By Sri. Bindu.R,  President:

          This complaint is filed  by Joseph M.J, Manaloth House, Thrikkaipetta,  Meppadi Post, Wayanad District  against  The Branch Manager, Star Health & Allied Insurance Company Ltd., Meenangadi and  others alleging  deficiency  of service and unfair trade practice on their part  under section 35(1) of the Consumer Protection Act.

          2. The Complainant alleges that the Complainant is having  Family Health Insurance  Policy with No.P/181324/01/2020/001238 and the policy is valid  till 7^th September 2020.  Soniya, W/o. the Complainant was treated as an inpatient in 3^rd  Opposite Party Hospital from 22.01.2020 onwards for abrasion on right  knee and the Complainant spent  Rs.49,653/-  as treatment  expenses.  While undergoing  treatment the representative of the  1^st  Opposite Party company had visited the patient in the hospital.  After  discharge the Complainant had produced all documents relating to the  treatment to the office of 1^st  Opposite Party for reimbursement of  medical expenses  and the 1^st  Opposite Party sent all the documents to the 2^nd  Opposite Party.  But the 2^nd  Opposite Party rejected the claim saying that the information given by the Complainant is incorrect.  The Complainant states that the treatment taken was for knee abrasion but the hospital records shows that the  treatment is for “Thrombocytopenia Purpura” and  hence the  2^nd  Opposite Party requested the Complainant for treatment records.  Complainant states that the wife of the Complainant was never treated for that disease.  The treated doctor  Dr. Dayal Chavan, at 3^rd Opposite Party hospital  stated that the patient had not any history of Thrombocytopenia Purpura and not availed any treatment for that  disease.  According to the Complainant it is a mistake happened from the duty doctor while diagnosing  the patient.  On 25.01.2020 Dr. Dayal Chavan sent a letter to the 1^st  Opposite Party stating that the patient doesn’t have any history of Thrombocytopenia Purpura and not received any treatment for the same.  The Complainant states that the documents given to the patient by  3^rd  Opposite Party is produced and the doctor clarified the mistake happened from the side of the 3^rd  Opposite Party.  Mistake of diagnosis from the side of 3^rd  Opposite Party amounts to deficiency of service  from the part of the 3^rd  Opposite Party and even after the clarification by 3^rd  Opposite Party,  the repudiation of claim by 1^st and 2^nd  Opposite Parties amounts to deficiency in service on the part of  1^st and 2^nd Opposite Parties and hence the Complainant approached the Commission  praying for issuing  direction  to the Opposite Parties to  reimburse  the  medical  bill and for grant of compensation and other reliefs.

