SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)
The complainant has filed this complaint petition, U/s 35 of the Consumer Protection Act, 2019 (here-in-after called as the “Act”) alleging deficiency-in-service against the Ops with a prayer for compensation.
2. The case of the complainant, in a nutshell, is that he had purchased one policy bearing No.11230063252304 from the OP No.1 for his family health protection and paid four instalments till 15.7.2022. In the said policy, the complainant, his wife and his three daughters were also included. Said policy was opened on 13.7.2018 and the same is continued till 14.7.2023.
It is further stated that on 16.2.2020, the wife of the complainant namely Sujata Sarangi was admitted in Durga Nursing Home, Balasore for removal of her uterus. At that time, he informed the OP No.1 for cashless treatment, but the OP No.1 replied that as the policy is within two years, no benefit is available to him for which he spent Rs.50,000/- for such operation.
It is the further case of the complainant that on 6.8.2022, the first daughter of the complainant namely Tamanna Sarangi, who was suffered from Dengue, admitted in District Headquarters Hospital, Balasore and subsequently referred to SCB MCH, Cuttack. As the complainant obtained health card from the Ops, he admitted his daughter in KIMS Hospital, Bhubaneswar for better treatment. At that time, the complainant had to bear the ambulance expenses of Rs.5,880/-, admission expenses of Rs.3,000/- so also he had purchased medicines out of his own fund. The Ops had also assured that the Ops would reimburse all the expenses incurred by the complainant. On the date of discharge, concerned Hospital given concession of Rs.2,490/- as his daughter was a college student. The complainant had handed over all the required documents along with expenses vouchers of Rs.6,658/- to the Ops through the agent, but the same was returned.
It is also averred that another daughter of the complainant namely Dibyani Sarangi was also suffered from Dengue and admitted in Blue Wheel Hospital, Bhubaneswar. The complainant had submitted his insurance documents for cashless treatment before the hospital authority and they had sent all the documents to the Ops for payment of the cost of treatment, but the Ops by their letter dated 17.9.2022 expressed their inability for cashless treatment as per National Vector Board guidelines. It is further averred that during the coverage of the insurance period, the wife and two daughters of the complainant have been admitted in different hospitals, but the Ops intentionally and deliberately avoided to pay the cost of treatment with different pleas. The above nature of the Ops not only amounts to unfair trade practice but also attributes deficiency in service on their part. Thus, finding no other way, the complainant served notice against the Ops on 21.11.2022 with a request to pay the expenses amount, but on 16.1.2023 the OP No.1 denied to give any claim amount for which the complainant was constrained to file the case.
The cause of action for filing of the case arise on 17.9.2022, when the OP No.2 refused the claim and on 21.11.2022, when the complainant served notice on the Ops and lastly on 16.1.2023, when the OP No.1 denied to give any claim amount. Hence, this case.
To substantiate his case, the complainant relied upon the following documents, which are placed in the record-
- Photocopy of Policy Schedule.
- Photocopy of Letter issued by Ops rejecting the claim of the complainant.
- Photocopy of Bill issued by Blue Wheel Hospital.
- Photocopy of Medicine purchased memo.
- Photocopy of Tax invoice for availing ambulance service.
- Photocopy of Medicine purchased memo.
- Photocopy of Discharge certificate issued by FM MCH, Balasore.
- Photocopy of Discharge summary issued by KIMS Hospital, Bhubaneswar.
- Photocopy of Notice dated 21.11.2022 with registration receipts.
- Photocopy of Tracking consignments.
3. The OP No.1 to 3 have made their appearance and filed their joint written version. OP No.4 has also made his appearance and filed written version.
4. OP No.1 to 3, in their written version, not only challenged the contents made in the complaint petition, but also emphatically stated that the complainant has no cause of action to file the present case and the case is not maintainable. The OP No.1 to 3 have stated, inter alia, that the complainant had claimed Rs.7,350/- for the treatment done in KIMS Hospital, Bhubaneswar vide claim No.CIR/2023/191213/0583780 and Rs.6,658/- for the treatment done in Blue Wheel Hospital, Bhubaneswar vide claim No.CIR/2023/191213/0792584. In respect of the claim No. CIR/2023/191213/0583780 out of total claimed amount of Rs.7,350/-, they had already settled Rs.5,036/- towards cashless payment and rest deductions were done against non-payable items as per policy terms and conditions. It is also stated that for the claim No. CIR/2023/191213/0792584, they had repudiated the claim on the ground that platelets counts are more than one Lakhs which confirmed that the patient could have been managed as OPD. That apart, the complainant had not submitted the original claim documents and did not raise any reconsideration request for reimbursement for which they could not able to process the reimbursement claim. Therefore, these Ops are prayed to direct the complainant to submit the original claim documents so that they can process the claim and they are ready to settle the claim as per terms and conditions of the policy.
