BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 235 of 2017

Date of Institution: 12.4.2017

Date of Decision: 17.11.2017 

Mr. Hans Raj S/o Sh. Brij Lal,  # 20 Village Chatiwind , Amritsar-143001 Punjab Mobile 9530956200

……Complainant

Versus

Star Health & Allied Insurance Company Limited through its Branch Manager SCO 25, Ist Floor, Ranjit Avenue, District Shopping Complex,Amritsar, India 143001

……Opposite Party

Complaint under section  12  of the Consumer Protection Act

Present: For the Complainant : Sh.Sumant Tuteja, Advocate.

              For  the Opposite Party: Sh. S.S. Salaria,Advocate

Coram:

Sh.Anoop Sharma, Presiding Member

Ms. Rachna Arora,Member

Order dictated by:

Sh.Anoop Sharma, Presiding Member

1.       Hans Raj,complainant has brought the instant complaint under section  12 of the Consumer Protection Act on the allegations that  complainant purchased a medical health care Insurance policy named Family Health Optima Insurance Plan for herself and his wife from the opposite party by paying annual premium of Rs. 16,638/- current policy No. P/211111/01/2017/004852 dated 19.11.2014. Thereafter the complainant paid two more annual premiums well in time. In the month of September 2016 complainant stated feeling acute pain in his knees . The complainant was referred to Dr. Tarandeep Singh gave certain pain killers to the patient and advised x-ray for both knees. On 6.10.2016 the complainant/patient followed up with the doctor alongwith x-ray report  and diagnosed osteoarthritis knee B/L and changed the medicines. Even after taking prescribed medicines regularly the complainant/patient did not get full relief so the complainant visited the doctor, who advised the patient to get the knees replaced. The complainant then approached Amandeep Hospital and Clinics for second option which hospital is also on the list of preapproved hospitals of the opposite party for cashless treatment. The complainant on reaching the hospital explained the health condition to the doctor , who after doing investigations diagnosed the same problem of B/L O.A. of Knee and advised knee replacement. The complainant intimated the hospital authorities that he is covered under a cashless health care program covered by the opposite party and on listening the same the hospital staff told the complainant to handover the copies of policy related documents for online cashless approval from opposite party. The complainant submitted all the necessary documents to the  person concerned of hospital upon which the hospital received a communication confirming the receipt of cashless claim  and the denial of cashless claim for want of further document. The complainant again visited Amandeep Hospital and  Clinics on 11.2.2017 and expressed his willingness to follow the surgical procedure upon which the doctor concerned checked for the fitness level of the patient. On investigation the doctor found all parameters well under control and gave a green signal to surgery. The complainant visited Dr. Tarandeep Singh on 1.3.2017 and asked him to prepare a doctor’s note for the compliance of cashless claim procedures . The complainant complied with the formalities of the requirement  of further documents and submitted all the documents required by the opposite party to them and intimated the concerned staff to send the required information to the opposite party which was complied with.  However despite complying with all the formalities the complainant got a phone call on his mobile regarding the rejection of cashless claim. Despite clear cut medical reports of no previous medical history opposite party did not entertain the request of cashless claim of the complainant.  Thereafter the complainant visited the office of the opposite party and narrated the entire story to the executive available, who in turn refused to accept the request of cashless claim and said that the complainant can get the surgery done on his own expenses and send the bills and documents to the opposite party for reimbursement which will be considered on merits at that time. The complainant who belongs to a middle class family and cannot bear the surgery cost  and keeping such contingency in mind the complainant got himself medically insured. The opposite party is guilty of rendering deficient services to the complainant  and has failed to discharge their responsibility at the time of transaction . Vide instant complaint, complainant has sought for the following reliefs:-

(a)     Opposite party be directed to allow the request of cashless claim for complainant with immediate effect ;

(b)     Compensation as well as litigation expenses to the tune of Rs. 30000/- be also awarded to the complainant.

Hence, this complaint.