          3. Upon notice from the Commission the Opposite Parties entered into appearance and filed their versions.

          4. 1^st and 2^nd  Opposite Parties in their version contented that the complaint is without any bonafides.  Opposite Parties 1 and 2  admitted the policy covering the Complainant and his wife for a sum  insured  of Rs.10,00,000/- which was renewed  upto 17.09.2020 and at the time of availing the policy,  the terms and conditions of the policy has been served to the Complainant with policy schedule.  According to  1^st and 2^nd  Opposite Parties the Complainant has specifically declared that  his wife Sonia was not suffering from any disease or ailment at the time of  submitting the proposal form or any  point of time earlier and that her health condition was good in all respects and the policy is  issued strictly in accordance with the terms and conditions.  The receipt of the  request for cashless hospitalization  from 3^rd  Opposite Party is admitted by  Opposite Parties 1 and 2  and which was  provisionally diagnosed with deep  Abrasion right knee.  It    was mentioned  as accidental fall from bike and in critical  finding column  it is shown as complaints of pain in right knee.  It is stated  by 1^st  and 2^nd  Opposite Parties  that the  3^rd  Opposite Party also forwarded the initial  assessment of inpatient  noting  the past illness column that the patient is a known case of “Thrombocytopenic pupura”.  Hence  1^st and 2^nd  Opposite Parties had issued a query to 3^rd  Opposite Party on 24.01.2020 directing the hospital to provide some documents regarding the consultation and the duration of the disease etc.  Based on the query,  the 3^rd  Opposite Party forwarded the treatment records and explanation in which the Complainant  states that the accident happened on 10.01.2020 and the scooter,  while the Complainant and his wife were travelling,  skid on the road and both suffered injuries which were  dressed in a nearby clinic.  But when they had gone for dressing on 22.01.2020,  the wound was septic and thereby she was referred to the  3^rd  Opposite Party hospital and admitted there.  The Complainant further states that the disease was diagnosed on  admission and no other treatment history available for the same.  More over from the outpatient records  forwarded by 3^rd Opposite Party it was clear that the patient was suffering  from thrombocytopenia  purpura.   3^rd  Opposite Party also forwarded a letter dated 25.01.2020 issued by Dr. Dayal Chavan MBBS MS ortho stating  that the patient does not have any symptoms related to Thrombocytopenia Purpura and does not  have any history related to the same.  It is stated by 1^st and 2^nd  Opposite Parties that based on the information and records  provided the Opposite Parties were not in a position to decide upon the admissibility of the claim  and hence the request for cashless treatment was denied.  It is  submitted by 1^st and 2^nd  Opposite Parties that  after the treatment the Complainant had submitted claim form with discharge summary reports with bills for Rs.52,116/-.  As per the discharge summary,  the Complainant’s wife Sonia had undergone treatment at  3^rd  Opposite Party hospital for the period from 22.01.2020 to 15.02.2020 and  was diagnosed with abrasion right knee and in the discharge summary the  “Thrombocytopenic Purpura” is not  mentioned  by 3^rd Opposite Party.  According to the Opposite Parties 1 and 2  there is mismatch in clinical  condition and treatment and hence  according to  1^st and 2^nd  Opposite Parties,  the 3^rd  Opposite Party colluded with the Complainant and hence  1^st and 2^nd  Opposite Party  issued a quarry letter dated 07.03.2020 to the  Complainant for producing  documents which  is also not submitted by the Complainant.  According to  1^st and 2^nd Opposite Parties,  from the available medical records,  the wife  of the Complainant had history of Thrombocytopenia  purpura but  as per the letter dated 25.01.2020 from Dr. Dayal Chavan,  shows  the patient  does not have any history of Thrombocytopenia purpura and hence according to 1^st and 2^nd  Opposite Parties there is mis representation and the  information furnished is found to be incorrect or false.  1^st and 2^nd  Opposite Parties contended that  after repudiation of claim as per the request of the Complainant,  the matter  was reopened  and found that there is no need to reconsider the decision made earlier and hence the review request was rejected.  It is stated by the 1^st and 2^nd Opposite Parties   that the allegation of the Complainant  that  2^nd  Opposite Party is appointing  3^rd  Opposite Party as their treatment centre at Kalpetta is baseless and it is contented that the Complainant colluded with 3^rd  Opposite Party,  the present  complaint is filed and there is no principal agent  relationship between  1^st and 2^nd  Opposite Parties and 3^rd Opposite Party.  The claim was repudiated since the Complainant had not produced any documents stating  that the history mentioned in the  treatment records was a mistake from the side of  duty doctor and there is no deficiency of service or unfair trade practice from the side of the  1^st and  2^nd  Opposite Parties and prayed for dismissal of the complaint.

          5. 3^rd  Opposite Party filed  separate version stating that the complaint is not maintainable and there is no negligence or deficiency of service on the part of 3^rd  Opposite Party and the allegation of principal  agent  relation between  1^st and 2^nd  Opposite Parties and 3^rd  Opposite Party is denied.  It is stated by  3^rd  Opposite Party that wife of the Complainant Smt. Sonia Antony came to the casualty of 3^rd  Opposite Party hospital for abrasion on right  knee.  The casualty Medical Officer attended  the patient and on examination the treatment was given by Dr. Dayal Chavan, Medical   practitioner at 3^rd  Opposite Party hospital.  According to 3^rd  Opposite Party the Complainant’s wife had undergone treatment for Thrombocytopenia  Purpura is not correct and the allegation in the complaint that the patient  had not any history of Thrombocytopenia purpura and not availed  any treatment for that is correct.  On 25.01.2020 Dr. Dayal Chavan had sent  a letter  to 1^st  Opposite Party stating that the patient  does not have any history or Thrombocytopenia  Purpura and does not have any history of the above disease  and not received  any treatment for the same  and hence there is no deficiency of service  from the side of  3^rd  Opposite Party.  They have  treated the patient with  reasonable care and caution on a proper diagnosis based on clinical  symptoms and investigation findings.  The  3^rd  Opposite Party stated that they have exercised due skill expertise and there is no negligence or deficiency of service on their part and hence they are not liable to compensate the Complainant and hence prayed for dismissal of the complaint with costs.

