By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act 1986 against the opposite parties to get the entire claim amount with cost and compensation.
2. Brief of the complaint:- The complainant obtained an Individual Health Insurance Policy from the 1st opposite party for a sum of Rs.50,000/-. As per the policy conditions each member in the policy shall be entitled to get Rs.50,000/- for treatment expenses. The duration of the policy was from 30.11.2011 to 29.11.2012. On 26.02.2012 complainant's son Midhun was admitted in Vinayaka Hospital, Sulthan Bathery and was undergone surgery due to the fracture of his left forearm and discharged on 27.02.2012. The total hospital expenses was Rs.17,750/-. Thereafter on 02.03.2012 the complainant's elder son Adhin was admitted and treated at MES Hospital, Sulthan Bathery and was discharged on 05.03.2012. Treatment expenses incurred in this hospital was Rs.25,414/-. Then the complainant submitted claim form with all relevant documents before the 1st opposite party. But complainant received only Rs.6,786/- towards treatment expenses of his son Midhun and Rs.14,445/- for his son Adhin. Thereafter the complainant approached the 1st opposite party several times to get the entire hospital expenses but 1st opposite party informed that they were not the apt person to settle the claim. 2nd opposite party TPA is the authority to settle the claims. Thereafter complainant made an application before the 1st opposite party that he want to renew his existing policy under the category of non TPA and remitted Rs.6,125/- by way of Demand Draft. But 1st opposite party not renewed the policy till this date. According to the complainant the opposite party deliberately denied the entire hospital expenses without sufficient reason. At the time of discharge 3rd opposite party issued an additional bill of Rs.11,000/- dated 27.02.2012 to this complainant. Opposite parties not accepted this stating that this is not a part of the hospital bill. Hence complainant filed this complaint alleging deficiency of service from the part of opposite parties.
3. Notice served to opposite parties. Opposite parties No.1 and 3 appeared and filed version and opposite party No.2 is set ex-parte on 06.12.2013. In the version, opposite party No.1 admitted the policy and stated that the claim submitted by the complainant with respect to the children of the complainant were processed by the TPA ie 2nd opposite party based on the policy conditions and settled the claim accordingly. The claim for Rs.25,414/- was processed as per the policy condition clause 1.2(A) “Room boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses”. Here the sum insured is Rs.50,000/- hence the room rent payable per day as per policy condition is Rs.500/- but the complainant claimed sum of Rs.2,800/- towards Room and nursing for three days but the eligible amount is only Rs.1,500/-. The amount payable as per the policy condition No.1.2. C&D shall be at the rate applicable to the entitled room category. In case the insured opts for a room with higher rent than entitled category as mentioned in clause 1.2 A, the charges payable under 1.2 C and D shall be limited to the charges applicable to the entitled category. Hence 53.57 % of the room rent claimed ie,Rs.2,800 x53.75 /100=1,499.96 (Rounded to Rs.1,500/-) was allowed and Rs.11,120/- (being 53.57 % of Rs.20,750/-) was allowed towards surgery charge proportionately and out of medical expense of Rs.1,864/- claimed a sum of Rs.39/- was deducted since the cost of surgi Raze and Easy fix were not the medical expense. Hence the 2nd opposite party has paid an eligible amount of Rs.14,445/- for the claim of Adhin No further amount is payable by this opposite party to the complainant as prayed for.
4. The claim of Midhun for Rs.17,750/- was received and it was processed by the 2nd opposite party and found that the eligible amount is Rs.6,786/-based on the policy conditions. The policy condition specifically mentioned that no payment shall be made under clause 1.2C other than as part of the Hospitalization bill. In this case the complainant produced the cash bill dated 27.02.2012 shows the actual bill is for Rs.4,280/-. Hence the 2nd opposite party calculated the total amount payable as Rs.175/-towards room rent, Rs.3,550/- towards surgeory charge, Rs.200/- towards investigation charge, Rs.2,631/- towards medicine charge and Rs.230/- towards miscellaneous charge. Hence the 2nd opposite party paid sum of Rs.6,786/- towards claim amount. The bill for Rs.11,000/- issued by the Vinayaka Hospital on 27.02.2012 cannot be payable since it is a payment made under clause 1.2c other than as part of hospital bill and it was not mentioned in the hospital bill. Hence the complainant is not entitled to get any further amount as claimed in the complaint. Again 1st opposite party submitted that an Individual Health Insurance Policy was renewed on 13.12.12 the original policy is ready in the office of the opposite party but the complainant did not collect the same. The complainant can collect the policy during the working days from the office of the opposite party. Hence prayed to dismiss the complaint.
