By Sri. A.S. Subhagan,  Member,

          This is a complaint  preferred under Section 12  of the Consumer Protection Act 1986.

          2. Facts of the case in brief:- The Complainant had joined in Medi-claim Insurance  Policy of the 1^st  Opposite Party as per policy  No.101601/28/P1/14092381  for the period from 06.02.2019  to 05.02.2020,  which was  a renewal of earlier policy.  As per the  terms and conditions of the policy,  the Complainant was entitled to cashless insurance in case of  inpatient for  more than twenty four hours.  On  28.10.2019, due to chest pain,  the Complainant was admitted in Fathima Mata Hospital,  Kalpetta which was diagnosed as “Coronory Artery Disease- ACS-NDTEMILRTI” and treated there till 28.10.2019 as inpatient.  From the hospital itself Complainant,  through the hospital, claimed the entire amount of hospital bill for treatment,  medicines and other expenses,  but the  Opposite Party  failed to pay the said amount without any lawful excuses.  Thus,  the Complainant was compelled to pay Rs.22,030/-  towards doctors fee,  lab, room rent, medicine etc  and the Complainant had paid Rs.2,000/-  at the time of admission.  Moreover,  the Complainant is also entitled to get the other expenses spent for vehicle and bystander amounting to Rs.10,000/-.  The hospital authority had given all the required things then and there to the Opposite Party.  But the Opposite Parties without any legal basis rejected  the  claim as per letter  dated 28.10.2019  stating that “ the possibilities of ailment being pre-existing to the policy inception could not be ruled out.  The pre-existing disease and related  complications/treatments are not payable at this stage as per policy limits,  hence cashless denied.  Kindly come for possible reimbursement”.    The rejection of the insurance claim by the Opposite Parties is without any basis and thus,  it amounts to deficiency in service and unfair trade practice on the part of the Opposite Parties.  This has resulted in huge loss and mental agony to the Complainant for which the Opposite Parties are liable to compensate.  The act of the Opposite Parties, instead of giving cashless facility,  to request for possible reimbursement is against the policy conditions and illegal.  Thus the Opposite Parties are liable to pay compensation of Rs.50,000/-  to the Complainant.  Hence this complaint with the following  prayers.

1.  To direct  the Opposite Parties to pay an amount of Rs.34,000/-  to the Complainant as medical expenses spent by the Complainant and Rs.50,000/-  as compensation towards  deficiency in service on the part of the  Opposite Parties and
2. To  direct the Opposite Parties to pay the cost of the litigation and any other or further relief  deem fit to grant in the interest of  justice.

3. Notices were  served upon the Opposite Parties for appearance.  The 1^st 

Opposite Party appeared before the Commission and filed version.

4. Contents of version filed by the 1^st  Opposite Party:-  The Opposite Party

submitted that the Synd Arogya (Group Health Insurance Policy) No.1008002817P6031257 was  issued  in favour of the Complainant for the period 06.02.2018 to 05.02.2019  and  the policy was renewed  from 06.02.2019  to 05.02.2020.  The sum insured was Rs.5,00,000/-.   As per the policy exclusion No.4.1 “Any pre-existing condition(s)  as defined in the policy,  until 36 months continuous coverage of such insured person have elapsed since inception of his first policy as mentioned in the schedule attached to the policy”.  Pre-existing disease defined in the policy as “Pre-existing disease is any condition, ailment or injury or related condition(s) for which the Complainant had signs or symptoms and or were diagnosed and or received medical advice/treatment within 48 months prior to the first policy issued by the insurer”.   In this case the Complainant was admitted in the hospital on 22.10.2019 for “Coronary Artery disease-ACS-NDTEMILRT”.  The end Opposite Party could not provide the cashless benefit to the complainant since possibilities of ailment being pre-existing to the policy inception could not be ruled out.  The pre-existing  diseases and related complications are not payable at this stage as per the policy  sub limits.  Hence cashless benefit was denied. The terms and conditions of the authorisation are:-    Cashless authorization letter issued on the basis of information provided in the pre-authorization form in case of misrepresentation/concealment of facts, any material difference/deviation/ discrepancy in information is observed in discharge summary/IPD records,  then cashless authorization shall  stand null and void.  At any point of claim  processing insurer  of TPA reserves right to rise queries for  any other document to ascertain admissibility of claim.  The documents are to be provided by the hospital in support of the claim such as detailed discharge summary and bills from the hospital, cash memo from the hospital/chemists supported by proper  prescription, diagnostic test reports and receipts supported by note from the attending  medical practitioner /Surgeon recommending  such diagnostic supported by note from attending medical practitioner/surgeon recommending such  diagnostic tests,  Surgeons Certificate stating nature of operation performed  and surgeon’s bill and receipt,  and certificate from attending medical practitioner/surgeon giving patient’s condition and advise on discharge.  Even after the discharge the Complainant did not provide original documents and claim  form to this Opposite Party for processing the claim.  The Complainant did not performed his part.   There is no deficiency in service on the part of the Opposite Party as alleged in the complaint.  Without ruling out the possibility of pre-existing disease, the Opposite Party cannot provide cashless benefit. The Opposite Party denied all the other allegations made in the complaint.   The Opposite Party submitted that the Complainant is not entitled to  get sum of Rs.34,000/-  towards medical  expenses,  Rs.50,000/-  towards  compensation and cost of  litigation as claimed in the complaint.    On the basis of above contentions, the Opposite Party prayed to disallow the complaint with compensatory cost.  

