Kerala

Idukki

CC/145/2020

Joy John - Complainant(s)

Versus

star health and allied insurance co - Opp.Party(s)

20 Jul 2022

ORDER

DATE OF FILING :22/10/2020

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, IDUKKI

Dated this the 20^th day of July 2022

Present :

SRI.C.SURESHKUMAR PRESIDENT

SMT.ASAMOL P. MEMBER

SRI.AMPADY K.S. MEMBER

CC NO.145/2020

Between

Complainant : Joy John,

Kochukarottu House,

Rajapuram P.O., Murickassery Kara,

Vathikudy Village, Idukki Taluk.

(By Adv.Shiji Joseph)

And

Opposite Party : 1 . The Star Health and Allied Insurance Co.Ltd.,

4^th Floor, Carmel Towers, Cotton Hill P.O.,

Vazhauthacaud, Thiruvananthapuram – 695 014.

2 . The Star Health and Allied Insurance Co.Ltd.,

Branch Office – Perumbavoor 1^st Floor,

Darsanam Chamber, VI/372 B(3),

MC Road, Perumbavoor, Ernakulam – 683 542.

Represented by its Manager.

(Both by Adv.K.Pradeep Kumar)

 

O R D E R

SMT.ASAMOL P., MEMBER

Facts of the complaint are briefly stated hereunder:-

.
1 . Complainant joined the health cum accident insurance policy with opposite parties in the year 2017 and has been paying the premium regularly. The policy covered the complainant and his wife and 2 children.

 

2 . The benefit assured by opposite party at the time of canvassing the policy, in case of hospitalization, the complainant would be able to avail cashless treatment for the entire family. Attracted by the cashless benefit the complainant joined the policy.

 

(Cont....2)

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3 . On 18/09/2020, complainant's wife fall down from the stair and sustained injury to the left leg. On 19^th September, complainant's wife consulted the orthopaedic surgeon and took an X-ray. Since there is no signs of fracture, complainant's wife was allowed to go home and some medicines were prescribed. In spite of taking the medicine, the pain was intensified and hence again consulted the doctor on 26/09/2020. After examination the doctor told that infection has developed and on 28^th, complainant's wife consulted the surgeon. The surgeon admitted complainant's wife for 5 days.

 

4 . On the same date, complainant intimated about the admission and sent the necessary documents on 02/10/2020, opposite parties repudiated the complainant's claim for cashless scheme. In the notice dated 02/10/2020 denying the cashless scheme, the second opposite party did not state any specific reason for repudiating the cashless scheme. Hence, complainant had to pay Rs.7556/- as hospital bills.

 

5 . Opposite parties charged the premium for availing cashless scheme and hence the denial of the cashless scheme is gross deficiency in service and unfair trade practice. This caused considerable pain and mental agony to complainant. Arranging the money is the most difficult part of hospitalization and the complainant expecting cashless benefit on hospitalization paid such a huge premium. Hence the complainant is entitled for compensation.

 

6 . Hence complainant prayed the following reliefs.

 

(a) Opposite parties may be directed to pay Rs.7556/- with 18% interest from 02/10/2020 to till the date of realization.

 

(b) Opposite parties may be directed to pay Rs.1 Lakh as compensation for illegal repudiation of the cashless scheme.

 

1. 1. 100. opposite parties may be directed to pay Rs.5000/- as cost of the complainant.

 

 

(Cont....3)

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1. 1.  

      100. 1. After receiving the notice, opposite parties have appeared before the Commission and filed written version. Their contentions are briefly discussed hereunder.

               

7 . According to opposite parties, it is submitted that complainant had availed the policy from Star Health and Allied Insurance Company, Perumbavoor branch office, Ernakulam. The claim was processed and decision taken in the claim at Chennai Office. No cause of action has taken place within the jurisdiction of this Honourable Forum at Idukki. In the decision of Sony Surgical Vs. National Insurance Co.(2009 KHC 5136) it was held by the Hon'ble Supreme Court that the branch office means the branch office where the cause of action has arisen. No cause of action either in whole or part has taken place at Idukki. Simply because the complainant resides in the Idukki district that will not confer any jurisdiction to this Hon'ble Forum. Therefore this Hon'ble Commission may be pleased to hear the maintainability of this complaint before the trial and the complaint may be dismissed in-limine. The complainant has no bona fides in in instituting the complaint and the same has been done with the ulterior motive of making illegal gains.

