IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 20thday of March, 2021
Present: Sri. Manulal V.S. President
Sri. K.M. Anto, Member
C C No. 11/2018 (filed on 22/01/2018)
Petitioner : Ananthu S.
Madhavam,
Kaduthuruthi P.O.
Pin- 686 604.
Vs.
Opposite Parties : 1) Manager,
Oriental Insurance Co. Ltd.
DO-2 Branch, Kochi – 682016.
(Adv. P.C. Chacko)
2) Administrator,
Matha Hospital,Thellakom P.O.
Kottayam - 686630
(Adv. M.C. Suresh)
O R D E R
Sri. Manulal V.S. President
The case of the complainant is as follows.
The complainant has taken a health insurance policy from the 1st opposite party for the period from 02-12-2016 to 01-12-2017 for an amount of sum insured of Rs.1,00,000/-. On 23-09-2017, the complainant was admitted in the 2nd opposite party hospital and underwent a surgery for appendicitis. The complainant was discharged on 25-07-2017. At the time of discharge, it was informed by the 2nd opposite party that an amount of Rs.29,780/- was paid by the 1st opposite party as claim for the treatment by the 1st opposite party and directed the complainant to pay Rs.34,683/- as the balance expense for the treatment. On enquiry, it was informed by the 2nd opposite party that the 1stopposite party has not disbursed the full amount of the treatment and rejected some bills which were forwarded by the 2nd opposite party to the 1st opposite party. The complainant availed a room at a rate of 700/- per day. The complainant was not aware of the bills which were rejected by the 1st opposite party and the reason for the same. Act of the opposite parties by rejecting a genuine claim of the complainant amounts to deficiency in service. Hence this complaint is filed by the complainant praying for an order directing the opposite parties to pay Rs.34,683/- which is the balance amount in the medical expense incurred by him and for compensation.
Upon notice from this Commission, opposite parties appeared before Commission and filed separate version.
Version of the 1stopposite party is as follows.
The complainant has taken a medi-claim insurance policy from the 1stopposite party for the period of 02-12-2016 to 01-12-2017. The sum assured under the policy was Rs.1 lakh. It is true that the complainant was inpatient for 2 days in the 2nd opposite party hospital for the period from 23-09-2017 to 25-09-2017. The 3rdparty administrator of the policy would process the claim application in terms of the policy and the conditions and admissible amount will be provided to the insured.
The complainant has lodged a claim for an amount of Rs.64,463/-. On receipt of the said claim, the 3rd party administrator has processed the claim and the admissible amount was arrived at Rs.29,780/-. The rest of the amount claimed was not legally admissible and accordingly the same was rejected and intimated the complainant through the hospital. After accepting the admissible amount of Rs.29,780/- and remitting the said amount, the complaint is estopped from contenting that he is eligible for more amount than Rs.34,683/-.
As per the terms and conditions of the policy, admission fee, cost of ICU expense, ventilator expense, non-medicines included in the pharmacy charges, servothaneexpenses etc. are not payable. Room charge and nursing care expenses are considered together as one head and no separate head will be eligible to be received by the complainant. Room charges and nursing expense are considered together as one head and has a limit to the extent of 1% of the sum assured per day. As per the linking with the network hospital, there are certain limit to the hospital expenses and amounts exceeding such limits are not payable. The consultant charges, investigation-lab test charges, operation theatre gas charges, X-ray charges etc. had such limits and admissible amountunder such heads were allowed. The repudiation of the bills and reason for the repudiation was also communicated to the complainant through the hospital. The opposite party has received the premium only to pay compensation to the complainant to the extent and it is allowed to him. The petitioner is not entitled for any compensation or claim in this case. There is no deficiency in service on the part of the 1st opposite party in processing the claim and disbursing the amount.
The 2ndoppositeparty filed version contenting as follows.
The 2nd opposite party hospital is unnecessarily joined in the complaint. The complainant’s cause of action is with regard to the amount disallowed by the 1stoppositeparty in his claim for cashless treatment in the 2nd opposite party’s hospital and in the determination of the issue the 2nd opposite party is not a necessary party.
The complainant was treated in the 2ndopposite party’s hospital from 23-09-2017 to 25-09-2017 for acute appendicitis and he underwent emergency laparoscopic appendicectomy on 23-09-2017. The complainant was holding a medi-claim insurance policy with the 1st opposite party and the 2nd opposite party had promptly proceeding with claim and obtain pre-autherisation for cashless treatment. The complainant was specifically informed that in case any amount was not payable by the insurer as per terms and conditions of the policy, the same would be payable by the complainant and he agreed to it. The total bill amount payable by the complainant was Rs.64,463/- and out of which the 1st opposite party had approved only Rs.29,780/- after deducting the amount. The 2nd opposite party informed the complainant about deduction of Rs.34,683/- made by the 1st opposite party and without raising any objection, the complainant remitted the said amount and got discharge from the hospital. The insurance department of the 2nd opposite party had provided all details to the complainant regarding the communication received from the 1st opposite party and issued copy of pre-approval certificate and given details of amount deducted by the 1st opposite party as per documents obtained from the 1st opposite party.
