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 hospital bills.
2. Brief of the complaint:- Complainant is the Health Insurance Policy holder of the 2nd opposite party since 2011 for a sum of Rs.2 Lakh. The policy was renewed up to 24.07.2014. On 25.07.2014 the sum assured has been enhanced to Rs.3,00,000/- and subsequent renewals were done upto 24.07.2017. Meanwhile the complainant developed pain on his left shoulder during the month of June 2015 and consulted orthopedic surgeon Dr. Ravi Jacob Korula at DM WIMS Hospital Meppadi on 06.06.2015. The complainant was later referred to MIMS Hospital, Calicut, from there his illness was diagnosed as 'Osteo Arthritis'. Later he was admitted at MIMS Hospital and underwent reverse shoulder replacement surgery on 18.05.2016 and was discharged on 21.05.2016. The total treatment expense of the complainant at MIMS hospital, Calicut was Rs.3,12,908/-. As per the terms and conditions of the insurance Policy the complainant was entitled to get cashless treatment up to Rs.2,93,725/-. But the opposite parties sanctioned only Rs.2,00,000/- towards cashless treatment. Since the complainant was expecting cashless treatment; he did not care to arrange that much amount. The complainant's son was forced to run from pillar to post to arrange the balance amount. This has caused much difficulty to the complainant's family. After clearing the hospital bills, the complainant claimed reimbursement of the said amount of Rs.93,725/-. 0riginal of the said Bills together with the medical records were sent to the opposite parties. But the complainant's claim was repudiated on the ground that as per the medical records of MIMS hospital, Calicut, the complainant was suffering from the present ailment for two years prior to 17.05.2016 and hence the relevant policy period was from 25.07.2013 to 24.07.2014 for which the sum insured was Rs. 2,00,000/-. Complainant further alleged that the period of illness was calculated on the basis of the wrong entry made in the medical records of MIMS Hospital, Calicut. In fact the complainant first developed the symptoms of the present illness in the month of June 2015, i.e. one year prior to the surgery. This was evident from the medical records of the complainant at WIMS hospital, Meppadi. As such the relevant policy period would be from 25.07.2014 to 27.07.2015. But due to over sight the doctor at MIMS Hospital, Calicut noted the duration of illness as two years instead of one year prior to the surgery. The complainant on receiving the letter of repudiation dated 20.06.2016 sent a letter to the opposite party with all the medical records including certificates from the doctors who treated the complainant at DM WIMS Hospital, Meppadi and MIMS Hospital, Calicut to clarify the doubts regarding the duration of illness. In reply the opposite party sent an e-mail on 05.08.2016 reiterating the previous stand. Thereafter the complainant preferred a complainant before the insurance ombudsman. The Ombudsman also, after hearing both the parties, found that the complainant is entitled to get reimbursement of Rs.93,725/-. But the award directed the opposite parties to pay the above said amount to the complainant, on producing affidavits from the hospitals where the complainant was treated, to the effect that the present ailment started only within one year prior to the surgery. Since the doctor who treated the Complainant left the hospital, it was practically difficult to get such affidavits from the Hospitals and the complainant did not accept the award of the Ombudsman. Though the complainant produced medical records of DM WIMS Hospital and certificates of the treating doctors and hospitals to prove that the present ailment started only within one year prior to the surgery, the opposite parties have not reimbursed the treatment expense of Rs.93,750/- so far. The refusal on the part of the opposite parties to reimburse the above said treatment expense without valid reason is nothing but deficiency of service on their part. Hence filed this complaint.
3. On receipt of notice opposite parties appeared and version filed. In the version opposite parties stated that the complainant had taken a Family Health Optima Insurance Policy form this opposite parties covering himself, his wife and daughter for the period from 25.07.2011 to 24.07.2012 vide policy No.P/181314/01/2012/002386 for a sum of Rs.2,00,000/- and thereafter enhanced the sum insured to Rs.3,00,000/- on 25.07.2014 which has been renewed up to 24.07.2017. Later on after discharge the complainant submitted claim form with medical records for balance payment. The discharge summary of the hospital issued by the treating doctor also reveals that the complainant was suffering from the ailment since 2 years of the treatment as on 17.05.2016. This means that the onset of illness contracted on May 2014 which falls within the policy period for which the sum insured was Rs.2,00,000/- and the claim had been admitted for this sum insured as cashless. Hence the claim of the complainant was repudiated as per condition No.9 of the policy at the time of reimbursement of balance claim and the same was informed to the complainant vide letter dated 20.06.2016. Thereafter the complainant had approached the insurance ombudsman against the repudiation of the balance claim. There the complainant produced Doctor's Certificate dated 24.01.2017 which was fraudulently obtained in order to get claim.
