Complaint filed on: 16.08.2014
Disposed on: 27-07-2016
BEFORE THE BENGALURU III ADDITIONAL DISTRICT
CONSUMER DISPUTES REDRESSAL FORUM,
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM COMPLEX, 1ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027
CC.No.1446/2014
DATED THIS THE 27th DAY OF JULY 2016
PRESENT
SRI.H.S.RAMAKRISHNA, PRESIDENT
SMT.L.MAMATHA, MEMBER
Complainant: -
B.S.Raghavan,
Aged about 56 years,
S/o B.N.Srinivasa murthy
R/ at No.1412, “Sowmya”,
South end A Main,
9th block, Jayanagar, Bangalore-560069
V/s
Opposite parties:-
- Star Health and Allied Insurance Co. Ltd.,
221, 1st floor, 9th main road, 5th block, Jayanagar, Bangalore-560041.
Rep by its General Manager, Having its Registered and Corporate Office at: 1,
New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai-600034,
Rep by its General Manager
- Star Health and Allied Insurance Co., Ltd., Corporate Claims Department, 6th Floor, K.R.M Centre, No.2, Harrington Road, Chetpet, Chennai-600031, Rep by its General Manager
ORDER
SRI.H.S.RAMAKRISHNA, PRESIDENT
This is a complaint filed by the complainant on 16.08.2014 against the Opposite Parties, under section 12 of the Consumer Protection Act, 1986, to direct the OPs to reimburse the hospital expenses of Rs.3,00,000.00 and to pay compensation of Rs.3,00,000.00 for the inconvenience and mental agony caused to him. Directing to the OPs to pay interest 24% from the date of denial cashless benefit that is from 13.02.2014 to till the date of payment.
2. In the complaint, the complainant alleged that complainant took a policy named as Family Health Optima Insurance Policy with OP No.1 which covered himself, his wife and daughter. The Policy bearing policy No.P/141125/01/2014/001199 for the period 05.06.2013 to midnight of 04.06.2014 and the limit of the coverage was 3,00,000.00. Total premium to be paid along with the service tax was Rs.14,416.00, Complainant paid the premium of Rs.14,416.00. After receipt of the premium amount the Opposite Party No.1 said that complainant had to undergo the medical checkup at the hospital suggested by them. Complainant agreed and underwent the medical checkup at Ragavs Diagnostic & Research Centre Pvt Ltd., as suggested by the Opposite Party No.1. The policy excluded diabetes mellitus & its complication from the insurance coverage. The limit of the insurance coverage was Rs.3,00,000.00. As per the terms of the policy complainant, his wife and daughter were to be reimbursed for any hospital expenses incurred by them for medical/surgical treatment during the period of the policy, to the limit of Rs.3,00,000.00. The complainant used to go his family Dr.Manjunath for regular health checkups, somewhere in the month of November/December 2014, when the said Dr.Manjunath examined the complainant and checked his BP, he informed the complainant that he has developed the slight hypertension and prescribed some tablets. Complainant again went for routine health check up with Dr.Manjunath on 08.02.2014. After examination of the complainant doctor suggested a few tests to be undergone by the complainant. As per the advice of Dr.Manjunath, complainant underwent various tests. Noticing that the stress test was positive. Dr.Manjunath suggested the complainant to undergo further tests as per which complainant underwent 64 SLICE CT CORONARY ANGIOGRAM. After going through the test reports of the complainant Dr.Manjunath further referred to Dr.Venkatesh cardiologist for further treatment. Complainant consulted Dr.Venkatesh at Fortis Hospital and the said doctor after examining the complainant and going through the test reports of the complainant suggested him to get admitted for coronary angiography. As per the advice of Dr.Venkatesh complainant got admitted to Fortis Hospital on 13.02.2014 and underwent Coronary Angiography and other tests. The Coronary Anzio report showed that the complainant suffered from Double Vessel Coronary Artery disease, Left dominant circulation and was advised immediate surgery. Complainant informed the hospital that he has medical insurance, the hospital sent across pre-authorization for cashless treatment to the Opposite Party No.2 who is the claims department of Opposite Party No.1 rejected the pre-authorization for cashless treatment stated that the complainant would have been symptomatic prior to the inception of the policy. Based on the all the test reports as per the advice of Dr.Venkatesh, complainant underwent OP CABG X 3 GRAFT (Coronary Artery Bypass Surgery) on 15.02.2014 on Fortis Hospital. Subsequent tests after the said surgery until the