IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 27th day of July, 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No. 75/2022 (Filed on 05-04-2022)
Complainants : K.E. Jose,
S/o. Eapen,
Kadamapuzha House,
Mundakkayam P.O.
Kanjirapally Taluk,
Kottayam.
(Adv. Sijo Joseph)
Vs
Opposite parties : 1. Medi Assist Insurance TPA Pvt. Ltd,
Represented by its Managing Director
Nagampadom Tower D 4th Floor
IBC Knowledge Park
Bannerghatta Road, Bangalore
Pin – 560 029
2. New India Insurance TPA Pvt. Ltd
Represented by its Divisional Manager,
Polachirackal Chambers,
Opposite Collectorate,
Kottayam – 686 002
(Adv. P.G. Girija)
3. Life Insurance Corporation,
Represented by its Divisional
Manager, Jeevan Prakash,
Kurian Uthup Road, Nagampadom,
Kottayam – 686 001
(Adv. Anie C Kuruvilla)
O R D E R
Sri.Manulal.V.S, President
Brief of the complaint is as follows:
The complainant is associated with LIC as an agent for the last 42 years. Complainant is the primary beneficiary of the policy holder of third opposite party bearing policy no.12030034200400000007 for which he pays an amount of Rs.300,000/- as premium annually. The complainant was admitted to Mar Sleeva Medicity Pala, on 31-10-2020 due to stroke. He was treated up to 4-11-2020 and was discharged on 4-11-2020. On 30 -10-2020 an amount of Rs.55047/- was paid as medical bill, for which a claim was made with first opposite party. Even though the complainant was entitled for full reimbursement of the medical bill the said claim was partly allowed by the first and second opposite parties for an amount of Rs.49,625/-.
The complainant had paid an additional amount of Rs.3,019/- towards the discharge bill of hospital on 4-11-2020, for which the complainant had made another claim with the first opposite party. Thus the complainant paid a total amount of Rs.87,066/- towards the medical expenses at Mar Sleeva Medicity hospital from 31-10-2020 to 4-11-2020. Eventhough all mandatory documents were submitted before the first opposite party, the first and second opposite parties have not so far allowed the reimbursement. On 8-4-2021 the complainant caused a lawyers notice to the opposite parties to which the first opposite party alone issued a reply , contending that first opposite party is only a service provider to the insurers and demanded the complainant to furnish few documents .
Even though the complainant furnished all the documents as demanded, no steps were taken to settle the claim so far. The complainant is entitled for a full medical reimbursement for an amount of Rs.37,441/- out of the total claim of Rs.87,066/-. The opposite parties have no manner of right to reject the claim of the complainant. Hence all the opposite parties are liable for deficiency in service. So this complaint is filed by the complainant praying for an order to direct the opposite parties to pay an amount of Rs.37,441/- along with Rs.1,00,000/- as compensation for mental agony and cost of this litigation.
Upon notice except first opposite party others appeared before the commission and filed version. Hence first opposite party is declared as ex-party.
Version of the second opposite party is as follows:
The claim of the complainant for Rs.55,047/- was processed and it was settled for an amount of Rs.49,625/-. The balance amount for Mask, under pad, bed wipes, housekeeping, canteen items and hospital discount were not paid. The said bill was the discharge bill. The complainant submitted another bill for Rs.29,966/- as discharge bill for the same period of inpatient treatment. Moreover, in the claim form, the exact bill amount was not specifically mentioned. Hence clarification regarding exact claim amount, clarification from the hospital for the separate bills for Rs.55,047/- and Rs.29,966/- for the same treatment during the same period and pre-numbered paid receipt for Rs.55,047/- were sought from the complainant. The complainant was requested to furnish the said details for processing his claim of Rs.37,441/-. But the complainant did not furnish the required documents, hence the claim could not be processed and settled for want of the required documents. There is no deficiency in service on the part of the second opposite party.
