Karnataka

Chitradurga

CC/88/2016

Sri A.R.Nagesh S/o Radakrishna setty - Complainant(s)

Versus

The Authorised Signatory/The Branch Manager,United Insurance Company Limited - Opp.Party(s)

Shri.C.J.Lakshminarasimha

20 Jul 2017

ORDER

COMPLAINT FILED ON:19.09.2016

DISPOSED      ON:20.07.2017

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA.

 

CC.NO: 88/2016

 

DATED:  20^th JULY 2017

 

PRESENT: - SRI. T.N. SREENIVASAIAH  : PRESIDENT                                   B.A., LL.B.,

                   SRI.N. THIPPESWAMY        : MEMBER

                                 B.A., LL.B.,   

……COMPLAINANTS	1. A.R. Nagesh S/o Radhakrishna Setty, Age:  55 Years, Senior Manager (Technical), KSFC, Mangalore.   2. A. Radhakrishna Setty, S/o Venkanarasaiah Setty, Age: 80 Years, Retired Superintendent Engineer, 3rd Cross, V.P. Extension, Chitradurga.      (Rep by Sri.C.J. Lakshminarasimha, Advocate)
V/S
…..OPPOSITE PARTIES	1. The Authorized Signatory/The Branch Manager, United Insurance Company Ltd., Satellite Branch, DRM Complex, Old Post Office Road, Holalkere Road, Chitradurga.   2. The Authorized Signatory/The Branch Manager, United Insurance Company Ltd., Brancassurance Division, D.O.12, 2nd Floor, Indian Mutual Building, N.R. Square, Bangalore-02.   3. The Authorized Signatory/The Branch Manager, Office of the Insurance Ombudsman, No.19/19, Jeevan Soudha Building, Ground Floor, 24th Main, J.P. Nagara, I Phase, Bangalore.   (Rep by Sri.B.M. Ravichandra, Advocate for OP No.1 and 2, OP No.3 ex-parte)

ORDER

SRI. T.N. SREENIVASAIAH:   PRESIDENT

The above complaint has been filed by the complainants u/Sec.12 of the C.P Act, 1986 for the relief to direct the OPs to pay a sum of Rs.1,14,718/-, Rs.25,000/- towards mental agony/sufferings, Rs.10,000/- towards costs with interest and such other reliefs.

2.     The brief facts of the case of the above complainants are that, they are son and father by relation.  OP No.2 is the issuer of the Health Insurance Policy and OP No.1 is the Branch Office of the United Insurance Company Ltd. Complainant No.1 was used to purchase of Health Insurance Policies i.e., Can-comfort Insurance Certificate since from the year 2000 from OP No.2 periodically and regularly, which covers the health risks of the complainant No.1, his wife, his children and his parents i.e., his father and mother.  The health risk is clearly covered under the said insurance certificate usually i.e., Accident, Injuries, Critical illness, Natural Surgeries etc.  The complainant No.1 purchased the said insurance certificate from OP No.2 on 01.11.2014 covering the risk of above said persons from 01.11.2014 up to 31.10.2015 vide policy No.72600/2014-15/00208/11 up to total sum assured and the said insurance policy is tie up with several Hospitals including HCG Hospital, Bangalore.  OP No.3 is the concerned person and if any claims of the customers is not settled with the OPs, then anybody can approach OP No.4 for settlement of the claim.  It is further submitted that, on 27.03.2015 complainant No.2 was admitted to HCG Hospital, Bangalore with a history of Carcinoma Prostate and taken treatment.  Consultant Radiation Oncologist Dr.Sanjeev Sharma suggested the treatment for Cancer like one is Surgery, second is Hormone Therapy and third one is Radiation Therapy, depends upon disease factors and patient general condition.  As per the advice of the said Doctor, complainant No.2 has taken treatment like Hormone Therapy depending upon the disease factors and patient’s general conditions including age factor and after the treatment, complainant No.2 submitted all the necessary papers for refund of medical claims to OP No.2 on two occasions i.e., on 31.03.2015 for Rs.84,768/- and on 20.07.2015 for Rs.29,950/-, the same have been repudiated by OP No.2 stating that, complainant No.2 has taken treatment on OPD basis i.e., out-patient basis, which is not the matter.  As per the advice of the Consultant Radiation Oncologist, the complainant No.2 has taken treatment on OPD basis with reference to his disease factors and also on patient general conditions including age.  The reasons assigned for repudiation of the claim is not correct which is against to the Principles of Natural Justice.  Then the complainant No.2 has approached the OP No.3 for settlement of the medical claims, they also not looked into the depth of the aspect and repudiated the medical claims on vague reasons, which is a deficiency of service.  The cause of action for filing the complaint arisen at Chitradurga when the OPs 2 and 3 have repudiated the medical claims of the complainant No.2, which is within the jurisdiction of this Forum and therefore, prayed for allowing the complaint.  

