By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get reimbursement of the hospital expenses as per policy No.P/18314/01/2015/001370.
2. Brief of the complaint:- The complainant had insured with opposite party under the Family Health Optima covering four persons, for the period from 30.06.2013 to 29.06.2014 and it was later renewed up to 09.07.2016 for a sum of Rs.2,00,000/-. The complainant was admitted on 31.05.2015 at MIMS Hospital Kozhikode for fibroid Uterus and had undergone Hysterectomy and spent Rs.70,282/- for surgery and Rs.50,000/- for diagnosis purpose. During the course in the hospital complainant submitted cashless claim form, pre-authorization request form before opposite party but opposite party rejected the cashless claim on the ground of “2 year exclusion clause”, and not approved the claim. Complainant alleged that due to the deficiency of service of opposite parties complainant caused much loss and mental agony and was forced to raise money at the time of hospitalization. Hence filed this complaint.
3. On receipt of notice, opposite parties No.1 and 2 version filed. Opposite party No.3 was not appeared hence his name called absent and set ex-parte on 24.08.2015.
3. In the version opposite party No.1 and 2 stated that the complainant had insured with opposite party under the Family Health Optima, for the period from 30.06.2013 to 29.06.2014 and it was later renewed up to 09.07.2016 for a sum of Rs.2,00,000/-. The first inception of the policy is on 30.06.2013, next year the insured renewed the policy, subsequently she was admitted on 31.05.2015 at MIMS Kozhikode for Fibroid Uterus and undergone Hysterectomy. This opposite party received Pre-authorization request from the hospital in which symptom were recorded as “poly menorrhagia for 3 months and the provisional diagnosis as “Fibroid Uterus” for which laproscopic hysterectomy was done. Admittedly hysterectomy for fibroid uterus/menorrhagia was conducted within two years of policy and the rejection of the cashless facility was proper and faultless. The date of inception of the policy in question was on 30.06.2013 and the opposite party rejected the cashless facility due to two year exclusion clause. They further submitted that as per Exclusion clause No.3 of the policy states that the “company shall not be liable to make payments under the policy in respect of any expenses whatsoever incurred by the insured person during the first two years of continuous operation of insurance cover”. The expenses on treatment of cataract, hysterectomy for menorrhagia or fibromyoma treatment for knee and or joint (other than caused by an accident) prolapse of intervertribral disc(other than caused by an accident), varicose veins and varicose ulcers are excluded under clause No.3 of exclusions.
4. Opposite parties further stated that complainant had not submitted any claim with documents and bills to these opposite parties at any point of time. Thus the claim has not been repudiated and hence there is no cause of action for this complaint at all. Again submitted that the cashless facility is not a part of contractual obligation as per the terms and conditions of the insurance policy contract. The said extra comfort level facility of cashless facility is extended to those cases where the liability of the insurance company under the policy is established beyond any doubt. In all other cases the insured has to submit a completed claim form with all supporting treatment documents to enable the opposite parties to understand and process the claim on merit. In this case complainant has violated the condition No.3 of the policy which is precedent to admission of liability under the policy ie “a claim must be filed within 15 days from the date of discharge from the hospital”, which is sufficient ground for repudiation of the claim. Hence they submitted that there is no deficiency of service from the part of them, hence prayed to dismiss the complaint.
5. Complainant filed affidavit and examined as PW1. Ext.A1 to A3 series documents were marked. Hospital records of complainant has been produced before this Forum as per the Order of the I.A.513/2015 and were marked as Ext.X1 series. For Opposite party No.1 and 2, Legal Manager adduced evidence as OPW1 and Ext.B1 to B4 documents were marked. Ext.A1 is the Family Health Optima Insurance Plan. Ext.A2 is the Discharge Summary. Ext.A3 series are the Hospital Bills (10 in numbers). Ext.B1 is the copy of Family Health Optima policy schedule. Ext.B2 is the Family Health Optima Insurance Plan. Ext.B3 is the copy of Pre-authorization request form. Ext.B4 is the copy of Rejection of Pre-authorization for cashless treatment. Opposite party No.3 was already set ex-parte on 24.08.2015.
