This case is coming for final hearing on 25-09-2014 in the presence of M/s.Sri D.Ravindranath and Sri K.Srinivasa Rao, Advocates for Complainant and Sri B.Purushothama Reddy, Advocate for 5th Opposite party and Opposite Parties 1 to 4 set exparte and having stood over till this date, the Forum delivered the following.
The complainant filed the present Complaint against the Opposite Parties 1 to 5 under Sec.12 of C.P.Act on 4.9.2012 and requested the forum to direct the Opposite Parties (1) to pay a sum of Rs.14,003.19 ps with interest @ 12% per annum from 22.09.2011 (2) to pay Rs.1,00,000/- towards compensation for causing mental agony (3) to pay a sum of Rs.3,000/- towards costs of legal expenditure and (4) to pass any order or orders as the Forum deems fit and proper.
The brief averments are as follows: The Complainant is working in Bharathi Airtel Limited at Hyderabad and joined in the T.T.K.Health care Services Pvt. Ltd. which is a medical and health insurance scheme by paying required premium and continuing the said scheme till date vide TTK ID No.BHARATI AIRTEL LIMITED, B0065032. The said scheme covers his entire family.
While so on September, 2011 his mother fell sick due to HTN, Type-II at Visakhapatnam and complainant got admitted his mother Smt.E.Satyavathi aged 64 years in Queen’s NRI Hospital (Chalasani Hospital Private Limited) on 19.09.2011. The complainant intimated about the admission of his mother in Hospital to the 2nd Opposite Party TTK Health Care Services at New Delhi and also to Dr.Vinay i.e. 3rd Opposite party with regarding to the Cashless treatment. The 2nd Opposite Party acknowledged the pre-authorisation (Cashless request) on 21.09.2011 and stated that the request was under process, which was intimated to the complainant vide Email on the same day. As there is delay in pre-aurhorisation for Cashless treatment, Complainant contacted the 3rd Opposite Party Dr.Vinay to his Cell Phone No.9849797019 and also the 2nd Opposite Party in Phone No.011-23715785 on 21.09.2011. As the Complainant’s mother case is an urgency case, even after seeing the situation of the Complainant’s mother also the Opposite Parties has not responded for the request of the Complainant and violated the terms of the TTK Health Care Assurance Agreement.The 3rd Opposite Party Doctor failed to understand the situation of the Complainant’s mother who requires the medical health in urgency and acted in negligent manner. On 22.09.2011 the Doctors’ in the NRI Hospital examined his mother and satisfied with the condition of the patient and signed on the discharge sheet on 22.09.2011 at about 9.00 AM. Observing the discharge sheet, Complainant was surprised to know that the Cashless treatment was not approved by the Opposite Parties 1 & 2. The 3rd Opposite Party stated that initial amount of Rs.10,000/- was sanctioned for treatment and nothing was received by the NRI Hospital authorities. Due to non-release of the phone by the Opposite Party hospital authorities, the Complainant’s mother was made to wait in the hospital from 10.00 am to 2.00 pm on the date of discharge i.e. on 22.09.2011. As the funds were not released by the Hospital authorities i.e. Opposite Parties, the Complainant was forced to borrow the hospital bill amount i.e. Rs.14,003.19 ps and he paid the same to the hospital authorities.
After paying the hospital bill when the complainant made a claim to the 2nd Opposite Party on 7.10.2011 for an amount of Rs.14,003.19 ps, the Opposite Party No.4 rejected the claim as “late submission”. Even after discharging the Complainant’s mother as per the advise of the doctors who has treated her in the Opposite Party Hospital she continued the treatment till Jan.2012 after the discharge from the NRI Hospital. Thereafter again in Jan 2012 his mother fell sick and got admitted in the Care Hospital, Visakhapatnam and after taking treatment for few days his mother expired on 03.02.2012.
The Complainant got issued Legal Notice to the Opposite Parties on 20.01.2012 and only Opposite Parties 2, 3 & 4 received the Notice and did not gave any reply. The Notice sent to the Respondent No.1 was returned unserved. Hence alleging the deficiency of service on the part of Opposite Parties 1 to 5, the Complainant filed the present complaint seeking reliefs as sought for.
The notice served to the 1st Opposite party was returned unserved. Thereafter after sending 2nd Notice and as there is no representation on 24.06.2013 OP-1 was set exparte. Opposite Parties 2 to 4 were set exparte on 11.10.12.
Opposite Party No.5 Opposite Party filed Counter and stated as follows: The fact of the scheme are covers the entire family of the Complainant vide TTK ID No.BHARATI AIRTEL LIMITED, B0065032 is not known to the Opposite Party. First of all there is no cause of action to entertain this complaint in this Forum. The complainant is making false allegations against the Opposite Party-5 with regarding to the treatment taken by his mother in NRI Hospital (Chalasani Hospital Pvt. Ltd.) at Visakhapatnam. The complainant has to prove his case that his mother fell sick in the month of November, 2011 due to HTL Type-II at Visakhapatnam and got admitted in NRI Hospital and 2nd Opposite Party acknowledged the pre-authorisation (Cashless treatment) request by the Complainant on 21.09.2011. Complainant falsely stated that the Opposite Parties 1 to 3 failed to act upon the request made by the Complainant and the NRI Hospital authorities, as per the terms and conditions of Health Care Insurance agreement. The 3rd Opposite Party being a Doctor have acted promptly and take care of the Complainant’s mother after she has been admitted in the NRI Hospital. So there is no point of alleging the Opposite Party for acting negligently. Initially an amount of Rs.10,000/- was sanctioned for the treatment and even after that also, the complainant is intentionally alleging that the Cashless treatment was not approved by the Opposite Parties. The allegations that at the time of discharge of his mother on 22.09.2011 his mother was put to inconvenience by waiting in the hospital from 10.00 am to 2.00 pm in the hospital was false and there is no fault on part of the hospital authorities with regarding to the issue. The hospital authorities has taken due care for his mother. The complainant is falsely alleging Opposite Parties that, the 2nd Opposite Party after receiving the claim from the Complainant on 07.10.2011 in prescribed proforma for the claim of Rs.14,003.19 ps was rejected with “late submission”. As the Opposite Party has acted with due care and provided the facilities as per the agreement of the scheme (TTK Health Care vide Scheme No.B0065032) there is no deficiency on part of the Opposite Parties. Hence the complaint is liable to be dismissed with costs.