5. OP No.4, in their written version, have stated that their forum does not sell policies or settle claims and their forum adjudicates the grievances that are not addressed by the insurers as per the provisions of the Insurance Ombudsman Rules, 2017. The OP No.4 is neither a necessary nor a proper party to adjudication of the complaint. Therefore, the averments made by the complainant in his complaint is not applicable for their forum as their forum have not received any complaint from the complainant.
6. From the case record, it is evident that on 25.4.2023, the OP No.1 to 3 filed a petition before this Commission wherein they prayed to direct the complainant for production of the documents as mentioned therein from Sl. No.1 to 11 for processing the claim. In compliance, the complainant had filed the original documents on 7.8.2023 before this Commission, as required by the OP No.1 to 3, which were received by one Manik Rout, who was authorized to collect the documents by the Authorized Representative, on 9.2.2024 with proper endorsement and signature. But, the Authorized Representative of OP No.1 to 3 remained absent since 11.3.2024 and did not come forward to take part in the hearing. Therefore, the hearing of the case was concluded on 2.7.2024 and subsequently posted for order.
7. In the present case, OP No.1 to 3 are the same Insurance Authorities, but located in different places. In order to arrive at a definite conclusion, it is required to be decided as to whether there is any deficiency of service on the part of the Ops. It is an admitted fact that the complainant had purchased the policy in question meant for family health optima insurance plan on 13.7.2018 for a sum assured of Rs.4,00,000/- and Bonus of Rs.2,20,000/-, total coverage of Rs.6,20,000/- from the Ops which was insured against the complainant, his wife and three daughters, as reflected vide Annexure-1. It is further reflected in the Tax Invoice issued by the Ops that the complainant had the premium of Rs.25,312/- on 15.7.2022 which itself speaks that the policy in question was within the coverage period since 13.7.2018. From Annexure-3 to 6, it is found that the complainant had incurred expenditure for purchasing of medicines and availing of ambulance service. It is the case of the complainant that he had incurred expenditure of Rs.50,000/- for the operation of his spouse in Durga Nursing Home, Balasore. At that time, the claim of the complainant was turned down by the Ops on the ground that the policy was within two years and no benefit was extended to him. Secondly, the first daughter of the complainant was admitted at DHH, Balasore on 6.8.2022 for suffering from Dengue and thereafter at KIMS Hospital, Bhubaneswar. At that time, the complainant met all the expenses i.e. purchase of medicines, cost of ambulance and admission fees. That claim has also been turned down by the Ops. Thirdly, another daughter of the complainant was admitted in Blue Wheel Hospital, Bhubaneswar. The complainant produced his insurance documents for cashless treatment before the Hospital Authority, but the Ops in their letter dated 17.9.2022 (Annexure-2) repudiated the claim of the complainant as per guidelines of National Vector Board.
8. On the other hand, OPNo.1 to 3 have claimed that they have settled the claimed amount of Rs.7,350/- to Rs.5,036/- in respect of claim raised by the complainant for medical expenses incurred for the treatment of his first daughter in KIMS Hospital, Bhubaneswar. To that effect, Ops have not filed a single document to show that there has been a settlement with the complainant. Ops have further claimed that they have repudiated the claim raised by the complainant for medical expenses incurred for the treatment of his another daughter who was treated at Blue Wheel Hospital, Bhubaneswar on the ground that platelets counts are more than one Lakhs, the complainant has not submitted the original claim documents. In the rejection of authorization for cashless treatment letter dated 17.9.2022 (Annexure-2) issued by the Ops, it has been mentioned that as per national vector board guidelines if the platelet count is more than 1 Lakh, it falls under low risk category so it does not require admission, it can be treated as OP. In the present case, the first daughter of the complainant suffered from Dengue and in that case, the Ops have settled the claim, as stated by them. But what prevented them to come to a settlement in the case of cashless treatment in respect of his another daughter, who was also suffering from Dengue and how could the Ops came to a conclusion that it can be treated as OP. Moreover, the Ops have failed to produce any guidelines implemented by the National Vector Board. That apart, it is claimed by the complainant that he had submitted all relevant documents before the authority of Blue Wheel Hospital, Bhubaneswar, who in turn sent the same to the Ops for payment of the cost of treatment. In that case, without informing the concerned hospital authority, Ops had intimated the complainant repudiating his claim. It is clearly mentioned in the Insurance Policy Schedule (Annexure-1) that in the event of hospitalization of insured person, intimation