IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Monday the 28th day of February, 2011
Filed on 29.03.10
Present
- Sri. Jimmy Korah (President)
- Sri. K. Anirudhan (Member)
- Smt. Shajitha Beevi (Member)
in
C.C.No.84/10
between
Complainant:- Opposite Parties:-
Sri.Sanjayarajan.M.K, 1. T.T.K. Health Care TPA Pvt Ltd,
Udaya Deepam, Anmol Palani, Number 88,
Kandalloor North, G.N. Chetty Road, 2nd Floor T.Nagar,
Kandalloor Village, Chennai - 600017
Pattolomarket P.O
(By Adv.S.Remanan Pillai) 2. T.T.K. Health Care TPA Pvt Ltd,
#39-4130, First Floor, Mareena Building,
M.G.Road, Ernakulam, Cochin-682016.
3. Indian Overseas Bank Ltd, Represented by its Branch Manager,
Kayamkulam Branch,
Main Road Kayamkulam
4. The United India Insurance Company Ltd.,
Divisional Office 011100,
‘Sudharsan’ Building, Old Number 14,
Whites Road, Chennai 600014
5. The United India Insurance Company Ltd.,
Kayamkulam Branch,
Represented by its Branch Manager
(By Adv.T.J.Lakshman)
O R D E R
SRI.K.ANIRUDHAN (MEMBER)
Sri.Sanjayrajan .M.K. Senior Citizen has filed this complaint before the Forum on 26.04.2010 alleging deficiency in service on the part of the opposite parties. The allegation of the complainant are briefly stated as follows:- He had joined in an insurance scheme namely “IOB Health Care Plus Policy”, a group of medical insurance scheme launched by the 3rd opposite party in association with 4th opposite party. As per the said scheme, it was assumed that it would facilitate to meet one’s hospitalization, and can be used to protect the insured and his family members against expenses incurred towards hospitalization for illness, diseases as well as domiciliary hospitalization along with room rent, operation theatre charges etc. He had joined the said policy through 5th opposite party vide policy No.2008/484100918/40 – certificate No.409/16684, and he had paid a sum of Rs.3488/- as its premium and the certificate for Indian Overseas Bank , health care policy has been issued to him by the 4th opposite party. He had joined the said policy under the instigation of the 3rd opposite party as he is one of its account holders. He is the policy holder since 07.11.2006. The first opposite party through their Bangalore office had issued identity card to him as well as the other members of his family who are covered by the Medical Insurance Policy. The identity card issued to him to avail Cashless Hospitalisation. His wife was admitted in GG Hospital Thiruvananthapuram for the treatment of Bilateral Bronchictasis from 24.03.2009 to 27.03.2009; and she was advised to undergo a chest surgery from the said GG Hospital. As such, she was admitted in M/s.Amrita Institute of Medical Science, Kochi, and she underwent surgery on 20.04.2009 at the above hospital, in which Cashless Hospitalization facility are available and she had discharged on 26.04.2009. For the above medical treatment he had incurred an expenses of Rs.71,344.46/-(Rupees Seventy One Thousand Three Hundred and Forty Four and Forty Six paise only). In order to avail policy benefit he had submitted the medi cards issued by the first opposite party to the said above hospital. But after verifying the names of opposite parties 1 and 2 the hospital authorities rejected the said mediclaim. Immediately he had forwarded the Original Policy Certificate, Original Identity Card and Original Medical Expense Rewords, Bills obtained from the Hospital Authorities to the opposite parties 1 and 2, claiming benefit. But the opposite parties have not turned up in sanctioning the amount. The opposite parties are jointly and severally liable to pay the medical expenses incurred to his wife, since she is covered by the said medical insurance policy. He has not obtained any positive steps from the opposite parties. Hence this complainant seeking relief.