 3.    On service of notice, OP No.1 and 2 appeared through Sri. B.M. Ravichandra, Advocate and filed version.  Inspite of service of notice, OP No.3 did not appear before this Forum and hence placed ex-parte.  OP No.1 and 2 filed version denying the averments made in para 1 to 8.  It is submitted that, the complainant has obtained Can-comfort insurance certificate from Divisional Certificate from OP No.2 valid for the period from 01.11.2014 to 31.01.2015 to policy card holder Sri. A.R. Nagesh, Senior Manager, Branch Office, KSFC, Mangalore and to this insurance, the insured persons comes under the policy are 1. A.R. Nagesh, 2. K.V. Suma, 3. Yogitha A.N, 4. A.R. Rukmini and 5. A. Radhakrishna Shetty who are the spouse, daughter and mother and father of card holder A.R. Nagesh and the same was issued in support of having covered the following persons for the plan thereon under the fore mentioned insurance subject to terms and conditions and exclusions.  It is further submitted that, as per the records given by complainant No.1 i.e., claim form of E-Meditek and also letter of Dr. Sanjeev Sharma of Health Care Global Enterprises Ltd., Bangalore that, complainant No.2 Radhakrishna Shetty is a known case of Carunomia prostate.  All of them have a place in the treatment and choice of method depends upon disease factors and patient’s general condition, radiation therapy are carried out on OPD basis.  There is no need for the patient to get admitted into the Hospital.  Hospitalization will be advised only as and when it is required for the patient.  It is further submitted that, after obtaining the documents and letter from the complainant No.1, E-meditek has been issued a repudiation letter to the complainant No.1 on 02.07.2015 stating that, on scrutiny of the papers of Radhakrishna Shetty, the company has observed that, he was admitted in HCG – Bangalore Institute of Oncology Specialty Center, patient was the K/C/O CA prostate treated by radiation in 2000 related investigation done came for biopsy and no any other active line of treatment given, so the claim is recommended for repudiation, as per clause No.4.10 and informed that, the claim is not payable as per Sec.4 exclusions – the company shall be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of clause 4.10 charges incurred at Hospital or Nursing Home Primarily for diagnostic, x-ray or laboratory examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital nursing home and therefore, as per the instructions of United India Insurance Co. Ltd., the claim is being denied.  It is further submitted that, the OP insurance company has issued a letter dated 29.09.2015 to the complaint of the complainant vide reference No.UI0005782015 dated 10.09.2015 stating that, it is observed that, the patient was treated for CA-Prostate and given Hormonal therapy for the same on OPD basis and hence, the claim was repudiated by TPA as per clause 2.3 which reads that, expenses on Hospitalization for minimum period of 24 hours are admissible.  The treatments usually done in outpatient department are not payable under the policy even if converted as an inpatient in the Hospital for more than 24 hours.  The complainant has filed a case before the proceedings before insurance Ombudsman, State of Karnataka under Rule 15(1)/16 before Ombudsman M. Prasad and the said proceedings has been dismissed by the Ombudsman on 16.02.2016 stating that, taking into account the facts and circumstances of the case, the information and documents placed on record and the submission made by both parties hereto during the course of personal hearing it is hereby concluded that the insurer decision of repudiating the claim under the policy is in accordance with the policy terms and conditions and thus does not want any interference at the hands of the Ombudsman and dismissed the complaint.  Therefore, the complaint filed before this Forum is res-judicata since the complaint filed before the Insurance Ombudsman on 30.12.2015 has been dismissed and again this complaint has been filed before this Forum and prayed for dismissal of the complaint.  The Policy No.77600/2014-2015/00208/11 for the period from 01.11.2014 to 31.10.2015 in favour of complainant No.1 and the same has not at all issued by OP No.1 and 2.    

   4.  Complainant No.2 has examined as PW-1 by filing affidavit evidence and the documents Ex.A-1 to A-4 were got marked.  On behalf of OP No.1 and 2, one Sri.Surendra Gaoonkar, the Divisional Manager has examined as DW-1 by filing affidavit evidence and the documents Ex.B-1 to B-5 were got marked.

5.     Arguments heard. 

6.     Now the points that arise for our consideration for decision of above complaints are that;

(1)  Whether the complainants prove that the OPs have committed deficiency of service and entitled for the reliefs as prayed for in the above complaint?

              (2) What order?

        7.     Our findings on the above points are as follows:-

        Point No.1:- Partly in Affirmative.

        Point No.2:- As per final order.

