Kerala

Malappuram

CC/139/2021

SINDHU NV - Complainant(s)

Versus

SENIOR DIVISIONAL MANAGER HEALTH INSURANCE - Opp.Party(s)

30 Jun 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL
MALAPPURAM
 
Complaint Case No. CC/139/2021
( Date of Filing : 13 Jul 2021 )
 
1. SINDHU NV
KARUVATH HOUSE KAIPAMANGALAM CHALINGAD POST THRISSUR 680681
2. ULLAS KC
KARUVATH HOUSE KAIPAMANGALAM CHALINGAD POST THRISSUR 680681
...........Complainant(s)
Versus
1. SENIOR DIVISIONAL MANAGER HEALTH INSURANCE
LIC OF INDIA DIVISIONAL OFFICE JEEVAN PRAKASH PB NO 177 LIC ROAS KOZHIKODE 673001
2. THE MANAGER
HEALTH INSURANCE LIC OF INDIA BRANCH OFFICE TIRUR MALAPPURAM 676104
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MR. MOHANDASAN K PRESIDENT
 HON'BLE MR. MOHAMED ISMAYIL CV MEMBER
 HON'BLE MRS. PREETHI SIVARAMAN C MEMBER
 
PRESENT:
 
Dated : 30 Jun 2022
Final Order / Judgement

By Sri. Mohamed Ismayil.C.V, Member

            Complaint filed under section 35 of the Consumer Protection Act.

1.         The complainants are wife and husband.  The second complainant availed a health policy (No.798215617) from the LIC of India, Branch office Tirur, the second opposite party. The first opposite party is the divisional office of the second opposite party. The policy commenced on 21-01-2013 and the second complainant continued to renew it time to time till the date.   As per the terms and conditions of above said health policy the complainants and family members (two children) are eligible for medical reimbursement and the second opposite party issued Health card for all their family members.  

2.         On 21/11/2019 the first complainant was admitted in Jubilee Mission Hospital, Thrissur with excessive uterine bleeding and treated for 3 days and got discharged on 23/11/2019 and advised to  review  after two weeks and posted for  surgery on follow-up date.

On 25-11-2019 the first complainant fell unconscious as result of dangerous low Hb level and low BP because of uterine bleeding.  She was rushed to nearby hospital named city hospital, Tirur for emergency blood transfusion.  In the very next morning she was taken to Jubilee Mission Hospital, Thrissur were surgery was planned.   So she was admitted there on 26/11/2019 and on 27/11/2019 subjected to a total Hysterectomy (Laparoscopic surgery) and got discharged on 30/11/2019.  She was advised to take bed rest for 2 months and to continue hormone therapy for 6 to 12 months.

3.         The  first complainant  was admitted  and treated in Jubile Mission hospital , Thrissur altogether  for 8 days (21/11/2019 to   23/11/2019 and 26/11/2019 to 30/11/2019) she spent a total sum of Rs.89,000/- for surgery,  medicines  and  the investigation like scanning , lab tests etc.  The first complainant is entitled to get 60% of the medical expenses reimbursed as per terms of the policy. So the first complainant got claim of Rs.53,400/- over the opposite parties .

