IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 29th day of October, 2024
Present: Sri. Manulal V.S. President
Smt.Bindhu.R, Member
Sri. K.M. Anto, Member
C C No. 67/2024 (Filed on 20/02/2024)
Complainant :
Jacob M.C
S/o Ouseph Chacko
Manalayi chira
Pulinkunnu.P.O
Alappuzha
(By Adv. Sony K Thomas)
Vs.
Opposite Parties : 1) Manager National Insurance Co.Ltd
Parakadavil Shopping Complex
Changanacherry 686 101
(By Adv. C.J.Jomi)
2) S.H.Medical Centre Hospital
Kottayam - 686 001
(By Adv. M.C.Suresh)
3) Family Health Plan T.P.A Ltd
1st Floor,
Brigade Plaza
Opp. Lotus Club,
Warrior road
Kochi - 682 016
O R D E R
Sri. Manulal V.S. President
This complaint is filed under Section 35 of the Consumer Protection Act, 2019.
The complainant and his family continuously had a medical insurance policy with the first opposite party since 2015. From 2015 to 2022, the complainant had a personal mediclaim policy that provided insurance coverage of Rs.1,00,000/- (Rupees One lakh only) for each family member. Subsequently as per the suggestion of the first and second opposite parties, the complainant's policy was converted into a family package policy from 28/02/2022 vide policy no. 570602502110000621.
The complainant's wife, Mrs. Mercy Jacob, was admitted to Medical Centre Hospital, Kottayam, on 30/01/2023 due to severe knee pain. Doctors recommended total knee replacement surgery for both knees after a specialized examination. Before the surgery, the hospital inquired about insurance coverage, and the complainant provided the relevant policy. The hospital then contacted the second opposite party's insurance help desk, which coordinated with the third opposite party, and after confirming Rs.5,00,000/- (Rupees Five Lakhs only) in coverage, the double knee replacement surgery was performed on a cashless basis on 01/02/2023, with no advance payment required from the complainant.
The third opposite party approved Rs.1, 20,000/- (Rupees One lakh twenty thousand only) of the total bill, leaving the complainant to pay Rs.3,91,642/-(Rupees Three lakh ninety one thousand six hundred and forty two only). The complainant decided to proceed with both knee surgeries based on assurances from the first and third respondents that the Rs.5,00,000/- (Rupees Five Lakhs only) insurance coverage would apply. Without this assurance, the complainant would have chosen to perform the surgeries one knee at a time.
The hospital's cashless authorization limited expenses to Rs.5,00,000/- (Rupees Five Lakhs only) under the insurance coverage. The third opposite party approved the surgery based on the information submitted by the second opposite party, but upon discharge, the second opposite party collected Rs. 3,91,642/-(Rupees Three lakh ninety one thousand six hundred and forty two only) from a total bill of Rs.5,11,642/- (Rupees Five lakh eleven thousand six hundred and forty two only) after deducting the approved Rs.1,20,000/- (Rupees One lakh twenty thousand only) instead of a cashless settlement.
If the complainant had been informed before the surgery that they would have to pay a significant amount out-of-pocket, they would have postponed one knee surgery and performed the second knee surgery after renewing the insurance; then the complainant would have received Rs.1,00,000/- ((Rupees One lakh only) in insurance coverage.
After collecting the insurance premium, the opposite parties failed to provide the promised insurance coverage, which amounts to a deficiency in service and constitutes an unfair trade practice. The repudiation letter from the first opposite party does not explicitly state why the total claim amount was not paid.
Hence, this complaint is filed by the complainant praying for an order to direct the opposite parties to pay the Rs.3,80,000/- (Three lakh eighty thousand only) along with interest, and to direct the second opposite party to refund the excess amount of Rs.91,642/- (Rupees ninety one thousand six hundred and forty two only) received from the complainant and direct the opposite parties to pay Rs.75,000 as compensation, along with Rs.10,000 as the cost of this litigation.
