IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM

Dated this the  22nd day of  December, 2023

Present:    Sri.Manulal.V.S, President

                                                                                                 Smt.Bindhu.R, Member

                                                                                                 Sri.K.M.Anto, Member

CC No.88/2023 (Filed on 23/03/2023)

                                                                 Complainant                         :     Robi Thomas, 

                                                                                                                     Koottumkal House,

                                                                                                                     Poonjar P.O,

                                                                                                                     Kottayam – 686 581.

                                                         (By Advs: Binoy Abraham & Jose Tom)                                                                                                                                                                                                                                                       Vs.  

                    Opposite party                        :     Star Health & Allied Insurance  Company Ltd.,

                                                                          Branch Office, 

                                                                                                                     First Floor, Peekas  Arcade,

                                                                                                                     No.20/728,

                                                                                                                     Ponkunnam P.O,

                                                                                                                     Kottayam – 686 506,

                                                                                                                     Represented by the Branch Manager,

                                                                                                                      (By Adv: Avaneesh V.N)                                            

O R D E R

Sri.Manulal.V.S, President

The complaint is filed under Section 35 of the Consumer Protection Act 2019.

Case of the complainant is as follows:

Complainant availed a medical insurance policy from the opposite party for the period from 22-03-2022 to 21-03-2023 for an amount of Rs.3,00,000/- which covered the complainant, his wife and his children. The daughter of the complainant named Ann Riya George was admitted in Immaculate Heart of Mary Hospital, Bharananganam due to severe fever and cough on 15-01-2023. She underwent inpatient treatment at the hospital for three days and after the treatment she was discharged on 18-01-2023. The complainant incurred a total amount of Rs.8,243/- as treatment expenses in the hospital. The opposite party rejected the cashless benefit claimed by the complainant and informed the same to the hospital through letter dated 16-01-2023 stating reason that as per the submitted documents hospitalisation not medically necessitated. Again on 18-01-2023 the opposite party gave a letter rejecting the claim stating the same reason. It is averred in the complaint that the opposite party has purposefully denied the claim of the complainant without any valid and cogent reason and the said act of the opposite party amounts to deficiency in service and unfair trade practice. Due to the act of the opposite party the complainant has suffered much difficulties and mental agonies .Hence this complaint is filed by the complainant praying for an order to direct the opposite party to pay an amount of Rs.8,243/- with interest and to pay Rs.25,000/- as compensation to the complainant.

Upon notice from this Commission opposite party appeared before the Commission and filed version contending as follows :

The complainant had taken a Star Group Health insurance policy for the bank customers covering himself, his wife and two children for the period commencing from 22-03-2022 to 21-03-2023 for a sum insured of Rs.3 lakhs vide Policy Number P/181221/01/2022/010302. At the time of issuing the policy the complainant was supplied with the terms and conditions of the policy. During the policy period the opposite party had received a request for cashless hospitalisation from Immaculate Heart of Mary Hospital stating that Ann Riya George was admitted at the hospital on 15-01-2023 and was provisionally diagnosed with upper respiratory illness. Along with the pre-authorization request the hospital forwarded the treatment records pertaining to the patient. As per the treatment records it was observed that the health condition and the nature of treatment given would have been necessitated an outpatient treatment only and no hospitalisation was necessary. Hence the opposite party had rejected the authorization for cashless treatment and the same was informed to the complainant and the hospital on 18-01-2023. It is submitted in the version that the denial of cashless facility is in no way to be construed as denial of treatment or denial of coverage. The insured person can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement. The complainant has not approached the opposite party for reimbursement of the medical expenses with the original bills/documents till date as stipulated in the claim procedure of the policy issued to the complainant by the opposite party. There has been no deficiency in service or unfair trade practice from the part of the opposite party.

Complainant filed proof affidavit in lieu of chief examination and Exhibits A1 to A5 were marked from the side of the complainant. Padma Prabha.P,  who is the Assistant Manager(Legal) of the opposite party filed proof affidavit in lieu of chief examination and marked Exhibits B1 to B5 from the side of the opposite party.

On evaluation of complaint, version and evidence on record we would like to consider the following points :

(1)Whether the complainant had succeeded to prove deficiency in service or unfair trade practice on the part of the opposite party?

(2) And if so, what are the reliefs and cost ?

For the sake of convenience we would like to consider Point Nos.1 and 2 together.

POINTS  1 & 2  :-

There is no dispute on the fact that complainant had taken a Star Group Health Insurance policy for the bank customers covering himself, his wife and two children for the period commencing from 22-03-2022 to 21-03-2023 for a sum insured of Rs.3 lakhs vide Policy Number P/181221/01/2022/010302. On going through the Exhibit A2 discharge summary issued from Immaculate Heart of Mary Hospital we can see that Ann Riya George who is one of the insured under Exhibit A1 policy was admitted in the hospital on 15-01-2023 for Acute Bronchitis and was discharged on 18-01-2023. Exhibit B2 is the request for cashless hospitalisation which is submitted to the opposite party from the hospital on 15-01-2023. In Exhibit B2 the proportional diagnosis is recorded as URI. The opposite party on 16-01-2023 vide Exhibit A3 rejected pre-authorization for cashless treatment stating that as per submitted documents hospitalisation not medically necessitated. Thereafter on 18-01-2023 that is the day of discharge of the patient from the hospital, the opposite party rejected the cashless claim vide Exhibit A5 stating that after producing of the documents they are of the view that the condition of the insured patient does not require hospitalisation and she could have been treated as an outpatient.