1. Notices were issued to the opposite parties. Opposite parties 1 and 2 have not entered appearance before the Forum. Considering their absence, they were declared as exparte by this Forum on 14.06.2010. The 3rd opposite party entered appearance. 4th and 5th opposite parties entered appearance and prays for filing version. But they have not filed any version and absent on subsequent posting of the cases. So they were declared as exparte on 22.11.10.
2. In the objection filed by the 3rd opposite party, it is stated that they are an unnecessary party in the complaint and admitted that the complainant was the holder of the “IOB Health Care Plus Policy” and they have remitted the premium amount on time as per the instruction of the complainant. It is stated that the complainant is bound by the terms and conditions of the policy stipulated, in the policy. It is further stated that as per the instruction from the 4th opposite party in the complaint “the complainant’s claim is medically repudiated under clause 8.1, since the illness is for the past 4 years and the policy is from 2006 only and the treatment is given is possible on opd basis and hence the claim of the complaint is rejected”. It is further stated that they are not in any way liable for the claim and compensation claimed by the complainant since the contract of policy in between the 4th opposite party and the complainant.
3. Considering the contentions of the 3rd opposite party, the Forum has raised the following issues for considerations:-
1) Whether there is any deficiency in service and negligence on the part of the opposite parties?
2) Whether the complainant is entitled to get the medical expenses based on the said policy?
3) Compensation and costs.
Issues 1 to 3
4. Complainant have filed proof affidavit along with documents is support of his case, and he has been cross examined by the 3rd opposite party. Documents - Ext.A1 to A36 – marked-. Ext.A1 is the letter dated, 20.05.2009 written by the complainant to The Manager, TTK mediclaim section, Chennai in connection with the mediclaim policy together with the claim form for Rs.71,344.46/-(Rupees Seventy One Thousand Three Hundred and Forty Four and Forty Six paise only) regarding the expenses for the medical treatment of the wife of the complainant. Ext.A2 is the certificate dated, 26.04.2009 of the concerned doctor of M/s.Amrita Hospital, Ernakulam who had treated the wife of the complainant. It shows the date of admission, details of the discharge of the patient and her diseases etc. Ext.A3 is the copy of the medical certificate filled up by the doctor treated the patient. Ext.A4 is the Impatient Collection and Appropriation Certificate of the Hospital – M/s.Amrita Institute of Medical Sciences and Research Centre, relating to the wife of the complainant. Ext.A5 is the Inpatient detail bill issued to the patient for a total sum of Rs.33,140.29/- (Rupees Thirty Three Thousand One Hundred and Forty and Twenty Nine paise only) in connection with the treatment. Ext.A6 is the medical bill of Amrita Hospital issued to the patient which comes to a total sum of Rs.16,052.71/- (Rupees Sixteen Thousand and Fifty Two and Seventy One paise only) towards the pharmacy bill s etc. Ext.A7 is the certificate issued to the patient showing the advance remittances of Rs.81,000/- (Rupees Eighty One Thousand only) in the said hospital. Ext.A8 is the pharmacy credit bill for Rs.15.39/- (Rupees Fifteen and Thirty Nine paise only) vide dated, 22/04/2009. Ext.A9 is the pharmacy credit bill for Rs.145.22/- (Rupees One Hundred and Forty Five and Twenty Two paise only) vide dated, 21/04/2009. A10 is the pharmacy credit bill for Rs.1,468.21/- (Rupees One Thousand Four Hundred and Sixty Eight and Twenty One paise only) vide dated, 20/04/2009.
