Order No. 17  dt.  26/04/2017

        The fact of the case in brief is that on or about 03/01/2015 o.p. 1 made an offer to o.p. 3 and entered into a contract of health insurance for each of the employees of o.p. 3. Since complainant is an employee of o.p. 3, the complainant became covered under the group health insurance policy of o.p. 1. The policy number was 00158400201400 dt. 03/01/2014 (Customer ID 0010014787) and the membership no. 2027545. Complainant was admitted to Belle Vue Clinic as per advice of Dr. Anirban Biswas, consultant neurologist (Bellle Vue Clinic) on 02/04/2014 following severe illness of vomiting, acute vertigo. The complainant was in hospital for 2 days. He was discharged on 04/04/2014. Thereafter the complainant submitted reimbursement claim vide claim no. 80163 on 17/04/2014 amounting to Rs. 35,854/- to o.p. and that was received by o.p. on 24/04/2014. The employer of the complainant wanted pre-authorization for a cashless treatment to o.p. but that was denied by them. The o.p. sent their authorized representative to verify the hospitalization and relevant documents. The o.p. rejected the claim of the complainant on 19/05/2014. When o.p. 3 enquired about the cause of rejection, o.p. showed the clause 4e vii – 2 and 5g 3 ii of the terms and condition of the policy. O.p. further informed that hospitalization was not required and the complainant has pre-existing disease which was not disclose by the complainant. The o.p. 3 sent representation and complainant also sent representation but the application of the complainant was rejected on 19/08/2014. Hence the application praying for re-imbursement of Rs. 35,854/- along with compensation of Rs. 50,000/- and litigation cost of Rs. 5,000/-.

        O.p.s 1 and 2 contested the case by filing w/v. In their w/v o.p.s 1 and 2 denied all the material allegations inter alia stated that the complainant was diagnosed with Vestibular neuritis and the pre-authorization request was raised for Rs. 52,400/-. However, an amount of Rs. 28,800/- was approved vide letter dt. 03/04/2014. The complainant was discharged on 04/04/2014. After going through the discharge summary and hospital bills the o.p.s 1and 2 ascertained that the complainant was admitted due to vertigo. After admission only evaluating examination was conducted on him. It was ascertained that the patient could have been treated as out-patient. The authorization was cancelled vide their letter dt. 04/04/2014. The case paper entry made on 02/04/2014 states that patient’s vital are stable, on 03/04/2014 it states “Patient is o.k., all tests are done. May be discharged. R.M.O. to discharge the patient”. However the complainant was not discharged then. Rather he was discharged on 04/04/2014. The tests were done within the span of 5 to 6 hours. Complainant could have been managed from OPD and he was suffered from pre-existing disease, vertigo. Hence the claim was denied. Therefore the present case is liable to dismiss with cost.

Though the notice was served against o.p. 3, they did not turn up before the Forum. So the case was proceeded ex-parte as against o.p. 3.

Decisions with reasons : -

        We have gone through the pleadings of the parties and evidence in particular. It is admitted fact that complainant is an employee of o.p. 3. O.p. s 1 and 2 issued a policy in favour of o.p. 3. The complainant was  covered as a beneficiary of the said health insurance policy. The policy number was 00158400201400 dt. 03/01/2014 (Customer ID 0010014787) and the membership no. 2027545. The complainant was admitted to Belle Vue Clinic as per advice of Dr. Anirban Biswas, consultant neurologist (Bellle Vue Clinic) on 02/04/2014 following severe illness of vomiting, acute vertigo. When the intimation was given to o.p.s 1 and 2, they approved Rs. 28,800/- vide their letter dt. 03/04/2014. Ultimately they cancelled the same and advise the complainant to submit claim form accordingly. Complainant submitted the claim form which was received by o.p. on 20/04/2014. Firstly they denied the claim citing the reason that the patient could have been treated as out-patient. This plea cannot be acceptable since there is document issued by treating doctor wherefrom it reveals that the treating doctor advised the patient for admission. It was not the choice of the complainant from where he would be treated. When treating doctor advised him to take admission there was no option for the patient and for that reason he was admitted in the hospital. After going through the doctor’s advice o.p. took another plea that the complainant was suffering from pre-existing disease, i.e. vertigo. It is to be noted here that the complainant was covered under group insurance policy. It cannot said that he was suffering from pre-existing disease. He was admitted to hospital due to sudden acute illness along with vertigo and under treating doctor’s advice. When the o.p. insurance company approved Rs. 28,800/-, we are in the view that the complainant is entitled with that amount. The plea taken by o.p. in their w/v. regarding the date of discharge is also not acceptable. The date of discharge is decided by the hospital and treating Doctors, not bu patient himself. Taking different types of pleas at different point of time is nothing but deficiency in service on the part of the o.p. 1 & 2. Therefore, we are in the view that the complainant is entitled to get relief in part.

        Hence,

                        ordered,

        that the case no. CC/702/2014 is allowed on contest against o.p.s 1 and 2 with cost and dismissed against o.p. 3 ex-parte.

       O.p.s 1 and 2 are directed to give an amount of Rs. 28,800/- (Rupees twenty eight thousand eight hundred) only to the complainant along with compensation of Rs. 3,000/- (Rupees three thousand) only for harassment and mental agony along with cost of Rs. 1,000/- (Rupees one thousand) only to the complainant.

        The o.p.s 1 and 2 are directed to give the aforesaid amount within 30 days from the date of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.

        Supply certified copy of this order to the parties free of cost.