          5.  Chief affidavits were filed by the Complainant and the 1^st  Opposite Party.  Exts.A1 to A3 were marked from the side of the Complainant and he was examined as PW1.  Exts.X1(a) and X2  series  were marked from the side of the 1^st  Opposite Party and Mr. Jithun Vijay, Branch Manager,  United India Insurance Co. Ltd.,  was examined as OPW1  for  the 1^st  Opposite Party. 

          6.  Considering all the above facts,  Commission raised the following points for consideration.

1.  Whether there has been deficiency in service/ unfair trade practice from the part of the Opposite party?
2. If so,  whether the Complainant is entitled to get compensation as claimed for?
3. If so,  Whether the Complainant is  entitled to get reimbursement of Admission fee,  expenses for vehicle and bystander?
4. If so,  whether the Complainant is entitled to cost of this complaint?

7.  Point No.1:-  The case of the Complainant is that though he had a cashless

Medi-claim Insurance Policy with the  1^st  Opposite Party,  the Opposite Party denied cashless facility  and  suggested to approach the Opposite Party with application for reimbursement of the claim which is deficiency in service and unfair trade  practice for which the Complainant claims payment  of the amount of expenses he spent in the hospital for his treatment and connected  expenses,  as well as   compensation and cost of the  litigation.  On the other hand the contention of the  1^st  Opposite Party is that the Complainant was admitted in the  hospital  on 22.10.2019 for “Coronary Artery disease-ACS-NDTEMILRI”.  The Opposite Party could not provide cashless benefit to the  Complainant since possibilities of ailment being pre-existing to the policy inception could not be ruled out and hence cashless facility was denied.  The  1^st  Opposite Party also contented that though cashless facility was denied,  the  Complainant was advised to approach the Opposite Party to claim reimbursement of medical treatment expenses.  Ext.A1 and Ext.X1(a)  document reveal that the Complainant was covered under the SYND AROGYA (GROUP HEALTH INSURANCE SCHEME)  for  cashless treatment facility.  The Opposite Party has admitted that cashless benefit was denied  to the Complainant  as the Opposite Party could not rule out the possibilities of ailment being  pre-existing to the policy inception.  The Opposite Party also contented that the pre-existing diseases and related complications are not payable at that stage as per policy sub-limits.  At the time of argument the counsel for the Opposite Party argued that the Opposite Party was not denied benefit under the insurance policy but he was advised to apply for reimbursement  of hospital expenses.  The Complainant did not act upon their advice.  Commission,  on perusal of the complaint, version,  documents marked and the oral depositions of  PW1 & OPW2 and considering  the arguments of  both the counsels for the Opposite Parties,  find  that the insurance scheme in which the Complainant was covered was meant for cashless benefit which was denied by the Opposite Party on mere possibilities of ailment being pre-existing to the policy inception could not be ruled out. Insurance  is a contract and both the parties to the contract are to abide by the terms of the contract.  Here,  the  policy covered by the Complainant was meant for cashless treatment for which the Complainant has the right to get benefit of  cashless treatment.  From the “case  summary and discharge  record” issued by the Fathima Mata Mission Hospital”  which is a part of the Ext.X1 series marked by the Opposite Party,  it is evident that the Complainant was admitted in the hospital on 22.10.2019  and was discharged on 28.10.2019.  That is  the Complainant was there in the  hospital for a week.  This one week time was enough  for the Opposite Party to rule out the possibility of pre-existing disease to the policy inception.  If the Opposite Party  was in need of any other information, documents or clarifications, they could have sought it from the hospital in the meantime.  But they failed to do so.  Moreover,   the Opposite Party has no right to deny cashless benefit on  a mere ground of  suspicion or possibility of pre-existing  diseases  or its related ailments.  If the insurance company is given such a right to deny cashless  benefit in cases of doubts or possibilities without valid and legally sustaining grounds,  there shall be an array of denial of such benefits to the policy holders,  which shall ultimately defeat the purpose of the insurance policies  with cashless treatment benefit.  That cannot  be allowed.  In addition,  in Revision Petition No.3219 of 2016,  the Hon’ble  National Consumer Disputes Redressal Commission has held that  where a medi-claim policy is issued and if it is  cashless policy,  there is an implied   assurance on the part of the Insurance  Company that in the event of insured suffering from any ailment,  he would be given cashless treatment at the concerned  clinic or hospital subject to terms and conditions of the insurance policy.  Here  instead, the Opposite Party advised the Complainant to approach them for reimbursement which is against the condition and spirit of the contract of insurance policy in this case.  The insurance company cannot deny cashless benefit  without any reasonable grounds.  In the present complaint,  the contentions of the Opposite Party as  narrated in version,  for substantiating  the possibilities of ailment being  pre-existing to the policy inception could not be ruled out,  is not able to be accepted by the Commission as a reasonable ground for denial of the benefit.  Here, the Opposite Party has denied cashless treatment facility to the Complainant under a valid cashless insurance policy.  Denial of cashless treatment benefit under a valid insurance policy, not in good faith, without  any valid ground constitutes  deficiency in service/unfair trade practice.  So,  here there has been deficiency in service /unfair trade practice from the part of the Opposite Party for which the 1^st  Opposite party is responsible and liable to compensate.  So,  point No.1 is proved  in favour of the Complainant.