date of discharge which produced. After going through the tests and examining the complainant the doctors at Fortis Hospital informed him that he was fit for discharge on 20.02.2014. Since the Opposite parties had refused cashless benefit, the complainant had to arrange for the payment of the hospital bills to get discharged. The complainant paid the amount borrowed from his brother to pay the hospital bill. Complainant submitted a claim form dated 25.02.2014. As the complainant got no response from the Opposite parties. He wrote a letter dated 01.03.2014 to the Opposite party No.1 explaining that he was not suffering from Hypertension, Hyperlipidemia and DVD prior to the inception of the policy. When he went for medical checkup at the time of inception of the policy at the designated hospital of the Opposite party No.1 and therefore requested them to settle his claim at the earliest. In support of his say that he was no symptomatic prior to the inception of the policy, he enclosed various documents like doctor’s prescriptions and hospital bills including advice letters of the Dr.Manjunath show that as on 12.02.2014 complainant was suffering from hypertension from fast 3 months that means complainant was suffering from hypertension from November 2013, whereas the policy issued in June 2013. Even after the receipt of the letter dated 01.03.2014 explained that he was not symptomatic before the inception of the policy and producing all documents in regarding to that the Opposite parties did not reply for the complainant. Hence the complainant sent an e-mail dated 26.03.2014 reminding them, the letter dated 01.03.2014 and requesting them to know all the status of his claim. The Opposite party No.1 replied by e-mail dated 26.03.2014 stating that the claim is under process and they will revert back on the developments in a next couple of days. Complainant waited hoping that the Opposite party No.1 would revert back to him within 2 days as told by them. But when the Opposite party No.1 revert back saying that the claim is under process. But after that, again, there was no response from the Opposite party. Hence the complainant sent an e-mail dated 05.04.2014 enquiring as to why he has not yet been given the claim reference number and why it is taking so long for the Opposite parties to process his claim. But there was no response from the Opposite parties. Complainant further sent them e-mails dated 08.04.2014, 10.04.2014, 14.04.2014, 16.04.2014 and 20.04.2014. Finally the Opposite parties replied by an e-mail dated 21.04.2014 stating that his claim is repudiated as his Hypertension was pre-existing disease and the same was not disclosed at the inception of the policy and present ailment is a complication of the pre-existing disease. Complainant replied back by mail dated 21.04.2014 clarifying again that he did not have hypertension at the time of inception of the policy. Complainant in the said mail clarifies that as per the letter dated 12.02.2014 of Dr.Manjunath, it can be very clearly made out that he had hypertension since 3 months that is from November 2013. Whereas he had taken the policy in the month of June 2013. He had also undergone medical checkup at the designated hospital of the Opposite parties before getting the policy and he was only diagnosed with Diabetes Mellitus and the same was excluded from the policy cover. He was not diagnosed that hypertension at that time. He further clarified that the hospital records on which Opposite parties are relying for coming to the conclusion that he had hypertension before the inception of the policy could not be relied out as the attending doctor by mistake had mentioned in the pre-authorization request form, that the complainant was suffering from hypertension from last 5 years in fact it is clear that where the doctor wrote 5 months in the request of pre-authorization letter as the same is not legible. Even after the receipt of the said e-mail of the complainant dated 21.04.2014 clarifying on all the issues raised by the Opposite parties. They did not revert back to the complainant. Complainant again sent e-mails dated 28.04.2014 and 30.04.2014 to the Opposite parties. When there was no response from the Opposite parties, the complainant sent them e-mail dated 05.05.2014 asking them to send back all his original documents which he had submitted to them. The Opposite parties replied stating that they will send across the same. The Opposite parties have repudiated the claim of the complainant for no valid reasons and without reasonable cause. Hence the complaint.
