Date of Filing      : 25.11.2019

                                                                                                                 Date of Disposal: 29.07.2022

 

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,B.Com.                                                                                      ....MEMBER-II

CC. No.48/2019

THIS FRIDAY, THE 29th DAY OF JULY 2022

 

Mrs.Sreedevi Prabhagaran,

No.5, Vivekanandha Nagar,

Kalaivanar Street, Thiruvallur – 602 002.                                               ……Complainant.

 

                                                                         //Vs//

 

1.Mr.Karthick, (Thiruvallur District Coordinator),

    MD India Health Insurance (TPA) Private Limited,

    (Third Party Administrator for United India Insurance),

    No.36/75, 2nd floor, TNHB Old Collector Office Road,

     Kakallur Bye Pass Road.

 

2.The Chief Coordinator,

    MD India Health Insurance TPA Private Limited,

    Guna Complex, New No.443 & 445 Anna Salai,

   Teynampet, Chennai -600 018.

 

3.The Branch Manager,

   United India Insurance Company Limited,

   No.153, J.N.Road, Thiruvallur – 602 001.                                 …..opposite parties

 

Counsel for the complainant                                                                     :   Party in person

Counsel for the opposite parties                                                              :   exparte 

                         

This complaint is coming before us on various dates and finally on 26.07.2022 and hearing argument of PIP/Complainant and the opposite parties set exparte and upon perusing the documents and evidences produced by the complainant this Commission delivered the following: 

 

ORDER

PRONOUNCED BY THIRU.P.MURUGAN. MEMBER

 

This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service against the opposite parties seeking direction to direct the opposite parties to pay Rs.5,00,000/- for the mental agony on those three days during the delay of complainant planned discharge, to pay a sum of Rs.3,26,905/- towards initial denied amount spent by the complainant,  to pay a sum of Rs.1,59,265/- towards expenditure incurred in the SRMC hospital and to pay a sum of Rs.4650/- towards additional charges spent by the complainant for the extension of planned discharge.

Summary of facts culminating into complaint:-

 

The complainant, Tmt.T.M.Sreedavi  aged 71 years has stated that on 15.10.2019 night, when she had been for a relative death, she developed breathing problem and taken to the nearest hospital namely Annai Arul Hospital, Tambaram for immediate treatment.  She was admitted and kept in M.Ventillator, since she had sudden arrest of breathlessness, Grade IV Orthopnea with Blood Pressure 200/120 & abnormal sugar level of 522 mg/dl.  On that day itself, the complainant’s son had requested the hospital authorities to apply for cashless treatment under PPO No.C325224/DW since the complainant is a pensioner and subscribed for Health Insurance Scheme meant for pensioner.  The TPA namely MD India Health Insurance Private Limited for United India Insurance Private Limited has declined to sanction the medical expenses met at Annai Arul Hospital stating that the treatment did not involve any surgery followed by emergency treatment.  Therefore, the complainant has paid Rs.65,381/- to get discharged from that hospital on 17.10.2019 i.e., 15.10.2019 to 17.10.2019. In the mean while, at the request of the complainant she was taken to SRMC for further treatment since her heart condition is not good and EF level was very low & on critical situation which is vouched by doctors in Annai Arul Hospital.  

The complainant was admitted in SRMC on 17.10.2019 and on medical assessment like Echo, ECG, Echo screening the cardiology doctor advised to go for cardio Resynchronisation therapy by using pacemaker device which will help to improve the condition of heart. The complainant gave consent to SRMC by Insurance claim on 18.12.2019. While the treatment is on progress the Insurance Company TPA was approached for payment based on the hospital billing.  The details of the medical expenses were provided by SRMC to MD India Insurance Private on 21.10.2019.  On 22.10.2019, the TPA MD India Insurance Private limited issued authorization letter to proceed for surgery on that day with a amount of Rs.1,30,000/- only without informing any ceiling amount.  Based on that letter from TPA Insurance the complainant was admitted and surgery procedure was done on 30.10.2019.  The SRMC hospital has raised a bill in which the ceiling of Insurance claim was stated as Rs.4,00,000/- only and the patient has to pay the balance of Rs.1,44,615/- to get discharged.  For the balance Insurance money i.e., apart from the initial insurance amount of Rs.1,30,000/- sanctioned on 22.10.2019, the Insurance company denied to make.  The TPA was approached for the balance money settlement but refused to pay through their letter.  The complainant’s son approached the company but in vain. Therefore the complainant’s son taken up the matter with Thiruvallur District Collector and also with Grievances Redressal Office (Joint Director of Heal & Rural service) at Thiruvallur.  Because of non settlement of amount, the complainant states that she has to extend her discharge from the hospital.  The complainant’s son made repeated request to the TPA of Insurance Company which resulted in futule.  After the intervention of Government Authorities and untried efforts by complainant’s son, the TPA has issued a second authorization letter of amount sanction for Rs.1,67,000/- vide reference No.CCN MDI4090496 and denied any further claim.  The state authorities have assured the complainant’s son for further coordination with the TPA of Insurance Company as on 06.11.2019.  Finally the TPA has released an amount of Rs.1,03,000/-. 

