Sri Shyamal Gupta, Member

The complaint case since been dismissed by the Ld. District Forum, aggrieved with such decision this Appeal is preferred by the Complainant, Sri Tarun Kumar Chatterjee.

Complainant’s case, as narrated in the petition of complaint, briefly stated, is that, his wife, Smt. Suparna Chatterjee, a beneficiary under the subject insurance policy, got admitted in a hospital for necessary treatment.  The hospital authority forwarded requisite medical papers to the OP Insurer through TPA along with an estimate sheet and pre-authorization form.  Subsequently, as per the requirement of the OP, the concerned doctor submitted additional report about the patient.  Despite this, the OP did not accord cashless facility to the Complainant.  Therefore, the complaint was filed.

In its WV the OP submitted that, on receipt of pre-authorisation request pertaining to the treatment of Complainant’s wife, by a letter dated 05-10-2013, it sought for certain information.  Such a query was raised because of the fact that cashless facility was sought for treatment of haemorrhoids by surgery, i.e., haemorrhoidectomy, which is usually done if all other conventional methods of treatment fails.  Therefore, it became necessary for the OP to ascertain whether the condition of the Complainant’s wife was pre-existing disease or not.  Said query was responded to by the hospital authority enclosing copies of documents, including a Certificate, issued by the treating doctor.  However, the response received from the hospital authorities did not squarely meet the queries raised and sought for by the OP.  On perusing the certificate issued by the treating doctor, the OP noticed an overwriting in the second line, where the duration of disease though mentioned as ‘last September 2013”, it was clear that the date was initially written as “last September 2012”.  Thus, a reasonable suspicion arose in the mind of the OP and at that stage, it was not possible for the OP to come to any firm conclusion regarding the medical history of the Complainant’s wife and hence the OP asked the hospital to collect payment from the Complainant and ask the Complainant to go for reimbursement.

Decision with reasons

We have attentively heard the averments of the parties and gone through the documents on record.

In this case, the medical condition of Appellant’s wife occurred on expiry of the initial waiting period of 90 days.  Yet, it seems, simply because there was an overwriting in respect of the duration of illness of Appellant’s spouse, so mentioned in the certificate issued by the treating doctor, the Respondent refused to extend cashless facility to the Appellant. 

It is to be appreciated that settlement of claims or extending due privileges to the beneficiaries of the policy strictly depends on the terms and conditions of the policy. The Insurer cannot act whimsically under any circumstances. 

Regulation 9(a) of the IRDA (Health Insurance) Regulations, 2013 runs as under:

“subject to the terms of a policy, General Insurers and Health insurers shall extend to all policy holders a cashless facility for treatment at specific establishments or the reimbursement of the costs of medical and health treatments or services availed at any medical establishment”.

Given that the medical condition of the Appellant’s wife developed after expiry of the initial cooling off period – it was totally immaterial in this case - whether such condition occurred within a day of expiry of the cooling period or a month or a year. 

Further, the treating doctor in his certificate in uncertain terms mentioned that the patient had no record of past hospitalization or any past medical history.  Despite this, if any suspicion indeed arose in the mind of the Respondent regarding the duration of said medical condition of the Appellant’s wife owing to overwriting of the year in the certificate in question, it was not at all a tough ask for it to get the same clarified/verified from the physician/hospital concerned.  However, we find that simply on the basis of sheer suspicion, it developed cold feet to extend cashless facility to the Appellant.  This is not appreciable.

A major benefit of cashless insurance is that it offers peace of mind. One may receive quality treatment and focus on speedy recovery instead of having to worry about paying medical bills. This ensures that one receives complete health care without worrying about making cash arrangements. However, if the Insurance Company arbitrarily withholds such facility, no doubt, it puts one in deep trouble to arrange requisite money from one’s own coffers; particularly when treatment cost in private hospital burns a deep hole in one’s pocket. 

Thus, we find gross deficiency in service on the part of the Respondent. 

We however make it clear that our aforesaid observation shall have no bearing on the merit of the insurance claim that the Appellant must lodge with the Respondent without any further delay, if he is indeed desirous of getting the same settled.  In this Appeal, we have restricted our focus strictly on the aspect of arbitrariness shown by the Respondent in dealing with the pre-authorization request made by the hospital authority concerned in respect of the treatment of Appellant’s spouse. 

The Appeal, accordingly, succeeds.

Hence,

O R D E R E D

The Appeal stands allowed on contest against the Respondent with a cost of Rs. 5,000/- being payable by the Respondent to the Appellant.  The Respondent shall also pay compensation to the tune of Rs. 10,000/- to the Appellant within 40 days from this day, i.d., it shall be liable to pay simple interest @ 9% p.a. over the sum of Rs. 10,000/- for the entire period of default.  The impugned order is hereby set aside.