Upon notice from this Commission, the first and second opposite parties appeared before the commission and filed versions. Despite receiving notice from this Commission on 05-03-2024, the third opposite party did not file version within the statutory period.
Version of the first opposite party is as follows:
The complainant had a medical insurance coverage policy for a sum insured of Rs 1,00,000/- (Rupees One lakh only) for (1) himself and his wife Mercy Jacob and their children, Ann Mary Jacob, Allen Mary Jacob and Alphy Mary Jacob from 2015 onwards. On 28/02/2021, the sum insured was enhanced to Rs 5,00,000/- as per policy no. 570602502010000648 for the period 28/02/2021 to 27/02/2022. The said policy was renewed for the period 28/02/2022 to 27/02/2023 for the same sum insured as per policy no. 570602502110000621. While enhancing the sum insured, the insured's enhanced portion will be controlled by clause 5.16 of the policy condition, which says that the sum insured can be enhanced only at the time of renewal. The sum insured may be enhanced to the next slab, subject to the discretion of the company. For the incremental portion of the sum insured, the waiting periods and Conditions, as mentioned in conclusions 4.1, 4.2, and 4.3, shall apply. Coverage of the enhanced sum insured shall be available after the completion of waiting periods. As per clause 4. 2 (IV) of the policy conditions, four years of waiting is prescribed for treatment for joint replacement unless arising from the accident.
The wife of the complainant was admitted to 2nd opposite party hospital, and the third party administrator of the 1st opposite party received a request from the hospital for a cashless facility. The request was properly answered per policy and approved Rs. 1,00,000/- (Rupees One lakh only) immediately. The 3rd opposite party has given final approval for Rs.1,20,000/- (Rupees One lakh twenty thousand only) on 13/02/2023, at the time of discharge, by considering the N.C.B. by the time. The knee replacement for both knees was fixed before initiating action under cashless facility. The complainant's wife replaced her knee joints on medical advice, and this opposite party has no role to interfere in such matters since all these are up to the wishes of the parties concerned. There is no deficiency of service on the part of the 1st opposite party or its third party administrator. The first opposite party has already paid the eligible insurance amount to the complainant. The first opposite party rejected the claim application made by the complainant after receiving the insurance amount of Rs 1,20,000/- ((Rupees One lakh twenty thousand only) as there was no merit. Hence, the complainant is not entitled to claim any relief.
Version of the second opposite party is as follows:
There is no consumer relationship between the complainant and the second opposite party, and the complainant is not entitled to get any relief against the second opposite party, as prayed for in the complaint.
Mercy Jacob was admitted to the Dept. of Orthopaedics on 30/01/2023 for the complaint of bilateral knee pain and difficulty in walking and climbing steps. On 01/02/2023, she underwent bilateral total knee replacement and was discharged in symptomatically better condition on 13/02/2023 without any complaints. The patient, Mercy Jacob, had medical insurance covering the treatment of knee replacement surgery with the first opposite party. Based on the documents submitted by the patient, the Insurance Dept. of the second opposite party proceeded for approval of the cashless treatment. As per request for pre- authorization for cashless treatment for the estimated expected bill amount of Rs.4,22,000/- (Rupees four lakhs twenty two thousand only) the insurance company had approved an amount of Rs. 1,00,000/- (Rupees One Lakh only). This pre-authorization approval for the amount of 1,00,000/- (Rupees One Lakh only) was informed to the patient and her husband and specifically told them that they should pay the balance amount deducted by the insurance company and agreed to continue with surgery for bilateral total knee replacement fully aware of the balance amount payable by them. The total hospital bill amount was Rs.5,11,642/- (Rupees five lakhs eleven thousand six hundred and forty two only) as on the date of discharge and the patient settled the hospital bill without any objection. The deductions made by the insurance company in the bill amount are in accordance with the terms and conditions of the policy conditions per agreement between the complainant and the insurance company. The second opposite party collected the balance amount from the patient after deducting the amount paid by the first opposite party, which is payable by the patient towards treatment expenses. The present dispute is about the amount deducted by the insurance company as per policy condition in which the second opposite party is unnecessarily joined as a party without any just or sufficient reason. The second opposite party never assured that the patient was covered for Rs. 5,00,000/- (Rupees Five lakhs only) for the surgical treatment. There was no deficiency in service or unfair trade practice on the part of the second opposite party.