should be given to the Company immediately, however, within 24 hours from the time of admission. In the present case, it is found that the complainant was not defaulted in sending information about the treatment of his another daughter in Blue Wheel Hospital, Bhubaneswar within the stipulated time. Further, it is seen that the complainant had purchased the Family Health Optima Insurance Plan on 13.7.2018 and used to pay the premium till 15.7.2022, which itself proved that the Insurance plan was valid from the date of medical treatment of the wife of the complainant till the date of medical treatment of his second daughter and it has not been expired. In the letter dated 15.7.2022 issued by the Ops in favour of the complainant, it is clearly mentioned that “Sum insured of this policy is meant for utilization till its expiry. Bearing this aspect in mind, we have no doubt, you will choose appropriate hospital, room rent and treatment charges etc”. Now a days, so many medical insurance companies are active in the society and by engaging their intermediators, collected customers with high ambitions, but at the time of claim raised by any policyholder, they Insurance Companies repudiated their claim on different grounds. This type of unfair trade practice are being adopted by the Insurance Companies not only in the State but also throughout the Country and the innocent citizen are used to suffer harassment financially and mentally. In the present case, as it is seen, the Ops have not paid a single pie to the complainant for the treatment of his wife, his first daughter and his another daughter. At the time of proposal for Medical Insurance, the Ops had assured the complainant for cashless treatment, but in the present case, the Ops have not coordinated with the complainant for cashless treatment, rather, they repudiated the claim, which amounts an unfair trade practice and deficiency in service.
9. Besides the above, it is seen from the case record that on 25.4.2023, the OP No.1 to 3 filed a petition before this Commission wherein they prayed to direct the complainant for production of the documents as mentioned therein from Sl. No.1 to 11 for processing the claim. The petition was heard and necessary direction has been imparted to the complainant for production of the documents. In compliance, the complainant had filed the original documents on 7.8.2023 before this Commission, which were received by one Manik Rout, who was authorized by the Authorized Representative of the Ops to collect the same, on 9.2.2024 with proper endorsement and signature. But, the OP No.1 to 3 remained absent since 11.3.2024 and did not come forward to take part in the hearing till date. From the above nature and character of the OP No.1 to 3, this Commission is of the considered opinion that the above Ops have nothing to say and thereby they have played a hide and seek game with the Commission.
10. It is the claim of the complainant that being harassed by the OP No.1 to 3, he has sent notice on 21.11.2022 by registered post (Annexure-9 & 10) with a request to pay the health protection claim amount, but the above Ops even after receipt of notice, remained silent. In this regard, a notice for deficiency in service can be sent by a consumer to the service provider or company who has not provided any kind of service and sending deficiency in service notice is the most primary step where the service provider gets an opportunity to compensate the consumer. The very fact in the present case is that the OP No.1 to 3 remained silent to the notice of the complainant which itself indicates that the Ops are guilty of selling a fraudulent insurance plan and consequent deficiency in service by their negligent attitude in attending to the complainant on the cashless treatment which is brought to its notice. Therefore, this Commission is constrained to hold that the OP No.1 to 3 are deficient in their service for the second and subsequent claim of the complainant and hence, they are jointly and severally liable for the compensation.
11. In the present case, taking into account the version of the OP No.4, it is held that the OP No.4 have no nexus with the complainant and thus, the case against OP No.4 is dismissed.
Hence, it is ordered: –
O R D E R
The complaint of the complainant be and the same is allowed in part on contest against the OP No.1 to 3 and dismissed against OP No.4. The OP No.1 to 3 are directed to pay a sum of Rs.14,863/- towards the medical expenses incurred by the complainant in the treatment of his first daughter at KIMS Hospital, Bhubaneswar and his another daughter at Blue Wheel Hospital, Bhubaneswar with interest @ 9% from 06.08.2022 till its realization. The OP No.1 to 3 are further directed to pay a compensation of Rs.50,000/- for suffering of harassment and mental agony and Rs.10,000/- for litigation cost. The above said order shall be complied by the OP No.1 to 3 within a period of 45 days from the date of receipt of this order, failing which the complainant is at liberty to realize the same through the process of law.
Pronounced in the open court of this Commission, this the 12th August, 2024 under the signatures & seal of the Commission.