The 2nd opposite party is not liable for the amount deducted by the 1st opposite party. The 1st opposite party is bound to explain the reason for the deduction and the said deduction of the amount was not because of any acts or omission on the part of the 2nd opposite party. The 2nd opposite party had issued final bill for treatment clearly stating the amount payable on various heads and the complainant has not objected the same at the time of payments. The complaint framed against the 2nd opposite party is purely experimental in nature and solely indented to undue financial gain. The complainant has no cause of action against the 2nd opposite party as there was no deficiency in service on the part of the 2nd opposite party.
The complainant filed proof affidavit in lieu of chief examination and Ext.A1 to A8 were marked. G. Sudakshina, Divisional Manager of the 1st opposite party filed proof affidavit in lieu of chief examination and Ext.B1 and B1(A) were marked. SabuSebeastian, who is the Manager of the 2ndopposite party filed proof affidavit and Ext.B2 got marked.
On evaluation of complaint, version and evidence on record, we would like to consider following points.
- Whether there is any deficiency in service or unfair trade practice from the side of opposite parties?
- If so, what are reliefs and costs?
For the sake of convenience we would like to consider point no.1 and 2 together.
Point No.1 and 2
There is no dispute on the fact that the complainant had availed a health insurance policy from the 1st opposite party vide policy No.440200/48/2017/3343 for the period from 02-12-16 to 01-1217. Ext.B1 is the policy schedule. The sum assured under B1 policy was Rs.1 lakh. It is also admitted by the opposite parties that the complainant was treated as inpatient from 23-09-2017 to 25-09-2017 in the 2ndopposite party hospital for acute appendicitis and he has underwent an emergency surgery on 23-09-2017. Ext.A1 proves that the complainant had incurred Rs.64,463/- for the said treatment. The specific case of the complainant is that though the 1st opposite party assured that they wouldindeminify him for the treatment expenses, they allowed only Rs.29,780/- for the same.Ext.A2 is the pre authorization letter issued from the 1st opposite party to the 2ndoppositeparty for the treatment of the complainant. The oppositeparties admitted that the 1stopposite party approve only Rs.29,780/- for the treatment of the complainant. The balance amount of Rs.34,683/- was paid by the complainant to the 2nd opposite party. The 1stopposite party contented that as per terms and conditions of policy admission fee, post IP, ICU expense, ventilator expense, non medicines including in the pharmacy charges, servothaneexpenses are not till payable. According to the 1st opposite party as per terms and conditions of the policy room charges and nursing care expanse are considered together as one head and had a limit to the extent of 1% of the insured amount per day. On perusal of B1(a) policy schedule we can see it was stated in clause No.1.2(A) as
A | HOSPITALISATION BENEFITS |
| Expenses covered | Limits of Covered Expense |
a | Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home | Not exceeding 1% of the Sum Insured per day. |
b | Intensive Care Unit (ICU) expenses as provided by the Hospital/Nursing Home | Not exceeding 2% of the Sum Insured per day |
| Number of days of stay under ‘a’ and ‘b’ above should not exceed total number of days of admission in the hospital. Admissibility of all related expenses (c and d), except for medicine / pharmacy bills and body implants, shall also be as per the entitled category vis-à-vis room rent. |
c | Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees | As per the limits of the sum insured |
D | Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices like Pacemaker implanted during surgical procedures, relevant laboratory / diagnostic tests, X-ray and similar expenses | As per the limits of the sum insured |
Thus we are of the opinion that the complainant is entitled for Rs.1,000/- per day for room rent and nursing charges. On perusal of Ext.A1 we can see that the room rent was Rs.1,050/- per day and nursing charges was Rs.2,365/- in total for a period of 23-09-17 to 25-09-17. This costs of Rs.1,182.5/- per day for the room rent and nursing care. It was further stated Ext. B1 (a) policy conditions that admissibility to related expenses which is stated in conditions C and D except for medicine / pharmacy bill and body implants shall also be entitled category vis-à-vis from room rent. Thus 1stoppositeparty is entitled to make a deduction of the associated charges except the medicines as per the ratio of the entitled room category. On perusal of record and evidence we could not seeany case thatany deduction is made by the 1st opposite party in contravention the terms of the policy. The complainant failed to adduce any cogent evidence to show that the opposite party has deficient in deducting any amount which is legally and contractually entitled by him as per the terms and conditionsofthe policy. Therefore we are of the opinion that the complaint is liable to be dismissed. Hence compliant is dismissed.
Dictated to the Confidential Assistant, transcribed and typed by her,corrected by me and pronounced in the Open Commission on this the 20thday of March, 2021.
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked on the side of the complainant
A1 :Copy of Enhancement A/L
A2 :E-mail communication (Query reply of Ananthu S.) dtd.25-09-17
A3 : E-mail communication (Query reply of Ananthu S.) dtd.25-09-17
A4 : Copy acknowledgement postal card and receipts
Exhibits marked on the side of opposite party
B1 : Certified copy of policy
B1 ((a) : Certified copy of policy terms and conditions
B2 : Letter dtd.03-10-17 from petitioner to 2nd opposite party
By Order,
Senior Superintendent.
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