Order No. 18 dt. 28/12/2016
The case of the complainant in brief is that the complainant had one mediclaim policy of Max Bupa Health Insurance Company Limited and the policy was valid from 09.07.2013 till 17.06.2014. The wife of the complainant Mrs. Suparna Chatterjee had illness of excessive bleeding for which she was taken to Fortis Hospital and as per advice of Dr Ramesh Agarwala she had to undergo an operation. Before admission Dr asked the complainant whether he had any Insurance Policy and on disclosure of the same and handing over the documents, the matter was referred to Max Bupa Insurance Company through TPA along with estimate pre-authorization form. The opposite party asked for some information and those information were provided including the additional report about the patient whereby Dr. Agarwala specifically mentioned that there was no record of past hospitalization of the patient. In spite of receiving information the cashless benefit was denied by the opposite party. It was stated by the complainant in spite of having the enjoyment of cashless benefit in respect of the said policy the denial of the same tantamount to deficiency of service and unfair trade practice committed by O.P.
In view of the facts and circumstances of the case the complainant prayed for necessary direction of the O.P. for refund of the two years insurance premium amounting to Rs.53,802/- as well as compensation of Rs.3,00,000/- and litigation cost of Rs.20,000/-.
The O.P. contested the case by filing a written version whereby all the material allegations were denied. It was stated that on or about 5th October, 2013 the o.p. received a pre-auhtorisation report for cashless facility from the hospital whereby the complainant’s wife was admitted for treatment of hemorrhoids . On receiving such request the o.p. sought for report from the hospital that was required for the disbursement of the cashless facility. On receiving the request the hospital issued a certificate whereby there was a overwriting on the date since when the complainant’s wife had symptoms of such disease. Such overwriting indicated that though in the report it was mentioned September,2012 and by way of overwriting it was written as September, 2013. Since there was ambiguity in the report itself the cashless facility was denied and the complainant asked to go for the reimbursement of the medical bill. The complainant without adopting such option filed this case making false allegations against the o.p. and accordingly the o.p. prayed for dismissal of the case.
On the basis of the pleadings of the respective parties following points are to be determined:
- Whether the complainant had the insurance policy at the relevant point of time ;
- Whether the policy was valid ;
- Whether there was any justifiable cause for negation of the cashless facility to the complainant;
- Whether there was any deficiency of service on the part of the o.p. if so will the complainant be entitled to get the compensation as prayed for .
Decision with reasons
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
The Ld. lawyer for the complainant argued that the complainant had mediclaim policy being policy no.30108103201301 to Max Bupa Health Insurance Company Ltd. The complainant had the enjoyment of cashless benefit . Suddenly the wife of the complainant Mrs. Suparna Chatterjee became ill and she was taking to Fortis Hospital. The doctor who attended the patient advised for an operation and asked the complainant whether the patient was covered under any mediclaim policy . On disclosure of the same and handing over the relevant papers, those were provided to o.p. for seeking permission to give cashless facility to the patient for her treatment. On receiving those papers a report was sought for from the doctor and in spite of submission of such report the o.p. denied the cashless facility to the patient. Being aggrieved with such denial of the cashless facility to the complainant , the complainant had to file this case praying for return of the premium amount paid to the o.p. and also compensation of Rs.3,00.000/-.
The Ld. lawyer for the o.p. argued that in order to give benefit to the policy holder for cashless facility certain norms are to be followed by the company and for that purpose report was sought for from the treating doctor who sent a report but in the report it was mentioned that the patient had the symptom of such disease from Septemebr,2012 but it was manipulated by overwriting the year 2013. so that the complainant can enjoy the cashless benefit. Since there was ambiguity the complainant was asked for to claim for medical reimbursement .There was no deficiency in service on the part of the o.p. accordingly the o.p. prayed for dismissal of the case.
Having regard to the submission of the respective parties it is an admitted fact that complainant had the medclaim policy with the o.p. and the policy was valid at the relevant point of time. So far as the denial of the cashless facility of the complainant is concerned the o.p. had to follow the usual practice of seeking a report from the treating doctor as regards the history of the illness of the patient. Accordingly the report was submitted and a photocopy of the said report has been annexed with the written version. On perusal of the report it appears that there was overwriting on the year though actually it was mentioned September,2012 but by way of overwriting it was mentioned as September,02013.Since there was confusion the o.p. denied the cashless facility and asked the complainant to go for medical reimbursement of the bills. The complainant without adopting the good advice of the o.p. rushed to the Forum and claimed for refund of the premium paid by him as well as compensation which are not feasible. Accordingly we hold that there was no deficiency in service or any unfair trade practice adopted by the o.p. As a consequence thereof we hold that the complainant has measurably failed to prove the case and complainant will not be entitled to get any relief as prayed for.
Hence, ordered
That the case no.366/2014 is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
