BEFORE THE DISTRICT FORUM:KURNOOL
Present: Sri.K.V.H. Prasad, B.A., LL.B President
And
Smt. C.Preethi, M.A.LL.B., Lady Member
Friday the 19th day of December, 2008
C.C.No. 96/08
Between:
D.Walter Dinakar, S/o. D.Arthur Richard, Correspondent, Press Trust of India,
D.No.40/808/-B3, Srinivasa Nagar, Kurnool. … Complainant
Versus
1. Managing Director, Gowri Gopal Hospital (Pvt) Lmited,
D.No.46/87, Budhavarpet, Kurnool.
2. The Branch Manager, The Claims Department, Family Health Plan Limited,
Aditya JR Towers , 8-2-120/86/9/A and B, 3rd Floor, Road No.2, Banjara Hills, Hyderabad.
… Opposite parties
This complaint is coming on this day for orders in the presence of Sri. P. Siva Sudharshan , Advocate, for the complainant, and Smt . D. S. Saileela, Advocate for opposite party No.1 and Sri.
K. Ramanjaneyulu, Advocate for opposite party No.2 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri. K.V.H.Prasad, President)
C.C.No.96/08
1. This case of the complainant is filed U/S 11 and 12 of C.P.Act seeking direction on the opposite parties to pay to the complainant Rs.73,322/- with 18% interest p.a, Rs.1 lakh as compensation for mental agony and cost of the case alleging deficiency of service of the opposite party No.1 in mentioning on admission request note incorrectly as the complainant was a known patient of diabetes and hypertension since last 3 years to then and the opposite party No.2 in not giving cashless treatment facility and in repudiating the medial claim of the complainant as holder of policy No. 050305/ 48 /06 / 00316 consequent to his treatment undergone with opposite party No.1 from 17-1-2007 , on the pretext of concealment of pre-existing decease by the complainant and not responding to the legal notice dated 7-2-2008 of the complainant .
2. In pursuance of the receipt of the notice of this forum as to this case of the complainant the opposite parties caused their appearance through their counsel and contested the case filling their written versions denying any of their liability to the complainants claim.
3. The written version of the opposite party No.1 besides questioning the justness and maintainability of the complainants case submit that every care was taken in lending treatment to the complainant who approached on 17-7-2007 the opposite party No.1 hospital with complaint of chest pain nausea and swetting and the past history of complainant was recorded on the very statement of the complainant who was conscious and coherent at that time of admission , as there is any technical procedure to find out the pre-existing history of diabetes and hypertension except on the version of the very patient or its attendant and it is having any role to play in sanction of cashless treatment his insured parents and in making admission note it has any benefit or profit and so any deficiency of service towards the complainant especially when the complainant was given VIP treatment and so there being any cause of action for this case and there by any of its liability to the complainants claim.
4. The written version of the opposite party No.2 besides questioning the justness and maintainability of the complainants case submits firstly that there is any privy of contract to it with the complainant secondly allege the case of the complainant is bad for non joinder of the United India Insurance Company Limited , as party to the proceeding , with which only the complainant is having the privy of insurance , thirdly for want of any cause of action against it and fourthly it submits as to its status as a mere duly licensed third party administrator to enroll the insured members and to process their claims received under health insurance policies as per its terms and conditions , in the light of its entering into an agreement to that effect with united India Insurance Company Limited . It further submits that the complainant obtained Group Medi Claim Policy from United India Insurance Company Limited under the scheme of “ working Journalist of A.P” and on the basis of the noting in admission request note and KIMS discharge summary “ as complainant a known diabetes and hypertension since three years , cashless service was denied to the complainant for said pre-existing decease . It denies of any collusion with opposite party No.1 for repudiating the complainants claim and its rejection of claim does not prevent from making claim and the premium insurance was paid by the complainant to United India Insurance Company Limited in lieu of the policy issued by it . It has merely scrutinized the claim of the complainant in the light of the terms and conditions in Cl. 4 – 1 and informed the reputability of the claim to the United India Insurance Company Limited for further disposal and on the approval of it by United India Insurance Company Limited , there on it has conveyed the said repudiation to complainant on 12-9-2007 as the United India Insurance Company Limited did not felt any interference there on and as a mere processor of the claim it has any liability to the complainants claim and so alleging no deficiency on its part seeks dismissal of complaint for want of proper cause of action.
5. In substantiation of the contentions while the complainant side has taken reliance on documentary record in Ex.A1 to A6 and the sworn affidavit of the complainant , the opposite party side has taken reliance on documentary record in Ex.B1 to B4 and sworn affidavits of opposite parties 1 and 2.
6. Hence, the point for consideration is whether the complainant has made out any deficiency of the opposite parties and there by any of their liability to the complainants claim.
