BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 18th of February 2011
PRESENT
SMT. ASHA SHETTY : PRESIDENT
SMT.LAVANYA M. RAI : MEMBER
SRI. ARUN KUMAR K. : MEMBER
COMPLAINT NO.145/2010
(Admitted on 07.05.2010)
Smt.Umashankari N. Bhat,
Wo. N.K. Bhat,
Aged about 54 years,
RA. Nandeesh, Kombettu,
Puttur. …….. COMPLAINANT
(Advocate for the Complainant: Sri.Sanjay D).
VERSUS
1. Manager,
ICICI Lombard,
Health Insurance Maximus Complex,
Light House Hill Road,
Hampankatte, Mangalore.
(Advocate for Opposite Party No.1: Sri.M.V. Shanker Bhat).
2. R.M.P. Infotech,
FI, 1st Floor, 100 Mahalingapuram,
Main Road, Appollo Dubai Plaza,
Chennai – 34.
(Advocate for Opposite Party No.2: Sri.K.P.A. Shukoor).
3. TTK Health Care TPA Pvt. Ltd.,
2nd Floor, Anmol Palani,
G.N. Chetty Road, T.Nagar,
Chennai – 17,
Tamil Nadu State. ……. OPPOSITE PARTIES
(Opposite Party No.3: Exparte).
***************
ORDER DELIVERED BY PRESIDENT SMT. ASHA SHETTY:
1. This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Parties claiming certain reliefs.
The brief facts of the case are as under:
The Complainant submits that, she was the holder of Health Insurance Policy of the 1st Opposite Party as per policy No.4016/0002268, the said policy is valid from 16.11.2007 to 15.11.2008.
It is stated that, the Complainant was admitted to A.J. Hospital Mangalore on 01.11.2008 for coronary Angiogram and operated on 05.11.2008 and was discharged on 07.11.2008. It is stated that, the Complainant has spent Rs.1,30,234/- for operation. It is stated that, A.J. Hospital has sent pre-authorization to the 3rd Opposite Party before operation, the 3rd Opposite Party sought certain documents and information through its letter dated 05.11.2008. Hospital has provided the documents and information on 06.11.2008, thereafter the 3rd Opposite Party has repudiated the claim stating that “possibility of long standing pathology cannot be ruled out, cashless not possible”. It is stated that, after rejection of the claim, the Complainant submitted fresh claim on 19.11.2008 to the 3rd Opposite Party, the 3rd Opposite Party sent a letter seeking certain documents and the same has been sent through letter dated 17.02.2009 but the Opposite Parties not paid the claim amount. Subsequently, the Complainant issued a legal notice, the same was served to the Opposite Parties despite of that not paid the amount which amounts to deficiency and hence the above complaint filed under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Parties to pay Rs.1,30,234/- along with interest at 12% p.a. from 05.11.2008 till payment and also claimed Rs.75,000/- as compensation and cost of the proceedings.
2. Version notice served to the Opposite Parties by RPAD. Opposite Party No.3 despite of serving notice neither appeared nor contested the case till this date. Hence, we have proceeded exparte as against the Opposite Party No.3. The acknowledgement placed before the FORA marked as court document No.1.
Opposite Party No.1 and 2 appeared through their counsel filed separate version.
Opposite Party No.1 admitted the policy and stated that, the Complainant did not comply with the required documents sought by their administrator. Since the Complainant not complied with the requirements, the claim of the Complainant could not be processed and stated that there is no deficiency and prayed for dismissal of the complaint.
Opposite Party No.2 stated that, this Opposite Party is unnecessary party and there is no deficiency and repudiation of the claim is not by this Opposite Party that is by Opposite Party No.1 and 3 and prayed for dismissal of the complaint.
3. In view of the above said facts, the points now that arise for our consideration in this case are as under:
- Whether the Complainant proves that the Opposite Parties committed deficiency in service?
- If so, whether the Complainant is entitled for the reliefs claimed?
- What order?
4. In support of the complaint, Smt.Umashankari N Bhat (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her. Ex C1 to C16 were marked for the Complainant as listed in the annexure. One Mr.Daval Chand (RW1), Chairman of the Opposite Party No.2 filed counter affidavit and answered the interrogatories served on him. The Complainant as well as Opposite Party No.1 and 2 filed notes of arguments.
We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No.(i): Affirmative.
Point No.(ii) & (iii): As per the final order.
Reasons
5. Point No. (i) to (iii):
The facts which are admitted is that, the Complainant was a holder of Health Insurance Policy bearing policy No.4016/0002268, the same is valid from 16.11.2007 to 15.11.2008 (as per Ex C1). The above said policy was obtained from the 1st Opposite Party. During the subsistence of the policy, i.e., on 01.11.2008 the Complainant was admitted to A.J. Hospital Mangalore for Coronary Angiogram and was operated on 05.11.2008 and discharged on 07.11.2008 as per Ex C11 i.e., the discharge summary. The above said document is not disputed by the parties before this Forum. As per the said discharge summary, the Complainant admitted to the A.J. Hospital on 01.11.2008 as stated above with the history of shortness of breath progressive since 5 days, admitted for further management. The above said hospital diagnosed as the Complainant was suffering from single vessel disease compromised LV function (CAG). The Complainant was admitted for coronary Angiogram, the same was done on 05.11.2008 and diagnosed as single vessel disease compromised LV function PTC A+stent to LAD was done on the same day and discharged on 07.11.2008.
