indoor patient. Rather,   admission to the hospital as an indoor patient is not justified as per the medical documents. It is further submitted that, after going through the documents submitted by the complainant, mother of the complainant was suffering from only fever with weakness admitted with diagnosis fever under evaluation, later was diagnosed as hypokalamia with AKI. As per ICPs, member was not having any major complaints, all vital organs where within normal limit and member was treated with intravenous Pan, Zofer and other oral medication. In this context the answering opposite party asked for justification for need of admission at hospital, but clarification which was received is not in line with treatment given. It is further submitted that, the all-lab reports were within normal limit (except serum Potassium and create which are slightly deranged and no treatment is given for the same). The mother of the complainant was admitted at Andhra Hospital (Vishakhapatanam) Pvt. Ltd was primarily done for only diagnostic and evaluation purpose. So, from this, it was clear that the mother of the complainant was not suffering from any disease but still she was admitted for 8 days in the hospital. The answering opposite party/insurer has rightly repudiated the claim for not fulfilling the terms and conditions and exclusion of the policy. Rather the opposite party No-3 (Andhra Hospital) has made wrong advice and unnecessary admitted the mother of the complainant as indoor patient only for abstraction of hug money dishonestly from him by causing financial loss, physical pain and mentally agony which the complainant has already admitted in his pleading. There is clear negligence, deficient service & unfair trade practice on the part of the OP3/(Andhra Hospital) .So OP3/(Andhra Hospital  will be liable to  indemnify the complainant .Claim of the complainant under subject insurance policy is rightly rejected based on the terms & conditions of the policy and the complainant is not entitle for any relief as claimed and with this submission the Op 1 /insurance company urged to dismiss this complainant with cost.

9. The Op 2 and Op 3 did not choose to contest this case though notice through registered vide R.P Consignment No. RO171214191IN is properly served to the OP2 dt.27/07/2024 and R.P Consignment No. RO171214228IN is properly served to the OP3 dt.26/07/2024.

10. After perusal of the complaint petition, written version and all the documents placed in the record, the points for consideration before this Commission are :-

(i). Whether the complainant is a consumer of the Ops?

(ii).Whether there is any cause of action arose for this complaint?

(iii). Whether this complaint is maintainable under C.P.Act 2019,

(iv. Whether there is any deficient service & unfair trade practice on the part of Ops caused injuries to the complainant? 

(v). And, whether the complainant is entitling to get the relief(s) claimed?

11. During hearing of this case, the Op1/insurance Company has filed the evidence affidavit of one Sri. Saubhagya Ranjan Mohanty , the  Manager MAGMA HDI General Insurance CO. Ltd, Bhubaneswar ,averments of which are corroborating with the averment of the written version of the Op1/insurance company whereas, the complainant virtually present and submits that, facts stated in his complainant are true & correct and that, affidavit filed along with his  complainant petition is to be treated as his evidence .The memo filed with this respect is taken in to consideration.

12. Heard. Peruse the material available on record. We have our thoughtful consideration on the submission of the rival parties. So also we have our thoughtful consideration on the argument placed by learned counsel for the OP 1(one) and complainant present.

13. Before going to decide the disputes involved in this case we may reproduce here the CLAIM PROCEDURE IN RESPECT OF A HEALTH INSURANCE POLICY there stipulated under Section 16 of Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests) Regulations, 2017 as follows :-

16. CLAIM PROCEDURE IN RESPECT OF A HEALTH INSURANCE POLICY:-

1.  Every insurer shall adhere to the procedure laid down under Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016 for settlement of health insurance claims.

(i)An Insurer shall settle the claim within 30 days from the date of receipt of last necessary document in accordance with the provisions of Regulation 27 of IRDAI (Health Insurance) Regulations, 2016.

(ii) In the case of delay in the payment of a claim, the insurer shall be liable to pay interest from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.

2. However, where the circumstances of a claim warrant an investigation in the opinion of the insurer, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, Insurer shall settle the claim within 45 days from the date of receipt of last necessary document.

(i).In case of delay beyond stipulated 45 days the Insurer shall be liable to pay interest at a rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of claim.

3. Return of premium on cancellation during Free Look Period shall be processed in accordance with the provisions of Regulation 14 of IRDAI (Health Insurance) Regulations, 2016. Any refund shall be processed with speed and shall be refunded within 15 days from the date of receipt of request for free look cancellation.

