Smt. Sheela Jacob (Member ):
The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.
2. The complainant’s case is that he and his family have availed a Family Health Optima Insurance policy of the 1st opposite party through the second opposite party since 2013. The policy covered with the period from 17.05.2015 to 16.05.2016 and the premium amount is Rs.11,947/-. The policy Number is P/181111/01/2016/001513. The policy covers the complainant as well as his family. As per the terms and conditions of the policy in question, the policy holders are entitled to get cashless treatment facilities in its network hospitals. The 2nd opposite party KIMS Hospital, Thiruvananthapuram is also included in the network hospitals.
3. While so the complainant had undergone treatment for perfuse nasal bleeding at KIMS Hospital, Thiruvananthapuram on 02.04.2016. He had undergone treatment as inpatient. The complainant submitted his claim form to 1st opposite party for getting cash less facilities. During the treatment nasal bleeding he had suffered severe back pain so he consulted ortho too.
4. At the time of discharge the opposite parties have not settled the complainant’s claim as per their assurance. Believing the words of them the complainant did not arranged any money for paying the bill so he was constrained to pay the hospital bills, a sum of Rs.15,642/-. The claim for cashless benefit under the said policy was repudiated on unreasonable grounds by 1st opposite party. On 01.06.2016 complainant sent a legal notice to the opposite party for reimbursement of the total premium amount of Rs.28,995/-. The above said acts of the opposite parties are unfair trade practice and deficiency in service, which caused mental agony and financial loss to the complainant and the opposite parties are liable to the complainant for the same.
5. After discharge from the hospital, on 01.06.2016 the complainant sent a legal notice to the opposite parties demanding to return the premium amount of Rs.28,995/- with 12% interest along with compensation of Rs.15,000/-. On 24.06.2016 the 1st opposite party replied the notice that the hospital authority had not furnished the test results in time, so they could not provide cashless facility. According to the complainant, he is entitled to get the treatment expenses and the non-payment of the same by the opposite parties is a clear deficiency in service which caused financial loss and mental agony to the complainant. Hence this complaint for the realisation of the claim amount of Rs.15,642/- along with 12% interest from 04.04.2016 along with compensation of Rs.10,000/- and cost of Rs.10,000/- of this proceedings jointly and severally from the opposite parties.
6. In this case, opposite parties 1 and 2 are exparte.
7. On the basis of the pleadings of the complainant, the only point to be considered is whether this complaint can be allowed or not?
8. The evidence consists of the oral testimony of PW1 and exhibits A1 to A9. After the closure of evidence, complainant was heard.
9. The Point:- The complainant’s allegation against the opposite parties is that he had taken a policy from the 1st opposite party through the 2nd opposite party on 09.05.2015 and paid Rs.11,947/-. As per the terms and conditions narrated by the 2nd opposite party at the time of taking the said policy is that the cashless treatment facilities in its network hospitals including KIMS Hospital, Thiruvananthapuram would have to be provided to the complainant. On the basis of the said assurance the complainant had subscribed Rs.11,947/- with the opposite parties vide Policy No. P/181111/01/2016/001513 for a period of 17.05.2015 to 16.05.2016. While so on 02.04.2016, the complainant had undergone treatment in connection with prefuse nasal bleeding at KIMS Hospital, Thiruvananthapuram. Necessary documents were produced by the complainant for getting cashless treatment facility. As per the policy, he was eligible for the cashless treatment, but the same was not provided to him. So the complainant paid Rs.15,642/- towards the hospital bill. He struggled hard to raise money within a short span of time. Therefore, the complainant sent a legal notice to the opposite parties demanding the cancellation of the said policy and for return of the premium amount paid by him Rs.28,995/- along with compensation of Rs.15,000/-. But they have not accepted the complainant’s demands, which is a grave deficiency in service and opposite parties are liable to the complainant for the same. Therefore, the complainant prays for allowing the complaint.