4.         It is stated by the complainants that on 30-12-2019 the first among them submitted a medical claim along with all relevant records.  Later, on 24-01-2020 the first complainant received a letter from one Medsave Health Insurance TPA Ltd, Delhi asking to submit document as need detailed discharge summary for the date of admission on 26/11/2019.  But according to the complainant, they had already submitted necessary documents along with the claim application. Considering the letter dated 24/01/2020 they sent a copy of documents as demanded.   Thereafter on 17-07-2020 as per the direction of the first opposite party the first complainant sent a detailed narration of facts in writing along with copies of related documents of treatment to the divisional office, Kozhikode, the first opposite party. But the opposite parties did not reimbursed the claim amount.  Even during the struggling period of Covid 19, the complainants approached Tirur office of the opposite parties for several times and enquired about claim status. She was informed by the Tirur office of the opposite parties that the claim is still pending for want of details.  Thereafter on 13-01-2021, the first complainant sent a letter to the Divisional office, LIC of India seeking explanation for the delay in sanctioning the claim.  The opposite parties did not replied. But instead, the first complainant received another query letter from “Medsave Health Insurance, TPA Ltd, Delhi, demanding a different document.  According to the complainants while the first query was demanded for detailed discharge summary on the date of 26/11/2019, the second query demanded   treating doctors clarification about the details of treatment given during hospitalisation (during the admission made on 21-11-2019 to 23-11-2019). It is stated in  the complaint  that treatment  details during the period of 21-11-2017 to 23-11-2019 were shown in the  discharge summary dated 23/11/2019 and detailed discharge bill  consolidated statement were already submitted to the opposite parties .

5.         The complainant submitted that the opposite parties are dragging the matter with crooked intention in order to get avoid of the lawful document of the complainants by raising frivolous queries as non production of sufficient documents.  The Jubilee Mission Hospital authorities informed the complainants that they have already handed over required documents as usual and not in a position to issue unusual certificates for reimbursement.  Hence complainants approached this commission.

6.         The complainant stated that even after fulfilling all the requirements the opposite parties are not willing to sanction the claim.   There is no insufficiency of documents as alleged by TPA.  All relevant documents showing the admissions, procedures, lab tests and the whole treatments were handed over to the opposite parties within time.   The doctor who treated had filled the relevant columns of the claim form and certified the diagnosis and nature of treatment specifically.  The supporting documents are not to be considered as insufficient.  Since the doctors have already certified details in the claim form and signed the discharge summaries, then demand of further clarification and dragging the claim is a gross deficiency in service on the side of the opposite parties.  So the delay in approving the claim of the complainants have caused irresponsible loss and hardships and also caused sufferings to the first complainant for her post operative treatment.   So the complainant  prayed before the Commission to pass an order directing  the opposite parties to sanction the claim submitted by the second complainant  as per the terms of the policy No.798215617 and pay Rs.53400/- as medical reimbursement. The complainant also prayed to allow Rs.50,000/- as cost and compensation for the sufferings of the first complainant  underwent during the post operative treatment  period, at the time of Covid 19 Pandemic Circumstances and other reliefs as the Commission deemed  fit and  proper.

7.         On admission of the complainant Commission issued notice to the opposite parties and on receipt of notice the opposite parties entered appearance and filed their version.   

8.         According to the opposite party, the complainant is not entitled to get 60% of the medical expenses reimbursed.  As per the proposal form and the policy document, Initial Daily Cash Benefit chosen by the complainant is 1,000/- per day.  The policy privileges and conditions reveals that in the policy year  being the first year of cover starting  from the date of cover commencement  in respect of an insured     under this policy, the applicable Daily Benefit due to hospitalisation  shall be equal to the Initial Daily benefit mentioned in the schedule.   After the first year of cover and for each policy year commencing at a policy anniversary and during the cover period in respect of an insured, the applicable Daily benefit of the previous policy year shall be increased by the arithmetic addition of an amount equal to 5% of the Initial Benefit.  In the case of the complainant, Initial Daily Benefit increased automatically from Rs.1000/- to Rs.1400/- .  The complainants were eligible for their 2days (21-11-2019 to 23-11-2019) hospitalisation i.e, Rs.2800/-. So Rs.2800/- was transferred to the Bank account of the complainant  on 23-09-2021 through  NEFT as full settlement of claim for their 2 days (21-11-2019 to 23-11-2019) hospitalisation. It is stated in the version that Hysterectomy (Laparoscopic Surgery) surgery was not find in the place in the list of Major surgical Benefit .  So the complainant is eligible for the benefit of other surgical Benefits as surgery due to medical necessity not listed under the privilege and condition of the policy.  So the complainant is eligible to get the applicable Daily benefit in the policy.  In case of hospitalisation in the I.C.U, the insured will get two times the applicable Daily Benefit.  So according to the opposite party complainant is eligible to get benefit of other surgical Benefit for their 4 days hospitalisation from 26/11/2019 to 30/11/2019 i.e. Rs.11,200/- (1400x2x4=11,200/-) Hospital Cash Benefit for 3 days i.e 1 day ICU = 1400X2=2800, and 2 days  non ICU = 1400X2=2800). So the complainants are eligible to set total benefit of other surgical Benefit and hospital Cash Benefit for their hospitalisation from 26/11/2019 to 30/11/2019 i.e. Rs.16,800/- accordingly an amount of Rs.16,800/-  was transferred to the bank account of the complainant on 01/09/2021 through NEFT as full settlement of claim for the hospitalisation or treatment.  