6. On perusal of complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Relief and Cost.
7. Point No.1:- The complainant's case is that opposite party rejected the cashless claim of this complainant during the admission period. The complainant was admitted on 31.05.2015 at MIMS Hospital Calicut for fibroid Uterus and had undergone Hysterectomy and submitted pre-authorization request to opposite party through the hospital. Even though the admission and treatment was admitted by opposite parties, they rejected cash less claim. On verification of Ext.X1 series discharge summary, diagnosis was noted as Multiple Fibroid Uterus and she was under went surgery on 01.06.2015. Admittedly complainant submitted pre-authorization request through the hospital. In which the symptom were recorded as poly menorrhagia for 3 months and Fibroid Uterus for which laproscopic hysterectomy was done within 2 year of inception of first policy. Hence opposite parties rejected cashless facility as it was excluded as per the Exclusion clause No.3 of the policy and the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person during the first two years of continuous operation of insurance cover.
8. Thereafter complainant have not submitted claim form before opposite party and opposite party argued that they have not received any claim form with documents/bills from the complainant at any point of time, and cashless benefit is an extra comfort and not mandatory. In normal cases insured has to submit a completed claim form with all supporting documents to enable the opposite party to understand and process the claim on merit. In this case complainant failed to prefer claim form.
9. In this case complainant has violated the condition No.3 of the policy which is precedent to admission of liability under the policy ie “a claim must be filed within 15 days from the date of discharge from the hospital”, which is a sufficient ground for repudiation of the claim. Opposite parties further stated that insurance are subject to conditions, clauses, warranties, exclusions etc and the same was issued to the complainant and conditions produced by opposite party were marked as Ext.B2.
10. On an overall evaluation of the pleadings, evidences and documents, we are of the opinion that the present claim of the complainant is within 2 years of the inception of the first policy and the repudiation of the cashless facility was proper. As per the submissions of opposite party No.1 cashless facility is an extra comfort given by them. Actually claim form with relevant documents were not received by opposite party No.1, claim has not been repudiated, instead of submitting the claim form before opposite party in proper way this complainant directly approached this Forum to get claim amount. On verification of Ext.B2 Family Health Optima Insurance Policy we noted that the inception of 1st policy was on 30.06.2013 and complainant admitted for surgery on 31.05.2015 that means 23 months were completed after the inception of the 1st policy. Even if the claim will come under clause No.3 of 24 months exclusions, the present surgery was done after the completion of 23 months, only few more dates are remaining to complete 24 months. Hence we opine that a humanitarian consideration can be given to this complainant's claim and we cannot attribute any deficiency of service from the part of opposite parties. The Point No.1 is found accordingly.
11. Point No.2:- Since opposite parties were not deficient in their service complainant is not entitled to get cost and compensation.
In the result, the complaint is partly allowed and the complainant is directed to submit claim form with documents and bills to the opposite parties within one month of receipt of this Order and opposite party No.1 and 2 are directed to reconsider the claim and reimburse the eligible amount to the complainant on receipt of claim form and connected documents from the complainant within one month of the date of receipt of claim form. No Order as to cost and compensation.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 28th day of March 2016.
Date of Filing:15.07.2015.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
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PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Jessy. V. V. Complainant.
Witness for the Opposite Parties:-
OPW1. Mridula. Executive Legal, Star Health.
Exhibits for the complainant:
A1. Family Health Optima Insurance Plan.
A2. Discharge Summary.
A3(Series). Bills(10 Nos).
X1(Series). Hospital Records.
Exhibits for the opposite parties:-
B1. Authorization Letter. Dt:23.12.2015.
B2. Family Health Optima Insurance Plan.
B3. Copy of Authorization Request Form.
B4. Copy of Rejection of the Pre-authorization
for cashless treatment. Dt:26.05.2015.
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PRESIDENT, CDRF, WAYANAD.
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