On perusal of the pleadings of both sides, the Forum framed the following points for consideration.
Whether there is any deficiency of service on the part of Opposite parties 1 to 5 ;
To what relief.
The Complainant filed his Evidence Affidavit reiterating the facts mentioned in the Complaint and on his behalf in support of his contentions Ex.A1 to A15 were marked. On behalf of 5th Opposite Party Sri D.Himchala Rao in capacity of Assistant Manager filed Evidence Affidavit and Ex.B1 is marked. The Complainant and the Opposite Parties filed Written arguments and oral arguments.
Point No.1: The present complaint is filed by the Complainant against Opposite Parties 1 to 5 for refund of Rs.14.003.19 ps along with interest @ 12% p.a. from 22.09.2011 and with other reliefs as he is entitled for the refund of the amount under Cashless treatment basing upon the scheme TTK ID No. No.BHARATI AIRTEL LIMITED, B0065032. The Opposite Party No.5 filed detailed Counter denying the entire averments of the complainant and even in the Evidence Affidavit also Opposite Party No.5 denied the same stating that the Complainant is not entitled for any refund of the amount nor any other relief basing upon the Terms of Agreement Ex.B1. The said settlement of the final bill for Rs.14,003.19 ps was not brought before the notice of the 5th Opposite Party. Even representation pending before the Opposite Parties 1 & 4 with regarding to the claim submitted by the Complainant is not known to Opposite Party No.5. More particularly the claim was not covered under the Policy, as the disease which was suffered by the Complainant’s mother does not falls within the scheme. So the claim of the complainant was not entertained. Hence as there is no deficiency on part of the Opposite parties, the complaint may be dismissed with costs.
Ex.A1 is the Email document dt. 13.07.2011 which shows that Employee code of the Complainant is 65032 and the Complainant has obtained policy along with his mother E.Satyavathi. The said policy is standard policy is a consolidated Medical policy. The 2nd page of the Ex.A1 reveals that the Policy will be in force from 14.06.2010 to 14.07.2011 and the complainant has paid Rs.11103.35 ps towards premium along with service charges Rs.1143.65 ps.
In the Evidence Affidavit, the Complainant admitted that his mother fell sick in the month of September, 2011 due to HTN Type-II at Visakhapatnam and she was admitted in Omni NRI Hospital (Chalasani Hospital) on 19.09.2011. The Ex.A7 is the discharge summary of the Queen’s NRI Hospital in which in column “Clinical summary”, it was mentioned as a 64 years female patient known case of HTN, Type-II DM admitted with complaint of fever since 3 weeks and treated for having P.Vivax positive and UTI. In Ex.A7, it was mentioned as date of admission is 19.09.2011 and date of discharge is 22.09.2011. The Ex.A8 is the final bill of the Hospital charges from 19.09.2011 to 22.09.2011 for Rs.12,293.99 (Rs.9,443.99 + Rs.1350 + Rs.1500/-). The payment of Rs.9,443.99 ps is confronted by Ex.A9. As per Ex.A2 (document in 2 pgs) dt. 21.09.2011 it reveals, the Complainant has sent his request for Cashless payment/request and the same was received by the TTK Health Care Pvt. Ltd. and in the 2nd page it seems the same was under process for clearance of the same. Ex.A4 is the Email dt.24.10.2011 submitted by the Reimbursement Team Health and Insurance Integrated which discloses that the TPA/Insurance Company has rejected the claim of the complainant observing the policy terms and conditions.
In the counter, the Opposite Party denied that the Complainant cannot claim the same basing upon the terms and conditions of the policies as complainant’s mother has suffered with hypertension. Ex.A14 & B1 are the same documents. In Cl.2.4 of Page No.3 in Ex.A14/B1 under the Column “Subject however that domiciliary hospitalization benefits shall not cover” – it seems the diseases (1) Sl.No.5 = Diabetes, Mellitus and Inspidus (2) Sl.No.7 = Hypertension will not cover the Cashless treatment.
As seen from the Ex.A7 and the Ex.A1 Policy along with Ex.A14/Ex.B1 terms and conditions (Cl.2.4) of the policy, as the Complainant’s mother, aged about 64 years, got admitted in Queen’s NRI Hospital with known case of “HTN Type-IIDiabetes Millitus and Inspidus”, we are of conclusive opinion that Complainant is not entitled for reimbursement of the medical charges. Thereby viewing Cl.2.4 of Ex.A14/B1 and Ex.A4, we confirm that there is no deficiency of service on part of Opposite Parties in repudiating the claim and the Complaint is dismissed without costs.
In the result the Complaint is dismissed without costs.
Dictated to the Shorthand Writer, transcribed by him, corrected and pronounced by us in the open Forum on this the 29th day of October, 2014.
Sd/- Sd/-
President (FAC) Member
District Consumer Forum-I
Visakhapatnam
APPENDIX OF EVIDENCE
Exhibits Marked for the Complainant:
Sd/- Sd/-
President (FAC) Member
District Consumer Forum-I
Visakhapatnam
