Kerala

Idukki

CC/133/2020

Diju M N - Complainant(s)

Versus

Manipal Cigna Heath Insurance Co ltd - Opp.Party(s)

25 Oct 2022

ORDER

 

DATE OF FILING : 13.10.2020

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the  25^th  day of October, 2022

Present :

SRI. C. SURESHKUMAR                   PRESIDENT

SMT. ASAMOL P.                               MEMBER

SRI. AMPADY K.S.                            MEMBER

CC NO.133/2020

Between

Complainant                                            :     Diju M.N., S/o. Narayanan Nair,

                                                                      Madavanayil House,

                                                                      Manakkadu P.O.,

                                                                      Thodupuzha.        

          (By Adv: Ajithkumar)

And

Opposite Parties                                       :  1.  Manipal Cigna Health Insurance

                                                                                   Company Ltd.,

                                                                       401/402, Raheja Titanium,

                                                                       Western Express Highway,

                                                                       Goregaon East, Mumbai.

           (By Advs: Saji Isaac K.J. & Lissy M.M.)

      2. The Manager,

                                                                       Andra Bank (now Union Bank of India),

                                                                      1^st Floor, Vellaringat Towers,

                                                                      Bhima Junction, Thodupuzha – 685 584.

 

O R D E R

 

SRI. C. SURESHKUMAR, PRESIDENT

 

1. This is a complaint filed under Section 35 of the Consumer Protection Act of 2019 (the Act, for short).  Complaint averments are briefly discussed here under :

 

          Complainant is residing in Thodupuzha and is an employee of Health Department.  1^st opposite party is Health Insurance Company having its Head Quarters at Goregaon East, Mumbai.  2^nd opposite party is Andra Bank having its branch at Thodupuzha, represented by its Manager.  Complainant had taken a family health insurance policy offered  by  opposite  party  through  2^nd  opposite  party,  policy  number  being                                                                                                                      (cont....2)

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100200000001/02/00 with customer ID No.1179377.  Sum  assured was Rs.3 lakhs.  Entire premium for 1 year of Rs.6,423/- was paid by complainant, through 2^nd opposite party.  Policy period was from 30.11.2018 till 29.11.2019.  As per the policy, 1^st opposite party is liable to cover / indemnify all medical expenses incurred for treatment undergone, for the infirmities outlined under the policy, another  advantage being cashless facility.  This policy was again renewed from 30.11.2019 till 29.11.2020, after payment of premium of even amount.  Policy number and customer ID number being the same as that of the old policy.  While the 2^nd policy was live, son of  complainant, namely, Abhiram D. Nair, 12 years, was admitted in Kolenchery Medical Mission Hospital as he had epileptic seizures on 27.12.2019.  The child was discharged on 28.2.2019.  Complainant had expended Rs.6,163/- towards treatment expenses, which are covered by policy.  Though cashless facility was available and applied for, it was not given.  Subsequently, a claim was forwarded to 1^st opposite party through the hospital for reimbursement of medical expenses.  All documents requested by 1^st opposite party were given on 2.1.2020, along with claim form duly filled up.  While so, son of complainant was again had Epileptic seizures and was admitted for treatment in Thrissur Jubilee Mission Medical College Hospital.  He was discharged on 28.1.2020, after undergoing treatment.  Treatment expenses come to Rs.7,925/-.  Here again, though cashless facility was requested, it was not given.  A claim form was then submitted seeking reimbursement.  However, the amount was not reimbursed.  Complainant submitted that 1^st opposite party was liable to reimburse the medical expenses and treatment charges claimed by complainant, since there was policy coverage.  Due to inaction of opposite parties, complainant had sustained a loss of Rs.14,088/- .  Such inaction amounts to deficiency in service.  Complainant therefore prays for reimbursement of medical expenses of Rs.14,088/-, compensation of Rs.10,000/- for deficiency in service and litigation costs of Rs.2,500/- from opposite parties.

 

          2.  First opposite party had filed written version.  Its contentions are briefly discussed here under :

 

          According to 1^st opposite party, complaint is not maintainable either in law or upon facts.  Upon receipt of claim, 1^st opposite party had sent repeated letters to complainant seeking production of additional documents for processing the claim.  As per conditions of policy, insured was bound to submit requisite documents as demanded by the Company, for processing the claim within a stipulated time.  Complainant was entitled for 3 reminders with intervals of 10 days each.  Despite such reminders, it is contended that additional information / treatment documents were not furnished.  Therefore, 1^st opposite party had repudiated the claim and had intimated the matter to complainant.  It is further contended that the contract of insurance is a contract based on terms and conditions of the policy.  Liability of opposite party is limited to the                                                                                                                      (cont....3)

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conditions of policy.  There are lengthy quotes from decisions of Supreme Court are mentioned in the written version, which we are not reproducing here under for the sake of brevity.  1^st opposite party submits that complainant is not entitled for any of the reliefs prayed for and seeks dismissal of the complaint with its costs.