3. In response to the notice the Opposite party No.1 & 2 put their appearance through their counsel. Opposite party No.1 & 2 filed agreement version, in their version pleaded that complaint is not maintainable either in law and or on facts. Complainant has taken the alleged policy for the period subject to the terms & conditions. As per the exclusion clauses of the policy, the company shall not be liable to make any payments under the policy in respect of any expenses what so ever incurred by any insured person in connection with or in respect of pre-existing diseases as defined in the policy until 48 months of the continuous coverage have elapsed, since the inception of the first policy. The Opposite party is obliged to process the claim subject to scrutiny of the documents that will be furnished by the insured, the claim will be examined accordingly, and if payable, it will be paid and if, the claim falls under any exclusion clauses of the contract, the decision will be taken accordingly. Thus, in the case of the complainant the claim has been repudiated as the claim pertaining to preexisting disease and the non-disclosure of the material facts at the time of the inception of the policy. The disease falls under the condition pertaining to the preexisting disease and also disease is excluded under first year of operation of the policy. Hence, the Opponents are unable to pay the amount as per the policy. Hence the complainant deserves to be dismissed.
4. There is no deficiency of services rendered by the Opposite parties as to invoke the provisions of Consumer Protection Act. Both for the reasons the claim is not payable and for the reasons that the claim of the complainant has been repudiated after the due application of mind on the documents and following due procedures as per the contract of the insurance. Within the short span after getting the copies of the documents and the claim being made by the complainant. Hence no deficiency of service is rendered. The transaction is purely contractual and deciding of the facts will be only within the great scope of contract, no independent or sympathetic farfetched view of the contract can be taken, contrary to the agreed terms & conditions and the rules and regulations and procedures enshrined in the insurance laws. The repudiation of the claim does not amount to deficiency of service when the same is done after due scrutiny of the claim and due application of mind in accordant with the contract. As per the discharge summary insured had past history and a known case of hypertension and is on medication. The case papers reveals that the insured is known case of hypertension for past 5 years. As per the authorization request form submitted by the hospital which was duly signed by the insured, he had past history of hypertension since 5 years. Thus the present hospitalization is for the management of an ailment which is related with the pre-existing condition of the patient. As per the exclusion number 1 of the policy, company is not liable to make any payment in respect of the expenses for treatment of pre-existing disease until 48 months of continuous coverage has elapsed, since the inception of the first policy with the company. Hence the claim was repudiated and same was communicated to the insured vide letter dated 17.04.2014. The claims that, complainant visited Dr.Manjunath on 08.02.2014 and he examined him and opined that he has developed hypertension slightly and prescribed some tablets for the first time and then he went for routine health check up to the said doctor on 08.02.2014. He suggested few tests by giving prescriptions and the Complainant underwent various tests. The bills and the contents therein are genuine, the ultrasonography report dated 08.02.2014 are rendered and TMT test was conducted and the laboratory reports dated 09.02.2014 speaks truth and the tests are really conducted and the findings are true and corrected as claimed. None of the averments and contents of the documents are admitted. The Complainant is called upon to prove each and every averment which opposed to the averments off the version stated above. The complainant is called upon to prove all the needs of the alleged tests, the tests conducted, the result of the tests, the alleged impacts of the alleged ailments suffering or would suffer and the expenses incurred and the advises of the doctors as claimed. The diabetes and hypertensions and the other related ailments have great influence on the heart disease also. The heart disease occur and aggravate when there is the said hypertension and diabetes. Hence, the alleged ailments claimed by the complainant have a source of problem from the diabetes and hypertension. Hence, the Opponent has rejected cashless on verification of the pre-authorization letter issued by the treating doctor, which revealed that complainant was suffering from hypertension since 5 years, which was not revealed at the inception of the policy, the complainant has breached that the policy terms & conditions. The complainant was not suffering from hypertension since more than 5 years and the rejection of claim is unjustified on deficiency of service. The approaching of claimant for settlement of his claims though is true, it is equally true that, the claim is not payable, as there is suppression of the fact pertaining to the hypertension and being there under medication. In the discharge summary past history it is clearly mentioned known case of hypertension on medication. The repudiation of the claim is not done without verification of facts and it has been done with due application of the mind and with by observing the qualified doctors expresses
opinion. Hence, there is no deficiency of service. Hence, he prays to dismiss the complaint.
