ORDER Date: 04 March 2017
Manju Bala Sharma, Member
Brief facts relevant for the disposal of this complaint are that the complainant is insured with OP No.1 under hospitalization benefit policy vide Policy No.350300/48/14/8500002675 for a sum of Rs.3,00,000/- for the period from 30.12.2014 to 29.12.2015 which is in continuation for the last several years with OP2 as its TPA and Smt. Anita Garg wife of the complainant is also one of the beneficiary under the said policy. Smt. Anita Garg suffered from postmenopausal bleeding and as such she planned for hospitalization and raised request for cashless facility to Pushpanjali Medical Centre for approximately Rs. 20,000/- which was allowed by OP2 vide its letter sent to the medical centre and Rs. 12,324/- were allowed for the purpose. She was hospitalizaed for one day (30.11.2015) for which hospital authorities issued discharge summary along with bill for Rs. 13,152/- and as such complainant paid settlement amount of Rs. 820/- in respect of which proper receipt was issued by the medical center. After discharging from the hospital complainant submitted his claim to both the OPs for a total sum of Rs.6,500/- against which OP 2 approved an amount of Rs.3,056/-. He sent discharge voucher duly signed and also raised certain objections in respect of the amount not approved by OP2 vide his letter dated 01.02.2016 with the request to consider his objection and make payment of the admissible amount. OP 2 credited approved amount of Rs.3,056/- in the bank of the complainant and did not send any intimation in respect of the objections raised by the complainant and complainant sent a letter to OP 2 on 30.03.2016 to clarify the objections raised by the complainant but OPs have neither settled the claim of the complainant nor sent any reply to the aforesaid letter of the complainant. Pleading deficiency in service on part of the OPs in not deciding the claim of the complainant apart from for adopting unfair trade practice in not bringing the facts into the knowledge of the complainant he prayed to direct OPs to decide claim of the complainant properly and to pay the balance amount of Rs. 3,534/- to him as per break-up given by OP2 along with interest for the period of delay @ 18% p.a. and pre/post expenses incurred by him with cost and compensation.
Notice was issued and OPs but nobody entered appearance on their behalf though served hence proceeded ex-parte.
The complainant filed affidavit of evidence and filed documents i.e. copy of Insurance policy Annexure C -1, Pre – authorization letter Annexure C -2, copy of receipt of Rs. 820/- issued by the hospital Annexure C-3 Colly, copy of claim form with breakup of non-payment of balance amount Annexure C- 4 (Colly) copy of letter raising objection for non payment of certain claims and reminder Annexure C 5 and C - 6 respectively in support of the complaint.
We have heard the counsel for the complainant, gone through the documents and written arguments filed by complainant. In the case points to be considered are as under :
(a) Whether complainant is a consumer?
(b) Whether there is deficiency in service on the part of OPs?
(c) Relief?
The complainant had placed on record copy of the mediclaim policy which was valid till 29/12/2013 hence complainant is a consumer.
Perusal of the complaint supported by the affidavit of complainant shows that Rs. 12,324/ was allowed by OPs as cashless facility to the complainant for the treatment of his wife vide pre authorization letter Annex C 2 and complainant paid Rs. 820/- as settlement amount vide receipt Annex C 3(colly). The complainant has placed on record letter dated 08/01/2016 sent to OP 2 along with claim form and original prescription given by medical officer and cash receipts, bill issued for various investigations with reports, cash receipts of medicines purchases as Annex C 4. The complainant has also placed on record the letter sent to OP 2 along with claim settlement cum debit voucher with breakup dated 22/11/2016 the breakup of the claim of the complainant not approved by the OP is as under :
Sr. Service Claimed Amount Approved Remarks
No. Amount
15. Consultant (PC004) 300.00 0.00 No Receipt
16. Consultant (PC004) 400.00 0.00 Pre 30 Days
17. Consultant (PC004) 250.00 0.00 Pre 30 Days
Medicines by Shop (MD002)
5 Medicines by Shop 326.00 0.00 No Prescription
(MD002)
Miscellaneous
8. Miscellaneous 338.00 0.00 Non payable
Miscellaneous (MSO10)
7 Miscellaneous (MS010) 820.00 0.00 Full Settlement
(Collection)
Ultrasound (IV001)
14. Ultrasound (IV001) 800.00 0.00 Pre 30 Days
On perusal of the above statement the reason for not considering the claim against certain investigations and medicines is clearly mentioned against each item. The complainant sent letter dated 01/12/2016 Annex C 5 mentioning not approving the claim against certain investigations and medication but complainant has neither submitted the documents to the OPs along with letter dated 08/02/2016 and subsequent reminder dated 30/03/2016 Annex C 5 and C 6 respectively nor produced the same before this Forum except receipt of the bill of Rs. 820/- (Eight Hundred Twenty only) as full settlement issued by the hospital.
OP 2, TPA is the service provider or we may say the mediator between the insured and the Insurance Company. Hence OP 2, TPA is merely mediators and a proforma party in the instant complaint.
From the foregoing discussion we are of the opinion that there is deficiency in service on the part of OP 1 in not allowing the claim of Rs. 820/- paid by the complainant as full settlement and OP 1 is directed to pay Rs. 820/- to the complainant paid by him to the hospital against the total Bill of Rs. 13,152/- (Thirteen Thousand One Hundred and Fifty Two only) out of which Rs. 12,324/- (Twelve Thousand Three Hundred Twenty Four only) was paid by OP 1. We also direct to OP 1 to pay Rs. 5,000/- (Rs. Five Thousand) as compensation to the complainant for harassment and mental agony and to pay Rs. 3,000/- (Rupess Three Thousand) as cost of litigation.
8. This order shall be complied with by OP 1 within a period of 30 days from the date of receipt of this order failing which interest @ 10% shall be payable on the entire above mentioned amount from the date of this order till realisation. Copy of this order be sent to all the parties free of cost. File be consigned to Record Room.
Announced on this ………..