 

          3. Second opposite party has filed a separate written version.  Its contentions are briefly discussed here under :

 

          According to 2^nd opposite party, it had not advised or recommended  taking of policy offered by 1^st opposite party.  It is true that complainant is an account holder of 2^nd opposite party and employee of Health Department.  However, 2^nd opposite party has not acted as its agent, or canvassed for the policy, as claimed by complainant.  Medical policy is issued by 1^st opposite party and coverage as per policy was not insured by 2^nd opposite party.  1^st opposite party  alone is liable to provide cashless facility or to reimburse the medical expenses as the case may be.  2^nd opposite party has no liability in that regard.  Claims made against 2^nd opposite party are not sustainable.  There is no deficiency in service from the side of 2^nd opposite party and complaint is to be dismissed with costs.

 

          4.  After filing of written version, case was posted for steps and then for evidence.  Despite repeated opportunities, complainant has not filed affidavit or had turned up to give evidence.  Able counsel appearing for complainant had only sought for marking of the documents produced by complainant.  Those were marked as Exts.P1 to P4 series, 9 in numbers.  Thereafter case was posted for evidence.  No affidavit was filed from the side of  1^st opposite party.  Upon request by learned counsel of 1^st opposite party, 2 documents produced from the side of 1^st opposite party were marked as Exts.R1 and R2 series, 5 in numbers.  Thereafter evidence was closed.  Complainant and counsel for 2^nd opposite party have addressed oral arguments.  1^st opposite party had filed argument notes.  Copies of notes were furnished to others.  They were heard in reply also.  Now the Points which arise for consideration are :

1)  Whether there was any deficiency in service from the side of opposite parties 1 or 2 ?

2)  Whether complainant is entitled to get medical expenses reimbursed from opposite parties 1 and 2 ?

3)  Reliefs and costs ?

 

5.  Point Nos.1 and 2 are considered together :

 

          It is admitted by 1^st opposite party that complainant had taken a Family Insurance Policy.  Policy was initially taken for the period from 30.11.2018 till 29.11.2019 and subsequently renewed for the next year from 30.11.2019 till 29.11.2020.  Ext.P1 and P2                                                                                                                   (cont....4)

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are the copies of policies, so taken.  1^st one is issued at the time of initial subscription and 2^nd one being renewal.  It is not in dispute that complainant, his wife and 2 children were covered under the policy.  This is clear from Exts.P1 and P2.  1^st opposite party has no disputed that Abhiram D. Nair, son of the complainant was covered by policy,  had bouts of Epilepsy and was admitted in Kolenchery Medical College Hospital initially and on 2^nd occasion in Thrissur Jubilee Mission Medical College Hospital.  The crux of contention taken by 1^st opposite party is that as per Ext.R2 series of 5 intimations, additional documents necessary for processing the claim were not submitted.  Arguments notes submitted by 1^st opposite party are literally verbatim reproduction of written version filed; case narrated therein has already been adverted to by us in the earlier paragraphs.   Hence we are not repeating these contentions again, for the sake of brevity.  As per Ext.R2 series, 3 documents were called for.  1^st one is 1^st consultation paper of seizure along with subsequent consultation papers.  2^nd one is treating doctor’s letter stating exact duration of seizure.  3^rd document is cancelled cheque or copy of cancelled cheque of policy holder apparently for the purpose of getting bank details to transfer the amount.  Information requested as per document No.1 and 2 apparently were sought for to process the claim as such.  At this juncture, it is necessary to advert to the documents which  complainant had submitted in respect of both claims.  Ext.P5 series are the documents proved by him in this regard.  Ext.P4(c) is copy of discharge summary issued from Medical College Hospital, Kolencherry.  1^st opposite party has no case that this document was not submitted along with the claim furnished by complainant.  It is specifically mentioned in the brief history provided in discharge summary that child was brought with complaints of first episode which was stiffening of both limbs and tonic clonic movements, frothing and unresponsiveness which occurred in sleep and lasted for about 10 seconds.  Eyes were closed at that time.  There was no history of fever, sleep deprivation. That there were no similar episodes in the past.  Name of the treating doctor is also given in the discharge summary.  Course of management of the patient is also outlined there.  Therefore, additional documents required as per Ext.R2, is not for gathering any new information as such which is not provided.  Information requested was already contained in the discharge summary submitted by complainant.  Ext.P4(d) is copy of discharge summary pertaining to the same patient issued from Thrissur Jubilee Mission Medical College and Research Institute.  It is specifically mentioned in the discharge summary that the boy was presented with 2 episodes of tonic seizure 1 month apart and that admission episode was not associated with fever, patient had tonic posturing lasting 5 minutes.  Medications taken earlier were also mentioned therein.  That being so, we do not think that additional information called for as Serial No.2 in Ext.R2 series was necessary.  1^st opposite party has not stated any circumstances which warranted for gathering additional information with regard to query  No.1 and 2 in Ext.R2 series, despite history of infirmity given in discharge summaries.  1^st opposite party ought to have considered discharge summaries                                                                                                                (cont.....5)

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properly and should have considered the claim and process it accordingly after scrutinising bills, without delay.  Instead it had resorted to calling for additional information which was not at all necessary.  1^st opposite party does not have a case that an investigation was conducted in the claim which would make discharge summaries unreliable or that  it had come across any document or information with regard to earlier episodes of same infirmity before the 1^st seizure mentioned in Ext.P4.  (See discharge summary issued from Kolenchery Medical College Hospital). Hence we are of the view that additional information called for were not at all necessary.

