DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM

       Dated this the 29^th day of  October 2024

[                                                                                             

                             Filed on: 11.10.2022

PRESENT

Shri.D.B.Binu                                                                            President

Shri.V.Ramachandran                                                               Member

Smt.Sreevidhia.T.N                                                                   Member

C C. No. 471/2022

COMPLAINANT

     Prasanna kumar T.,Padmavihar, Thrichattukulam P.O., Cherthala-688 526

(By Adv.N.Ratheesh, D.Harish Chand, Adv.T.K.Haribalan, Adv.Aiswarya S., Cherthala)

Vs.

OPPOSITE PARTIES

1. Administrator/Manager, Medical Trust Hospital, M.G.Road, South
2.  

(By Adv.Najumal Hussain, “Srivathsa”, Judges Avenue, Kaloor, Ernakulam, Pin-682 017)

2. Branch Manager, United India Insurance Co.Ltd., Branch office-Cherthala

              (op2 rep. by Adv.Joy Joseph, J & J Associates, MRRA-82, New India Lane, Kochi-682 023)

F I N A L    O  R  D  E  R

Sreevidhia T.N., Member

1. A brief statement of facts of this complaint is as stated below:

The complainant was holding a policy of health insurance covering the complainant, his wife and two children for the period from 16.12.2021 to 15.12.2022.  As per the insurance policy the complainant and his wife are having insurance coverage of Rs.2.5 lakhs each.  The children of the complainant are also having an insurance coverage of Rs.1,00,000/- each as per the policy.

The complainant’s daughter Miss.Renjini P Nair was admitted in the hospital on 17.03.2022 for the treatment of OTITIS Media inactive Microsal (left side).  On the date of admission of itself, the complainant has submitted the insurance documents with the help desk of 1^st opposite party for processing the cashless access service.  Later the doctor who treated the complainant’s daughter the 1^st opposite party Hospital has advised the complainant to undergo a surgery for the patient on the next day and for that an amount of Rs.10000/- has to be remitted in advance and the complainant had remitted the amount as per the advice of the doctor on 17.03.2022.  An A/C room was provided to the complainant as per the request of the complainant.  The complainant’s daughter was discharged from the hospital on 19.03.2022 and the opposite party 1 hospital had issued a bill of Rs.83665.21 towards the hospital charges.  Out of this amount Rs.46,208/- was allotted by the 2^nd opposite party towards the insurance claim.  The 1^st opposite party has demanded an amount of Rs.27,447/- to pay the balance amount before discharge of the patient from the hospital.  The complainant was not in a position to pay the balance amount.  He has faced much difficulty for remitting the balance amount of Rs.27,447/-.  The complainant has already paid Rs.10000/- as advance.  The office of the 1^st opposite party has told the complainant that 2^nd opposite party deducted the bill amount since the patient availed an A/C room.  The complainant did not know that the insurance claim would be deducted in availing the A/c room.  The complainant is entitled to get the full hospital bill of Rs.83665.21 from the opposite parties which is less than the sum assured as per the insurance policy.

The complainant states that no such exclusions, terms and conditions are informed to the complainant by the 2^nd opposite party or their agent at the time of taking the policy from the 2^nd opposite party.  The complainant has no knowledge about the deduction of the policy amount while requesting for an A/c room.  The complainant states that such terms and conditions are disclosed by the 2^nd opposite party only at the time of granting policy benefit to the insured.  No such conditions are included in the proposal form also.

The complainant states that there is deficiency in service from the part of the opposite parties and the complainant is eligible to get compensation from the part of the opposite parties and the complainant is eligible to get compensation from the part of the opposite parties due to the deficiency in service.  Hence the complaint.  

2. Notice

Notice was issued to the opposite parties from this Commission.Upon notice 1^st and 2^nd opposite parties appeared and filed their version.