There was in total three payments from the TPA of Insurance Company i.e., 

Rs.1,30,000/- on 22.10.2019

Rs.1,67,000/- on 05.11.2019

Rs.1,03,000/- on 06.11.2019 

These payments were received after a struggle only and the complainant made to stay in hospital for further two days because of non settlement.  Thus aggrieved by the act of the opposite parties the present complaint was filed for the reliefs to direct the opposite parties to pay Rs.5,00,000/- for the mental agony on those three days during the delay of complainant planned to get discharged, to pay a sum of Rs.3,26,905/- towards initial denied amount spent by the complainant,  to pay a sum of Rs.1,59,265/- towards expenditure incurred in the SRMC hospital and to pay a sum of Rs.4650/- towards additional charges spent by the complainant for the extension of planned discharge.

On the side of the complainant proof affidavit was filed and documents were marked as Ex.A1 to A10. In spite of sufficient opportunities the opposite parties did not appear and they were set ex-parte on 14.02.2020. 

 Points for consideration:

1) Whether there is any deficiency in service on the part of the opposite parties? 

2) If so to what relief the complainant is entitled?

 

 Point No.1&2:

On the side of the complainant following documents were filed in support of her allegations of deficiency in service;

Guidelines for implementation of NHIS, 2018 was marked as Ex.A1;

In-patient bill issued by the Annai Arul Hospital in the name of complainant dated 15.10.2019 was marked as Ex.A2;

Discharge on Request issued by the Annai Arul Hospital dated 17.10.2019 was marked as Ex.A3;

Reconsideration letter to MD India through Annai Arul Hospital was marked as Ex.A4;

Additional document request issued by MD India Health Insurance TPA private Limited to SRMC  dated 18.10.2019 was marked as Ex.A5;

Authorization letters was marked as Ex.A6;

denial of additional authorization letter dated 04.11.2019 was marked as Ex.A7;

SRMC bill summary was marked as Ex.A8;

SRMC Discharge Summary was marked as Ex.A9;

Letter to Thiruvallur District Collector to help for claim processing dated 05.11.2019 was marked as Ex.A10; 

The complainant is a pensioner who is eligible for medical reimbursement of Rs.4,00,000/- as per G.O.No.222 Finance (Pension) Dept. Dt.03.06.2018.  The entire medical expenses from hospital initially on the treatment given by  Annai Arul Hospital  vide bill No.UHID1500078225 Dt.08.11.2019 amounting to Rs.65,381/- and the final medical bill of SRMC IP S.No.201910001578947 dt.06.11.2019 amounting to Rs.5,59,265.25/- makes total claim of Rs.6,24,646.25/-. Though the claim may be Rs.6,24,646.25/-, the ceiling for reimbursement would be Rs.4,00,000/- which has been paid by the TPA on three occasions with stressful efforts by the complainant.  It is for the insurance company to shell out the money on claims and they do think twice before releasing the amount of claim.  The method of releasing is based on the recommendation by the medical expert group working for the TPA/Insurance Company. Though the TPA has released the payment within the span of 15 days in which the complainant was inpatient only. Considering the fact that the complainant was made to make little more efforts to get the claim, the penalty clause as specified in G.O.No.222 Finance (Pension) Dept dt.30.06.2018 could not be enforced as such it is not purposeful, wilful delay made by Insurance Company or by TPA.  The G.O. specially mentions the list of hospitals where the treatment can be taken and reimbursement could be made.  Also in this case, the initial treatment only made to the complainant in the first mentioned i.e., Annai Arul hospital and the absolute medical process of fixing  pacemaker was done at SRMC for which the claim  is settled up to the ceiling level.  So directing to pay at the penalty level does not match.  The question of penalty clause is therefore closed in this case.

In the result, the complaint is dismissed.  No order as to cost. 

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 29th day of July 2022.

 

   SD-                                                   SD-                                                         SD-

MEMBER-II                                   MEMBER-I                                           PRESIDENT

 

 

List of document filed by the complainant:-

 

 

 

Ex.A1 ........... Guidelines for implementation of New Health Insurance Scheme,2018 Xerox

Ex.A2 15.10.2019 In patient Bill. Xerox

Ex.A3 17.10.2019 Discharge on Request issued by Annai Arul Hospital. Xerox

Ex.A4 ............ Reconsideration letter. Xerox

Ex.A5 .............. Additional document request letter. Xerox

Ex.A6 ............. Authorization letters. Xerox

Ex.A7 04.11.2019 Denial of additional authorization letter. Xerox

Ex.A8 ........... SRMC Bill summary. Xerox

Ex.A9 ............ SRMC Discharge Summary. Xerox

Ex.A10 05.11.2019 Letter to Thiruvallur District Collector to help for claim processing. Xerox

 

 

 

Sd-                                                                   Sd-                                                Sd-

MEMBER-II                                              MEMBER I                                    PRESIDENT