2.       Upon notice, opposite party appeared and filed written version in which it was submitted that the complainant obtained the policy of Family Health Optima Insurance Policy from the opposite party covering Mr.Hans Raj self, Mrs. Shakuntla spouse for the sum insured of Rs. 4,00,000/- vide policy N. P/211111/01/2015/003001 from 19.11.2014 to 18.11.2015, policy No. P/21111/01/2016/003659 from 19.11.2015 to 18.11.2016 and Policy No. P/211111/01/2017/004862 from 19.11.2016 to 18.11.2017. The claim was reported in the third year of the policy  and the insured was admitted in Amandeep Hospital on 2.2.2017 for the treatment of B/L OA KNEE and submitted pre-authorization request for cashless treatment vide claim No. 399061. On perusal of documents submitted by the treating hospital, it was observed that :-

“As per Pre-Auth Form, the insured was admitted with the complaints of pain and unable to walk properly and the provisional diagnosis was OA Knee Bilateral.

-X-ray image shows severe osteoarthritis

-As per the treating doctor letter, which is submitted in response of the query dated 1.2.2017, the insured was first diagnosed as OA Knee Bilateral on 6.10.2016 whereas the X-ray was taken on 4.10.2016.

From the above findings, it was observed that there was discrepancy in the onset and the duration of the current claim. Hence, the cashless authorization was denied and complainant was requested to approach for reimbursement of medical expenses vide letter dated 2.2.2017. However, after that the opposite party sent the claim form to the insured  to approach for reimbursement of medical expenses vide letter dated 4.2.2017 and it was followed by reminders dated 19.2.2017, 6.3.2017 and 21.3.2017 but the insured has not submitted the claim records for reimbursement of medical expenses. The complainant was again admitted in Amandeep Hospital on 5.2.2017 for the treatment of B/L OA Knee and submitted pre authorization request for cashless treatment  vide claim No. 403292. On perusal of the documents submitted by the treating hospital, it was observed that :-

As per Pre-Auth Form, the insured was admitted with the complaints of pain and unable to walk properly and the provisional diagnosis was OA Knee Bilateral.

X-ray image shows severe osteoarthritis

-with the available documents, it was unable to ascertain the onset of disease. Hence, the opposite party was unable to authorize cashless and as such the complainant/insured was requested to approach for reimbursement of medical expenses and the same was communicated to the insured and the treating hospital vide letter dated 3.2.2017. But the insured has not submitted the claim records for reimbursement of medical expenses

While submitted that as the complainant has not submitted the claim records for reimbursement of medical expenses for both the claims , as such the complaint of the complainant being pre-mature is liable to be dismissed and while denying and controverting other allegations, dismissal of complaint was prayed.

3.       In his bid to prove the case Sh.Sumant Tuteja, Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.CW1/A, copy of insurance policy Ex.C-1, copy of renewal receipt Ex.C-2 and Ex.C-3, copy of doctor prescription slips Ex.C-4 and Ex.C-5, copy of x-ray Ex.C-6, copy of second  doctor prescription slip Ex.C-7, copy of the OPD receipt Ex.C-8, copy of insurance cover note Ex.C-9, copy of denial Ex.C-10, copy of OPD receipt and investigation report Ex.C-11 and Ex.C-12 and closed the evidence on behalf of the complainant.

4.       To rebut the aforesaid evidence Sh. S.S. Salaria,Adv.counsel for the opposite party tendered into evidence duly sworn affidavit of Sh. P.C. Tripathy, Zonal Manager  Ex.OP1, copy of terms and conditions Ex.OP2, copy of proposal form Ex.OP3, copy of policy schedule Ex.OP4, copy of policy schedule Ex.OP5 Ex.OP6, copy of advance premium receipt Ex.OP7, copy of claim form Part A Ex.OP8, copy of claim form Part B Ex.OP8/1, coy of the request for cashless hospitalization for medical Insurance policy Ex.OP9, copy of the query on pre-authorization Ex.OP10 and Ex.OP11, copy of denial for pre-authorization for cashless treatment Ex.OP12, copy of medical examination report Ex.OP13, copy of letter from Shakuntala to the opposite party Ex.OP14 and Ex.OP15, copy of reimbursement of medical claim dated 4.2.2017 Ex.OP16 and Ex.OP17, copy of rejection letter dated 21.3.2017 Ex.OP18, copy of first reminder dated 19.2.2017 Ex.OP19, copy of second reminder Ex.OP20, copy of OPD receipt  Ex.OP21 and Ex.OP22 and closed the evidence on behalf of the opposite party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the record on the file.