REASONS

8.     It is not in dispute that, the complainant No.1 has purchased Can-comfort Insurance Certificate from OP No.2 on 01.11.2014 covering the risk of his family persons for the period from 01.11.2014 up to 31.10.2015 vide policy No.72600/2014-15/00208/11 up to total sum assured and the said insurance policy is tied up with several Hospitals including HCG Hospital, Bangalore.  OP No.3 is the ombudsman, if the claims of the customers are not settled with the OPs, customers can approach OP No.3 for settlement of the claim.   On 27.03.2015 complainant No.2 was admitted to HCG Hospital, Bangalore with a history of Carcinoma Prostate and taken treatment.  Dr.Sanjeev Sharma, Radiation Oncologist suggested the treatment for Cancer like one is Surgery, second is Hormone Therapy and third one is Radiation Therapy, depends upon disease factors and patient general condition.  As per the advice of the said Doctor, complainant No.2 has taken treatment for Hormone Therapy depending upon the disease factors and patient’s general conditions including age factor and after the treatment, complainant No.2 submitted all the necessary papers for refund of medical claims to OP No.2 on two occasions i.e., on 31.03.2015 for Rs.84,768/- and on 20.07.2015 for Rs.29,950/-.  OP No.2 repudiated the claim stating that, complainant No.2 has taken treatment on OPD basis i.e., out-patient basis.  As per the advice of the Radiation Oncologist, complainant No.2 has taken treatment on OPD basis with reference to his disease factors and also general conditions including age.  Then the complainant No.2 has approached the OP No.3 for settlement of the medical claims, OP No.3 also not looked into the depth of the aspect and repudiated the medical claims on vague reasons, which is a deficiency of service.  

 9.    In support of their contention, the complainants have filed affidavit evidence of complainant No.2 and reiterated the contents of complaint and relied on documents like repudiation letter dated 29.09.2015 of OP marked as Ex.A-1,  letter dated 09.03.2016 issued by OP No.3 to the complainant  marked as Ex.A-2, Order of dismissal dated 16.02.2016 befor the OP No.3 marked as Ex.A-3 and medical certificate issued by the Health Care Global Enterprises Ltd., dated 20.11.2015 marked as Ex.A-4, wherein it is mentioned by the Doctor that, “the radiation therapy and hormone therapies are carried out on OPD basis.  There is no need for the patient i.e., complainant No.2 to get admitted into the Hospital.  Hospitalization will be advised only as and when it is required for the patient.  However, the condition of Mr. Radhakrishna Shetty is stable and he is able to tolerate the hormone therapy on OPD basis”.

10.   On the other hand, OP No.1 and 2 have argued that, the complainant No.1 has obtained Can-comfort insurance certificate from Divisional Certificate bearing Policy No.77600/2014-2015/00208/11 for the period from 01.11.2014 to 31.10.2015 in favour of complainant No.1 and the same has not at all issued by OP No.1 and 2 to himself and his family members who are the spouse, daughter and mother subject to terms and conditions and exclusions.  As per the records given by complainant No.1 i.e., claim form of E-Meditek and also letter of Dr. Sanjeev Sharma of Health Care Global Enterprises Ltd., Bangalore that, complainant No.2 Radhakrishna Shetty is a known case of Carunomia prostate.  All of them have a place in the treatment and choice of method depends upon disease factors and patient’s general condition, radiation therapy are carried out on OPD basis.  There is no need for the patient to get admitted into the Hospital.  Hospitalization will be advised only as and when it is required for the patient.  After obtaining the documents and letter from the complainant No.1, E-meditek has been issued a repudiation letter to the complainant No.1 on 02.07.2015 stating that, on scrutiny of the papers of Radhakrishna Shetty, the company has observed that, he was admitted in HCG – Bangalore Institute of Oncology Specialty Center, patient was the K/C/O CA prostate treated by radiation in 2000 related investigation done came for biopsy and no any other active line of treatment given, so the claim is recommended for repudiation, as per clause No.4.10 and informed that, the claim is not payable as per Sec.4 exclusions – the company shall be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of clause 4.10 charges incurred at Hospital or Nursing Home Primarily for diagnostic, x-ray or laboratory examination not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury for which confinement is required at a Hospital nursing home and therefore, as per the instructions of United India Insurance Co. Ltd., the claim is being denied.   The OP insurance company has issued a letter dated 29.09.2015 to the complaint of the complainant vide reference No.UI0005782015 dated 10.09.2015 stating that, it is observed that, the patient was treated for CA-Prostate and given Hormonal therapy for the same on OPD basis and hence, the claim was repudiated by TPA as per clause 2.3 which reads that, expenses on Hospitalization for minimum period of 24 hours are admissible.  The treatments usually done in outpatient department are not payable under the policy even if converted as an inpatient in the Hospital for more than 24 hours.  The complainant has filed a case before the proceedings before insurance Ombudsman, State of Karnataka under Rule 15(1)/16 before Ombudsman M. Prasad and the said proceedings has been dismissed by the Ombudsman on 16.02.2016 stating that, taking into account the facts and circumstances of the case, the information and documents placed on record and the submission made by both parties hereto during the course of personal hearing it is hereby concluded that the insurer decision of repudiating the claim under the policy is in accordance with the policy terms and conditions and thus does not want any interference at the hands of the Ombudsman and dismissed the complaint.  Therefore, the complaint filed before this Forum is res-judicata since the complaint filed before the Insurance Ombudsman on 30.12.2015 has been dismissed and again this complaint has been filed before this Forum.