 

It is submitted that the opposite has denied the cashless facility only and the denial of Pre authorization request is in no way to be construed as denial of treatment or denial of coverage. The complainant can go ahead with the treatment, settle the hospital bills and submit the claim for a permissible reimbursement. Moreover the opposite parties requested the complainant to submit the original documents for reimbursement as per policy condition. The complainants have not approached the opposite parties till this date. The claim of the complainant is not rejected so far, there is no cause of action for the complaint. So this case is not maintainable before the Forum.

 

8 . Opposite parties also submitted that complainant has taken policy of Family Health Optima Insurance Policy from the opposite parties for the period commencing from 20/10/2017 to 19/10/2018 and the same has been renewed up to 20/10/2020 for the sum insured of Rs.4,00,000/- vide policy No.P/181219/01/2020/006178. At the time of availing the policy the complainant

 

(Cont....4)

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were supplied with the terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to them along with the policy schedule. Moreover it is clearly stated in the policy schedule that “The Insurance under this policy is subject to conditions, clauses, warranties, exclusions etc., attached.

 

It is submitted that the opposite parties have received a pre-authorization request for cashless treatment from Alphonsa Hospital, Idukki stating that the complainant's wife (Mrs.Valsamma Joy) was admitted at the hospital on 28/09/2020 and provisionally diagnosed with hematoma left leg and 1 & D done. Moreover the treating doctor also noted in the pre authorization request form that the first consultation of the complainant was on 19/09/2020. On receiving the pre-authorization, hence the opposite parties had forwarded a query dated 28/09/2020 to the hospital and requested to forwarded the following documents:-

 

a . Incompletely filled pre-authorization form with estimated number of stay at hospital ? estimated final bill amount?

 

b. Submit documents of any comorbidities (DM, HTN, CAD, Kidney disease, Liver disease, copd/asthma, other chronic diseases etc.,) along with the first consultation reports and all treatment details done.

 

1. 1. 100. Copy of first consultation from where the patient was first diagnosed and treated, with duration of symptoms also send copy of case sheets, copies of investigation reports done for the patient.

            

           d . Detail line of management.

            

           1. Based on the query letter, the hospital authority had issued only the copy of the present treatment details and not provided the other treatment details like first consultation dated 19/09/2020, X-Ray report. Hence due to non availability of the proper documents to decide the admissibility of the claim, the opposite parties denied the cashless facility and the same was informed to the hospital authority and the complainant on 29/09/2020 and 02/10/2020. Moreover the opposite parties clearly informed to the hospital authority and to the complainant

 

(Cont....5)

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1. 1. 100. 1. that “ the insured may however submit the documents for reimbursement of the expenses incurred relating to the treatment”.

               

It is submitted that the complainant has not approached the opposite parties for reimbursement with original bills/ documents till this date as per Condition No.5 (2) and (3) of the policy.

 

It is submitted that as per Condition No.5 (2) & (3) of the policy, the claim must be filed within 15 days from the date of discharge from the hospital and the insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and documents to be submitted in support of claim are:-

 

A . Duly completed claim form, and

B . Pre admission investigations and treatment papers.

C . Discharge summary from the hospital in original.

D . Cash receipts from hospital , Chemists.

E . Cash receipts and reports for tests done.

F . Receipts from doctors, surgeons, anesthetist.

G . Certificate from the attending doctor regarding the diagnosis.

 

It is submitted that the complainant has not submitted the above mentioned documents/ details to the opposite parties for processing the claim based on policy terms and conditions.

 

After the denial of cashless, the opposite parties had forwarded a letter dated 05/10/2020 to the complainant and advised to submit the claim form and hospital records to the opposite parties for reimbursement. But the complainant has not approached the opposite parties for reimbursement. After that the opposite parties again sent reminder letters on 20/10/2020 and 04/11/2020 to the complainant but the opposite parties did not receive any reply till this date. The opposite parties did not get any opportunity to decide the merits of the claim on available medical documents. Hence there is no deficiency in service on the part of the opposite parties. But complainant approached the Forum without submitting a claim

 

(Cont....6)

 

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despite repeated requested by opposite parties at several times as per policy conditions.

 

The complainant in para No.6 of the complaint alleged that he had incurred expenses of Rs.7556/- but no such original bills has been produced before the company. Hence it is submitted that the Hon'ble Forum may kindly direct the complainant to submit the claim for reimbursement to the opposite parties with original documents and allow the opposite parties to process the claim as per terms and conditions of the policy.

 

It is respectfully submitted that there is no deficiency of service from the part of the opposite parties. The opposite parties have acted only as per the terms and conditions of the policy.