3. Version of the 1^st opposite party.

It is admitted that the complainant had availed a medi claim policy of United Insurance Company Ltd. as the Third party Administrator.The complainant’s daughter was required to get admitted at the 1^st opposite party hospital for treatment of left tympanoplasty under GA.The complainant has approached the 1^st opposite party’s insurance Desk and required for obtaining pre-authorization from the Third party administrator.The 1^st opposite party hospital has sought pre-authorisation for Rs.50000/- as per pre-authorization request dated 01.01.2022.The 2^nd opposite party informed that they were willing to pay an amount of Rs.25000/- as pre-authorization amount subject to the complainant’s daughter getting admission in a shared room with maximum amount of Rs.1000/- as rent per day.The complainant on coming to know about the same deferred from admitting his daughter for the said procedure.Subsequently, the complainant approached the 1^st opposite party hospital and sought for re-submission of the pre-authorization for an approximate estimate of Rs.50000/- into consideration the single room (A/c) to be provided to the patient in the old block of the hospital.The insurance company informed the 1^st opposite party that they were willing to grant an amount of Rs.35000/- towards pre-authorization for cashless treatment for a single A/C room subject to a maximum rent of Rs.1000/- per day and insisted that his daughter should be admitted in an A/c room in the East Block and they undertook to pay the difference in rent and service change that would be incurred on account of such change.

The complainant was fully aware that as per the terms, conditions and covenants of the policy of insurance which was in his possession with regard to the limitations in respect of room rent, professional charges, nursing charges etc.The complainant’s daughter was discharged on 19.03.2022 and a final bill of Rs.83,655.21 was raised for the said treatment by the 1^st opposite party.From out of the aforesaid final bill amount of rs.83,655.21, the Third party Administrator of the Insurance Company had sanctioned and paid an amount of rs.46,208/- to the 1^st opposite party which was made known to the complainant. The complainant thereafter of his own accord paid the balance amount of rs.37,447.21 to the 1^st opposite party at the time of discharge and settled the bills without anydemur.

The complainant was only entitled to get an amount of Rs.46,208/- only.In view of the same, the complainant was bound to pay the balance bill amount which he had done voluntarily of his own free will and choice without any objection whatsoever.

The 1^st opposite party is not in any way liable or responsible to pay any compensation to the complainant and all the allegations regarding deficiency in service or negligence are concocted by the complainant for the purpose of making a false claim.

The complainant has no cause of action against the 1^st opposite party.The complainant is not entitled to get any of the reliefs claimed in the complaint.

4. Version of the 2^nd opposite party

The complaint is not maintainable either in law or in facts and hence liable to be dismissed.

The 2^nd opposite party admits that a Medi Claim Policy No.1015022821P109394669 was issued to the complainant as stated in Para 1 of the complaint providing insurance coverage to him, spouse and two daughters.  The policy is only as per the Terms & conditions and Exclusions contained in the policy. The Operative Clause of the Policy reads: If during the policy period of the insured persons required to be hospitalized for treatment of an illness or injury qualified medical practitioner, the Company shall indemnify medically necessary reasonable and customary medical expenses towards the coverage mentioned hereunder provided further that any amount payable under the policy shall be subject to the terms of coverage (including any limit or sub limits) Exclusions, Conditions and Definitions contained herein, maximum liability of the Company under all such claims during each policy year shall be the sum insured opted and specified in this schedule.

The TPA of the 2^nd opposite party received a request for cashless facility on 19.03.2022 towards the IP treatment of the Daughter of the Insured under the Policy from the Hospital of the 1^st Opposite party.  The claim was processed based on the Terms & Conditions and Exclusion of the policy and paid an amount of Rs.46,208/- against the total Discharge bill of Rs.83,655/-.

The complainant admitted in para 1 of the complaint that the sum insured for the Daughter in the policy is only Rs.1,00,000/- . The complainant also  admitted in para 2 of the complaint that they opted a higher category room exceeding eligible limit in room rent plus nursing charges.  An amount of Rs.37,447/- is deducted while settling the claim as those items are not payable under the policy due to the following reasons:

1. The policy Clause 4. Coverage: Base Coverage:4.1.1. reads that :Room, Boarding and Nursing expenses (all inclusive) incurred as provided by the Hospital/Nursing Home up to 1% of Sum insured per day or actual expenses whichever is less.  So in the instant claim the Insured Person is entitled only for Rs.1,000/- per day towards Room, Boarding and Nursing expenses all together.  But they opted a higher category room @ Rs.2675/- per day towards Room and Nursing Expenses which exceeded by Rs.1675/- of their policy eligibility.  The amount in excess of their eligibility would come to Rs.3350/- for 2 days IP which is not payable and hence deducted.
2. The Policy Clause 4.1 , Note 2.Reads : In case of admission to a room at rate exceeding the aforesaid limit in clause 4.1.1 the reimbursement or payment of all Associated Medical Expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of room rent.