5. We heard arguments of the both the parties, now the points arise for our consideration are:-
- Whether the complainant proves that there is a deficiency of service by the Opposite party No.1 & 2 ?
- What the order ?
6. Our findings on the above points are:-
1. Point No.1: Affirmative
2. Point No.2: As per the final order
REASONS
7. It is the case of the Complainant, the Complainant took Family Health Optima insurance policy bearing No.P/141125/01/2014/001199 for the period 05.06.2013 to midnight 04.06.2014 and the limit of coverage was 3,00,000.00. The total premium to be paid along with service tax was Rs.14,416.00, covering risk of complainant, his wife and daughter. In order to substantiate this, the complainant in his sworn testimony reiterated the same and produced the Family Health Optima insurance policy. By looking in to this document it is in the name of the complainant and policy bearing No.P/141125/01/
2014/001199, total premium amount is Rs.14,416.00 and period of the insurance is 05.06.2013 to 04.06.2014. Name of the insured persons are Mr.B.S.Ragahvan the complainant, Mrs.Kavitha Ragahavan – wife and Raksha Raghavan – daughter and the total sum assured is 3,00,000.00 and also produced the copy of the receipt regarding the payments of premium amount of Rs.15,118.00. This evidence of the complainant remains unchallenged to disbelieve. The evidence of the complainant, there is no rebuttal evidence. Thereby it is proper to accept the contention of complainant. Complainant took Family Health Optima insurance policy bearing No.P/141125/01/2014/001199 for a period 05.06.2013 to 04.06.2014, limit of the coverage was 3,00,000.00 and premium amount is Rs.14,416.00 and insured for himself, his wife Kavitha Raghavan and his daughter Raksha Ragahvan.
8. It is further case of the complainant that after receipt of the premium amount the Opposite party No.1 said that the complainant had to undergo a medical checkup at the hospital suggested by hem. The complainant agreed and underwent medical checkup at Ragavs diagnostic & research centre pvt ltd., Jayanagar. To substantiate this fact complainant in his sworn testimony reiterated the same and also produced the laboratory test reports issued by the Ragavs diagnostic & research centre. By looking in to this documents, the report is dated 18.06.2013 and reported that complainant is non-diabetic.
Even this evidence of the complainant also unchallenged and discard the evidence of the complainant, there is no rebuttal evidence, thereby it is proper to accept the contention of the complainant that, complainant after receipt of the premium amount by the Opposite party and as per the direction the complainant undergone medical checkup in Ragavs diagnostic & research centre and he has non-diabetic.
