BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 18^th DAY OF FEBRUARY 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1. This complaint is filed by the complainant through her guardian mother for the following reliefs:-

(a) Direct the OP to pay the entire bill amount of Rs.1,54,763/- paid by the complainant to the Hospital along with interest at the rate of 18% p.a. on the amount mentioned above from the date of payment till realization.

(b) Direct the OP to pay the complainant sum of Rs.1,00,000/- towards mental agony and physical suffering due to the deficiency of service on the part of OP.

(c) Direct the Op to pay compensation of Rs.2,00,000/- to the complainant towards compensation due to deficiency in service on part of OP along with legal expenditure.

(d) Grant such other reliefs deemed fit and proper under the circumstances of the case in the interest of justice and equity.

2. The case set up by the complainant in brief is as under:-

The complainant took treatment for five days in the OP with mediclaim policy of Apollo Munich with I.D.No.6246212.  The claim of the complainant for cashless facility came to be rejected by the insurer stating that patient with Asthama excluded from mediclaim underwriter. 

3. The complainant contends that the rejection of cashless benefit was only due to utter negligence on the OPs. Later, the OPs realize their mistake and send a letter to the insurance company stating that diagnosis was wrongly mentioned in the discharge summary by attached the correct discharge summary.  The complainant has paid in all Rs.1,54,763/- towards cost of treatment to the OPs.  The complainant has lost this amount due to negligence or deficiency of service on the part of OPs. Despite legal notice dated 04.09.2019, OPs failed to held the request of the complainant.  The act of the OPs amounts to deficiency of service.  The cashless benefit was rejected by Apollo Munich due to the deficiency of service on the part of OPs.  Hence, this complaint.

4. After receipt of notice, the OPs appear and file version.  The claim of complainant for refund of Rs.1,54,763/- is in the nature of reimbursement.  This Forum has no jurisdiction to adjudicate the claim of the complainant.  The claim of the complainant can be decided only by jurisdictional civil court.  The request of the complainant for cashless facility was rejected by Apollo Munich.  The discharge summary was prepared incorrectly by a staff of the OPs.  Immediately at the request of the insurance company, the correct discharge summary was issued to enable the complainant to take benefit of insurance policy.  The error occurred in the discharge summary was human error and not willfully or with malice.  There is negligence and deficiency of service on the part of OPs.  They request to dismiss the complaint.

5. The mother of the complainant files her affidavit evidence and relies on seven documents.  The OPs failed to file affidavit evidence.  Heard the arguments and perused the written arguments.   

6. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OPs?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

7. Our answers to the above points are as under:

       Point Nos.1 and 2:  In the negative.

      Point No.3: As per final orders

REASONS

8. Point Nos.1 and 2:  Even though, OPs have not lead evidence.  The question arises, whether complainant proves her case against the OPs?  The complainant filed affidavit evidence and relies on seven documents in support of allegations made in the complaint.  Even though, OPs have not lead evidence in support of their version.  But, it is the duty of us to decide the case on available materials on record.
9. It is admitted fact that the complainant Alaina Angeline was admitted in the hospital of OP on 25.07.2019.  This fact is proved from Annexure-1.  It is also proved from Annexure-2 that mother of the complainant paid Rs.1,54,763/- to the OPs towards the cost of the treatment.  It is also proved from document No.2 that Alaina Angeline was admitted in the OP hospital between 25.07.2019 to 30.07.2019.  The request of the complainant through OPs for cashless treatment made to the insurance company Apollo Munich came to be rejected on 30.07.2019 as could be seen from Annexure-5.
10. It is relevant to note that the complainant has not produced the first discharge summary to show what mistake was committed by the OPs.  However, it is admitted by the OPs that the mistake was crept in first discharge summary which was not an intentional and later on corrected discharge summary came to be issued with letter.  Annexure-3 and Annexure-4 indicate that the OPs hospital issued a letter that diagnoses was wrongly mentioned in the discharge summary by mistake and same has been rectified.  Ex.A.4 corrected discharge summary came to be issued on 30.07.2019.  It is admitted fact that insurer of the complainant rejected the cashless service as could be seen from Annexure-5 dated 30.07.2019.  The rejection of cashless service was intimated to the OP No.2 stating that in view of the exclusion for Asthama, cashless facility was not granted.  It is relevant to note that while issuing denial of cashless service facility, the insurer made a specific note that “Please note that cashless denial in no way indicates denial of claim, insured/s are requested to submit their claim documents after completion of treatment for review on admissibility”.  It further indicates that in case you believe that we have overlooked any material fact or circumstances, kindly let us know for evaluation by writing to us at The complainant got issued a legal notice dated 04.09.2019 and called upon the OPs to pay Rs.1,54,763/- with interest and compensation of Rs.3,00,000/-.  This notice came to be served on the OPs.  But, OPs failed to give reply.
12. According to the advocate for the complainant, the act of the OPs amounts to negligence and complainant lost reimbursement of Rs.1,54,763/-.  It is true that on the basis of wrong discharge summary, the insurer of the complainant denied the cashless facility. But, OPs realizing their mistake, have issued a covering letter with rectified discharge summary.  The insurer has given an opportunity to submit claim document after completion of treatment for review on admissibility.  It is the case of the complainant that after rejection of cashless facility and on the basis of rectified discharge summary, she had submitted the claim petition with her insurance company Apollo Munich.  It means that only on the basis of rejection of cashless facility, the complainant has approached this Commission for the above reliefs.  The OPs rectified their mistake in the month of July 2019, without any delay. It shows no deficiency of service and negligence on the part of OP No.5.  On the basis of rectified correct discharge summary, the complainant failed to file claim petition for reimbursement with her insurance company. Without claiming petition on the basis of rectified discharge summary, the complainant has approached this Commission.  If the insurance company repudiated the claim of the complainant after verifying the claim petition on the basis of corrected discharge summary, the portion would have been different.  But, complainant without submitting the claim petition with her insurer, on the basis of rectified discharge summary, to claim refund of amount with compensation from the OPs.  Even though, OPs had committed mistake while issuing first discharge summary, but immediately OPs rectified their mistake.  When there is an opportunity as per Annexure 3 and 5, complainant failed to submit claim petition with insurer. Therefore, there is no deficiency of service on the part of OPs. In fact, the complainant approaching her insurer with claim petition, on the basis of rectified discharge summary, she has approached this Commission. Under such circumstances, complainant is not entitled to any of the reliefs. 
13. Point No.3:- In view of the discussion and reasons assigned above, complaint requires to be dismissed.  We proceed to pass the following 

  O R D E R

1. The complaint is dismissed.  No costs.
2. However, complainant is at liberty to approach Apollo Munich Insurance Company with claim petition if she wishes to do so.
3. Furnish the copy of this order and return the documents to the complainant with extra pleadings.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 18^th day of February, 2022)

Documents produced by the Complainant which are as follows:-