Associated Medical Expenses is defined in the Policy Clause 3 sub clause 40, which reads as : means hospitalization related expenses on surgeon, anaesthetist, medical practitioner, consultants and specialist fee whether paid directly to the treating doctor or surgeon or to the hospital, anaesthetist, blood, oxygen, operation theatre Charges, surgical appliances appliances and such other similar exp

Appliances and such other similar expenses with the exception of  Charges, surgical appliances and such other similar expenses with the exception of

1. Cost of pharmacy and Consumable medicines
2. Cost of implant or medical devices
3. Cost of diagnostics

In the instant claim the complainant opted a higher category room and hence as contained in the policy clause 4.1.1  Note 2 the claim is liable to be deducted on the same proportion on the expenses coming within the meaning of Associated Medical Expenses as defined in Clause 3 (5) of the policy as above which would come to Rs.25,190/- .  Accordingly, Rs.25,190/- is deducted from the discharge bill.

3. The Discharge bill contains altogether Rs.7667/- towards non medical, service charges, Consumption and Care charges and monitoring charges which are not payable in the policy and hence Rs.7667/- is deducted.

Policy Clause 5.029 excludes payment of any items or treatment specified in the list of non-medical expenses.  So deduction of Rs.7667/- as above is only as per the policy.

4. Rs.1240/- in the Discharge bill is towards Canteen expenses which is not payable under the Policy and hence deducted.

Accordingly total Rs.37,447/- is deducted legally and rightly as per the Policy and the complainant is not entitled for the same.The insured cannot claim anything more than what is entitled under the policy.

Hence the 2^nd opposite party is not liable for any interest, cost and compensation a prayed in the complaint.

(5)     Evidence

          Evidence in this case consists of the proof affidavit filed by the complainant and the documentary evidence filed by the complainant which were marked as Exbt.A1 to a7.

          Complainant is cross examined by the opposite party’s counel and his depositions are recorded as ‘PW1’.

          The 1^st opposite party has no documentary evidence.  The 2^nd opposite party produced one document, true copy of the Mediclaim policy scheduled with Terms and conditions which was marked as ‘Exbt.B1’.

          Evidence closed.  Heard both parties.

6.  The issues came up for consideration in this case are as follows.

1. Whether any deficiency in service or unfair trade practice is proved from the side of the opposite parties towards the complainant?
2. If so, reliefs and costs?

For the sake of convenience we have considered issue Nos. (1) and (2) together.   The case of the complainant that the 1^st opposite party had allotted only Rs.46,208/- towards hospital charges eventhough the 1^st opposite party had issued a bill for Rs.83655/- towards hospital charges as per the insurance policy taken by the complainant from the opposite parties.

Exbt.A1 is the proposal form submitted by the complainant for individual Health insurance policy.

Exbt.A2- is the policy certificate issued by the 2^nd opposite party.

Exbt,A3- is the original of the payment receipt, issued by the 1^st opposite party to the complainant on 19.03.2022 for Rs.27,447/-.

Exbt.A4- is the prescription details, discharge summary and inpatient bills issued by the 1^st opposite party .

Exbt.A6- are the acknowledgement cards of the legal notice sent to the opposite parties.

Exbt.A7- is the copy of the reply notice sent by the 1^st opposite party to the complainant dated 16.05.2022

Opposite parties’ document

Exbt,.B1- True copy of the Medical claim policy scheduled with terms and conditions.

The 1^st opposite party stated in their version that the complainant’s daughter was discharged on 19.03.2022 and a final bill of Rs.83655.21 was raised for the said treatment by the 1^st opposite party.  From out of the aforesaid final bill amount of Rs,.83665.21 the third party administrator of the insurance Company had sanctioned and paid an amount of Rs.46208/ to the 1^st opposite party which was made known to the complainant. The complainant thereafter of his own accord paid the balance amount of Rs.37447.21 to the 1^st opposite party at the time of discharge and settled the bills without any demur.