 

The complainant has absolutely no cause of action for filing this petition.

 

8 . Hence this complaint is to be dismissed with cost and compensation to opposite parties.

 

After filing version, the case was posted for evidence. Complainant filed proof affidavit and 4 documents produced. Complainant was examined as PW1 and Exts.P1 to P4 series 8 in numbers were marked. Though repeated postings were given for opposite parties evidence, no evidence were adduced by them. Therefore, opposite parties evidence closed. Heard the counsel for complainant. No representation for opposite parties and hence it was taken for orders. The points which arise for consideration are as follows:-

 

(a) Whether there is any deficiency in service on the part of these opposite parties?

 

(b) If so, what reliefs the complainant is entitled to?

 

 

(Cont....7)

-7-

 

Points are considered.

 

We have perused the documents which were produced by complainant and gone through the deposition of complainant. It is evident that complainant had taken mediclaim policy from opposite parties on 21/10/2019. As per Ext.P3 ie, discharge summary, it is find that the wife of complainant had admitted in Alphonsa Hospital, Murickassery for treatment of Hematoma leg problem on 28/09/2020 and she was discharged on 02/10/2020. Thus, she was under the treatment in the above said hospital for 5 days. It was requested to opposite parties that approval of cashless claims by complainant's wife on 02/10/2020 ie, date of discharge from hospital. The request letter was marked as Ext.P2. But, the request of complainant was denied by opposite parties under Ext.P1. But the specific reason of denial of cashless claim was not mentioned in this P1 document. In the deposition of complainant, as per the policy, opposite parties had assured cashless benefit for hospital treatment to entire family members. For availing that, complainant's wife requested to opposite parties on 02/10/2020 which was admitted in the hospital. But opposite parties did not give the benefit assured by them at the time of taking the policy. Therefore, complainant had to pay hospital bills at the time of discharge. By attracting the cashless benefit of the policy, complainant had joined this policy. As per Ext.P4 series, it is seen that complainant had paid the hospital bills himself. No evidence tendered by opposite parties to prove otherwise. According to opposite parties, they had denied the cashless facility only and the denial of pre-authorisation request is in no way to be construed as denial of treatment or denial of coverage. After discharging from the hospital within 15 days, complainant can submit the claim for a permissible reimbursement as per the policy conditions. Where the complainant is entitled for cashless facility, opposite parties was bound to provide the same. Hence there is no meaning in contending that amount expended for treatment can be reimbursed later upon submission of bills. Complainant had taken cashless policy to avoid such hassles and cumbersome procedures and to get payment dues by opposite parties initially itself. Opposite parties have not adduced evidence to prove that as per the policy conditions that no cashless facility for complainant's policy. According to complainant, he availed a policy which has cashless facility for hospital treatment. But, opposite parties had denied the cashless facility without specific reason as pet Ext.P1 document. We are of the considered view that

(Cont....8)

-8-

opposite parties are liable to give cashless facility as they assured the benefit of the time of taking the policy to complainant. Since it was denied, complainant had to pay the hospital bills. Hence, it caused mental agony and financial difficulties to complainant. This is deficiency in service on the part of opposite parties. Denies of cashless facility, considering the amount involved appears to be grave. Hence we are of the view that complainant is entitled for Rs.25,000/- as compensation from opposite parties, under the circulation. Hence, the complaint is allowed in part as hereunder.

 

Opposite parties are directed to pay Rs.7556/- with 12% interest from 02/10/2020 till the date of payment or realisation. They are also directed to pay Rs.5000/- as compensation and Rs.5,000/- as cost of litigation to complainant within 30 days from the date of copy of receipt of this order, compensation amount shall carry 12% interest from the date of order till its realisation.

 

Pronounced by this Commission on this the 20^th day of July 2022.

 

 

Sd/-

SMT.ASAMOL P., MEMBER

Sd/-

SRI.C.SURESHKUMAR, PRESIDENT

Sd/-

SRI.AMPADY K.S., MEMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

(Cont....9)

-9-

 

APPENDIX

 

Depositions :

On the side of the Complainant :

PW1 -Joy John

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1 - Denial of Pre authorisation request for cashless treatment.

Ext.P2 - Letter to Star Health Insurance Manager dated 02/10/2020

Ext.P3 - Alphonsa Hospital – Discharge summary

Ext.P4(Series) - Hospital Bills.

On the side of the Opposite Party :

Nil

 

 

Forwarded by Order

 

 

ASSISTANT REGISTRAR