4. On 23.12.2016 award from the Ombudsman was passed directing the opposite parties to consider the balance amount as and when on submission of the affidavit from the hospital authorities where the complainant had undergone treatment, but the complainant has not produced the affidavit for compliance of award. Hence there is no deficiency of service on the part of opposite parties.
5. Complainant examined as PW1 and Ext.A1 to A8 and X1 and X2 documents were marked. Opposite party also examined as OPW1 and Ext.B1 to B15 were marked. Ext.A1 is the Copy of Family Health Optima Insurance Plan policy schedule for the period from 25.07.2015 to 24.07.2016. Ext.A2 is the copy of Family Health Optima Insurance Policy Schedule for the period from 25.07.2014 to 24.07.2015. Ext.A3 is the Copy of Family Health Optima Insurance Policy Schedule for the period 25.07.2013 to 24.07.2014. Ext.A4 is the copy of Orthopaedic Note dated 06.06.2015. Ext.A5 is the Certificate issued by Dr. Mahendra Varma, Aster MIMS, Calicut dated 24.01.2017. Ext.A6 is the copy of Certificate issued by Dr. Sameerali Paravath dated 11.07.2016. Ext.A7 is the Award passed by the Insurance Ombudsman, Kochi dated 23.12.2016. Ext.A8 is the Letter issued from Office of the Insurance Ombudsman dated 03.01.2017. Ext.X1 is the Orthopedic Note dated 15.07.2014 issued by DM WIMS. Ext.X2 is the Discharge Summary issued by ASTER MIMS. Ext.B1 is the copy of Family Health Optima Insurance Policy Schedule for the period from 25.07.2011 to 24.07.2012. Ext.B2 is the copy of Family Health Optima Insurance Policy Schedule for the period from 25.07.2014 to 24.07.2015. Ext.B3 is the copy of Family Health Optima Insurance Policy Schedule for the period from 25.07.2015 to 24.07.2016. Ext.B4 is the Copy of Family Health Optima Insurance Plan. Ext.B5 is the Copy of Request for cashless Hospitalization for Medical Insurance Policy. Ext.B6 is the Copy of Authorization for Cashless Treatment of the insured patient dated 14.05.2016. Ext.B7 is the Copy of Authorization for Enhancement of amount dated 21.05.2016. Ext.B8 is the Copy of Claim Form. Ext.B9 is the Copy of Discharge Summary. Ext.B10 is the Copy of OP Sheets from MIMS Hospital, Calicut dated 13.08.2016. Ext.B11 is the Copy of Repudiation of Claim letter dated 20.06.2016. Ext.B12 is the copy of letter dated 17.09.2016 by the complainant to the Insurance Ombudsman. Ext.B13 is the Self contained note submitted before the Insurance Ombudsman, Kochi. Ext.B14 is the copy of Award passed by Insurance Ombudsman dated 23.12.2016. Ext.B15 is the Authorization Letter dated 19.09.2017.
6. On perusal of complaint, version and document 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:- Complainant has treated for Osteo Arthritis and underwent surgery on 18.05.2016. Admittedly the policy amount was enhanced to Rs.3,00,000/- on 25.07.2014. Opposite parties admitted the claim and an amount of Rs.2 Lakh was disbursed as cashless benefit based on Ext.B10 discharge summary from MIMS Calicut. In which duration of illness was noted as '2 years' on 07.05.2016, this means that the onset of illness contracted on May 2014 which falls within the policy period for which sum insured was Rs.2 Lakh. After discharge complainant claimed for reimbursement of balance amount of Rs.93,725/- with original bills and medical records. But opposite parties repudiated the claim on the ground that the relevant policy period was from 25.07.2013 to 24.07.2014 for which the sum insured was Rs.2 Lakhs only.
8. Thereafter complainant approached before Insurance Ombudsman with a clarification from treated doctor stating that ''the duration of illness was wrongly recorded as 2 years on 17.05.2016, but as per the previous medical records from WIMS Hospital, Wayanad(Ext.X1) the present illness has the past history of one year only. But insurer took a contention that at the signs and symptoms of present ailment fall within the policy for which sum isnured is Rs.2 Lakh based on Ext.X2. The Certificate issued by treating Doctor who was working in another hospital could not be considered as a factual evidence. Hence an award was passed directing the insurer to consider the balance amount of the claim as and when on submission of the affidavit from the hospital authorization. Where the insured has undergone the treatment. Instead accepting the Order from the insurance Ombudsman the complainant approached before this Forum against repudiation of balance claim amount. Complainant produced Ext.A5 and A6 clarification Certificate from treated Doctors to prove that the complainant was admitted at Aster MIMS, Calicut on 17.05.2016 with complaints of pain over left should for last 1 year. Also documents from DM WIMS and Aster MIMS hospital were produced before the Forum and was marked as Ext.X1 and X2. In Ext.X2 discharge summary it is clearly written as ''pain over left should for last 1 year''.