9.         It is admitted in the version that complainant submitted their claim application for hospitalisation at Jubilee Mission hospital dated on 21/11/2019 and 26/11/2019.  But documents submitted by the complainants were insufficient or not in order and queries are issued to them to fulfil queries.  The opposite party also alleged that instead of sending fulfilled queries, the complainant sent letter to the opposite parties.  The opposite parties were not in position to consider the claim application as the complainants did not fulfilled queries in time.  Hence some official delay occurred in settling the claim amount.   The opposite parties admitted the fact of letter dated 13/01/2021 sent by the first complainant to the first opposite party. According to the opposite party delay occurred only due to the act of the complainant. The claim papers were not sufficient in order. The query documents were not sent to the TPA or to the opposite parties in time. So some delay was occurred in settling the claim. There is no deficiency of service or unfair trade practice or cause of action as alleged by the complainants.  So complainants are not entitled to any amount towards the policy claim amount or compensation or cost.

10.       The complainant and opposite parties filed affidavits and documents.  Documents on the side of the complainants marked as Ext. A1 to A9.  Ext. A1 is the copy of the policy certificate issued by the opposite party to the 2nd complainant.  Ext. A2 is the copy of the discharge summary dated 23/01/2019 issued by Jubilee Mission hospital, Thrissur to the first complainant. Ext. A3 is the copy of the discharge summary dated 30/11/2019 issued by Jubilee Mission hospital, Thrissur to the first complainant.   Ext. A4 is the copy of the ultra scan report dated 22/11/2019 issued by Jubilee Mission hospital, Thrissur to the first complainant.  Ext. A5 series is the copies of the four bills issued by the Jubilee Mission hospital Thrissur to the first complainant.  Ext. A6 is the copy of query letter issued by MedSave Health Insurance TPA Ltd dated 24/01/2020 to the first complainant.  Ext. A7 is the copy of letter dated 17/07/2020 issued by the first complainant to the first opposite party.  Ext. A8 is the copy of the registered notice dated 13/01/2021 issued by the first complainant to the first opposite party.   Ext. A9 is the copy of the query dated 18/01/2021 issued by Medsave Health Insurance TPA Ltd.       The opposite parties produced documents and marked as Ext.B1 to B4.  Ext. B1 is the copy of proposal form for health insurance policy dated 16/01/2013 filled and submitted by the complainants.   Ext. B2 is the copy of policy certificate issued in the name of the complainants.  Ext. B3 is the copy of LIC’s Jeevan Arogya conditions and privileges. Ext. B4 is the copy of payment details of full settlement of claims in favour of the first complainant by the opposite party.   