5. Ext.A11 is the Material credit bill dated, 20/04/2009 for a sum of Rs.3,786.12/- (Rupees Three Thousand Seven Hundred and Eighty Six and Twelve paise only). Ext.A12 is the Material credit bill dated, 20/04/2009 for a sum of Rs.81.67/- (Rupees Eight One and Six Seven paise only). Ext.A13 is the Material credit bill dated, 20/04/2009 for a sum of Rs.1.77/- (Rupees One and Seventy Seven paise only). Ext.A14 is the Material credit bill dated, 21/04/2009 for a sum of Rs.3,184.30/- (Rupees Three Thousand One Hundred and Eighty Four and Thirty paise only). Ext.A15 is the Material credit bill dated, 21/04/2009 for a sum of Rs.22.06/- (Rupees Twenty Two and Six paise only). Ext.A16 is the Material credit bill dated, 21/04/2009 for a sum of Rs.2,310.21/- (Rupees Two Thousand Three Hundred and Ten and Twenty one paise only). Ext.A17 is the Material credit bill dated, 21/04/2009 for a sum of Rs.200.80/- (Rupees Two Hundred and Eighty paise only). Ext.A18 is the Pharmacy credit bill dated, 26/04/2009 for Rs.461.80/- (Rupees Four Hundred and Sixty One and Eighty paise only). Ext.A19 is the copy of the Discharge summary in respect of the patient showing the details of treatment, date of admission and date of discharge and the details of the procedure, and the O.P. bills dated, 06/04/2009 for Rs.1,875/- and Rs.200/-, Rs.77.87/-, Rs.369/-, Rs.2.98/-, Rs.245.64/-, Rs.1,013.56/-, Rs.76.89/-, Rs.32/-, Rs.104.80/-, Rs.1.14/-, Rs.9.36/-, Rs.54.56/-, Rs.3.20/-, Rs.55.96/-, and Rs.2.22/-.
6. Ext.A20 is the Scan and the laboratory report dated, 25/03/2009 of the patient, signed by the concerned doctor. Ext.A21 is the copy of the identity card of the patient, the Health card of the 4th opposite party and the MRD card of the said Hospital, issued to the patient. Ext.A22 is the prescription chart of Dr.M.Joshi dated, 24.03.2009 and discharging the patient for CT Scan. Ext.A23 is the Discharge summary of the G.G. Hospital, Thiruvananthapuram issued to the patient. Ext.A24 Cash bills of Rs.3,649.59/-, Rs.198.59/- and for Rs.896/- in connection with the treatment and other expenses of the patient. Ext.A25 are the Micro Biology Report, Clinical Pathology Report, Clinical Biochemistry Report of the patient of G.G. Hospital, Thiruvananthapuram. Ext.A26 is the copy of the request for the additional information by the first opposite party vide dated, 26.03.2009 and its reply sent by the complainant to the first opposite party. Ext.A27 is the copy of the Renewal Proposal of IOB Health Care Plus, sent by the 3rd opposite party to the 1st opposite party at Chennai, requesting to insure the party and issue the card and the policy. Ext.A28 is the copy of the Proposal Form issued to the 4th opposite party. Ext.A29 is the Scan and the Laboratory report dated, 25.03.2009. Ext.A30 is the printed matter showing the details of the IOB Health Care.
7. Ext.A31 is the copy of the Network Hospitals of the first opposite parties in Kerala. It shows that in Kerala, M/s.Amrita Institute of Medical Sciences and Research Centre is one of their hospital having the Medical facility for the first and the second opposite parties. Ext.A32 is the Original Health Card issued by the 4th opposite party to the wife of the complainant. Ext.A33 is the Original Family Health Card issued by the 3rd opposite party to the wife of the complainant. Ext.A34 is the copy of the Insurance Certificate issued by the 4th opposite party relating to the IOB Health Care Plus policy. It shows that the sum insured was for Rs.2Lakh and that Rs.3,393/- was the premium amount. Ext.A35 is the Legal Notice dated, 29.10.2009 issued to the opposite parties, by the complainant requesting to settle the claim. Ext.A36 is the copy of the Identity Card of the Family Members of the complainant, in connection with the said Mediclaim.
8. 3rd opposite party have not filed any proof affidavit. They submitted that they have no oral evidence. But produced one document Ext.B1 marked this document through the complainant. Ext.B1 is the reply notice dated, 30.11.2009 sent by 3rd opposite party to the complainant, in connection with the claim amount.