Third opposite party filed version contending as follows:
It is admitted by the third opposite party that the complainant is an LIC agent and he is a ‘Chairman Club’ member agent since 1995-96. The third opposite party has scheme “Group Medi claim Insurance Scheme for Club Member Agents for reimbursement of hospitalization charges to agents. The scheme is regulated by Group Mediclaim Policy issued by the Second opposite party within policy no.12030034200400000007 for the year 1-9-2020 to 31-8-2021.
The complainant had paid Rs.7,371/- towards group medi claim premium for the period of 1-9-2020 to 31-12-2021 for him and his wife. The first opposite party is a third party administrator who is acting on behalf of the second opposite party for processing the health insurance claims. When the claim is processed by TPA, if according to them the claim is admissible, the TPA will intimate the details of the claim and the amount admitted to the beneficiary. After processing, if the decision of the TPA is to settle, it will be intimated to the New India Assurance Company and the claim will be settled by the insurance company. The third opposite party has not rejected the claim of the complainant. The third opposite party has no role in the decision on the claim. Being insured in the aforesaid group policy which the complainant is a beneficiary the third opposite party forwarded the claim form and bills received from the complainant to the first opposite party on 18-11-2020. Another set of documents received from the complainant was also sent to the first opposite party on 1-3-2021 and that alone was the role of the third opposite party in connection with this claim .There is no deficiency in service on the part of the third opposite party.
Complainant filed proof affidavit in lieu of chief examination and marked exhibit A1 to A7. The witness of the complainant is examined as Pw1. Asha R Thomas who is the Divisional Manager of the second opposite party filed proof affidavit in lieu of chief examination. C.D. George who is the Manager of the legal and HPF department of the third opposite party filed proof affidavit in lieu of chief examination. Exhibits B1 and B2 were marked from the side of the opposite parties.
On evaluation of complaint version and evidence on record we would like to consider the following point for consideration
- Whether there is any deficiency in service or unfair trade practice on the
part of the opposite party?
- If so what are the reliefs and costs?
Point number 1 and 2
It is an admitted fact that the complainant is an LIC agent and he is a ‘Chairman Club’ member agent. The third opposite party has regulated a scheme as Group Mediclaim Policy issued by the Second opposite party within policy no.12030034200400000007 for the year 1-9-2020 to 31-8-2021.The complainant is a beneficiary of the said scheme. On perusal of exhibit B2 policy schedule we can see that the chairman club members of the LIC are the insured persons and the sum insured was Rs.5,00,000/-.
It is also not disputed that the complainant was treated at Mar Sleeva Medicity Pala, as inpatient from 31-10-2020 to 4-11-2020 due to stroke. It is also admitted by the second opposite party that out of the claim for an amount of Rs.55047/- the second opposite party allowed an amount of Rs.49,625/- The specific case of the complainant is that he had paid an additional amount of Rs.32,019/- towards the discharge bill of hospital dtd.4-11-2020, which is not settled by the opposite party.
The complaint was resisted by the second opposite party stating that the complainant submitted separate bills for Rs.55,047/- and Rs.29,966 for the same treatment during the same period hence explanation was sought from the complainant. But the complainant did not furnish the required documents, hence the claim could not be processed and settled for want of the required documents.
According to the second opposite party the first claim of the complainant for Rs.55047 is processed and settled for an amount of Rs.49265/-. The second opposite party has not paid the amounts for Mask, under pad, bed wipes, housekeeping, canteen items. Ongoing through the terms and conditions of the policy we can see these expenses for these items are included in the list of expenses excluded which is attached to B1 policy. Thus we are of the opinion that the opposite party is rightly deducted Rs.5,422/- out of the claim for Rs.55,047/-.
The next question is to be answered is that whether the complainant is entitled for the reimbursement of his subsequent claim for Rs.29,996/- for the same treatment. Pw1 who is the PRO of the Marsleeva Medicity Hospital deposed before this commission that the complainant has admitted in the emergency department on 31-10-2020 at 4.20pm and discharged on the same day from the said department and admitted there as inpatient and treated till 4-11-2020.
