CONSUMER DISPUTES REDRESSAL FORUM,PALAKKAD

Dated this the 30^th January, 2016

PRESENT :  SMT. SHINY.P.R, PRESIDENT

               :  SMT. SUMA. K.P, MEMBER                      Date  of filing : 22/12/2014

CC /204/2014

V.Balasubramanian,

S/o.Velayudhan,                                                       :        Complainant

Karampatta H.O,

Kozhinjampara P.O,

Palakkad District, Kerala

(By Adv.K.K.Thankappan) 

             Vs

1. The C.E.O, M/s.Religare

    Health Insurance Company Limited,                       :        Opposite parties

    Regd.Office D3, P3B, District Centre,

    Saket, New Delhi-110 017

    (By Adv.Ullas sudhakaran)

2. Mr.K.S.Shaji, Team Leader,

    Muthoot Financiers,

    Muthoot Insurance & Brokers,

    1^st Floor, Lakshmi Arcade, Palakkad Road,

    Anikkode Junction, Chittoor.

    (Exparte)

3. Mr.Jayakanth.S.

    Associate Vice President,

    Religare  Health Insurance Company,

    IIIrd Floor, Thadikkaram Centre,

    Palarivattom, Cochin-682 025

   (By Adv.Ullas sudhakaran)

4. Mr.Jo Davis,

    Muthoot Insurance & Brokers,

    IInd Floor, Cochin Dental Clinic,

    Near Compara Junction,

    Cochin – 682 018

    (Exparte)

5. The Manager,

    M/s.Palana Institute of Medical Sciences,

    Kannadi P.O, Palakkad- 678 701

    (By.Adv.E.Ramachandran)

6. Dr.Shibu Mathew,

    Consultant Orthopaedic Surgeon,

    Palana Institute of Medical Sciences,

    Kannadi P.O, Palakkad – 678 701

    (By Adv.V.K.Venugopalan)

O R D E R

By Smt. Suma. K.P, Member,

The complainant herein have joined to Religare Health Insurance Company Ltd. (1^st Opposite party)  Health Insurance Policy for cashless hospitalization, after remitting a premium of Rs.3,000/- on 17/12/2013.  Duration of the said insurance policy was 1 year from 17/12/2013 to 16/1/2014 and the policy number was 10059808(RHID:50704244).  His wife and two children had also joined to the health policy on the same day along with him.  The 2^nd opposite party has lured to him to join with said policy, who is a deputed agent of Muthoot Insurance and Brockers  (4^th opposite party) company for canvassing general public to join with the Religare Health Insurance Company Ltd.  When the complainant was travelling on a TVS-50, a light vehicle, on 15/12/2014  met with an accident after a stray dog unexpectedly crossed the road.  He sustained injuries on both hands, on both keens of legs and serious bruise on his left leg.  On the next day he felt severe pain on his left leg it was difficult to stand and move.  Then he approached to the Paalana hospital which is a listed hospital of Religare Health Insurance Company for treatment.  Dr.Shibu Mathew, Consultant Orthopaedic Surgeon of Paalana hospital has examined him and admitted in Paalana hospital on 16/12/2014.  He had undergone treatment and had informed to the hospital management about his health insurance policy  from Religare Health Insurance Company Ltd. and handed over his health insurance card.  Meanwhile he had informed the 1^st opposite party New Delhi Office, about the nature of his accident and details of his admission in the Paalana hospital through the toll free number.  After that, he had repeated the above details to the 1^st opposite party’s Cochin office (3^rd opposite party) as directed by the Delhi Office.  Then the executive of the Religare Health Insurance Company contacted him and informed him on 16/12/2014 that “As you have Religare Health Insurance Company’s health insurance policy, you have all the rights to a cashless hospitalization in Paalana hospital.  Religare Health Insurance Company has given instructions to the hospital and the company will settle all the bills for his treatment.”  Meanwhile, Paalana Hospital Authorities asked him to pay for the medicine bill when the complainant enquired about the Health Insurance Coverage, the hospital people told him that it will take time, meanwhile he should buy the medicines for continuing the medicines.  He had convey these details to Religare Health Insurance Company Ltd. and they replied that they had given necessary instructions to the hospital for his cashless treatment, so that complainant need not pay any medicine bills.  Since he had already paid the medicine bills Religare company will re-imburse his claims.  On 17/1/2014, Paalana hospital authorities  asked him to pay the hospital bill for discharge from the hospital.  Then he contacted to the Religare company and they replied that as hospital has given a report that he were under the influence of alcohol when he met with the accident, a drunkard will not get the health insurance coverage.  When the complainant contacted to the Paalana hospital and Dr.Shibu Mathew, they promised that neither hospital nor the doctor has given a report as per the Religare company’s claim.  Again he contacted the Relegare company and detailed about the hospital authorities assurance with a proof of discharge summary.  Then the 1^st opposite party replied to him that as he was not being suffering adequate illness for admitted treatment in hospital, company is hereby denying his cashless hospitalization and health insurance claim.  The complainant submits that a reputed and highly qualified doctor (Dr.Shibu Mathew, MS (Ortho) and Mch Ortho ) has diagnosed his illness and admitted him in hospital, for a period of 24 hours  he is entitled  for cashless hospitalization claims. Hence he had approached before this Forum claiming compensation for deficiency of service for mental agony and abuse suffered from the opposite parties along with hospital expenses.    

