DATE OF FILING : 12.8.2010
BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI
Dated this the 29th day of December, 2010
Present:
SRI.LAIJU RAMAKRISHNAN PRESIDENT
SMT.SHEELA JACOB MEMBER
SMT.BINDU SOMAN MEMBER
C.C No.171/2010
Between
Complainant : P.S. Anil,
Padikkuzhayil House,
Vengalloor P.O.,
Thodupuzha, Idukki District.
(By Adv : K.M. Sanu)
And
Opposite Parties : 1. The Relilance General Insurance Co. Ltd.,
1st Floor, 570 Rectifire House,
Naigom Cross Road,
Vadala (west), Mumbai – 400 031. 2. The Medi Assistant India Pvt. Ltd.,
406 Kurisupalli Road, Temple Lane,
Ravipuram, Cochin – 682 015.
(Both by Adv: Pradeep Kumar)
O R D E R
SRI. LAIJU RAMAKRISHNAN (PRESIDENT)
The complainant availed a mediclaim policy from the 1st opposite party in the year 2007 as Reliance Family Healthwise (Gold Plan Cash Less) Policy and was renewing the premium promptly from that date onwards. As per the policy, the 1st opposite party is liable for all the expenses for the treatment and diagnosis of the policy holder in the hospitals where the opposite party is having tie up with. The Amritha Institute of Medical Sciences and Research Centre, Kochi is included in the list of the hospitals published by the opposite party in which the opposite party is having tie up for the Reliance Family Healthwise Policy. So the opposite parties are liable for the payment of all the hospital bills in which the policy holder taking treatment. In the year 2009, the complainant's right hand and right side of the body started heavy pain and it increased and affected the sleeping of the complainant. The complainant examined in the Excelciar Hospital, Thodupuzha and they have referred the complainant to consult a neurologist and advised for further treatment. As per the reference, the complainant consulted the neurologist named Dr.Arun Grace at Amritha Medical Institution, Ernakulam and the complainant was admitted there on 2.12.2009 for further treatment. The complainant informed the hospital that the complainant is having Reliance Family Healthwise (Gold Plan Cash Less) Insurance Policy and requested for the cash less facility from the hospital. But it was informed from the hospital that the hospital was providing cash less facility to the patients having the said policy, but the opposite party has never made the payment to the hospital and so they are not able to provide cash less facility to the complainant. So the complainant contacted the 1st opposite party through telephone and they told that after completing the treatment and discharged from the hospital, the amount will be reimbursed as per the bill issued by the hospital. So the complainant was treated there, conducted MRI scanning, NCVT sleep test etc. and it was diagnosed that the valve contacting to the lungs of the complainant was shrinking because of the lack of the oxygen and so it affected deep sleep of the complainant. It affected the heart and brain of the complainant. So an instrument named Bedmass is very necessary for the further treatment of the complainant. It is also found that there is dislocation in the back bone disc of the complainant's body. After discharged from the hospital, the complainant filed a claim before the opposite party on 25.1.2010 with all the bill issued from the hospital. But the opposite party repudiated this claim on 10.6.2010. The opposite parties are liable to pay the expenses met with by the complainant at the hospital which amounts to Rs.30,622/- and this petition is filed for getting the amount Rs.30,622/- with 12% interest and also for compensation.
2. As per the written version filed by the 1st opposite party, it is admitted that the complainant filed a claim to the opposite party for his treatment, but the amount claimed was Rs.18,342/- during the month of December. As per the directions of IRDA, which is the statutory body set up to protect the interest of the policy holders, and to regulate the insurance business in India, the opposite party deputed 2nd respondent who is an independent third party administrator of the claims, to consider the claim of the complainant. After keen observation of the treatment details and impatient bills, 2nd opposite party found that there was no active line of treatment administered upon the complainant. Since claimant was hospitalized mainly for investigation and no active medical line treatment undergone, the claim is not admissible as per policy exclusion clause 21 and 28. Hence the 2nd opposite party who is only a third party administrator of claim was constrained to repudiate the claim, based on the terms and conditions of the insurance contract. The complainant also requested to return the documents submitted by him for processing the claims and they were returned vide letter dated 10.6.2010. The 2nd opposite party is only an independent third party administrator of the claim. The opposite parties are bound by the terms and conditions of the contract of insurance, the claim of the complainant was only Rs.18,342/- and this petition is liable to be dismissed.
3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to ?