In our opinion the doctors are the best to decide on admitting the patient to the hospital for the treatment. The doctor is the authority to decide the nature of the treatment to be given to his patient. When taking such decision, the primary factor in front of the doctor would be the patient’s health condition and well being only. The insurance company cannot construe it in the strict sense of the application of the machine on the basis of text book and records. The doctor cannot overlook the chance of any harmful reaction of the medicine administered and simply discharge the patient. So the admission of the patient as inpatient may be necessary as the need of the hour. The insurance companies repudiate the claim in such cases in a business perspective only by saying that the treatment undergone by the insured is only a day care procedure and no need of admission of 24 hours continuous is only mechanical and against the objectives of the health insurance. The opposite party further contended that the absence of cashless approval should not be interpreted as a refusal of treatment or coverage. The insured individual is permitted to proceed with the required treatment, settle the hospital expenses, and subsequently submit a claim for potential reimbursement. As per the outlined claim procedure in the policy provided by the opposite party, the complainant has not yet submitted the original bills/documents to request reimbursement for the incurred medical expenses. It’s important to highlight that the opposite party lacks any evidence to support their claim that the complainant is ineligible for the cashless facility. Amid the ongoing escalation in medical expenses, people obtain health insurance policies to mitigate the impact of unexpected healthcare expenses. A primary allure of these policies is the assurance from insurance companies to cover medical expenses for unexpected illnesses through cashless means. Individuals invest in health insurance with the expectation and trust that they will receive cashless treatment as promised by these companies. Therefore, denying the cashless treatment facility after issuing an insurance policy and initially offering this service constitutes unfair trade practice and demonstrates a deficiency in service on the part of the opposite party. It is  proved by Exhibit A5 that the  complainant had spent Rs.8,243/- for  treatment of Ann Riya George who is one of the insured under Exhibit A1 policy at Immaculate Heart of Mary Hospital.  The repudiation of the claim for cashless facility for the expense of treatment amounts to imperfection  and  inadequacy which is to be maintained by a service provider of insurance and amounts to deficiency in service from the part of the opposite party. No doubt the complainant has suffered much hardships due to the deficiency in service on the part of the opposite party.    Considering the nature and circumstances of the case we are of the opinion that this complaint is to be allowed. Hence, we allow this complaint and pass the following order.

(1) We hereby direct the opposite party to pay to the complainant Rs.8,243/- (Rupees Eight Thousand Two Hundred and Forty Three only) which is the amount spent by the  complainant for the treatment of Ann Riya George along with 9% interest per annum from 23/03/2023 i.e., the date on which this complaint is filed  till realisation.

(2) We hereby direct the  opposite party to pay Rs.15,000/- (Rupees Twenty five thousand only) as compensation to the complainant for the deficiency in service on the part of the opposite party.

The order shall be complied within 30 days from the date of receipt of copy of this Order. If not complied as directed, the compensation amount shall carry 9% interest from the date of Order till realisation.

Pronounced in the Open Commission on this the  22nd day of  December,  2023

  Sri.Manulal.V.S,  President    Sd/-

  Smt.Bindhu.R,  Member         Sd/-

  Sri.K.M.Anto,  Member          Sd/-

APPENDIX :

Exhibits from the side of the Complainant :

A1   -   Copy of Star Group Health Insurance Policy Certificate

A2   -   Copy of Discharge Summary dated 18/01/2023 issued

            from  Immaculate Heart of Mary Hospital, Bharananganam

A3   -   Copy of  letter of denial of claim dated 16/01/2023 issued

            by the opposite party to the hospital authority

A4   -   Copy of rejection of pre-authorization for cashless

            treatment dated 18/01/2023 issued by the opposite

            party to the hospital authority

A5   -   Copy of Medical Bills dated 18/01/82023 issued

            from  Immaculate Heart of Mary Hospital, Bharananganam

Exhibits from the side of Opposite parties :

B1   -   Copy of Policy Schedule  with Conditions

B2   -   Copy of request for cashless hospitalization from 

            Immaculate Heart of Mary Hospital, Bharananganam

B3   -   Copy of Medical Records from Immaculate Heart of

            Mary Hospital, Bharananganam

B4   -   Copy of rejection of pre-authorization for cashless

            treatment dated 18/01/2023

                                                                                                            By Order,

                                                                                                              Sd/-

                                                                                                   Assistant  Registrar