9. It is the case of the complainant, the complainant used to go his family Dr.Manjunath for regular health checkup. Somewhere in the month of November/ December 2013, when the said Dr.Manjunath examined the complainant and checked his BP, he informed the complainant that he has developed slight hypertension and prescribed some tablets. The complainant again went for routine health check up on 08.02.2014, after examination of the complaint Dr. Manjunath suggested a few tests to be undergone by the complainant, noting that stress test was positive. Dr.Manjunath suggested the complainant to undergo for the tests as per which the complainant underwent 64 SLICE CT CORONARY ANGIOGRAM. After going through the test of the complainant, Dr.Manjunath referred to the Dr.Venkatesh cardiologist for further treatment. The complainant consulted Dr.Venkatesh at Fortis Hospital, after examining the complainant and going the through the test reports of the complainant, doctor suggested him to get admited for coronary angiography and as per the advice of the Dr.Venkatesh, Complainant got
admitted to the Fortis Hospital on 13.02.2014 and under went coronary angiography and other tests. The complainant informed the hospital that he has medical insurance. The hospital sent across pre-authorization for cashless treatment to the Opposite party No.2 who is the claims department of Opposite party No.1 rejected the pre-authorization for cashless treatment stating that complainant would have been symptomatic prior to the inception of the policy. Based on all the test reports as per the advice of Dr.Venkatesh, the complainant underwent for operation Coronary Artery Bypass Surgery on 15.02.2014 at Fortis Hospital and discharged on 22.02.2014. Since Opposite parties had refused cashless benefit, the complainant had to arrange for the payment of the hospital bills and get discharged. Complainant submitted claim form dated 25.02.2014 seeking for settlement his medical claim. The Opposite party replied by e-mail dated 21.04.2014 stating that his claim repudiated as his hypertension was preexisting disease and same was not disclosed at the inception of the policy and present ailment is a complication of the preexisting disease. In order to substantiate this fact, complainant under his affidavit reiterated the same and also produced the prescription of medical bill and various reports. By looking in to these reports, complainant undergone difference tests as advised by the Dr.Manjunath and found that he had developed hypertension, due to this Dr.Manjunath referred to Dr.Venkatesh cardiologist for further treatment. This fact is also supported as looking in to the letter dated
12.02.2014 issued by Dr.Manjunath. Under this letter Dr.Manjunath referred the complainant to Dr.Venkatesh cardiologist and also reveals that complainant is known hypertension since 3 months. Dr.Venkatesh of Fortis Hospital after examining the complainant advice to him for Coronary Angiography on 12.02.2014 and as per the Coronary Angiography report of Fortis Hospital complainant had Double Vessel Coronary Artery disease, Left dominant circulation and advice for CABG. For that reason complainant send pre-authorization request form across by the Fortis Hospital and the said preauthorization request of the complaint was rejected by the Opposite party No.2. To substantiate this fact complainant produced the copy of the pre-authorization request form. By looking in to this documents it clearly reveals that the complainant submitted pre-authorization request form for the CABG treatment. Approximate cost of the treatment is 2,78,400.00 but Opposite party No.2 in his letter dated 13.02.2014 denial the pre-authorization for cashless treatment. On the ground that the patient would have been symptomatic prior to the inception of the policy. Complainant on the advice of the Dr.Venkatesh underwent the operation CABG on 15.02.2014 at Fortis Hospital. In support of this complainant produced the operation theatre note and also discharge summary. By looking into this it is clear that the complainant admitted to Fortis Hospital on 13.02.2014 and discharged on 20.02.2014 and undergone surgery on 15.02.2014. Since the Opposite parties fails to settle the pre-authorization request the complainant
himself paid the hospital charges of bills for sum of Rs.3,54,966.00. This evidence of the complainant also unchallenged to discard of the testimony of the complainant, there is no rebuttal evidence, therefore it is proper to accept the contention of the complainant. When the complainant on the advice of the Dr.Venkatesh he undergone surgery of CABT on 15.02.2014 in Fortis Hospital and for that he incurred expenses of Rs.3,54,966.00 and the complainant settled the Fortis Hospital bill.
