Date of Filing      : 21.04.2021

                                                                                                                 Date of Disposal : 26.10.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                                .…. PRESIDENT

                 THIRU.J.JAYASHANKAR., B.A., B.L.,                                                                        .....MEMBER-I

                 THIRU.P.MURUGAN,  M.COM.,ICWA (Inter),B.L.,                                              ......MEMBER-II

 

CC. No.26/2021

THIS WEDNESDAY, THE 26th DAY OF OCTOBER 2022

 

Mrs.R.Senthamarai,

W/o.Mr.Arivazhagan,

No.14, Kandasamy Nagar,

Poonamalle Road, Manavala Nagar,

Thiruvallur Taluk & District -602 002.                                           ……Complainant.  

                                                                                 //Vs//

1.The Manager,

    MD India Health Insurance Private Limited,

    (United India Insurance Company Limited)

    Guna Complex,

    New Door No.443&445,

    Old Door No.304&305, Anna Salai,

    Teynampet, Chennai- 600 018.

 

2.The Director,

    Prime Indian Hospitals,

    No.1051, Poonamallee High Road,

    Arumbakkam, Chennai -600 0106.                                      …..opposite parties.

 

Counsel for the complainant                               :   Mr.A.R.Poovannan, Advocate.

Counsel for the opposite parties                        :   exparte 

                         

This complaint is coming before us on various dates and finally on 10.10.2022 in the presence of Mr.A.R.Poovannan counsel for the complainant and the opposite parties were set exparte for non appearance and upon perusing the documents and evidences of the complainant this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. S.M. LATHA MAHESWARI, PRESIDENT

 

        This complaint has been filed by the complainant u/s 35 of the Consumer 

Protection Act, 2019 alleging deficiency in service against the opposite parties with respect to the medical claim insurance availed by the complainant along with a prayer to sanction the complainant’s claim of Rs.1,84,790/- with interest and to pay a sum of Rs.2,00,000/- towards compensation for the mental agony and hardship and to pay a sum of Rs.10,000/- towards cost of the proceedings to the complainant.

Summary of facts culminating into complaint:-

The case of the complainant was that she was working as a Secondary Grade Teacher and she got Health Insurance coverage under the new Health Insurance Scheme 2016 of Government of Tamil Nadu which was valid up to 30.06.2027 vide ID Card No.TLR/01/EJ/409/NHIS16/1451427.  During the month of October 2020 the complainant developed severe stomach pain and consulted the 2nd opposite party and was admitted as patient and was diagnosed that the complainant had ‘Ventral hernia with Umbilical hernia with sub acute intestinal obstruction due to interloop adhesions and anterior abdominal adhesion’ and she was advised to undergo surgery for the same Rs.5,000/- was charged for admission fees and the Doctor advised to take CT scan of abdomen and Chest at Gemini Scans Private Limited and the complainant paid Rs.6500/- and Rs.5,500/- for the surgery and treatment with the 2nd opposite party’s hospital. As the complainant wanted to avail the cashless service under Health Insurance Scheme, the 2nd opposite party also accepted for the same.  The complainant submitted that the 1st opposite party initially sanctioned a sum of Rs.20,000/- on 07.10.2020 and the complainant was issued medical bills for a sum of Rs.1,84,790/- at the time of discharge and she was asked to pay Rs.1,64,790/-.  On request it was informed by the 2nd opposite party that they will not give any receipt and they would give only discharge summary.  Thus the complainant was forced to pay the entire amount including the pre authorized sum of Rs.20,000/-.  It was submitted that the 2nd opposite party failed to claim the bill amount from the 1st opposite party which was statutorily liable to pay the bill amount.  Thus after issuance of a legal notice the present complaint was filed for the following reliefs as mentioned below;

To direct the opposite parties to sanction the complainant’s claim sum of Rs.1,84,790/- with interest;

  To pay a sum of Rs.2,00,000/- towards compensation for the mental agony and hardship;

To pay a sum of Rs.10,000/- towards cost of the proceedings to the complainant.

  On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A8. In spite of sufficient notice and opportunities the opposite parties did not appear before this Commission and hence they were set ex-parte on 30.05.2022 for non appearance and for non filing of written version.

Points for consideration:

Whether the opposite parties 1 & 2 have committed deficiency in service in not honouring the claim of medical insurance availed by the complainant for the treatment availed by him for Ventral hernia with Umbilical hernia with sub acute intestinal obstruction due to interloop adhesions and anterior abdominal adhesion?

If so to what reliefs the complainant is entitled?