Explanation: Health Insurance claims for the purpose of this Regulation shall be claims arising under all insurance policies issued by Life, General and Health Insurers in respect of Health Insurance Business as defined in Section 2 (6C) of the Act.

14. Issue No (I) :- Whether the complainant is a  consumer of the Ops?. Here in this case insurance as well as treatment of the insured mother of the complainant during insurance period and expenditure incurred with this respect is not disputed and that, the Op2/Family Health Plane Insurance TPA Ltd. is engaged by the Op1/Insurance Company to settled the claim under the subject Insurance Policy is not disputed. So also it is not disputed that, the complainant has paid Rs 87,695/-to the Op3/ Andhra Hospital (Vikshapatnam) Pvt.Ltd. towards treatment of his mother/beneficiary while the subject Health Insurance Policy was in force. It is also not disputed that, a claimed vide No MHD156611765 is made before the Op1/Insurer to reimburse the expenditure incurred during treatment of the insured mother of the complainant and that, the Op2/Family Health Plane Insurance TPA Ltd. is engaged by the Op1/Insurance Company to settled the claim under the subject Insurance Policy has denied the claim is not disputed. Accordingly, this commission may safely hold that, the complainant is a consumer of Ops. Hence, Issue No (I) decided in favor of the complainant.

15. Issue No. (IV):- Whether there is any deficient service & unfair trade practice on the part of Ops caused injuries to the complainant?  And Issue No. ( v)  Whether the complainant is entitle to get the relief(s) claimed? These issues are deciding together as follows:-

(i). Admittedly, both insured/complainant & OP 1&2 Insurer shall be bound by the terms & conditions of the subject insurance policy. 

(ii). The Op2 for 1/Insurance Company has rejected the claim of the complainant vide letter dt.10.05.2024 stating therein that: “Cashless facility is denied as claim, as there is no active line of treatment and need for admission is not justified”. Thus, onus lays on the Ops 1&2 /TPA & Insurance Company respectively to prove their contentions.

(iii). To substantiate their claim the Op1/Insurance Company has filed the evidence affidavit of one Sri, Saubhagya Ranjan Mohanty , the  Manager MAGMA HDI General Insurance CO. Ltd, Bhubaneswar ,averments of which are corroborating with the averment of the written version of the Op1/insurance company.

(iv) Admittedly, Sri, Saubhagya Ranjan Mohanty is not a person of medical expert. Hence, this Commission is unable to hold, the averment of the Sri, Saubhagya Ranjan Mohanty as the opinion of medical expert.

(v). No opinion of medical expert, who has ever examined the medical paper of patient Suryakanti Panda/the mother of the complainant, is filed by either the Op1/Insurance company or the Op 2/TPA to proved that:-“ there is no active line of treatment of the mother of complainant & there was no need for admission and, that admission of the mother of the complainant in the hospital as an indoor patient was not justified.”

(vi). The Op1/Insurer has misunderstood the complaint averment that, the complainant has admitted the facts that, opposite party No-3 (Andhra Hospital) have made wrong advice & unnecessary admitted the mother of the complainant as indoor patient only for abstraction of hug money dishonestly from him by causing financial loss, physical pain and mentally agony to the complainant. This Commission found nothing such admission there on the part of the Complainant.

(vii). The mother of the complainant was under active supervision of physicians Dr.K Santosh Kumar MD, General medicine, Dr. L.R. Girinath , MD,DM Gastro ENT Rology , Dr. Bhaskar MD, Nephrology of Andhra Hospital/Op3 and as per their  advise she undergone treatment as indoor patient form 02.05.2024 to 10.05.2024 in theOP3/Hospital remain un-rebutted. It is seen that,on receiving of letter of denial of cashless treatment of the indoor patient Smt.Suryakanti Panda/the mother of the complainant vide letter dt.09/05/2024 of the OP1/Insurer vide Annexure 5 of the complainant petition, a clarification was made by Dr, L.R.GIRINADH (MD.DM) of OP 3/Hospital, the treating physician of the mother of the complainant, and justified necessity of treatment of the mother of the complainant as indoor patient vide Annexure- 6 of the complaint petition remain un-rebutted.

(viii). It is found that, the Andhra Hospital authority /O.P 3 has again requested to reconsider cashless approval of patient Suryakanti Panda under  claim No.MHD156611765 certified therewith that, there was sufficient reason for treatment of Suryakanti panda/mother of the complainant as indoor patient vide Annexure 6 of the complainant petition remain un-rebutted .