7. The Ex.A1 is the Xerox of Family Health Plan Limited Card bearing No. FHAU 0000636594 in the name of D. Walter Dinakar with policy No. 050305 / 48 / 06 / 00316 for the plan period 11-10-2006 to 10-10-2007 and its insurer as UIIC / BO : 050305 : Kachiguda and the said was under Group “ working Journalist of A.P : 0316 Family Health Plan Limited” . It contains the terms and conditions governing said family health plan limited as out patient treatment , admission for investigation / evaluation not covered under the said scheme and compulsoriness of FHPL pre-authorization to cashless treatment for planed admission / for emergency admission within 24 hours and a direction for leaving all documents relating to claim with net work hospitals and for availing cashless facility the necessity of photo identification and the applicability of the terms and conditions of insurance companies .
8. The opposite party No.2 alleges itself as a duly licensed third party administrator in the filed of health insurance under the authority of insurance regulatory and development authority formulated under the Insurance Act 1938 and so the United India Insurance Company Limited has entered an agreement with it for the purpose of enrolling the members for health insurance and process their claims under health insurance and hence its role is of a mere third party administrator in processing the claims . But any documentary record in substantiation of said contention was filed by the opposite party . In the absence of any such cogent record in substantiation of its alleged status , the mere Ex.A3 28-8-2007 addressed by opposite party 2 to “ The Divisional Manger, United India Insurance Company Limited , Bhasirbagh, Hyderabad remains of any avail to the opposite party No.2 in making out any privy of it with United India Insurance Company Limited as to its alleged role of processing the claims and their submission for further consideration of United India Insurance Company Limited , especially when there appears any corresponding response to Ex.B3 from United India Insurance Company Limited .
9. As per the terms and conditions mentioned in Ex.A1 the pre authorization for planned admission and for emergency admissions and for cashless hospitalization could be issued by FHPL and no where it says the medi claim under said FHPL for reimbursement is to be submitted to the United India Insurance Company Limited . Hence there appears any justifiability in the contentions of the opposite party as to its mere status as third party administrator to merely process the claims and no concern of it in settlement of complainants claim .
10. If the opposite party No.2 is a mere processor of claims as third party administrator it would have merely submitted its observation findings to the claim of the complainant to the United India Insurance Company Limited for further disposal instead of it itself exercising the rejection of the claim retaining the claim documents with itself for further reference and conveying the same under Ex.A6 to the complainant .
11. If there is any truth in the contentions of the opposite party as to its no concern in settlement of claim and its exclusive concern with United India Insurance Company Limited alone there would have been a policy of insurance in favour of the complainant said to have been issued by the United India Insurance Company Limited with terms and conditions governing said policy and the said policy with terms and conditions would have been supply to the complainant at least in response to ex.A2 letter dated 3-10-2007 of the complainant requiring the opposite party No. 2 to furnish the same instead of keeping quite at that letter .
12. If the complainant is not having any privy with the opposite party No.2 as to its medical claim for reimbursement and in the settlement of the same by opposite party No.2 either for its acceptance or for rejection and the said settlement either by acceptance or by rejection of the claim has to be exclusively be exercisable by the United India Insurance Company Limited alone , the opposite party No.2 would have not furnished the Ex.A4 standing with its address to the complainant for the submission of the claim .
13. If the United India Insurance Company Limited is only having concern as to Ex.A1 standing in the name of the complainant , when the complainant has applied for cashless service treatment to complainant the denial of said facility must have been exercised by United India Insurance Company Limited and would have been conveyed to complainant by said United India Insurance Company Limited itself and not by opposite party No. 2 as in Ex.A5 .
14. If the contention of the opposite party No. 2 as to its alleged status of third party administrator with role of the mere processing of the claims and the exclusive concern of the United India Insurance Company Limited for settlement of claim of complainant is true , the opposite party No. 2 would have availed the chance of reply representing the same in response to Ex.A3 legal notice of the complainant .
15. The Ex.B4 signed by the opposite party No. 2 does not find the “ to addressee “ to which it has been caused . If the alleged status of the opposite party No.2 is true , firstly it would not have mentioned in Ex.B4 in scribed last lines as “ this claim is repudiated under PED ( pre existing decease) Clause “ , taking the power of repudiation of claim into its hands, secondly if it is to consider as a mere recommendation basing on its observation in processing the claim basing on any cogent material , this Ex.B4 must have been addressed to the United India Insurance Company Limited for further disposal.
16. From the perusal of Ex.A1 , Ex.A4 , A5/B2 , A6 and B1 as entire role in rejection of the claim of the complainant appears to have been played by opposite party No.2 exclusively and any concern of the United India Insurance Company Limited appears there in there appears any merit and force in the contention of the opposite party No.2 as to his alleged status and as to the necessity of United India Insurance Company Limited as party to this case proceedings. Hence the plea of the opposite party No. 2 that the case of the complainant is bad for non joinder of United India Insurance Company Limited as party to this case being devoid of merit and force is rejected .
17. Now coming to the point justification or otherwiseness of the rejection of claim of complainant exercised by the opposite party No.2 is concerned .