8.  Point No.2:-  As point No.1 is proved in favour of the Complainant,  he is

entitled to get compensation but the Compensation  claimed  is seen exorbitant.  He has a right to get compensation of Rs.20,000/-

          9.  Point No.3:-  As point No.1 and 2 are  proved in favour of the Complainant,  he has the right to get cost of this complaint.

          10.  Point No.4:-  The Complainant  has claimed an amount of Rs.2,000/-  being

fee paid in the hospital at the time of admission and another Rs.10,000/-  spent for vehicle and bystander.  But Ext.A2,  which is the final bill issued by the hospital,  reveals that the total expenses  come   to  Rs.22,030/-.  So, the other expenses such as admission fee, expenses for vehicle and bystander are not allowable to the Complainant.

          In the result,  the complaint is partly allowed and the 1^st  Opposite Party is ordered to :-

1.  Pay Rs.22,030/- (Rupees Twenty Two thousand  and Thirty only) being the amount of cashless treatment as per bill  issued by the hospital as per Ext.A2.
2. Pay a compensation of Rs.20,000/-  (Rupees Twenty thousand only) for deficiency in service/unfair trade practice.
3. Pay an amount of Rs.5,000/-  (Rupees Five thousand only) as cost of this complaint.

The above amounts shall be paid to the Complainant within one month from

the  date of this order,  failing which the amounts  will carry interest  at the rate of 8%

per annum from the date of this order.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 18^th day of October 2022.

Date of filing :11.11.2019.

                                                          PRESIDENT :    Sd/-

                                                          MEMBER    :    Sd/-

                                                          MEMBER    :    Sd/-

APPENDIX.

Witness for the complainant:

PW1.                    Kunhimayin. E               Complainant.       

Witness for the Opposite Party:

OPW1.                 Jithun Vijay.                             Branch Manager,

                                                                        United India Insurance Co. Ltd.

Exhibits for the complainant:

A1.       Copy of Cashless Authorization Letter.     dt:28.10.2019.

A2.       Final Bill.                                                 dt:28.10.2019.

A3.       Case Summary & Discharge Record.                          

Exhibits for the Opposite Party:

X1 Series.   Copy of  Documents produced by  1^st  Opposite Party.

X1(a)          Copy of Policy.

X2 Series.   Case Sheet.