11.   In support of their contention, OP No.1 and 2 have filed affidavit evidence of one Sri.Surendra Gaonkar, the Divisional Manager, examined as DW-2 reiterating the contents of their version and relied on the documents like Concomfort Insurance certificate covering the risk of the family members of the complainants marked as Ex.B-1,  wherein it is mentioned that, the complainants have paid Rs.19,268/- towards insurance premium amount on 01.11.2014, terms and conditions of the policy marked as Ex.B-2, letter of ombudsman dated 09.03.2016 marked as Ex.B-3, Orders passed by the Ombudsman marked as Ex.B-4 and repudiation letter dated 02.07.2015 marked as Ex.B-5.

12.   On hearing the contention of both parties and on perusal of the documents including the affidavit and documentary evidence, it clearly made out that, the complainants obtained health insurance policy from the OP No.2 and OP No.1 is the one of the Branch Office, covers like accident, injuries, critical illness, natural surgeries valid for the period from 01.11.2014 to 31.10.2015 under policy No.72600/2014-15/00208/11.  The said policy is tie up with several hospitals including HCG Hospital, Bangalore.  The complainant No.2 was admitted to the HCG Hospital, Bangalore on 27.03.2015 with a history of Carcinoma Prostate and taken treatment.  After taking treatment, the complainant No.2 submitted all the necessary papers for refund of medical claims to OP No.2 on two occasions i.e., on 31.03.2015 for Rs.84,768/- and on 20.07.2015 for Rs.29,950/-, the same have been repudiated by OP No.2 stating that, complainant No.2 has taken treatment on OPD basis i.e., out-patient basis.  But, as per Ex.A-4 the doctor concerned to health care global enterprises have issued a certificate on 20.11.2015 and stated that, there is no need for the complainant No.2 to admit to the Hospital for treatment as an inpatient.  Whatever, the decisions submitted by the OP is not relevant and supported to the case of the OPs.  The repudiation of the OPs in not settling of the claim of the complainant is the deficiency of service.  Hence, the complainant has suffered mental agony and financial loss, which cannot be compensated by the OPs unless on payment of compensation.  Therefore, we come to the conclusion that, there is a deficiency of service on the part of OPs.  Accordingly, this Point No.1 is held as partly affirmative to the complainant.

 

          13.     Point No.2:- As discussed on the above point and for the reasons stated therein we pass the following:-

ORDER

It is ordered that, the above complaint filed by the complainants u/Sec.12 of C.P. Act is hereby allowed in part.       

It is ordered that, the OP No.1 and 2 are hereby directed to pay a sum of Rs.1,14,718/- to the complainants along with interest at the rate of 2% p.a from the date of complaint till realization. 

It is further directed the OP No.1 and 2 to pay                   Rs.25,000/- towards compensation and Rs.5,000/- towards cost of the proceedings to the complainants.

It is further ordered that, the OP No.1 and 2 are hereby directed to comply the above order within 30 days from the date of this order.

            (This order is made with the consent of Member after the correction of the draft on 20/07/2017 and it is pronounced in the open Court after our signatures)         

 

                                     

 MEMBER                                                   PRESIDENT

-:ANNEXURES:-

Witnesses examined on behalf of Complainant:

PW-1:  Complainant by way of affidavit evidence.

Witnesses examined on behalf of OPs:

DW-1: Sri.Surendra Gaonkar, by way of affidavit

Documents marked on behalf of Complainants:

01	Ex-A-1:-	Repudiation letter dated 29.09.2015 of OP
02	Ex-A-2:-	Letter dated 09.03.2016 issued by OP No.3 to the complainant
03	Ex.A-3:-	Order of dismissal dated 16.02.2016 before the OP No.3
04	Ex.A-4:-	Medical certificate issued by the Health Care Global Enterprises Ltd., dated 20.11.2015

 

Documents marked on behalf of OPs:

01	Ex-B-1:-	Concomfort Insurance certificate
02	Ex-B-2:-	Terms and conditions of the policy
03	Ex.B-3:-	Letter of ombudsman dated 09.03.2016
04	Ex.B-4:-	Orders passed by the Ombudsman
05	Ex.B-5:-	Repudiation letter dated 02.07.2015

 

 

MEMBER                                                            PRESIDENT

Rhr**