11.       Heard both sides, perused affidavits and documents. The following points arised for consideration.

  1. Whether there was any deficiency of services from the side of the opposite parties?.
  2. Relief and cost?        

12.       Point No.1 & 2

            The complainants stated in their complaint that second complainant subscribed health policy (No.798215617) from the second opposite party.   As per the terms and conditions of the policy, the complainants and two children are eligible for medical reimbursement.  On 21-11-2019 the first complainant admitted in Jubilee Mission hospital, Thrissur with excessive uterine bleeding and treated for 3 days and got discharged on 23/11/2019 for fatal Hysterectomy. On 27/11/2019 the complainant was subjected to total Hysterectomy. (Laparoscopic surgery) and discharged on 30/11/2019.  According to the first complainant she spent total Rs.89,000/- (Eighty none thousand only) as medical expenses and as per  terms  of the policy the complainants are  entitled to get 60%  of the total expenses reimbursed. So on 30/12/2019 the complainant applied for the claim of Rs.53,400/- for reimbursement  as per policy terms.  According the complainant she submitted medical reimbursement claim along with all the relevant documents. But so far the complainants did not get the claim amount reimbursed. The opposite party admitted the first opposite party that the second complainant was the holder of the  Jeevan Arogya  policy and the first complainant and the  children are  the beneficiary under the policy.

13.As per evidence adduced by the opposite parties, the benefits under Jeevan arogya policies are not directly related to the actual expenses incurred. Jeevan arogya is a fixed benefit policy and benefits are calculated on the basis of the Initial Daily Benefit opted in the proposal forms.  The opposite party produced Ext. B1 and B3 to substantiate their case. Ext. B1 is the proposal form signed by the complainant.  Ext. B1 document shows that benefits can be calculated on the basis of Initial Daily Cash Benefits as opted by the complainants.  Ext. B3 document revealed conditions and privileges of the policy. The case of the complainant was that the first complainant undergone Hysterectomy surgery.  But according to the evidence of the opposite party as per the policy condition, Hysterectomy surgery find no place in the list of Major surgical benefits.   So in this situation, after evaluating the evidences, the Commission finds that the complainants are not eligible to get reimbursed the medical expenses as prayed in the complaint. The complainants are only entitled to be benefited as per the terms and privileges of the policy envisaged under Ext. B1 and B3 documents.

14.       This commission also finds that the opposite parties already remitted Rs.2,800/- on 23/09/2021 and Rs.16,800/- on 01/09/2021 to the complainant  as per the terms and conditions of the policy.  

15.       It is also contended in the complaint that there is deficiency of the service from the side of the opposite parties as delay occurred in approving the claim of the complainant and same caused irreparable loss and hardships. The undisputed fact that the second complainant is the holder of insurance health policy of LIC ‘Jeevan  Arogya and the wife and two children are the  beneficiaries. It is stated in the complaint and in the affidavit that the claim petition was submitted on 30/12/2019 along with all relevant documents.  But on 24/01/2020 the complainants received a letter from MedSave Health Insurance TPA Ltd, Delhi making to fulfil a query regarding detailed discharge summary for the date of admission on 26/11/2019. It can be seen that even though the first complainant submitted the discharge summary, she again sent a copy of discharge summary directly to Medsave Health Insurance TPA Ltd, Delhi, on the basis of the above query. But the first complainant did not receive the claim amount.  So as per the direction of second opposite party the first complainant again sent a letter dated 17/07/2020 along with documents to the office of first opposite party.  Moreover it is evident from the documents and affidavits of both side no communication was made out between 24-01-2020 and 17-07-2020 by the opposite party. It is a long span of time without taking any steps for addressing the claim of the complainants.  It is also stated in the complaint that the first complainant approached the office of the  Second opposite party   for several times to get her claim reimbursed but not heeded except the reply of want of details. Those facts are not denied by the opposite party in the version and in the affidavit.  But according to the opposite party delay occurred due to the non production of sufficient documents and query documents were not sent to the TPA or to the opposite parties in time by the complainant. This contention cannot be taken into consideration as it lacks support of adequate evidences.