The 2^nd opposite party contented that the liability of the 2^nd opposite party is only as per the terms and conditions and exclusions contained in the policy – exbt.B1.  As per policy clause 4.1.1 in case of admission to a room at rate exceeding the aforesaid limit is clause 4.1.1 the reimbursement or payment of all Associated Medical Expenses incurred at the hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of room rent.  The 2^nd opposite party also states that the TPA of the 2^nd opposite party received a request for cashless facility on 19.03.2022 towards the IP treatment of the daughter of the complainant under the policy from the hospital –the 1^st opposite party. The claim was processed based on the terms and conditions and exclusions of the policy and paid an amount of Rs.46208/- against the total discharge bill of Rs.83655/-

The complainant filed argument notes stating that there is no such terms and conditions and exclusions are shown in the proposal form.  The complainant also states that terms and conditions and exclusions are disclosed at the time of granting policy benefit to the insured and this is also deficiency in service from their part.

Ohm Prakash Ahuja Vs. Reliance General Insurance Company 2023 (4) KHC SN 23) the Hon’ble Supreme Court held that “once there is  a valid insurance policy available in favour of the appellant, the claim made by him for reimbursement of the expenses incurred is justifiable and deserves to be paid to him.  Considering of the judgment cited above it can be seen that the opposite parties have committed deficiency in service towards the complainant.  The complainant was holding a valid insurance policy during the treatment period of his daughter Renjini P. Nair, for the treatment of OTITIS Media.  It is admitted by the opposite parties 1 and 2.  The opposite party 1 has issued a bill of Rs.83665.21 towards hospital charges.  It was also admitted that out of Rs.83665 only Rs.46208/- was allotted by the 2^nd opposite party towards insurance claim.  The complainant has already paid Rs.10000/- as advance towards payment as evidenced by Exbt. A3.  Balance amount of Rs.27447.21 was also seen remitted by the complainant on 19.03.2022 as evidenced by the IP deposit Receipts produced by the complainant.  The 2^nd opposite party has produced one document Exbt.B1 policy.  The 2^nd opposite party deducted the bill amount as the patient availed of A/c. Room.  No such exclusions are mentioned in the policy.  The sum assured for the complainant was Rs.1,00,000/-.  Since the complainant is having a valid insurance policy at the time of admission in the hospital and since the hospital bills are not exceeded to the sum assured as per the policy, the complainant is eligible to get the balance amount of Rs.37447.21 from the opposite parties.  Deficiency in service is proved from the opposite parties towards the complainant and the following orders are hereby issued.

1. The opposite parties shall pay the balance amount Rs.37447/- to the complainant.
2. The opposite parties shall pay a compensation of Rs.10000/- (Rupees Ten thousand only) to the complainant.
3. The opposite parties shall pay an amount of Rs.5000/- (Rupees five thousand only) as cost of proceedings to the complainant.
4. The liability of the opposite parties shall be jointly and severally.

 The above order shall be complied by the opposite parties within 45 days from the date of receipt of a copy of this order.  If the opposite parties are failed to comply the order within 45 days the amounts specified in order (1) and (2) will accrue interest @9% per annum.  The interest will be calculated from the dated of filing of the complaint 11.10.2022 until the date of realization.

    Pronounced in the open commission on the 29^th day of October  2024.

Sd/-

                                                                                    Sreevidhia.T.N, Member

Sd/-

D.B.Binu, President

Sd/-

                                                                                    V.Ramachandran, Member

                                                                                                Forwarded by Order

                                                                                                Assistant Registrar

APPENDIX

Complainant’s Evidence

Exbt.A1 is the proposal form submitted by the complainant for individual Health insurance policy.

Exbt.A2- is the policy certificate issued by the 2^nd opposite party.

Exbt,A3- is the original of the payment receipt, issued by the 1^st opposite party to the complainant on 19.03.2022 for Rs.27,447/-.

Exbt.A4- is the prescription details, discharge summary and inpatient bills issued by the 1^st opposite party .

Exbt.A6- are the acknowledgement cards of the legal notice sent to the opposite parties.

Exbt.A7- is the copy of the reply notice sent by the 1^st opposite party to the complainant dated 16.05.2022

Opposite parties’  Exhibits

Exbt,.B1- True copy of the Medical claim policy scheduled with terms and conditions.

Date of despatch        ::

By Hand  ::                 By Post

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