          6. Evidence in this case consists of the oral testimony of PW1 and Exts.A1 to A4 from the side of the Complainant and oral testimony of OPW1 and Exts.B1 to B12 from the side of  Opposite  Parties 1 and 2.  (Marking of B10 objected).

          7. The following are the  main points to be  analysed in this complaint to derive into an inference  of the fact.

1.  Whether the Complainant had sustained to any deficiency of service or unfair trade practice from the side of the Opposite Parties?
2. If so the quantum of compensation and  costs for  which the Complainant is eligible to get?

8.  Heard  both sides and perused the records in detail.

9. Ext.A1 is the claim repudiation letter issued by Opposite Party Ext.A2 is the

discharge summary Ext.A3 is the medical  report and Ext.A4 is the Doctor’s initial  assessment for inpatient.  Ext.B1  produced from the side of the Opposite Party  is the proposal form signed by the Complainant.  Ext.B2 is the copy of out patient  record  of Fathima Matha Mission Hospital.  Ext.B3 is the Letter issued to the Complainant regarding renewal of policy.  Ext.B4 is the proposal form for star  comprehensive insurance policy. Ext.B5 is the request for cashless hospitalization for health insurance.  Ext.B6 is the Doctor’s initial assessment for inpatient.  Ext.B7 is the query  on authorization for cashless  treatment.  Ext.B8 is the letter from the Complainant to the Medical Officer,  Star Health.  Ext.B9 is the Letter of denial  of pre authorization request for cashless treatment. Ext.B10  is the discharge summary from the department of orthopedics (marking objected). Ext.B11 is the request to the Complainant for additional documents.  Ext.B12 is the letter of repudiation of claim.

10. The specific case of the Complainant is that he had taken a Family Insurance Policy from 1^st and 2^nd  Opposite Parties as per policy No.P/181324/61/2020/001238 and from 22.01.2022 the wife  of the Complainant was undergoing  treatment for the  injury in right knee in 3^rd  Opposite Party hospital.  According to the Complainant the representative of  1^st  Opposite Party visited the patient in the hospital and the Complainant had to spent Rs.49,653/- for the treatment.  After discharging the wife of the Complainant from the hospital,  he had submitted bills and other documents to the 1^st  Opposite Party but 1^st and 2^nd  Opposite Parties repudiated the claim stating that the  patient had “Thrombocytopenia purpura”.  According to the Complainant his wife had undergone treatment for the injury in the right knee and she had not treated for the said disease and hence the Complainant could not submit the records of treatment for the said disease as requested by 1^st and 2^nd  Opposite Parties.    The Complainant states that it is due to the mistake on the part of the duty doctor in the 3^rd  Opposite Party hospital that such a mistake was crept in the records and senior doctor of the  3^rd  Opposite Party hospital had given a clarification letter which is also submitted to  1^st and 2^nd  Opposite Parties.  According to the Complainant,  his wife  never took treatment for “Thrombocytopenia Purpura” and he had not suppressed any details at the time of taking the policy.  In these circumstances there is deficiency of service on the part of the Opposite Parties and the Complainant is entitled get  the relief as prayed for.