10. After discharge from the hospital complainant submitted claim form on 25.02.2014 for settlement his medical claim. But Opposite party by sending e-mail on 21.04.2014 repudiated the claim. Even to substantiate this also complainant in his evidence reiterated the same and produced the claim form. By looking in to this claim form complainant claimed at reimbursement of Rs.3,54,966.00. Even though the complainant submitted the claim form on 25.05.2014, the Opposite party have not taken any action inspite of demand and request made by the complainant. This is the evidence, by looking in to the letter addressed by the complainant on 01.03.2014 and also email correspondences. After making several efforts by the complainant, the Opposite party repudiated the claim of the complainant by addressing the letter dated 16.04.2014. By looking in to this letter it clears that Opposite party have repudiated the claim of the complainant. On the ground that complainant is a known
case of hypertension for past 5 years prior to the date of inception of the policy. Now in support of the defence of the Opposite party that the claim of the complainant was rejected on the ground that the complainant is known case of hypertension since 5 years prior to the inception of the policy. John Noronha, Assistant Vice president of the Opposite party filed his affidavit and in his affidavit reiterated the same and also produced the proposal form of the complainant. In the proposal form the complainant has clearly mentioned that he has no BP, Heart disease at the time of the inception of the policy and the complainant was referred to the Ragavs Diagnostic & Research Centre for medical checkup. And Ragavs Diagnostic & Research Centre, Jayanagar after examining the complainant on 09.06.2013 submitted the report. As looking in to this report it is not mentioned that complainant had no hypertension at the time of submitting the proposal form for the policy. And after taking this report from the Ragavs Diagnostic & Research Centre, the Opposite party issued the policy in favour of the complainant and further Opposite party have produced the copy of the admission history and physical assessment form of Fortis Hospital. Only in this document it is mentioned that the complainant had hypertension since 5 years. But to establish the same the Opposite party have not examined the concerned doctor who has issued this documents. On the other hand the Opposite party themselves produced the report submitted by Ragavs Diagnostic & Research Centre at the time of inception of the policy. If the complainant had known hypertension the Ragavs Diagnostic &
Research Centre ought to have report the same. But on the other hand, by looking in to their report issued by the Ragavs Diagnostic & Research Centre, there is no such report that the complainant had hypertension, thereby oversight or mistake at the time of admission in the Fortis Hospital it is wrongly mentioned as the complainant had hypertension since 5 years. Even this fact falsifies, as looking in to the evidence produced by the complainant. That is the report of the Dr.Manjunath who is the family physician of the complainant, thereby it is not proper to accept the defence taken by Opposite party that the complainant had hypertension prior to 5 years since the inception of the policy.
11. The learned counsel for the Opposite party argued before me, the repudiation of the claim of the complainant is proper and in accordance with the procedure as per the terms & conditions of the policy. The Complainant suppressed that he had hypertension since 5 years prior to the date of the inception of the policy, so on that basis the claim of the complainant was repudiated, since the contract of insurance is a abromofide and by rejection of the claim of the complainant will not amounts to deficiency in service. In support of his arguments he relied upon the decision. A decision reported in Oriental Insurance Co. Ltd. Vs Samayanallur Primary Agricultural Co-op Bank, AIR2000SC10, on looking in to the above said decision referred by the learned counsel for the Opposite party, the ratio rendered in the above said decision are not
applicable to the facts of this case. There by it is not proper to accept the arguments of the learned counsel for the Opposite party that the repudiation of the claim of the complainant is in accordance and by adopting proper procedure.