  Point:1

The following documents were filed on the side of complainant in support of his contentions;

Government of Tamil Nadu New Health Insurance Scheme – 2016 in the name of complainant’s husband was marked as Ex.A1;

Identity Card of the complainant was marked as Ex.A2;

Aadhaar Card of the complainant was marked as Ex.A3;

 Medical bills dated 15.10.2020 was marked as Ex.A4;

CT-Abdomen Report of the complainant dated 08.10.2020 was marked as Ex.A5;

Discharge Summary of the complainant was marked as Ex.A6;

Legal notice issued by the complainant to the 1st opposite party dated 22.01.2021 was marked as Ex.A7;

Reply by the opposite party dated 27.01.2021 was marked as Ex.A8;

 We heard the oral arguments and perused the materials evidence submitted by the complainant.  The crux of the arguments advanced by the learned counsel for the complainant is that the complainant who was admitted with the 2nd opposite party’s hospital and undergone the surgery for Ventral hernia with Umbilical hernia with sub acute intestinal obstruction due to interloop adhesions and anterior abdominal adhesion was not honoured the insurance claim by the 1st opposite party though initially a sum of Rs.20,000/- was sanctioned.  When questioned by the complainant the 1st opposite party sent a reply legal notice stating that they have cancelled the pre authorization request under the instructions of the 2nd opposite party.  Thus the complainant argued that the opposite parties had committed deficiency in service in cancelling the pre authorization and in declining the reimbursement request by the complainant.

On appreciation all the documents filed by the complainant we could see that the complainant was having a valid insurance coverage under Ex.A1 and her ID card was marked as Ex.A2.  Ex A4 dated 15.04.2020 proves that she has undergone the surgery with the 2nd opposite party and that the expenses incurred as Rs.1,84,790/- by way of medical bills.  The discharge summary Ex.A6 shows that the complainant suffered with Ventral hernia with Umbilical hernia with sub acute intestinal obstruction due to interloop adhesions and anterior abdominal adhesion and that she has undergone the surgery under general Anastasia and was discharged on 21.10.2020.  Thus when the complainant had a valid insurance coverage it is established that she is entitled to medical insurance from the 1st opposite party.  While so, when both the opposite parties decline the request for the reimbursement of medical insurance without assigning any valid reason the complainant had issued a legal notice for which the 1st opposite party answered that the complainant’s pre authorization for treatment was cancelled on request from the 2nd opposite party’s hospital and they also produce Ex.A8 in proof of the same.  Now the question arises has to why the 2nd opposite party requested the 1st opposite party to cancel the pre authorization request without any valid reason.  If at all on the claim submitted by the 2nd opposite party if the 1st opposite party declines the claim this commission would hold that it is the 1st opposite party who should be held responsible to prove why the claim was not honoured but in the present case the 1st opposite party has submitted a document though failed to appear before this commission to show that they have cancelled the pre authorization request only on instructions from the hospital/2nd opposite party with whom the complainant had undergone the surgery.  In these circumstances this commission feels that it is only the 2nd opposite party who should be held responsible to answer the question has to who instructed them to request the 1st opposite party to cancel the pre authorization or under what circumstances or for what reasons they request the 1st opposite party to cancel the pre authorization request for the complainant.  When the 2nd opposite party failed to appear before this commission to answer the same we are of the opinion that the decision taken unilaterally and arbitrarily by the 2nd opposite party requesting the 1st opposite party to cancel the pre authorization request made in favour of the complainant clearly amounted to deficiency in service. Thus we answer that it is only the 2nd opposite party who has committed deficiency in service for non encashment of the insurance claim of the complainant.  Thus we hold that the 2nd opposite party had committed clear deficiency in service and thus we answer the point accordingly.

Point No.2:

With regard to the reliefs to be granted to the complainant as we have held above that it is only the 2nd opposite party who had committed deficiency in service by acting arbitrarily in the cancellation of pre authorization request of the complainant, we hold that it would be proper to direct the 2nd opposite party to pay a sum of Rs.1,84,790/- to the complainant and to realize the same from the 1st opposite party by taking appropriate procedures.  Further for the deficiency in service committed by the 2nd opposite party we also award a compensation of Rs.25,000/- to be paid to the complainant. We also award Rs.5,000/- towards litigation expenses to the complainant.

In the result, the complaint is dismissed against the 1st opposite party and partly allowed against the 2nd opposite party directing them

a) to pay a sum of Rs.1,84,790/- (Rupees one lakh eighty four thousand seven hundred and ninety only) to the complainant within six weeks from the date of receipt of copy of this order and to realize the same from the 1st opposite party; 

b) to pay a sum of Rs.25,000/- (Rupees twenty five thousand only) towards compensation for the mental agony caused to the complainant;

c)  to pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant;

d) Amount in clause (a) if not paid within six weeks from the date of receipt of copy of this order, interest at the rate of 6% will be levied on the said amount from date of complaint till realization. 

 Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 26th day of October 2022.

 

    Sd/-                                                            Sd/-                                               Sd/-   

MEMBER-II                                              MEMBER I                                    PRESIDENT

 

List of document filed by the complainant:-

 

Ex.A1 ................ Government of Tamil Nadu New Health Insurance Scheme – 2016 in the name of complainant’s husband. Xerox

Ex.A2 .............. Identity Card of the complainant. Xerox

Ex.A3 ............... Aadhaar Card of the complainant. Xerox

Ex.A4 15.10.2020 Medical Bills. Xerox

Ex.A5 08.10.2020 Ct-T-Abdomen Report. Xerox

Ex.A6 ........... Discharge Summary. Xerox

Ex.A7 22.01.2021 Legal notice issued by the complainant. Xerox

Ex.A8 27.01.2021 Reply by the opposite party. Xerox

 

List of documents filed by the opposite parties;

 

 

Nil

 

 

Sd/-                                                             Sd/-                                                Sd/-

MEMBER-II                                          MEMBER I                                     PRESIDENT