Notice was issued to opposite parties for appearance.  Excepting 4^th opposite party all opposite parties appeared before the Forum.  But only opposite parties 1,3 and 6 had  filed their written version. Opposite parties 1-3 filed version contending the following.  They admit that the complainant had availed health insurance policy numbered 10059808 issued by Religare Health Insurance Company Ltd. and that the duration of the said policy was from 17^th December 2013 to 16^th December 2014. It was also admitted that complainant’s family consisting of his wife and two children had also availed the policy coverage provided to the insured members subject to the policy terms and conditions.  They submits that injuries claimed to have been sustained by the complainant were not grievous in nature i.e. no bony injury and contusion on knee and forearm and the same did not require any hospitalization and could have been managed by first aid.  Complainant got himself admitted as he was aware that he could not have preferred a claim under the health policy issued by these opposite parties unless he is treated as an inpatient.  Opposite parties 5 and 6 had rendered necessary assistance to the complainant for getting himself admitted at the 5^th opposite party hospital with an object of enabling the complainant to maintain a claim which would not have been normally maintainable had he been treated as an out-patient.  They had also submitted that the decline of cashless facility, does not imply denial of claim.  If the complainant submits all the hospitalization papers including the discharging summary as a reimbursement claim, then the claim will be reassessed as per the Policy Terms and Conditions.  Considering the injury alleged to have been sustained by the complainant, treatment by the 6^th opposite party, who is a Specialist an Orthopedic Surgeon, was not necessary and he could have been treated as an out patient.    The complainant’s claim that he had intimated about the nature of the accident and the details of his admission at 5^th opposite party hospital through the toll free number and that he had passed on information to these opposite parties’ Cochin office as directed by the Delhi office are all denied by these opposite parties.  They did not inform the complainant that they had given necessary instructions to the 5^th opposite party to provide cashless treatment to the complainant and that complainant need not pay the bills and that the bills already paid would be reimbursed by them are all denied by the opposite parties 1-3. They had also denied the allegation that they had informed the complainant that they had received a report from the hospital to the effect that the complainant was under the influence of alcohol while he met with accident.  No such fact was communicated to these opposite parties by the hospital authorities and hence there is no question of passing on any such information to the complainant as claimed by him.  The Opposite parties  had repudiated the claim of the complainant in accordance with the terms and conditions of the policy.  The minor injuries alleged to have been sustained by the complainant could have been managed by treating the complainant  as an outpatient and hospitalization was not warranted and admission for the purpose of evaluation and diagnosis is not covered as per the aforesaid terms and condition of the policy issued to the complainant.  Hence there is no deficiency of service on the part of the opposite parties 1-3 and the complaint has to be dismissed.

6^th opposite party filed the version contenting the following.  The above dispute is between the complainant and opposite parties 1-4 and the 6^th opposite party is unnecessarily dragged in to litigation without any just or sufficient cause.  The complaint has to be dismissed against 6^th opposite party.  The 6^th opposite party has been working as Consultant Orthopaedic Surgeon in the 5^th opposite party hospital.  The complainant came to the casualty of Paalana Institute of Medical Sciences at 7.50 am on 16/12/2014 with history of sustaining injuries following a fall from bike.  The initial examination findings and history were recorded by the casualty medical officer as per the history.  No consumption of alcohol is noted in the case records.  The complainant had severe swelling around the left ankle and multiple deep abrasions and he was unable to bear weight on the left leg.  He was applied POP slab for ankle injury and dressing for the abrasions.  The complainant was admitted as he was having pain and swelling and started on IV antibiotics, alalgesics and anti-oedema medication.  On 17/12/2014 pain and swelling reduced and the complainant was discharged with oral antibiotics and alalgesics.  The complainant came for review on 20/12/2014 and POP slab was removed and dressing changed and advised medication.  The complainant did not make any complaint regarding the treatment and there is no allegation regarding treatment as per the complaint as well.  The clinical history given by the complainant was truly recorded in the treatment records maintained in the hospital and issued discharge summary based on the records.  The 6^th opposite party had filled up insurance form as per the request of the complainant and any history of consumption of alcohol is no where recorded in the said form.  In a dispute between the complainant and the insurance company regarding repudiation of claim, the 6^th opposite party is not even a formal party to be joined in the party array.  He had issued required records for medical insurance claim as per request of the complainant stating true and correct account of treatment. The complaint raised against the 6^th opposite party is frivolous in nature and he has to be exonerated from the liability. 