12. On the other hand, learned counsel for the complainant argued before me that the complainant is a policy holder during the enforcement of the policy, complainant undergone treatment in Malathi Manipal Hospital and also Fortis Hospital. Where the complainant undergone surgery, for that the complainant incurred a sum of Rs.3,54,966.00, at first instance the complainant send pre-authorization request but that was denied by the Opposite party No.2. Thereafter the Complainant paid the entire bill and after discharged. When the Complainant along with all the necessary documents presented by the claim form, but Opposite party without assigning proper reasons repudiated the claim. On the ground that there is preexistence of hypertension since 5 years prior to the inception of the policy. Even though there is no such ailment in support of his arguments, he relied upon. A decision reported in Charan Singh Vs Health touch hospital and others AIR2000SC3138, as looking in to this decision, the law laid down in the above decision is applicable to the facts of this case. Since the Opposite party rejected the claim of the complainant without proper reasons, therefore it is proper to accept the arguments put forth by the learned counsel for the complainant. That the
complainant entitled for reimbursement of medical bills, hospital bills, since the repudiation of the claim of the complainant is not justifiable. The evidence of the complainant clearly goes to show that the complainant had known hypertension prior to 5 years from the date of inception of the policy. Since in the admission history and physical assessment form of Fortis Hospital, it has wrongly mentioned as complainant had hypertension since 5 years basing on that the claim of the complainant was repudiated. That is unreasonable because before issuing the policy, Opposite party themselves referred to the complainant for medical checkup with Ragavs Diagnostic & Research Centre. In Ragavs Diagnostic & Research Centre after thorough examination, submitted the report, in the event of the complainant having a hypertension since 5 years. That should be reflecting in the report submitted by the Ragavs Diagnostic & Research Centre. But it is not so, thereby the reason assigned by the Opposite party for rejecting the claim of the complainant is not proper and in accordance with the procedure. Thereby this amounts to deficiency in service, since it is the bounden duty of the Opposite party to honour the claim of the complainant, instead honour the claim of the complainant they rejected the claim without proper reasons and inspite of repeated requests and the letter for reconsideration also rejected by the Opposite party. This clearly amounts that deficiency of service on the part of the Opposite party. Hence I answered point No.1 in affirmative and proceed to pass the following.
ORDER
The complaint is allowed holding that there is deficiency of service on the part of the Opposite Party No.1 & 2. The Opposite Party No.1 & 2 are directed to reimburse a sum of Rs.3,00,000.00 to the complainant and also to pay a sum of Rs.50,000.00 as compensation for causing mental agony and to pay a sum of Rs.5,000.00 towards cost of this proceedings. The Opposite Party No.1 & 2 are directed to pay the aforesaid amount within 30 days from the date of this order. Failing which the aforesaid amount shall carry interest at 15% p.a. from the date of this order till the date of this realization.
Supply free copy of this order to both parties.
(Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 27th day of July 2016).
MEMBER PRESIDENT
-:ANNEXURES:-
1. Witness examined on behalf of the complainant by way of affidavit:
B.S.Raghavan, who being the complainant was
examined.
2. Documents produced on behalf of the complainant:-
1) Receipt dated 05.06.2013
2) Report issued by Ragavs Diagnostic & Research
Centre
3) Letter dated 20.06.2013 issued by OP No.1
4) Medical Insurance policy bearing
No.P/141125/01/2014/001199
5) Customer Identity Card of the complainant
6) Prescription dated 08.02.2014
7) Bill dated 08.02.2014
8) Ultrasonography Report dated 08.02.2014
9) TMT Report dated 08.02.2014
10) Reports dated 09.02.2014
11) Test report of 64 SLICE CT CORONARY
ANGIOGRAM
12) Bill dated 11.02.2014
13) Reference letter dated 12.02.2014 issued by
Dr.Manjunath
14) Hospital bill dated 12.02.2014
15) Advice of Dr.Venkatesh dated 12.02.2014
16) Coronary Angio Report dated 13.02.2014 of the
Complainant
17) Test reports dated 13.02.2014 to 15.02.2014
18) Pre-authorization request dated 13.02.2014
19) Letter of Denial of pre-authorization for cashless
treatment dated 13.02.2014
20) Operation notes dated 15.02.2014
21) Test reports dated 16.02.2014 to 18.02.2014
22) Discharge summary
23) Hospital bills
24) Hospital receipts
25) Claim Form dated 25.02.2014
26) Letter dated 01.03.2014
27) Entire e-mail communication between the
complainant and opposite parties
28) Repudiation letter dated 16.04.2014
3. Witness examined on behalf of the Opposite party by way of affidavit:
John Noronha, Asst.Vice president of the zonal office
at Bangalore who being the Opposite Party was
examined.
4. Documents produced on behalf of the Opposite party :-
1) Admission History and Physical Assessment Form (pertaining to the health of the complainant-of Fortis Hospital)
2) Proposal Form No.80025249
MEMBER PRESIDENT