4. The evidence consists of the oral testimony of PW1 and Exts.P1 to P6(series) marked on the side of the complainant.
5. The POINT :- The complaint is filed for getting medical insurance policy amount for the treatment expenses of the complainant. The complainant was examined as PW1. PW1 availed Reliance Family Healthwise Policy (Golden Plan Cash Less) as policy No.28251022740701 and it was renewed from the period from 2.1.2010 to 1.1.2011. It was assured in the policy that they are having tie up with prominent hospitals in Kerala and the complainant will be getting free treatment in these hospitals. The amount will be paid by the opposite party directly to the hospital and the premium amount Rs.1,492/- was paid by the complainant. Ext.P1 is the copy of the policy and premium details. During the pendency of the policy, the complainant started heavy pain in his right hand and right side of the body which increased and affected the sleeping of the complainant. When the complainant was treated in Excelciar Hospital, Thodupuzha, they referred to a neurologist. So the complainant was examined by the Neurologist Dr.Arun Grace at Amritha Institute of Medical Sciences and Research Centre, Kochi on 29.11.2009 and as per the advice of the neurologist, he was admitted at Amritha Institute of Medical Sciences and Research Centre, Kochi on 2.12.2009 and treatment was conducted there for 2 days. Ext.P4 is the treatment result report issued from Amritha Institute of Medical Sciences and Research Centre, Kochi. The cash less facility was not given to PW1 because the payment by the opposite party to the hospital was not prompt. As per the direction of the opposite party that the treatment expenses will be reimbursed, the complainant treated there and an amount of Rs.30,622/- was incurred for the treatment. The illness affected the lungs, heart and brain of the complainant and so an instrument named “Bedmass” was very necessary for the treatment of the complainant. It costs Rs.85,000/- and the hospital authority denied the said machine because of the non-payment of the advance money for the machine. The complainant was not able to pay the amount. But even there was tie up with the opposite party and the hospital, the hospital authorities never supplied the same as per the tie up written in the policy conditions. So the opposite party is entitled to pay an amount Rs.85,000/- to the complainant for the purchase of that machine. A claim form was filed on 25.1.2010. But it was rejected by the opposite party by a letter dated 26.3.2010. Copy of the same is marked as Ext.P2. The bills issued by the hospital were marked as Ext.P3(series) and Ext.P5. As per the cross examination of the learned counsel for the opposite party, it is stated that the amount claimed was Rs.18,342/- by the complainant and the expenses incurred was for the tests conducted for diagnosis and not for treatment. So the claim was repudiated as per the 21 and 28 clause of the policy and the original policy conditions and copy of the claim form are also produced by the opposite party. It is also submitted by the opposite party that the amount claimed by the complainant as per the claim form was Rs.18,342/- and not for Rs.30,622/-.
As per the policy and conditions issued by the opposite party, it is very clearly stated in the brochure issued by the opposite party with “key advantage as 24 hours cashless facility at more than 3000 network hospitals”. And it is also advertised that hospitalisation, domiciliary hospitalisation, pre hospitalisation, post hospitalisation, pre-existing diseases coverage after 2nd year, critical illness (with separate double sum insured), donor expenses and day care treatment are the basic features of the allowances here in the policy card. Daily hospitalisation allowance, nursing allowance (per day amount Rs.300/-), local road ambulance service (maximum of Rs.1000/-), recovery Benefit, expenses on accompanying person (per day amount Rs.300/-), cost of health check up were offered as value added features of the policy. The hospitalisation expenses such as hospital (room, boarding and operation theatre), doctors and nurses, medical tests, medicines, blood, oxygen, appliances etc.. So it is very clear from the brochure of the policy itself, the opposite parties are providing even expenses of medical tests in the Golden policy of the Reliance Healthwise policy. The health card also issued to the complainant. As per the request of the complainant, the claim form and details of this policy were returned to the complainant by the opposite party after repudiation and the returned claim is also produced. But there is no amount has mentioned in the claim form. So the arguments of the opposite party that the claim was for an amount of Rs.18,342/- is not sustainable. The complainant believed in the policy issued by the opposite party and treated in the hospital where the opposite party is having tie up, so the complainant was not able to buy a “Bedmass” which is an instrument very necessary for the treatment of the complainant which costs Rs.85,000/-. As per Ext.P3(series) bills produced by the complainant shows that the amount for the treatment of the complainant is Rs.20,122/-. One bill which is Ext.P3(c) which is paid for an advance amount of Rs.10,500/-. So that it cannot be counted, the balance will comes to an amount of Rs.20,122/- and the repudiation of the claim of the opposite party is a gross deficiency from the part of the opposite party. There is no evidence produced by the complainant to show that the “Bedmass” is very necessary of the treatment of the complainant and the act of the opposite party denied the availability of the same.
Hence the petition allowed. The opposite parties are directed to pay Rs.20,122/- with 12% interest from the date of this petition and Rs.2,000/- as cost of this petition within one month of receipt of a copy of this order failing which the amount shall carry 12% interest per annum from the date of default.
Pronounced in the Open Forum on this the 29th day of December, 2010
Sd/-
SRI. LAIJU RAMAKRISHNAN (PRESIDENT)
Sd/-
SMT. SHEELA JACOB (MEMBER)
Sd/-
SMT. BINDHU SOMAN (MEMBER)
APPENDIX
Depositions :
On the side of the Complainant :
PW1 - Anil P.S.
On the side of the Opposite Parties :
Nil.
Exhibits :
On the side of the Complainant :
Ext.P1 - Copy of the Reliance General Insurance Policy.
Ext.P2 - Copy of the letter dated 26.3.2010, from the 2nd opposite party to the complainant.
Ext.P3(a to g) - Bills issued by the Amrita Institute of Medial Sciences and Research Centre,
Kochi.
Ext.P4 - Treatment result report of the complainant, issued by Amrita Institute of
Medical Seciences and Research Centre, Kochi.
Ext.P5 - Bill issued by the Amrita Institute of Medial Sciences and Research Centre,
Kochi.
Ext.P6(series) - Letters from the opposite parties, claim form given by the complainant and a
brochure of the insurance policy.
On the side of the Opposite Parties :
Nil.