(ix) Admittedly, no one, even the complainant or his mother got pleasure to stay in any hospital as indoor patient.

(x) Nothing material placed on record to hold that, opposite party No-3 (Andhra Hospital) have made wrong advice and unnecessary admitted the mother of the complainant as indoor patient only for abstraction of hug money dishonestly as such we found no negligence or deficient there on the part of Op3/Andhra Hospital. Rather, the Op1/insurance Company has failed to justify denial of cashless treatment facility to the mother of the complainant under subject Health Insurance Policy.

(xi) In view of Section 16 (2) of Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests) Regulations 2017 where the circumstances of a claim warrant an investigation in the opinion of the insurer, it shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document. In such cases, Insurer shall settle the claim within 45 days from the date of receipt of last necessary document. But here in this case, we found no cogent evidence placed on the record to hold that, the Op 1& 2 /insurer& TPA respectively have ever followed the claim procedure stipulated there under IRDA Regulation 2017 while rejecting the claim of the complainant. The O.P 1 &2 have   not responded the request for reconsider cashless approval of the patient Surya Kanti panda and denied the genuine claim of the complainant vide  MHDI50611765 is not proper which squarely proved negligence, deficient service & unfair trade practice there on the part of the Op 1&2 for which the Op 1 being the principal of Op2 shall be solely liable to compensate the injuries caused to the complainant .

16. Based on the above discussion this Commission is of the opinion that, denial of service of cashless treatment to the mother of the complainant during the policy period and repudiation of genuine claim of the complainant under subject insurance policy is  found arbitral & illegal which clearly proof the unfair trade practice &  deficient service there in the part of O.P 1&2 for which only the complainant was compel to pay the entire bill amount of Rs.87,695/- to the O.P 3/Andhra Hospital and suffered  financial loss  & mental agony cannot be denied. Accordingly, this Commission is of the opinion that, the complainant is entitled to get release of claimed insurance benefit of Rs.87,695/-from the Op 1/Insurance company with interest @9% P.A from dt. 11/07/2024  i.e from the date of filling of this complaint   till its realization.  The OP1&2 are also liable to compensate the complainant towards suffering of mental agony caused due to their deficient services and to pay cost of this litigation not less than Rs.10,000/-and, further  Op 1/Insurance & Op2/TPA company  are jointly liable to be punished by awarding punitive  damages so that, they shall not repeat the same acts of deficient service/Unfair trade practice towards any other insured/Consumer. Issue No.   (iv) & ( v ) are decided in favor of the complainant.

17. Admittedly, the insurance benefit claimed under the subject policy is not yet realized rather, genuine claim of the complainant is arbitrarily denied by the Op1/Insurance company & 2 /TPA  vide letter dt. 10/05/2024 annexed as  Annexure 7 of the complainant petition as such this Commission is of the opinion that, there is sufficient cause exists to present this complaint and it is filed on time well within the jurisdiction of this Commission where the complainant is residing as such this consumer complaint is maintainable under C.P.Act 2019. Issue No (ii) & (iii) are decided in favor of the complainant. Hence, it is ordered.

ORDER

This complaint is allowed in part against the OP 1 /Insurance company & 2/TPA on contest and dismissed against the O.P 3/Andhra Hospital (Vikshapatnam Pvt. Ltd.)with the following directions:-                                              

I. The OP 1 / Magma HDI General Insurance Company Ltd is   here by directed to release the claimed amount of Rs.87,695/ - with interest @ 9 % P.A from the date of filing of this complaint i.e from dt.11/07/2024 till its actual payment to the complainant  as insurance benefit under the subject insurance policy and to pay compensation of Rs 10,000/-towards financial hardship  mental agony suffered and Rs.10,000/- towards litigation cost to the complainant.

II. It is further directed to comply this  order within 45 days of receiving of the copy of this order, failing which Op 1& 2 shall liable to pay Rs 200/-each per day as delayed compensation to the complainant till compliance of this order.

Pending  application if any is also stands disposed off accordingly.

Dictated and corrected by me.

   Sd/-

​Member

                                                Sd/-

                                              Presdent                                                                             

Pronounced in open Commission today on this 24^th October   2024, under the seal and signature of this Commission.

       Free copy of this order be supplied to the parties for their perusal or party may download the same from the Confonet be treated as copy served to the parties.

        Complaint is disposed of accordingly.