The complainant filed proof affidavit in lieu of chief examination and marked Exhibits A1 to A7 from the side of the complainant. Ajith Sasthri, who is the Assistant Manager of the first opposite party, filed the proof affidavit in lieu of chief examination and marked exhibits B-1 to B-4 from the side of the first opposite party. Sr. Catharine Joseph, who is the director of the second opposite party, filed the proof affidavit in lieu of chief examination. There is no documentary evidence from the side of the second opposite party.
We would like to consider the following points on evaluation of the complaint, version, and evidence on record.
- 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?
For the sake of convenience, we would like to consider the point number 1 and 2 together.
It is an admitted fact that the opposite parties issued a health insurance policy to the complainant along with his wife, Mercy Jacob, and children in the year 2015 with a sum insured of Rs. 1,00,000/- (Rupees One lakh only); since its inception, the complainant renewed the policy regularly. The complainant in the year 2021, the sum insured of the policy enhanced from Rs. 1,00,000/- (Rupees One lakh only) to Rs. 5,00,000/- (Rupees Five lakh only) by paying a requisite premium, and the opposite parties issued policy No. 570602502010000648 covering period of insurance from 28/02/2021 to 27/02/2022for enhanced coverage of Rs. 5,00,000/- (Rupees Five lakh only) and policy for the year 2022 was renewed covering the period from 28/02/2022 to 27/02/2023 for enhanced Sum Insured of Rs. 5,00,000/- (Rupees Five lakh only) vide policy no. 570602502110000621.
The complainant's wife, Mercy Jacob, consulted Doctors at second opposite party for pain in both knees associated with difficulty in walking distances and climbing steps and was diagnosed with Osteo Arthritis of both knees after investigations, and doctors advised surgery of both knees on 2-01-2023 the complainant put forward the request for cashless treatment to his wife's both knee joint replacement through second opposite party hospital. Accordingly, the first and third opposite parties initially approved an amount of Rs. 1,00,000/- (Rupees One lakh only) through Exhibit A5 and sent a pre-authorization approval letter to the second opposite party hospital.
That after receiving pre-authorisation approval letter for Rs.1,00,000/- (Rupees One lakh only) from the opposite parties, the complainant assented for surgery of total knee replacement and surgery on Right knee and Left knee was done on 01-02-2023 at second opposite party Hospital and discharged 0n 13-2-2023. The final bill of Rs. 5,11,642/- (Rupees five lakhs eleven thousand six hundred and forty two only), along with all required documents forwarded to the office of the opposite parties for approval of the final amount for cashless treatment; on receiving the same on 13-2-2023 the first and third opposite parties approved enhancement to Rs.20,000/- (Rupees Twenty thousand only) through Exhibit B4. the opposite parties revised amount to Rs. 1,20,000/- (Rupees One lakh Twenty thousand only) as final approval amount with observation that after deducting the non-payables from the final bill submitted, the amount payable is Rs. 1,20,000/- (Rupees One lakh Twenty thousand only)
Aggrieved by the settlement made by the opposite parties, the complainant raised a request for reimbursement, but the opposite parties did not consider the request and issued Exhibit A7 reply on 16/05/2023.
The first opposite party affirmed in written statement that they approved and settled claim of Rs. 1,20,000/- (Rupees One lakh Twenty thousand only) as per terms of policy. The first opposite party produced exhibit B1 policy and its terms and conditions. In clause 4 of Exhibit B1 Exclusions. The relevant paragraphs of clause 4. 2 are reproduced as under:
- Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 90 days /one year/ two years/4 years (as specific disease/procedure) of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.
- In case of enhancement of the sum insured, the exclusion shall apply afresh to the extent of the sum insured increase.