Complainant filed chief affidavit. Opposite parties 1-3 and 6 also  filed their respective chief affidavits. Ext.A1- A8 was marked from the part of the complainant.   Ext. B1-B4  were marked from the part of the opposite parties.    Evidence was closed and  the matter was heard.

The following issues are to be considered.

1. Whether there is any deficiency of service on the part of the opposite party? 
2. Reliefs and costs?

 ISSUE No. 1

We had perused the documents as well as affidavits from both sides.  Opposite parties 1-3 had submitted in their version as well as in their chief affidavit that the claim for reimbursement would be considered as per the terms and conditions of the policy subject to the production of original treatment records.  In the cash less facility decline letter dtd.17/12/2014 clearly mentions that “Denial for authorization for cashless facility does not prevent the complainant from claiming reimbursement”.  They had also submitted that in this particular case when the cashless facility was denied as per the terms and conditions of the policy, the complainant instead of submitting original records for processing the claim for reimbursement, rushed to prefer complaints before Insurance Ombudsman and before this Forum simultaneously.  His complaint before the insurance Ombudsman cease to have jurisdiction in the complaint as the complaint is pending before this Forum.   This complainant’s claim for cashless treatment cannot be approved as per Permanent Exclusion Clause 4.3.(a)(i) read with clause 7.1, i.e, Admission for evaluation/diagnosis is not payable.  The opposite parties 1-3  had rightly declined   the cashless facility requests of the complainant in accordance with the terms and conditions of the policy which was marked as Ext.B2.  Since the opposite parties   1-3  had already admitted that decline of cashless facility does not imply denial of claim they are bound to reimburse the claim forwarded  by the complainant. It is evident from Ext.A6,7,8 that the complainant had incurred an amount of Rs.3,500/- towards hospital bills and medical expenses. 

  In the result, complaint is allowed, and  we direct the opposite parties 1-3 to pay an amount of Rs.3,500/-(Rupees Three thousand five hundred only)  towards the medical expenses incurred by the complainant along with Rs.3,000/-(Rupees three thousand only)  as compensation for mental agony suffered by him.  We also direct the opposite parties to pay Rs.2,000/- (Rupees Two thousand only) as cost of this litigation.  Since there is no evidence to the effect that the opposite parties 1-3 had abused him as a drunkard no compensation to that effect can be allowed.  The aforesaid amount shall be paid within one month from the date of receipt of this order failing which the complainant is entitled to get 9% interest for the compensation amount from the date of order till realization.   Opposite parties 4-6 are exonerate from the liability.

Pronounced in the open court on this the 30^th  day of January, 2016.

                                                                 Sd/-

                                                                   Smt. Shiny.P.R

                                                                     President

                                                                      Sd/-                                                                                                                   Smt. Suma. K.P

                                                                      Member

A P P E N D I X

Exhibits marked on the side of complainant

Ext.A1 Customer Identity Card(Original)  

Ext.A2 –  Brochure of Religare Health Insurance (original)

Ext.A3-  Photographs after hospital discharge (original)

Ext.A4– Close up, photographs of leg injury(original)

Ext.A5 –Discharge summary Paalana Hospital  dtd.17/12/2014 (Original)

Ext.A6- Medicine bills  dtd.16/12/2014 Rs.532.15 (original)

Ext.A7- Medicine bills dtd.16/12/2014 Rs.391.30 (original)

Ext.A8- In-patient final bill Rs.2490/- dtd.17/12/2014.

Witness marked on the side of complainant

Nil

Exhibits marked on the side of opposite party

Ext.B1- Copy of letter to Religare Insurance Co.Ltd

Ext.B2-Copy of Pre-authorization Request dtd.17/12/2014

Ext.B3- Copy of Policy certificate

Ext.B4(1)-  Insurance Ombudsman letter dtd.12/02/2015 (Photocopy)

Ext.B4(2)-Order dtd.11/2/2015 of Insurance Ombudsman(Photocopy)

Witness examined on the side of opposite party

Nil

Cost Allowed

Rs.2000/- as cost.