ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT.

This is the Complaint filed by the Complainant U/S Section 12 of Consumer Protection Act 1986, against the Opposite Parties (herein referred in short as O.Ps) alleging the deficiency in service in not honoring the reimbursement of medical expenses even though the insurance policy in force and for refund of the said medical expenses along with Rs.50,000/- towards damages for causing deficiency in service and for other reliefs as the Commission deems fit.

2.      The brief facts of the complaint are that;

Earlier the complainant for himself, for his wife and two children took insurance policy with oriental insurance company ltd., in the year 2010.  Afterwards in the year 2015 he got the same transported to Max bupa Health Insurance Company i.e., OP1, by paying the prescribed premium for himself, his wife, and two children.  His wife underwent treatment in the year 2016 for which OP1 reimbursed Rs.38,835/- towards the hospital expenses of Rs.43,612/-.  The said insurance policy was renewed for the year 2017-18 and the said insurance is in force from 18.03.018 to 17.03.2019.

3.      It is further contended that on 27.06.2018, his wife Smt. Tanya Chouhan admitted to OP2 hospital for treatment of right renal parenchymal calcifications, right lower ureteric calculus with HDUN and surgical procedure was performed and discharged with the summary.  On 03.07.2018 the request made by OP2 to OP1 for cashless entry for his wife was denied, with an endorsement that “patient has adverse medical condition due to which not possible to ascertain the liability at this juncture, hence cashless entry not extended”. His wife did not have hypothyroidism since 13 years.  The doctor at Apollo hospital i.e., OP2 inadvertently by typographical error mentioned in the Discharge summary that she was having hypothyroidism for the last 13 years. Afterwards, a clarification was issued by the doctor on 17.07.2018 stating that the said thyroidism was from last three years.  Inspite of bringing the said fact to the knowledge of OP1 on several occasions, the expenses for the said surgery was not reimbursed.  Hence there is deficiency in service on the part of OP and hence the complaint.

4.      Upon the service of notice, OP2 remained exparte, whereas though OP1 appeared before the Commission through its advocate and took several time to file the version, did not file the same.  Hence right to file the version was forfeited.

5.      In order to prove the case, complainant has filed the affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1) Whether the complainant has proved deficiency in service on the part of the Opposite Parties?

2) Whether the complainant is entitled to the relief prayed for in the complaint?

6.     Our answers to the above points are:-

POINT NO.1:            In the Affirmative against OP1

POINT NO.2:            Partly in the affirmative from

OP1, for the following.

REASONS

7.     POINT No.1:-

   Perused the complaint, affidavit evidence and the documents produced by the complainant.  From the above, it becomes clear that the complainant for himself, for his wife and children, took medical policy insurance certificate and is in force. The free hospitalization or cashless hospitalization has been denied by OP1 and further the claim of the complainant was also denied on the ground that the complainant did not disclose the material fact of hypothyroidism of the wife of the complainant having the same since 13 years. 

8.     The doctors of OP2 on 17.07.2018 has written a clarificatory note that 13 years of hypothyroidism is wrongly mentioned whereas, its duration is three years only.  Legal notice has also been issued to OP1 and 2,, which was served on them, whereas no reply has een sent by them.

9.     On 27.08.2020 the counsel for OP1 filed a Memo stating that they are ready to pay a sum of Rs.23,869/- out of the claim of Rs.30,890/- after deducting

Total Claim Amount – 30890

Deduction – 7021 (CSSD 351, INSTRUMENT 4020, ADMINISTRATION 580, NUTRITIONAL 300, SPONG 230, GAUZE 60, MASK 45, FILTER 285, PACK 900, GLOVE 60, MASK 190

Payable Amount – 23869

10.   In view of the said Memo, we are of the opinion that repudiating the claim of the complainant by OP 1 amounts to deficiency in service and answer point NO.1 in the affirmative.

11.   Though complainant has refused for the Memo agreeing to pay Rs.23,869/-, the insurance company is not liable to pay towards the consumables, such as cost of instruments, administration charges, nutritional, gauze, mask, filter, glouse etc., in view of this we are of the opinion that the offer made by the OP1 to pay Rs.23,869/- towards the claim of the complainant is just and proper.  Hence we direct OP1 to pay Rs.23,869/- along with interest at 12% on the said amount from the date of repudiation i.e., 17.07.2018 till payment of the entire amount. Further we order OP1 to pay a sum of Rs.2,000/- towards damages for causing mental agony and physical strain and further Rs.2,000/- towards litigation expenses. With this observation, we answer point No.1 and 2 partly in the affirmative and pass the following;

ORDER

1. Complaint is allowed in part with cost.
2. OP is directed to Rs.23,869/- along with interest at 12% on the said amount from the date of repudiation i.e, 17.07.2018 till payment of the entire amount.
3. OP further directed to pay a sum of Rs.2,000/- towards damages for causing mental agony and physical strain and further Rs.2,000/- towards litigation expenses.
4. Complaint against OP2 is dismissed.
5. The OP is further directed comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
6. Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 13^th Day of OCTOBER 2020)

MEMBER                                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Insurance policy booklet along with receipt for having paid premium for the year 2015-16

Ex P2: Pre-authorization letter, Discharge summary along with connected medical document (Insurance Company i.e., OP No.1 has already amount paid for this request)

Ex. P3: Policy booklet along with receipt for having paid the premium for the year 2017-18

Ex P4: Pre-authorization letter, Discharge summary relating to RT URS+RGPO+DJ Stunting surgery and connected medical documents

Ex P5: Application for cashless benefit for removal of stunt

Ex P6: Letter of denial in respect of cashless benefit

Ex P7: Clarification from the Apollo Hospital regarding typographical error

Ex P8: Invoice regarding payment made by the complainant for removal of stunt along with copy of the Discharge summary

Ex P9: Email correspondence between OP1 and complainant.

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

NIL

Copies of Documents produced on behalf of Opposite Party/s

NIL

MEMBER                                PRESIDENT