As per clause 4 .2(iv) (a) Exclusions under Ex. B1 encompasses a waiting period of 4 years for the treatment of Joint replacement (other than caused by accident). The complainant enhanced the sum insured from Rs. 1,00,000/- to Rs. 5,00,000/- covering the period from 28-02-2021 to 27-02-2022, and the policy was renewed, covering the period from 28-02-2022 to 27-02-2023 for enhanced Sum Insured of Rs. 5,00,000/- (Rupees Five lakhs only) . As per clause 2 (b) of clause 4 of Exhibit B1 in case of enhancement of the sum insured the exclusion should apply afresh to that extent; the complainant enhanced the sum insured to Rs. 5,00,000/- (Rupees Five lakhs only) on 28-02-2021 and surgeries were administered on 1-02-2023, the enhancement of the sum insured had not completed 4 years from its increase. Therefore, the complainant is entitled to coverage of the sum insured of Rs. 1,30,000/- (Rupees One lakh thirty thousand only) i.e., including the cumulative bonus as per terms of the policy on the date of surgery under Exhibit B1.
Therefore, we are of the opinion that there is no deficiency in service on the part of the first and third opposite parties. One of the reliefs sought for is to direct the second opposite party to pay an amount of Rs.91,642/- (Rupees ninety one thousand six hundred and forty two only), which was collected in excess of the approved treatment expenses of Rs. 4,22,000/- (Rupees Four Lakhs twenty two thousand only). However, we already found that the first and third opposite parties have approved only an amount of Rs. 1,20,000/- (One lakh twenty thousand only) for the treatment expenses of the wife of the complainant.
In the case of SGS India Ltd Vs. Dolphin International Ltd (2021 AIR SC 4849), it was held that:
"19. The onus of proof of deficiency in service is on the complainant in the complaints under the Consumer Protection Act of 1986. It is the complainant who had approached the commission, therefore, without any proof of deficiency, the opposite party cannot be held responsible for deficiency in service. In a Judgement of this Court reported as Ravneet Singh Bagga v. KLM Royal Dutch Airlines &Anr., this court held that the burden of proving the deficiency in service is upon the person who alleges it."
In a series of decisions, it has been established that the burden of proof lies with the complainant to demonstrate negligence or deficiency in service by presenting evidence before the commission. Mere allegations of negligence are insufficient to support the complainant's case. As stated in the case of SGS India Ltd Vs. Dolphin International Ltd (2021 AIR SC 4849), "the onus of proof of deficiency in service is on the complainant in complaints under the Consumer Protection Act." The complainant approached the commission, and without any proof of deficiency, the opposite party cannot be held responsible for deficiency in service.
After careful consideration, we found that the case presented by the complainant is meritless. As a result, the following orders have been issued.
The commission finds that the complainant failed to provide sufficient evidence to substantiate their claims of deficiency in service or negligence by the opposite party. Therefore, the complaint is dismissed, and no relief is granted to the complainant.
Pronounced in the Open Commission on this the 29th day of October, 2024
Sri. Manulal V.S. President Sd/-
Smt.Bindhu.R, Member Sd/-
Sri. K.M. Anto, Member Sd/-
APPENDIX :
Exhibits from the side of the Complainant :
A1 - Copy of policy no. 570602502110000621
A2 – Discharge Summary issued by SH Medical Centre, Kottayam
A3 – Discharge Bill issued by SH Medical Centre, Kottayam
A4 - Copy of Claim form – SH Medical Centre, Kottayam
A5 – Copy of Cashless Authorisation Letter dtd. 01/02/2023
A6 – Complaint Letter dtd. 28/03/2023
A7 – Repudiation Letter dtd. 16/05/2023
Exhibits from the side of Opposite parties :
B1 - Copy of policy no. 570602502110000621
B2 - Copy of policy no. 570602501910000797
B3 - Copy of policy no. 570602502110000648
B4 - copy of approval letter dtd. 01/02/2023
By Order,
Assistant Registrar