          11. During cross examination of PW1 by 1^st and 2^nd  Opposite Parties  he had admitted that proposal form  “`m-c-ybv¡v Hcp Akp-J-hp-anà F¶v ]d-ªn-«p-­v.    `mc-ysb 22.01.2020  BWv Fathima  Hospital   admit sNbvXXv A¶v cashless claim  \p th­n At]£ FXr I£n-IÄ¡v Ab-¨n-«p-­v.  AXp {]Imcw `mc-y-bpsS  Akp-J-¯n\v  deep abration right knee F¶mWv h¶n-cn-¡p-¶-Xv”.  He further deposed that Ext.B2 {]Imcw   wife  sâ AkpJw Thrombocytopenia Purpura  Df-f-Xm-bn- Nn-In-Õn¨ Dr tcJ-s¸-Sp-¯n-bn-«pt­m F¶-dn-bn-Ã.  A§ns\ Dr Fgp-Xn-sIm-Sp-¯n-«p­v Duty Dr   BWv Fgp-Xn-s¡m-Sp-¯Xv B reason sIm-­mWv cashless claim repudiate  sNbvXXv F¶v a\-Ên-em-¡n-bn-«p-­v”.  The Complainant specifically deposed in the box that “clinic   treat sNbvXn«v  thZ\ h¶-t¸mÄ BWv Fathima  t]mbXv Purpura   F¶p-ff tcmK-¯n\v treat sNbvXn«nÃ.  25.01.2020 \v Dr. Dayal Sarma  bpsS certificate \ÂIn-bn-«p-­v”.

12. PW1 further deposed that “Rm\pw 3-þmw FXr-I-£nbpw Bbp-ff [mc-W-bn-emWv subsequent Bbn Dr. Dayal Chavan kÀ«n-^n-¡äv \ÂIn-b-sX¶v ]d-ªm sXäm-Wv”.  During cross examination of 3^rd  Opposite Party,  PW1 deposed that “wife Sonia ¡v Imense ]cn-¡n-\mWv NnInÕ \S-¯n-b-Xv.  Case file sNbvXXv 1 Dw 2 Dw FXr-I-£n-I-fn  \n¶pw insurance  In«p-¶-Xn-\p-th-­n-bm-Wv.  Wife  sâ Im ap«nsâ  abrasion  \p am{X-amWv  hospital   NnInÕ \S-¯n-b-Xv.  Wife  \p t\cs¯ ]dª  Purpura F¶p-ff tcmK-¯n\v NnInÕ C¶p hsc sNbvXn-«nà Sn tcmKw F´p tcmK-amWv F¶v F\n-¡-dn-bn-Ô  he further deposed that “Purpura F¶ AkpJw Duty Dr  \v Adn-bmsX  Fgp-Xn-b-Xm-sW-¶mWv Adnbm³ Ign-ª-Xv.  A_²w ]än-bXv F¶mWv ]d-ª-Xv.  Wife  \v aäv bmsXmcp Akp-J-§fpw D­m-bn-«n-Ô. 

13. OPW1 was examined from the side of  1^st and 2^nd  Opposite Parties and according to him “Complainant sâ  `mcy tkmWnb ap«n\v  apdn-th-äXv NnIn-Õn-¡m-\mWv  hospital  t]mb-Xv.  10.01.2020 \v Bike  \n¶pw hoWv apdn-th-ä-Xm-bmWv  Statement    \ÂIn-bn-«p-f-f-Xv.  BZyw sNdnb apdn-hn\v near by clinic  t]mbn-cp-¶-Xmbn ]d-ªn-«p-­v”.  OPW1 also deposed in the  box “that Thrompocytopaedic Purpura  F¶ tcmKs¯¸än tNmZn-¨p-a-\-Ên-em-¡n-bn-«p-­v.  Blood disorder  BWv Blood test sNbvXm AXv  Adn-bm³  Ignbptam  F¶v   Doctor  BWv   Xocp-am-\n  -¡p-¶-Xv”.  OPW1 further deposed that “medicine sheet  H¶pw Xs¶ Cu tcmK-¯n\v acp¶v sImSp-¯-Xmbn ImWn-Ô.  He further deposed that “claim application  In«n-b-t¸mÄ past history  Bh-i-y-s¸«v Doctor ¡v Letter Ab-¨n-cp-¶p. Senior Doctor  AXn-\v reply X¶n-cp-¶p.  B reply  Sn tcmKw CÃm-bn-cp¶p F¶pw treatment B tcmK-¯n\v \S-¯n-bn-«n-söpw ]d-ªn-cp-¶p.  B reply apJ-hn-e-s¡-Sp-¡m-Xn-cn-¡m³ treatment records  B AkpJw DÅ-Xmbn I­-Xn-\m-em-Wv”.