However, the Complainant sworn to the fact that, A.J. Hospital has sent pre-authorization to the Opposite Party No.3 before the operation and the Opposite Party No.3 sought certain documents and information, the same was furnished to the 3rd Opposite Party, despite of that the Opposite Parties not reimbursed the medical expenses. Thereafter, the Complainant submitted fresh claim on 19.11.2008 to the 3rd Opposite Party and the document sought by the 3rd Opposite Party has been processed/ complied by the Complainant by letter dated 17.02.2009 to the Opposite Party No.3 i.e., as per Ex C7, even after that the Opposite Parties not paid the medical expenses as covered under the policy.
The Opposite Party on the other hand stated that, the claim has not been rejected but the Complainant not complied the required documents, hence they could not process the claim.
On scrutiny of the oral as well as documentary evidence placed on record, we find that, the policy issued by the Opposite Party was in force and during the subsistence of the policy the Complainant admitted to the hospital and taken treatment as stated supra and also submitted the bill i.e., Ex C10 for Rs.1,28,906/- i.e., the discharge bill issued by the A.J. Hospital Research Centre. The above said bills as well as other required documents has been sent to the Opposite Party No.3 as per Ex C7 i.e., the letter addressed by the Complainant to the Opposite Party No.3, even though the Opposite Parties not reimbursed the claim of the Complainant till this date which amounts to deficiency. However, it could be seen on record that, the Opposite Parties despite of receiving all relevant documents, raised a contention that the Complainant not complied the required documents. But the discharge bill, pre-authorization form, discharge summary and other documents sent by the Complainant are more than sufficient to honour the claim of the Complainant. Even in case, the Opposite Parties requires some more documents, the Third Party Administrator i.e., the 3rd Opposite Party could have collected those documents from the concerned hospital instead of withholding the claim till this date. Atleast after filing of this complaint, the Opposite Parties should have honoured the claim of the Complainant during the pendency of this complaint. No such attempt has been made by the Opposite Parties which amounts to deficiency in service as stated supra.
As far as relief of the Complainant is concerned, the Complainant admittedly taken treatment during the subsistence of the policy and spent Rs.1,28,906/- as per Ex C10, there is no contra evidence produced by the Opposite Party to disprove the same. Under that circumstances, we hold that the Complainant is entitled for the medical reimbursement as per the policy issued by the Opposite Parties. Therefore, the Opposite Party No.1 i.e., ICICI Lombard Health Insurance Company is hereby directed to pay Rs.1,28,906/- towards the medical expenses incurred by the Complainant. Further Rs.10,000/- awarded as compensation for the inconvenience and harassment and Rs.1,000/- as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.
Since there is no contractual relationship between the Complainant and Opposite Party No.2 and 3, the complaint against Opposite Party No.2 and 3 is hereby dismissed.
6. In the result, we pass the following:
ORDER
The complaint is partly allowed. Opposite Party No.1 i.e., ICICI Lombard Health Insurance Company is hereby directed to pay Rs.1,28,906/- (Rupees one lakh twenty eight thousand nine hundred and six only) towards the medical expenses incurred by the Complainant. Further Rs.10,000/- (Rupees ten thousand only) shall be paid as compensation and Rs.1,000/- (Rupees one thousand only) as cost of the litigation expenses to the Complainant. Payment shall be made within 30 days from the date of this order.
On failure to pay the aforementioned amount within the stipulated time as mentioned above the Opposite Party No.1 is hereby directed to pay interest at the rate of 10% p.a. on the total amount from the date of failure till the date of payment.
Complaint against Opposite Party No.2 and 3 is hereby dismissed.
The copy of this order as per the statutory requirements be forwarded to the parties free of charge and therefore the file be consigned to record.
(Page No.1 to 9 dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 18th day of February 2011.)
PRESIDENT MEMBER MEMBER
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 – Smt.Umashankari N Bhat – Complainant.
Documents produced on behalf of the Complainant:
Ex C1 – 16.11.2007: Insurance Card issued by the 1st and 2nd Opposite Party.
Ex C2 – 01.11.2008: Copy of the medical certificate issued by A.J. Hospital to the 3rd Opposite Party.
Ex C3 – 05.11.2008: Letter issued by the 3rd Opposite Party.
Ex C4 – 07.11.2008: Repudiation letter by the 3rd Opposite Party.
Ex C5 – 20.11.2008: Copy of the letter addressed by the Complainant along with proof of delivery.
Ex C6 – 06.02.2009: Reply of the 3rd Opposite Party.
Ex C7 – 17.02.2009: Copy of the letter addressed by the Complainant to the Opposite Party No.3 along with postal acknowledgement.
Ex C8 – 01.11.2008: Copy of pre-authorization request form.
Ex C9 – 01.11.2008: Copy of the authorization for medical/surgical treatment.
Ex C10 – 08.11.2008: Copy of the discharge bill issued by A.J. Hospital for Rs.1,28,906/-.
Ex C11 – 07.11.2008: Copy of the discharge summary issued by A.J. Hospital and Research Centre.
Ex C12 – 03.11.2008: Copy of the Coronary Angiogram report.
Ex C13 – 03.03.2010: Lawyer’s notice sent to the Opposite Parties on behalf of the Complainant.
Ex C14 to C16 - : Postal acknowledgements (3 in numbers).
Witnesses examined on behalf of the Opposite Parties:
RW1 – Mr.Daval Chand, Chairman of the Opposite Party No.2.
Documents produced on behalf of the Opposite Parties:
Dated:18.02.2011 PRESIDENT
