SMT. RAVI SUSHA  : PRESIDENT

         Complainant filed this complaint under sec.35 of the Consumer Protection Act 2019 seeking to  get an order directing opposite parties to pay Rs.74,456/-  towards treatment expense incurred to the complainant for the treatment availed to his wife together with  compensation of Rs.50,000/- for the mental agony happened to the complainant for the deficiency in service on the part of OPs.

   Brief facts of the complainant’s case is that he is a health insurance policy holder under 1^st OP for the period from 27/6/2019 to 26/6/2020.  As per the terms of the health insurance policy the insurance coverage is extended to the complainant’s wife and children also.  On 25/2/2020 the complainant’s wife fall from bathroom causing injury to her left leg, she was admitted in 3^rd OP hospital itself and  underwent surgery  from there and a steel plate was implanted as  part of the procedure. The patient was discharged on 29/2/2020.   The 1^st OP was duly intimated regarding the accidental fall and a claim from countersigned by the treating doctor of 3^rd OP was also  submitted to 1^st OP. The 1^st OP declined to pay the hospital bill raising untenable objections and the complainant was compelled to pay the hospital bill of Rs.74,456/- at the time of discharge.  The complainant produced all documents required by the 1^st OP before the 2^nd OP, who according to 1^st OP is the authorized claim settler, was raising untenable  objections.  It is submitted that  2^nd OP has no authority to deny the claim of the complainant.  On receiving the letter from 2^nd OP  requiring the complainant to produce the sticker of the steel plate implanted at the time of surgery, the complainant met the 3^rd OP and demanded the  sticker of the steel plate.  It was told that 3^rd OP is making bulk purchase of steel plates from the manufacturers  so that there will not be a sticker to each piece of steel plates but they issued  invoices showing the details of the  steel plate and its accessories purchased.  1^st OP is not justified in repudiating the claim on the ground that there is a delay in producing  the sticker to 2^nd OP.  Hence this complaint.

     After receiving  notices  OPs 1&3 fled their  version separately stating their contentions.  1^st OP submitted that as per the health insurance  policy the insured is liable to intimate the  insurer/3^rd party administrator, immediately regarding the incident which gave rise to the claim along with the full details of  the  identity of the beneficiary who had undergone the treatment, the cause of the  injuries, treatment records with full description of the all the medical bills and description/original sticker of the implants if any used for the  beneficiary.  But whereas, the complainant in the  above case has not complied with the said mandatory conditions by producing the said documents before the  OPs 1&2 within the  time frame  prescribed in the  policy conditions. The 2^nd OP has issued two letters dtd.11/6/20 and 23/7/20, to the complainant, requesting him to produce original sticker of the implants used and any of the  ID proof copy of the beneficiary in order to process the claim.  But in spite of the repeated request made by the 2^nd OP, the complainant failed to comply with the same. So the 2^nd OP was constrained to close the claim file of the complainant because the 3^rd OP refused to give the sticker number of the implants.  Hence the cause of action if any for the complainant will only be against the 3^rd OP.  Hence prayed for the dismissal of the complaint.

    3^rd OP stated that  he has issued  all the documents as demanded by the complainant and he does not have any complaint or allegation against the medical service provided by them.  It is further submitted that the  complainant has taken insurance policy of 1^st OP, the 1^st OP is liable to indemnify the complainant.  To the information of the  3^rd OP, the complainant has submitted all the  bills to  1^st OP.  Condition of the insurance policy does not says that the original sticker of the steel plate implant is to be submitted along with the medical claim.  If the 1^st OP is convinced that implant was made to the leg of the complainant’s wife they are bound to reimburse the medical expenses of the complainant.  There is no deficiency of service and unfair trade practice on the  side of 3^rd OP.

      2^nd OP remained absent , not contested the case. Hence 2^nd OP was declared as exparte.   

   At the evidence time, complainant filed his proof affidavit and documents.  He was examined as  PW1. The documents were marked as Exts.A1 to A8. OPs.NO.1&3 cross examined  and  marked  Exts.B1&B2. On the side of OPs, the Manager of 1^st OP  filed his chief affidavit and was examined as DW1. Exts B3&B4 were marked. Further legal officer of 3^rd OP hospital filed his proof affidavit and  examined as DW2.  Ext.B5 authorization was  marked.