 

          Requested information necessary for processing the claim was furnished by complainant.  Complainant has a specific case that the policy offered cashless facility.  This is not denied by 1^st opposite party in its written version.  Upon verification of policy documents, we find nothing there to show that the policy does not carry or offer cashless facility.  Admittedly, on both occasions, cashless facility was not provided.  Complainant had then paid the expenses initially and sought reimbursement of both occasions.  This was also not granted.  Instead, his claim was repudiated, vide Ext.R2(d) for the only reason that additional information sought for in Exts.R2(a), R2(b) and R2(c) was not furnished. All  information was provided, yet additional information was sought apparently only to decline the rightful claim of complainant as per conditions of policy.  Such acts on the part of 1^st opposite party certainly amounts to deficiency in service and unfair trade practice. 

 

          Second opposite party cannot wash its hands of the liability contending that there is no privity of contract between it and complainant.  As per P1&2  submitted, 2^nd opposite party is the master policy holder.  It has also some responsibility in seeing that rightful claim of policy holders under it is not denied or declined by 1^st opposite party.  There is nothing to show that 2^nd opposite party has done anything in further to process the claim put forth by complainant on both occasions of hospitalisation of his son.  To some extent, there is deficiency in service on the part of 2^nd opposite party also.

 

          Complainant has claimed hospital expenses covered by Ext.P4 series of bills except Exts.P4(c) and P4(d), which are discharge summaries.  He has claimed Rs.14,088/- towards hospital expenses incurred for the treatment of his son, who was admittedly covered under the policy, which claim is supported by the bills mentioned above.  Complainant is entitled for reimbursement of  same from 1^st opposite party and in case of non-payment, by 2^nd opposite party the master policy holder.

 

          Complainant has claimed Rs.10,000/- towards compensation for financial loss and mental agony due to deficiency in service on the part of opposite parties. Considering the circumstances, we are of the view that compensation in this regard should be entirely                                                                                                                      (cont...6)

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borne by 1^st opposite party.  Complainant has claimed litigation costs of Rs.2,500/- from opposite parties, complainant is entitled to realise the same from both opposite parties. Point Nos.1 and 2 are answered accordingly. 

 

6.  Point No.3 :

 

          In the result, complaint is allowed with costs as here under :

 

(a)  Opposite party No.1 is directed to pay Rs.14,088/- to complainant towards reimbursement of medical expenses incurred in connection with the treatment of his son and in case the amount is not paid by 1^st opposite party, it shall be paid by 2^nd opposite party, the master policy holder.  This amount shall carry interest at the rate of 12% per annum from 28.5.2020, till the date of payment or realisation.

 

(b)  Opposite party No.1 is directed to pay a compensation of Rs.10,000/- to complainant and in case of non-payment, amount shall carry interest at the rate of 12% per annum from the date of complaint, that is, 13.10.2020, till the date of payment or realisation as the case may be.    In case compensation is not paid by 1^st opposite party, it will be paid by 2^nd opposite party.

 

(c)  Opposite parties No.1 & 2 shall pay costs of Rs.2,500/- each to complainant.

 

All amounts mentioned above will be paid within 45 days from the date of receipt of a copy of this order.  If not, complainant will be entitled to realise the same in accordance with the provision of this Act.  Copies of pleadings, petitions and documents submitted shall be taken back by the concerned parties, after expiry of appeal time.

 

                    Pronounced by this Commission on this the   25^th  day of October, 2022

 

 

                                                                                                 Sd/-

SRI. C. SURESHKUMAR, PRESIDENT

 

                            Sd/-

        SMT. ASAMOL P., MEMBER

 

                               Sd/-

      SRI. AMPADY K.S., MEMBER

 

                                        (cont.....7)

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APPENDIX

 

Depositions :

Nil.

Exhibits :

On the side of the Complainant :

Ext.P1     -  Original policy certificate.

Ext.P2     -   copy of certificate insurance.

Ext.P3     -  copy of bank passbook of complainant.

Ext.P4 series  -  copy of hospital bills and discharge summaries.

On the side of the Opposite Party :

Ext.R1    -  certificate of insurance with terms and conditions of policy.

Ext.R2 series  -copy of letters issued by 1^st opposite party.

 

 

                                                                                           Forwarded by Order,

 

 

                                                                                       ASSISTANT REGISTRAR