9. On going through the entire evidences and records it appears that Duration of illness shown as 2 years in discharge summary of MIMS Hospital(Ext.X2) but later complainant produced clarification certificate from MIMS Hospital and the treated doctor (Ext.A5 and A6). On considering the above documents, Ombudsman directed the complainant to produce an affidavit by treated doctor for getting balance claim amount but complainant could not produce the same because now the doctor was working in abroad.
10. On perusal of Certificates (Ext.A5 and A6) obtained from MIMS Hospital and treatment records from hospitals (Ext.X1 and X2) it is clear that the treated illness was diagnosed in the year 2016 and it has the past history of one year from the date of surgery, the surgery was done on 08.05.2016. Hence in our opinion complainant's claim falls during the policy period from 25.07.2014 to 24.07.2015 vide Policy No.P/181315/01/2015/001096 (Ext.A2) for a sum insured of Rs.3,00,000/-. Since the sum insured during that period is Rs.3,00,000/-, complainant is entitled to get balance claim amount of Rs.93,725/-. The non-submission of affidavit before the Ombudsman is for genuine and valid reasons and complainant is entitled to get claim amount on a humanitarian consideration. Opposite parties repudiated the claim as per the conditions of the policy hence there is no deficiency of service proved against the opposite parties. Point No.1 is found accordingly.
11. Point No.2:- Since the Point No.1 is found in favour of complainant, he is entitled to get the balance claim amount from the opposite parties. Since there is no deficiency of service proved as alleged against the opposite parties, complainant is not entitled for cost and compensation. Point No.2 is decided accordingly.
In the result the complaint is partly allowed and opposite parties are directed to pay the balance claim amount of Rs.93,725/- (Rupees Ninety Three Thousand Seven Hundred and Twenty Five) to the complainant. No Order as to cost and compensation. This Order must be complied by the opposite parties within 30 days from the date of receipt of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 20th day of November 2017.
Date of Filing:12.05.2017.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. George. Business.
Witness for the Opposite Parties:-
OPW1. Balu. Executive Legal, Star Health and Allied Insurance Co
Ltd, Thiruvananthapuram.
Exhibits for the complainant:
A1. Copy of Family Health Optima Insurance Plan policy schedule for the period from 25.07.2015 to 24.07.2016.
A2. Copy of Family Health Optima Insurance Policy Schedule for the period from
25.07.2014 to 24.07.2015.
A3. Copy of Family Health Optima Insurance Policy Schedule for the period 25.07.2013 to 24.07.2014.
A4. copy of Orthopaedic Note. Dt:06.06.2015.
A5. Certificate issued by Dr. Mahendra Varma, Aster MIMS, Calicut. Dt:24.01.2017.
A6. Copy of Certificate issued by Dr. Sameerali Paravath. Dt:11.07.2016.
A7. Award passed by the Insurance Ombudsman, Kochi. Dt:23.12.2016.
A8. Letter issued from Office of the Insurance Ombudsman. Dt:03.01.2017.
X1. Orthopedic Note issued by DM WIMS. Dt:15.07.2014
X2. Discharge Summary issued by ASTER MIMS.
Exhibits for the opposite parties:-
B1. Copy of Family Health Optima Insurance Policy Schedule for the period from 25.07.2011 to 24.07.2012.
B2. Copy of Family Health Optima Insurance Policy Schedule for the period from
25.07.2014 to 24.07.2015.
B3. Copy of Family Health Optima Insurance Policy Schedule for the period from
25.07.2015 to 24.07.2016.
B4. Copy of Family Health Optima Insurance Plan.
B5. Copy of Request for cashless Hospitalization for Medical Insurance Policy.
B6. Copy of Authorization for Cashless Treatment of the insured patient. Dt:14.05.2016.
B7. Copy of Authorization for Enhancement of amount. Dt:21.05.2016.
B8. Copy of Claim Form.
B9. Copy of Discharge Summary.
B10. Copy of OP Sheets from MIMS Hospital.
B11. Copy of Repudiation of Claim letter. Dt:20.06.2016.
B12. Copy of letter. Dt:17.09.2016.
B13. Self contained note submitted before the Insurance Ombudsman, Kochi.
B14. copy of Award passed by Insurance Ombudsman. Dt:23.12.2016.
B15. Authorization Letter. Dt:19.09.2017.
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PRESIDENT, CDRF, WAYANAD.
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