He further deposed that as per the system followed in the hospital if it is necessary to admit the patient in the hospital they would admit the patient in the hospital as inpatient after discharging him from the emergency department and after paying the bill for the same. He admitted that exhibit A7 bill is issued to the complainant when he is discharged from the emergency department and A1 is issued to the complainant when he was discharged on 4-11-20. He further deposed that the endorsement in Exhibit A7 as ER-20/011310 indicates that it is an emergency number. On perusal of exhibit A7 we can see that the complainant was admitted in the emergency department on 31-10-2020 16.28 pm and discharged from there on the same day at 20.00pm. It is stated in the discharge bill which is annexed to exhibit A1 discharge summary the complainant was again admitted in the hospital on 31-10-2020 at 7:56:38 pm and discharged on 4-11-2020 at 3:23:10 pm. Thus it is proved that the bill which was annexed to Exhibit A1 was issued for the treatment in the inpatient department from 31-10-2020 to 4-11-2020.
In exhibit A5 which is the reply notice issued by the first opposite party it is stated that TPA has no discretionary power to take a decision to decline/settle. Either accepting the claim or rejecting the claim is totally the right of the insurance company. The third opposite party submitted in the version as well as in the proof
affidavit that a set of documents received from the complainant was sent to the first opposite party on 1-3-2021.
Thus we are of the opinion that the contention of the second opposite party that the claim could not be processed and settled for want of the required documents.
Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016 the same reads as under:-
“27. Settlement/Rejection of claim by insurer: i. An insurer shall settle or reject a claim, as may be the case, within thirty days of the receipt of the last ‘necessary’ document.”
In the light of the above discussion, we are of the considered view that the non-processing of the claim by the second opposite party does not appear to be reasonable or justifiable. In the given circumstances, in our considered view, it would be just and proper if second opposite party is directed to consider and reimburse the claim in respect of exhibit A1 hospital bill of the complainant from 31-10-2020 to 4-11-2020 strictly in accordance with the terms and conditions of the policy along with compensation of costs of Rs.25,000/-.
As a result of above discussion, the complaint is allowed with direction to second opposite party to consider and reimburse the claim in respect of exhibit A1 hospital bill of the complainant from 31-10-2020 to 4-11-2020 strictly in accordance with the terms and conditions of the policy to the complainant within 30 days from the date of receipt of copy of the order.
Second opposite party is further directed to pay compensation of Rs.25,000/- (Rupees Twenty Five Thousand only) to the complainant. The compliance of the order be made within 30 days from the date of receipt of copy of the order. If not complied as directed, the compensation amount will carry 9% interest from the date of Order till realization.
The complaint as against first and third opposite parties is, however, dismissed.
Pronounced in the Open Commission on this 27th day of July, 2023
Sri. Manulal.V.S, President Sd/-
Smt. Bindhu.R, Member Sd/-
Sri. K.M.Anto, Member Sd/-
Appendix
Witness marked from the side of complainant
Pw1 – Jay K. Mathew
Exhibits marked from the side of complainant
A1 – Copy of discharge summary of K.E. Jose from Mar Sleeva Medicity, Palai
A2 – Copy of e-mail communication by 1st opposite party to complainant
A3 series – Copy of e-mail communication by 1st opposite party to complainant
A4 –Advocate notice dtd.15-04-21 by Adv. Soni Thomas to opposite parties
A5 – Reply notice dtd.21-04-21 by 1st opposite party to Adv. Soni Thomas
A6 –Letter dtd.10-10-21 by complainant to 1st opposite party
A7 –Copy of discharge bill dtd.31-10-20 by Mar Sleeva medicity Palai.
Exhibits marked from the side of opposite party
B1 – Copy of policy by 2nd opposite party
B2 - Copy of loan agreement – vehicle finance
By Order
Assistant Registrar