5. In the version, opposite party No.3 stated that they had issued genuine bill for the expenses, Doctor fees etc to the complainant. They had only received the amount as per the bill given to the complainant. They had not received any excess amount from the complainant and the bill dated 27.02.2012 for Rs.11,000/- is a genuine one and the allegation that the bill for Rs.11,000/- appears to be not forming part of the hospitalization is not at all correct. Hence prayed before the Forum to dismiss the complaint.
6. On perusal of complaint, version and documents 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 filed affidavit and examined as PW1. Ext.A1 to A4 documents were also marked. Opposite party No.1 examined as OPW1 and Ext.B1 to B3 were marked. Opposite party No.3 stated that no oral evidence. Heard both parties, on perusal of records and submissions advanced before the Forum, we finds that the claim and policy period is admitted by the opposite party No.1. The room rent and boarding expenses are limited to 1% of the sum assured and the policy conditions. The amount payable as per the policy condition Clause 1.2 C&D shall be at the rate applicable to the entitled room category. The main dispute is regarding Ext.A3 this is an additional bill for Rs.11,000/- issued by the opposite party No.3 hospital. The claim of Midhun for Rs.17,750/- was received and it was processed by the 2nd opposite party and found that the eligible amount is only Rs.6,786/- based on the policy conditions. The policy condition specifically mentioned that no payment shall be made under clause 1.2C other than as part of the Hospitalization bill. But the 2nd opposite party paid a sum of Rs.6,786/- towards claim amount. Opposite party No.1 argued that the bill for Rs.11,000/- issued by the Vinayaka Hospital on 27.02.2012 cannot be payable since it is a payment made under clause 1.2C other than as part of Hospital bill and it was not mentioned in the first discharge bill. But in the version, opposite party No.3 submitted that the second bill dated 27.02.2012 for Rs.11,000/- issued by them to the complainant is genuine, it shall be considered as the part of the discharge bill. Hence we find that Opposite party No.3 issued genuine bills for the treatment expenses of the complainant's son. Again opposite party No.1 stated that based on the policy conditions the claim of complainant's child Adhin for Rs.25,414/- was received and it was processed by the 2nd opposite party and found that the eligible amount is only Rs.14,445/-.
8. Again opposite party No.1 submitted that the Individual Health Insurance Policy was renewed on 13.12.2012, the original policy is ready in the office of the 1st opposite party but the complainant did not collect the same. The complainant can collect the policy at any time during the working days from the office of the opposite party.
9. On going through the evidences and records this Forum is of the view that not allowing claim amount as per Ext.B3 is deficiency of service from the part of opposite parties No.1 and 2. Since the genuity of Ext.B3 is admitted by opposite party No.3 it can be treated as the part of hospital bill and the deductions in Ext.A4(a) and (b) are made as per the policy conditions. So we are not intending to interfere with the deductions. Opposite party No.1 argued that the renewed policy is ready with them but they can very well send it to the complainant through post. Opposite party No.1 failed to provide renewed policy in time. The Point No.1 is found accordingly.
10. Point No.2:- Since the Point No.1 is found in favour of the complainant, the complainant is entitled to get the amount as per Ext.A3 with cost and compensation. The Point No.2 is decided accordingly.
In the result, the complaint is partly allowed and the opposite party No.1 is directed to pay the entire amount as per Ext.A3 ie Rs.11,000/- (Rupees Eleven Thousand only) to the complainant. Opposite party No.1 is also directed to renew the policy of the complainant without delay if it is not in force. Opposite party No.2 is directed to pay Rs.7,000/- (Rupees Seven Thousand only) as compensation and Rs.3,000/- (Rupees Three Thousand only) as cost of the proceedings. This Order must be complied by the opposite parties within 30 days from the date of receipt of this Order, failing which the complainant is entitled get 10% interest for the whole sum. There is no Order against opposite party No.3.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 30th day of April 2015.
Date of Filing:24.08.2013.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. V. N. Sajimon. Complainant.
Witness for the Opposite Parties:-
OPW1. Sajeevan. Branch Manager, United India Insurance Co Ltd,
Sulthan Bathery.
Exhibits for the complainant:
A1. Insurance Policy.
A2(Series). Copy of Medical Certificate/Attending Doctor's Certificate. (2 Nos).
A3. Copy of Cash Bill. Dt:27.02.2012.
A4(Series). (a). Copy of Detailed claim information.
(b). Copy of Detailed claim information.
Exhibits for the opposite parties:-
B1. Insurance Policy.
B2(Series). Medical Bills (10 Nos).
B3. Cash Bill. Dt:27.02.2012.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