18. The claim of the complainant is rejected by the opposite party No. 2 on the ground of concealment of pre existing decease by the complainant on mere recitals of Dr.K. N. Madhusudhan of Gowri Gopal Hospital mentioned in final diagnosis column of case sheet pertaining to the complainant . The said information , was alleged in written version of the opposite party No. 2 , as ascertained either from the complainant or from his relative . It was not admitted by the complainant . The said fact was not proved by the opposite party side by examination of said doctor who recorded said material in final diagnosis column of case sheet pertaining to complainant issued by opposite party No.1 especially when the written version of the opposite party No.1 is not clear as to the source basis on which such finding in final diagnosis was noted . It is alleged as authorization for investigation , surgical operation procedure treatment and payments was singed by the wife of the complainant and hence she is know of the recitals made in final diagnosis column appearing first page of the case sheet . By the wording authorization for investigation , surgical operation procedure treatment and payment and its recitals under which the signature of the complainants wife said to have subscribed her signature , belies the contentions of the opposite parties that the information in final diagnosis column of the first page of the case sheet issued by opposite party No.1 hospital was at the inspections of the complainants wife as the recitals under which the said signature of the complainants wife finds exhibits her mere undertaking to take the responsibility for payments and not to hold the opposite party No.1 for any legal consequences . When the said observation in final diagnosis column of case sheet was not duly substantiated by any cogent material the opposite party No.2 relying on its solely for rejection of the claim of the complainant is not remaining justified prima facie .
19. The decision of the Hon’ble National Consumer Disputes Redressal Commission in LIC of India Vs Bhadri Nageswaramma ( deceased) and others reported in II (2005) CPJ Pg.9 (NC) holds the burden of proof of false representation and suppression of facts is on insurer and the doctor certificate without affidavit in support shall be no basis for repudiating the claim and when no conclusive evidence produced to support suppression on the part of the deceased company is liable under policy.
20. The decision of Hon’ble Uttaranchal State Consumer Disputes Redressal Commission at Dehradhan in LIC of India Vs Zayada Begum reported in IV (2004) CPJ Pg.124 holds the mere statement at admission time without actual proof not admissible in evidence , cannot form basis for repudiation and liability of company when insured knew about the decease earlier not proved .
22. The decision of Hon’ble A.P. State Consumer Disputes Redressal Commission in LIC of India and other Vs Mora Rajeswari reported in IV ( 2005) CPJ 2005 – holds the burden of proving false representation and suppression of material facts and the knowledge of the deceased and willful suppression of facts when not discharged by the company the policy amount is payable .
23. In the light of the above decisions as to guidelines given as to the nature of proof and the burden of proof as to the aspect of suppression of material facts as to any pre existing decease , as the opposite parties has not discharged their burden by any cogent proof , the rejection of the claim by the OP.No.2 and taking an evasive plea in defense as to the concern of United India Insurance Company Limited , is not at all remaining justifiable . Hence the rejection of the complainants claim by the OP.No.2 is amounting to deficiency of service on its part to the complainant and there by not only making out the liability of the OP.No.2 to reimburse the medical claim of insurance of the complainant but also the liability of the OP.No.2 for making good of the ensued mental agony and cost of the complainant as driven the complainant to the forum for redressal of to justifiable grievances .
24. As the OP.No.2 any where disputes the genuineness of the incurred expenditure of the complainant but only disputes the entitleness of it on account of the non discloser of alleged pre existing decease, the complainant is remaining entitled to the reimbursement of Rs.73,322/- towards the incurred medical expenditure at the liability of the OP.No.2 under E.xA1 FHPL insurance scheme.
25. There being any substantial role of OP.No.1 in rejection of the complainant claim and there by any substantial liability of the Op.No.1 for complainants claim the case of the complainant against opposite party No.1 is dismissed.
26. Consequently the case of the complainant is allowed against the opposite party No.2 alone directing it to pay to the complainant Rs.73,322/- towards reimbursement of incurred medical expenditure , to pay Rs.25,000/- as compensation towards mental agony suffered by the complainant at the deficient conduct of the OP.No.2 , and Rs.5,000/- as cost of this case within a month of receipt of this order. In default the OP.No.2 shall be liable to pay the supra stated award amount with 12% interest from the date of default till realization.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 19th day of December, 2008.
Sd/- Sd/-
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant :Nil For the opposite parties :Nil
List of exhibits marked for the complainant:-
Ex.A1. Xerox copy of complainants family health card No. FHAU 000636594.
Ex.A2. Office copy of letter dated 03-10-207 of complainant to OP.No.2.
Ex.A3. Office copy of legal notice dated 07-02-2008 along with
Postal receipts.
Ex.A4. Check list for submission of claims.
Ex.A5. Denial of cash less service dated 17-07-2007.
Ex.A6. Claim repudiation letter dated 12-09-2007.
List of exhibits marked for the opposite parties:
Ex.B1. Fax copy of family health plan.
Ex.B2. Denial of cash less service.
Ex.B3. Letter dated 28-08-2007 of family health plan limited to OP.No.2.
Ex.B4. Doctor opinion in claim ID Hyderabad 60676.
Sd/- Sd/-
MEMBER PRESIDENT
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties
Copy was made ready on :
Copy was dispatched on