9. We have carefully examined the entire matter of this case and fully verified the documents, Ext.A1 to A36 produced by the complainant in evidence, together with the Ext.B1 document and verified the deposition of the complainant. It is alleged that the complainant had joined the said Insurance Scheme – IOB Health Care Plus Policy, a group mediclaim Insurance launched by the 3rd opposite party in association with the 4th opposite party; and he had paid Rs.3,488/- as its premium and policy has beeen issued to him by the 4th opposite party(Ext.A34). He had joined the said policy under the instigation of the 3rd opposite party. As per the terms and conditions, the said Insurance Policy can be used to protect the insured and his family members against the expense incurred towards hospitalization and other entire expenses. The complainant was a policy holder since 07.11.2006. The complainant had obtained the identity card to avail “Cashless Hospitalization”. While so, the complainant’s wife was consulted by the Doctor of M/s.Deepam Hospital, Kandalloor due to a chest infection. As per the advise of the Doctor, they have contacted the Doctor of M/s.G.G. Hospital, Thiruvananthapuram for detailed treatment. There the doctor advised her, for a surgery. As such , they have contacted Amrita Institute of Medical Sciences and Research Centre, Ernakulam and there also she was diagnosed to have the said disease and admitted her to undergo surgery. Accordingly she underwent surgery – Exploratory Thoracotomy plus Lingulectomy on 20.04.2009 at that hospital. She was admitted in the above hospital on 16.04.2009 and discharged on 26.04.2009. For the treatment for the complainant’s wife they have spent a huge amount at that hospital. They have spent a sum of Rs.71,344.46/-(Rupees Seventy One Thousand Three Hundred and Forty Four and Forty Six paise only) in connection with the treatment of the patient and other concerned expenses. It is alleged that M/s.Amrita hospital have rejected their Medicard issued by the first opposite party for the insurance facility. The exts. Produced by the complainant shows that they have spent an exorbitant amount for the treatment of the wife of the complainant. The complainant had submitted the required documents to the opposite parties 1 and 2 for getting the benefit under the Medicare policy with which they are covered. But the opposite parties have not cared to sanction the amount. Instead of sanctioning the claim amount in time, the opposite parties are taken a negligent view in this matter and delayed the case unnecessarily. Considering the facts and circumstances of this case, we are of the strong view that the opposite parties are taken an irresponsible attitude against this case and delay the matter willfully. For this the opposite parties are jointly and severally liable. The allegations put forward by the complainant are highly genuine and opposite parties are fully bound to taken reasonable attitude in time. The opposite parties had rejected the claim of the complainant with flimsy ground and there is no justification of the action taken by them. Since the matter of the complainant was a genuine issue, the opposite parties have ought to have taken further necessary steps to sanction the claim amount in time. The whole actions of the opposite parties are highly illegal, unauthorized and arbitrary. The objection raised by the 3rd opposite party cannot be accepted as valid ground to deny the benefit to the complainant. In this respect it is to be noticed that even though the opposite parties 1,2,and 4th have accepted the notice of this Forum, they have not cared to appear before the Forum in the further proceedings of the case. This shows their irrespectable attitude towards this case. The entire action of the opposite parties shows the unfair trade practice, grossest deficiency in service and culpable negligence. For this, the opposite parties are jointly and severally liable and they are answerable to the complainant. So, considering the whole matter of this case we are of the view that the complainant’s allegations are to be treated as genuine. In this respect, the complaint is to be allowed as prayed for.