6.       Ld. Counsel for the opposite party has vehemently contended that there was discrepancy in the onset and the duration of the current claim. Hence, the cashless authorization was denied and the complainant was requested to approach for reimbursement of medical expenses vide letter dated 2.2.2017. However, after that the opposite party sent the claim form to the insured  to approach for reimbursement of medical expenses vide letter dated 4.2.2017 and it was followed by reminders dated 19.2.2017, 6.3.2017 and 21.3.2017 but the insured has not submitted the claim records for reimbursement of medical expenses. The complainant was again admitted in Amandeep Hospital on 5.2.2017 for the treatment of B/L OA Knee and submitted pre authorization request for cashless treatment  vide claim No. 403292. On perusal of the  available documents, it was unable to ascertain the onset of disease . Hence, the opposite party was unable to authorize cashless and as such the complainant/insured was requested to approach for reimbursement of medical expenses and the same was communicated to the insured and the treating hospital vide letter dated 3.2.2017. But the insured has not submitted the claim records for reimbursement of medical expenses. It was submitted that as complaint being pre-mature is liable to be dismissed . Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party.

7.       During the course of arguments, it was found the opposite party is limited company and the written version has been filed by Zonal Manager P.C. Tripathy, whereas no resolution has been passed by the company authorizing the Zonal Manager to proceed with the instant complaint. It is settled law that the resolution should be passed in favour of the person appearing on behalf of the company. Reliance in this connection can be placed upon L.G. Electronic India Pvt.Ltd. Vs. Sita Ram Chaudhary in First Appeal No. 1235 of 2015 decided on 25.1.2017 of our own Hon’ble Punjab State Consumer Disputes Redressal Commission,Chandigarh in which it was held that  in the absence of any resolution of the company or any memorandum/articles of the company to show that Sh.Soonwon Kwon is Director and that he was further authorized to issue power of attorney in favour of Sh.Bhupinder Singh, as such the appeal stands dismissed being not filed by competent person on behalf of the company. As the written version has been filed by Sh.P.C. Tripathy, Zonal Manager in whose favour no resolution by the company has been passed to appear before this Forum, as such no evidentiary value can be placed upon the written version filed by the opposite party.

8.       The case of the complainant that he obtained Family Health Optima Insurance Plan bearing policy No. P/211111/01/2017/004852 dated 19.11.2014. Thereafter the complainant paid two more annual premiums well in time. In the month of September 2016 complainant stated feeling acute pain in his knees and even after taking prescribed medicines regularly the complainant/patient did not get full relief so the complainant visited the doctor, who advised the patient to get the knees replaced. The complainant then approached Amandeep Hospital and Clinics for second option which hospital is also on the list of preapproved hospitals of the opposite party for cashless treatment and intimated the hospital authorities that he is covered under a cashless health care program covered by the opposite party and on the asking of the hospital authorities, the complainant submitted all the necessary documents. But the cashless claim of the complainant was denied by the opposite party. The complainant again visited Amandeep Hospital and  Clinics on 11.2.2017 where Dr. Tarandeep Singh asked him to prepare a doctor’s note for the compliance of cashless claim procedures . The complainant complied with the formalities of the requirement  of further documents and submitted all the documents required by the opposite party to them and intimated the concerned staff to send the required information to the opposite party which was complied with.  However despite complying with all the formalities the complainant got a phone call on his mobile regarding the rejection of cashless claim. It was the case of the complainant that he belongs to a middle class family and cannot bear the surgery cost  and keeping such contingency in mind the complainant got himself medically insured.

9.       From the appraisal of the evidence on record, it becomes evident that the complainant has been obtaining the Family Health Optima Insurance Plan since 19.11.2014 under cashless scheme. Copies of Insurance policies are Ex.C-1 to Ex.C-3. The request for cashless treatment was denied by the opposite party on false and frivolous ground as per denial letter , copy of which is Ex.C-10 on record. As the complainant has been obtaining the Health Insurance policy since 2014 and thereafter renewing the same from time to time, as such the complainant is entitled to the cashless treatment and the act of the opposite party to deny the genuine claim of the complainant amounts to deficiency in service. On the other hand the written version was filed by Sh.P.C. Tripathy,Zonal Manager, but however no resolution has been filed by the opposite party authorizing him to file written version on behalf of the opposite party. As such, we hold that the complainant is entitled to the cashless treatment .

10.     Consequently , the complaint is allowed and the opposite party is directed to allow the cashless claim of the complainant . As the opposite party by not allowing the complainant for cashless treatment harassed the complainant for which the opposite party is liable to pay compensation to the tune of Rs. 5000/- while litigation expenses are assessed at Rs. 2000/-. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated : 17.11.2017