16.       On 13/01/2021 the complainant again sent detailed letter to the first opposite party seeking explanation for the delay.  So it can be seen that the opposite parties were not taken steps to discharge the liability even during the time between 17-07-2020 to 13/01/2021. But instead, she received another  enquiry from MedSave Health Insurance TPA Ltd, Delhi demanding  a different  document regarding the doctor’ s clarification  about the details of treatment given during  the period of 21-11-2019 to 23/11/2019.   Analysing the above facts, the Commission finds that the second query   could have been avoided if the first query   dated 20/01/2020 was a proper and definite one. It is admitted by the opposite party in the affidavit that some delay was occurred in settling the claim.  While evaluating the entire documents and evidences it can be found that the complainant had produced sufficient documents at the time making claim.  It was the duty of the opposite party to disburse the claim amount due to the complainants at the earliest as per the terms and conditions of the policy.

16.       It can be also seen that the opposite party was very well aware of the nature of treatment undergone by the first complainant at Jubilee Mission hospital, Thrissur.  So Commission finds that there is delay caused in disbursing the benefits as per norms of the policy to the complainant due to the deficiency in service of the opposite party

17.       In the light of above facts and circumstances the Commission partly allows the complaint as follows:-

            1) The first opposite parties are directed to pay Rs.30,000/- ( Rupees Thirty thousand only) to the complainant  on account of  deficiency in service in causing  inconvenience and hardships to the first complainant. 

2) The first opposite parties are also directed to pay Rs.10,000/- as the cost of the proceedings to the complainant.

            The opposite parties shall comply this order within one months from the date of receipt of copy of this order, failing which the entire above mentioned amount shall bear 9% of interest per annum from the date of this order till realisation.

Dated this 30th  day of June, 2022.

Mohandasan . K, President

PreethiSivaraman.C, Member

     Mohamed Ismayil.C.V, Member

 

 

 

APPENDIX

Witness examined on the side of the complainant: Nil

Documents marked on the side of the complainant: Ext.A1 to A9

Ext.A1: Copy of the policy certificate issued by the opposite party to the 2nd

complainant.

Ext.A2: Copy of the discharge summary dated 23/01/2019 issued by Jubilee Mission

hospital , Thrissur to the first complainant .

Ext A3: Copy of the discharge  summary dated 30/11/2019 issued by Jubilee Mission

hospital, Thrissur to the first complainant.

Ext A4: Copy of the ultra scan report dated 22/11/2019 issued by Jubilee Mission

hospital , Thrissur to the first complainant.

Ext A5: Copies of the four bills issued by the Jubilee Mission hospital Thrissur to the

first complainant.

Ext.A6: Copy of query letter issued by Medsave Health Insurance TPA Ltd dated

24/01/2020 to the second complainant.

Ext.A7: Copy of letter dated 17/07/2020 issued by the first complainant to the first

opposite party.

Ext A8: Copy of the registered notice dated 13/01/2021 issued by the first

complainant to the first opposite party.

Ext A9: Copy of the query dated 18/01/2021 issued by Medsave Health Insurance 

TPA Ltd.

Witness examined on the side of the opposite party: Nil

Documents marked on the side of the opposite party: Ext. B1 to B4

Ext.B1: Copy of proposal form for health insurance policy dated 16/01/2013 filled and submitted by   the complainants.

Ext.B2: Copy of policy certificate issued in the name of the complainants.

Ext.B3: Copy of LIC’s Jeevan Arogya conditions and privileges.  

Ext.B4: Copy of payment details of full settlement of clauses in favour of the

complainant by the opposite party.

 

Mohandasan . K, President

PreethiSivaraman.C, Member

     Mohamed Ismayil.C.V, Member

 

VPH

 

 

 

 

 

 
 
[HON'BLE MR. MOHANDASAN K]
PRESIDENT
 
 
[HON'BLE MR. MOHAMED ISMAYIL CV]
MEMBER
 
 
[HON'BLE MRS. PREETHI SIVARAMAN C]
MEMBER
 

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