In the result, we hereby direct the opposite parties to release the Medical Expenses, Bills amount of Rs.57,986.59/-(Rupees Fifty Seven Thousand Nine Hundred and Eighty Six and Fifty Nine paise only) to the complainant, with interest at the rate of Rs.12% from the date of filing of this complaint, together with an amount of Rs.25,000/-(Rupees Twenty Five Thousand only) as compensation for the mental agony, physical strain, sufferings, harassment and loss of the complainant due to the purposeful denial of the ‘Mediclaim Policy’ amount to the complainant in time, without assigning any valid reason, by way of unfair trade practice, grossest deficiency in service, culpable negligence of the opposite parties. Considering the facts and circumstances of this matter, we further direct the opposite parties to pay punitive costs of Rs.5,000/- (Rupees Five Thousand only) to the complainant, and also direct the opposite parties to pay a sum of Rs.2,000/- (Rupees Two Thousand only) as costs of this proceedings to the complainant; and that opposite parties are directed to pay the above said amounts to the complainant within 30 days from the date of receipt of this order.
Pronounced in open Forum on this the 28th day of February, 2011
Sd/-Sri. K. Anirudhan
Sd/-Sri. Jimmy Korah
Sd/-Smt. N. Shajitha Beevi
Appendix:-
Evidence of the complainant:-
PW1 - Sanjayarajan.M.K (Witness)
Ext. A1 - The letter dated, 20.05.2009 written by the complainant to The Manager
Ext.A2 - The certificate dated, 26.04.2009
Ext.A3 - The copy of the medical certificate filled up by the doctor treating the
patient
Ext.A4 - The Impatient Collection and Appropriation Certificate of the Hospital
Ext.A5 - The Inpatient detail bill
Ext.A6 - The medical bill of Amrita Hospital
Ext.A7 - The certificate issued to the patient showing the advance remittances of
Rs.81,000/-
Ext.A8 - The pharmacy credit bill for Rs.15.39/-
Ext.A9 - The pharmacy credit bill for Rs.145.22/-
Ext.A10 - The pharmacy credit bill for Rs.1,468.21/-
Ext. A11 - The Material credit bill dated, 20/04/2009
Ext.A12 - The Material credit bill dated, 20/04/2009
Ext.A13 - The Material credit bill dated, 20/04/2009
Ext.A14 - The Material credit bill dated, 21/04/2009
Ext.A15 - The Material credit bill dated, 21/04/2009
Ext.A16 - The Material credit bill dated, 21/04/2009
Ext.A17 - The Material credit bill dated, 21/04/2009
Ext.A18 - The Pharmacy credit bill dated, 26/04/2009 for Rs.461.80/-
Ext.A19 - The copy of the Discharge summary
Ext.A20 - The Scan and the laboratory report dated, 25/03/2009
Ext. A21 - The copy of the identity card of the patient
Ext.A22 - The prescription chart of Dr.M.Joshi dated, 24.03.2009
Ext.A23 - The Discharge summary of the G.G. Hospital, Thiruvananthapuram
Ext.A24 - Cash bills
Ext.A25 - Micro Biology Report, Clinical Pathology Report, Clinical Biochemistry
Report of the patient
Ext.A26 - The copy of the request for the additional information by the first opposite
Party vide dated, 26.03.2009
Ext.A27 - The copy of the Renewal Proposal of IOB Health Care Plus
Ext.A28 - The copy of the Proposal Form issued to the 4th opposite party
Ext.A29 - The Scan and the Laboratory report dated, 25.03.2009
Ext.A30 - The printed matter showing the details of the IOB Health Care
Ext. A31 - The copy of the Network Hospitals of the first opposite parties in Kerala
Ext.A32 - The Original Health Card issued by the 4th opposite party to the wife of the
complainant
Ext.A33 - The Original Family Health Care issued by the 3rd opposite party to the wife
of the complainant
Ext.A34 - The copy of the Insurance Certificate issued by the 4th opposite party
relating to the IOB Health Care Plus policy
Ext.A35 - The Legal Notice dated, 29.10.2009
Ext.A36 - The copy of the Identity Card of the Family Members of the complainant
Evidence of the opposite parties:-
Ext.B1 - The reply notice dated, 30.11.2009
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite Parties/S.F.
Typed by:- k.x/-
Compared by:-