14. Even according to OPW1,  the treated  Senior Doctor had sent a reply to 1^st and 2^nd  Opposite Parties stating that the patient had  no such disease and the treatment was not for the said disease.  According to  3^rd  Opposite Party the Senior Doctor     Dr. Dayal Chavan had sent letter stating that the patient does not have any history of Thrombocytopenia purpura and not received any treatment for the same which is also not considered  by  1^st and 2^nd  Opposite Parties while repudiating the claim.  More over the collusion as contented between the Complainant and  3^rd  Opposite Party is also  not proved by Opposite Parties 1 and 2.

15. The over all consideration of the evidence before the Commission shows that  1^st and 2^nd  Opposite Parties had repudiated the claim without analyzing  the case properly and hence we finds that there is  deficiency  of service on the part of  1^st and 2^nd Opposite Parties.  Since  3^rd  Opposite Party is the treated hospital and non payment of the insurance claim cannot be lean on the shoulder of 3^rd  Opposite Party, they are not held liable for any deficiency of service on their part.

16. Hence the Commission finds that  point No.1 is proved  by the Complainant against  1^st and 2^nd  Opposite Parties and  hence the following orders are issued.

1.  1^st and 2^nd Opposite Parties are directed to reimburse  the medical bills  amounting to  Rs.49,683/- (Rupees Forty Nine thousand Six hundred and Eighty Three only) with 6% interest to the Complainant.
2. 1^st and 2^nd  Opposite Parties are also directed to pay Rs.15,000/- (Rupees Fifteen thousand only)  towards compensation to the Complainant.
3. 1^st and 2^nd  Opposite Parties are also  held liable to pay Rs.5,000/- (Rupees Five thousand only) towards cost of the proceedings.

In the  result  Consumer Case is partly allowed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 21^st    day of March 2024.

          Date of filing:16.01.2021

                                                                             PRESIDENT    :  Sd/-                                 

MEMBER        :    Sd/-

MEMBER        :    Sd/-

APPENDIX.

Witness for the Complainant:

PW1.          Joseph. M.J                    Complainant.                                               

Witness for the Opposite Party:

OPW1.        Balu. M.                         Deputy Manager- Legal

Exhibits for the Complainant:

A1.       Copy of Letter.                               dt:25.08.2020.

A2.       Copy of Discharge Summary.                  

A3.       Copy of Medical Report.               

A4.       Copy of Doctor’s Initial Assessment for  Inpatient.                                  

Exhibits for the Opposite Party:

B1.       Copy of  Proposal Form for Star Comprehensive Insurance Policy.

B2.       Copy of Out Patient Record.

B3.       Copy of Letter.                                                            dt:13.09.2019.

B4.      Copy of  Proposal Form for Star Comprehensive

             Insurance Policy.

B5.      Copy of Request for Cashless Hospitalisation for

             Health Insurance.

B6.       Copy of Doctor’s Initial Assessment for  Inpatient.

B7.        Copy of Query on Authorisation for Cashless Treatment.  dt:24.01.2020.

B8.        Copy of Letter.

B9.        Copy of Denial of Preauthorisation  Request for Cashless   

               Treatment.                                                                      dt:24.1.2020.

B10.      Copy of Discharge Summary.

B11.      Copy of Letter.                                                                 dt:07.03.2020.

B12.      Copy of Letter.                                                                dt:13.05.2020.

                                                                                                PRESIDENT:   Sd/-  

                                                                                                PRESIDENT:   Sd/- 

                                                                                               MEMBER    :   Sd/-