10. In order to prove the case of the complainant, complainant filed a proof affidavit along with 9 documents. On the basis of the proof affidavit, complainant was examined as PW1 and the documents produced were marked as Exts.A1 to A9. Ext.A1 series are the photocopy of the insurance policy (3 Nos.) issued by 1st opposite party in the name of the complainant and his family valid from 17.05.2013 to 16.05.2014, 17.05.2014 to 16.05.2015 and 17.05.2015 to 16.05.2016. Ext.A2 is the copy of the premium receipt of Rs.11,947 dated 09.05.2015 issued by the 2nd opposite party. Ext.A3 is the photocopy of the request for cashless hospitalization for medical insurance policy dated 03.04.2016. Ext.A4 is the photocopy of letter of denial of cashless treatment dated 04.04.2016 issued by 1st opposite party. Ext.A5 is the copy of provisional discharge summary dated 02.04.2016 in connection with the treatment from the 2nd opposite party. Ext.A6 is the copy of discharge summary dated 04.04.2016 issued by the 2nd opposite party. Ext.A7 is the photocopy of the nasal endoscopy report dated 03.04.2016. Ext.A8 is the copy of the legal notice dated 01.06.2016 issued by the complainant to the opposite parties. Ext.A9 is the reply notice dated 24.06.2016 issued by the 1st opposite party to the complainant’s counsel.
11. On a perusal of the deposition of PW1 and Ext.A1 to A9, it is seen that the complainant is a health insurance policy holder of the opposite party. It is also read from the deposition of the complainant that necessary documents were produced by him for getting cashless treatment facility but they were not provided the same. So the complainant paid Rs.15,642/- towards the hospital bill. He struggled hard to raise money within a short span of time.
12. We have gone through the evidences adduced by the complainant and we found that there is no reason to disbelieve the allegation of the complainant against the opposite parties since the opposite parties are exparte and the evidence adduced by the complainant as PW1 is unchallenged.
13. The hard earned money of the complainant was collected by the opposite parties for a cashless treatment therefore complainant is entitled for a cashless treatment facility. Ext.A9, the reply notice dated 24.06.2016 issued by the 1st opposite party to the complainant’s counsel stated that the 2nd opposite party had not produced the documents and necessary treatment records in time and stated that no provision exists for refund of premium on policies where risk has already run. However, when we look in to the facts and circumstances of this case, it is seen that the repudiation of complainant claim happened due to the non-production of treatment records in time by the 2nd opposite party. We find that 1st and 2nd opposite parties are equally and severely liable to the complainant as far as this case is concerned.
14. Therefore, we find that the above said act of the 1st and 2nd opposite party, the denial of the said claim is an illegal act and is an unfair trade practice and is a clear deficiency in service and hence the opposite parties are liable for the same. Therefore, this complaint is allowable.
15. In the result, this complaint is allowed, thereby the opposite parties are directed to pay an amount of Rs.15,642/- (Rupees Fifteen Thousand six hundred and forty two only) with 10% interest from the date of filing this complaint along with compensation of Rs.7,500/- (Rupees Seven Thousand Five hundred only) and cost of Rs.3,000/- (Rupees Three Thousand only) to the complainant within 15 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with an interest at the rate of 10% from today till the realization of the whole amount.
Declared in the Open Forum on this the 28th day of February, 2017.
(Sd)- Sheela Jacob,
(Member)
Sri. P. Satheesh Chandran Nair (President) : (Sd)-
Appendix:
Witness examined on the side of the complainant:
PW1 : V.O. Robinson
Exhibits marked on the side of the complainant:
A1 series : Photocopy of the insurance policy (3 Nos.) issued by
1st opposite party in the name of the complainant
A2 : Copy of the premium receipt of Rs.11,947 dated 09.05.2015 issued
by the 2nd opposite party.
A3 : Photocopy of the request for cashless hospitalization for medical
insurance policy dated 03.04.2016.
A4 : Photocopy of letter of denial of cashless treatment dated
04.04.2016 issued by 1st opposite party.
A5 : Copy of provisional discharge summary dated 02.04.2016.
A6 : Copy of discharge summary dated 04.04.2016 issued by the
2nd opposite party.
A7 : Photocopy of the nasal endoscopy report dated 03.04.2016.
A8 : Copy of the legal notice dated 01.06.2016 issued by the complainant
to the opposite parties.
A9 : Reply notice dated 24.06.2016 issued by the 1st opposite party
to the complainant’s counsel
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties: Nil.
(By Order)
Copy to:- (1) V.O. Robinson, Varavukalayil, Mangaram,
Pandalam.P.O.
(2) M/s. Star Health & Allied Insurance Co. Ltd., KRM Centre,
VI Floor, No.2, Harington Road, Chilpet, Chennai,
Pin – 600 031.
(3) M/s. KIMS Hospital, Anayara. P.O., P.B.No.1,
Thiruvananthapuram – 695 029.
(4) The Stock File. By Order)
