O R D E R
SMT.K.G.BEENA, MEMBER
Complainant availed a family Health plan insurance policy from opposite party numbering P/181313/01/2012 from 30-04-2011 to 29-04-2012. As per policy conditions the opposite party has to bear the treatment expenses of the insured within the policy period. On 28-09-2011 the complainant has admitted to Sachidananda Institute of Medical Science due to cervical problem and discharged on 30-09-2011. Soon after the admission in hospital, the complainant informed the matter to opposite party and the agent one Mr.Manoj visited the complainant and made an enquiry regarding treatment expenses and offered to pay the amount. Opposite party made the complainant to wait the whole day on the date of discharge. Opposite party failed to remit the hospital bill of the complainant on the date of discharge after the whole day’s waiting complainant some how managed the hospital bill.
2. Opposite party filed version stating that the complaint is not maintainable either in law or on facts. But opposite party admitted that the complainant has taken a family health optima insurance policy for a sum of 2 lakhs. Contention of opposite party is that the cashless facility is not a part of contractual obligations as per the terms and conditions of Insurance Policy Contract when cashless facility is provided all treatment records like discharge summary results of all medicines purchased and other services availed will be submitted to the insurance company by the hospital and the insurance company would pay the treatment expenses directly to the hospital. When cashless facility is not extended by the company or when it is not availed by the insured, then all treatment records and bills will be collected by the insured and he will make payment to the hospital only when he makes a claim in the prescribed claim form with all the treatment records and supporting bills, the insurance company will able to understand the claim and arrive at payable amount. Eventhough cashless facility is not mandatory as per policy contract opposite party has sent cashless authorization to the hospital on 30-09-2011 at 5.32 PM. Only on receiving court notice, opposite party came to know about the non-utilization of the cashless facility by the complainant.
3. Complainant filed affidavit. Exts A1 to A3 marked. Complainant is cross-examined by opposite party’s counsel. Opposite party’s counsel represented that they have no oral evidence. Exts B1 and B2 marked. Heard both sides.
4. It is admitted by opposite party that the complainant has availed a family health plan insurance policy from 30-04-2011 to 29-04-2012. The insurance agent made him believe that cashless facility is available under this policy. On28-09-2011 complainant has admitted to Sachidanda Institute of Medical Sciences due to Cervical problem. He informed the case of admission to opposite party’s through telephone. After admission the insurance agent visited the complainant in hospital and collected all treatment records and bills for payment of hospital expenses on discharge. So the complainant expected that opposite party will pay the hospital bill and waited for them for the whole day but was in vein after discharge, in the evening somehow the complainant paid the bill, this caused mental agony and loss to the complainant. After admission in hospital opposite party assured the complainant that they will bear the hospital expenses. It is clear from the affidavit and Ext.B2 series that complainant has undergone treatment in Sachidanda Institute of Medical Sciences Hospital. But it is alleged by the complainant that opposite party failed to meet the hospital expenses as promised earlier. Ext.B1 series proves that the case of the complainant is true.
5. Complainant opted to purchase the policy only due to the representation made by the insurance agent Manoj who acted on behalf of opposite party that cashless facility is available under this policy. After the complainant’s admission in hospital when insurance agent Manoj visited him and collected all treatment records like discharge summary results in lab investigations and bills of all medicines, it is a part of cashless facility as informed by the agent so the complainant bonafidely given those documents expecting cashless facility only after discharge the complainant came to know that he is cheated by the opposite party. Another contention raised by the opposite party is that complainant has not approached the insurance company for reimbursement of the claim amount is not sustainable as the insurance agent visited the complainant in hospital and collected all treatment records, it is the duty of opposite party to explain the procedure of processing the claim.
6. It is admitted by opposite party in their version that out of the total bill amount of Rs.6,103/- payable amount is Rs.5,683/- as the policy recital clause A to F clearly states that admission fee, registration fee and miscellaneous charges are not falling under any of the heads and hence are not payable.
7. Opposite party in their version expressed their willingness to settle the claim for Rs.5,683/-. But there is a delay in settling the claim due to the deficiency in service on the part of opposite party which caused mental agony and loss to the complainant. So the complainant is entitled damages.
In the result, the complaint is allowed and opposite party is directed to pay Rs.5,683/- to the complainant as reimburse of the claim with Rs.5,000/- as damages within 30 days from the date of receipt of this order. Failing which Rs. 5,683/- will carry interest @ 9% from 30-09-2011 till the date of payment.
MEMBER PRESIDENT
A1.Photocopy of Family Health Optima Insurance Policy Scheme.
A2. Photocopy of policy certificate.
A3. Photocopy of Discharge Card.
B1. Family Health Optima Insurance Policy Scheme
B2.series Medical bills.
PW1.Mathew.
MEMBER PRESIDENT
Pj/