    The undisputed facts in this case are that (a) the complainant had taken  a health  insurance policy from 1^st OP. (b)  the policy period was from 27/6/2019 to 26//2/2020(Ext.A1) (c ) Insurance coverage is extended to complainant’s wife and two children also(d) on 25/2/2020 complainant’s wife Sapna Shamith was admitted  in 3^rd OP hospital due to a fall (Ext.A4)        (e) procedure done was ORIF angle left side under SA on 25/2/2020( f) discharge from the  hospital on 29/22020(g) cashless claim of complainant’s wife was rejected by the insurance company(h) Inpatient bill issued by 3^rd OP hospital was for Rs.74456/-(i) complainant had paid the said amount(j) After discharged from the hospital complainant’s wife submitted claim form to 1^st OP(Ext.A2).  2^nd OP sent a letter to  the complainant on 11/6/2020 informing to submit certificate from treating  doctor stating  exact cause and circumstances of  fall, X-ray report, sticker  for the implants used-original, invoice for the  implants used-copy(Ext.B4).  Ext.B2 is the 2^nd letter sent by 2^nd OP to the complainant dtd.23/7/2020, stating that the inadequate information received. “Sticker for the implant used-original” (which means all other documents were submitted by the complainant as per Ext.B4 letter except sticker for the implant).  In Ext.B2 letter 2^nd OP specifically stated that “ we shall be able to  proceed further  with the  matter only on your submission of the above requirements along with copy of this letter”.

     Complainant submitted that though he approached 3^rd OP hospital in order to get ” sticker for the implant used”,  it was not received from 3^rd OP hospital.  Complainant alleged that there is deficiency in service on the part of OPs 1 to 3.  According to complainant, 2^nd OP does not  have right to repudiate his claim.  Complainant had no privity of contract with 2^nd OP.  Moreover at the time of joining the policy, neither 1^st OP nor its agent informed about the role of 2^nd OP.  Further submitted that 3^rd OP hospital informed him that as they are purchasing steel plate in bulk, they  are not able to issue separate sticker in the steel plate in each and every steel plate.  Thus 3^rd OP had not furnished the sticker of steel plate implanted in the left leg of his wife.  Complainant submitted that there is no such latches from his side in submitting all the relevant documents before the Insurance company in order to get the policy benefit.

   3^rd OP filed separate version, their legal officer was examined (DW2).  Their contentions are that  he has issued  all the documents as demanded by the complainant and he does not have any complaint or allegation against the medical service provided by them.  It is further submitted that the  complainant has taken insurance policy of 1^st OP, the 1^st OP is liable to indemnify the complainant.  To the information of the  3^rd OP, the complainant has submitted all the  bills to  1^st OP.  Condition of the insurance policy does not says that the original sticker of the steel plate implant is to be submitted along with the medical claim.  If the 1^st OP is convinced that implant was made to the leg of the complainant’s wife they are bound to reimburse the medical expenses of the complainant.  There is no deficiency of service and unfair trade practice on the  side of 3^rd OP.

    On perusal of available documents Exts.B2& B4 clearly evident that except the original sticker of the steel plate implant, all other medical documents were issued by the treating doctor of 3^rd OP to the complainant and the complainant had submitted those documents to 1^st OP.  As contended by 3^rd OP, in clause 2.15 of Ext.B3 policy, no where stated about  submission of sticker of the implant.  Ext.A3 shows the detailed patient bill issued from 3^rd OP hospital in which details of implant and rate also was mentioned. So our view is that there is no deficiency in service on the part of 3^rd OP and the  denial of the complainant’s claim by OPs 1&2 amounts  deficiency in service and unfair trade practice.  Since the complainant had taken health insurance from 1^st OP, 1^st OP has to indemnify the complainant.  Ext.A3 shows  the total medical bill incurred was Rs.74456.00/-.

      In the result complaint is allowed in part.  1^st opposite party is directed to pay Rs.74456/- to the complainant with 4% interest from the date of complaint till realization.  1^st opposite party is also directed to pay Rs.10,000/- towards compensation.  1^st opposite party shall  comply the order within one month from the date of receipt of the copy of this order  failing which the amount Rs.74456/- carries 9% interest from the date of complaint till realization, the complainant is at liberty to execute the order as per provision in Consumer Protection Act 2019.

Exts:

A1-Photocopy of insurance policy

A2-claim form

A3-Bill issued by 3^rd OP

A4-Discharge summary issued by 3^rd OP

A5-Certificate issued by 3^rd OP

A6-Bill issued by 3^rd OP

A7-letter sent by complainant to 2^nd OP

A8-letter issued by 2^nd OP to complainant

B1-copy of letter dt.11/6/2020(Ext.A7)

B2- Copy of letter issued by 2^nd OP to complainant

B3- policy schedule

B4- No claim

B5- Authorisation letter(Resolution of board)

PW1-Shamith.A.T- complainant

DW1-Haridasan.K-1^st OP

DW2- Rajesh.A.V-3^rd OP
 

Sd/                                                                            Sd/                                                                     Sd/

PRESIDENT                                               MEMBER                                                        MEMBER

Ravi Susha                      Molykutty Mathew.                            Sajeesh K.P

eva         

                                                   /Forwarded by Order/

                                                       ASSISTANT  REGISTRAR