CONSUMER DISPUTES REDRESSAL FORUM
Palakkad, Kerala
Dated this the 24th day of November 2014
CC.NO.2/2014
PRESENT : SMT. SEENA. H, PRESIDENT Date of filing: 30/12/2013
: SMT. SHINY.P.R ,MEMBER
: SMT. SUMA K.P, MEMBER
Madhusoodhanan,
S/o.Achutha Varrier,
Kulangara Variyam, : Complainant
Thiruvegapura Post,
Palakkad District Pin. 679 304
(By Adv. A.V.Ravi)
Vs
1. LIC of India, Ottapalam Branch Office,
P.B.No.7, sunder Iyer Road, Ottapalam
Rep by its Chief Manager.
(By Adv.T.P.George)
2. LIC of India, Divisional Office,
19/114 Mythree Arcade, Poothole, : Opposite parties
Thrissur 680 004.
Rep.by its Manager (Health Insurance)
(By Adv.T.P.George)
O R D E R
By Smt. Shiny . P. R. Member.
Brief facts of the case: - The complainant along with his wife, are subscribers of LIC Health Plus Plan as per policy No.777051704 dated 13-1-2009 issued by the opposite parties. The complainant has not committed any default in remitting the installment premium towards the said policy and the policy is live as on today. The complainant has undergone treatment at EMS Memorial Co-operative Hospital & Research Centre, Perinthalmanna, due to acute chest pain and he was admitted in the said hospital for a period of 7 days from 11-7-2013 to 18-7-2013. While he was admitted in the hospital, he had undergone surgery also. Thereafter the treatment, the complainant submitted hospitalization claim to the opposite parties on the basis of the aforesaid insurance policy to the tune of Rs.1,14,875/-(Rupees One Lakh Fourteen thousand Eight hundred and seventy five only) in the office of the opposite parties but it was not properly considered by the opposite parties. Opposite parties have willfully delayed the payment. The opposite parties are legally responsible and liable to pay the aforesaid claim. Due to the inaction of the opposite parties, the complainant issued a notice dated 2-11-2013 through his counsel. The second opposite party has sent a reply for the said notice with false and frivolous and born out of mala fide motives. Even after five months, no positive action has been initiated as to disburse the claim to the complainant on the basis of the aforesaid policy, which caused much hardship and mental agony to the complainant. Due to the willful inaction of the opposite parties, the complainant sustained heavy monetary loss also. Hence the complaint. Complainant prays for a direction to pay Rs.1,14,875/- /-(Rupees One Lakh Fourteen thousand Eight hundred and seventy five only) towards hospitalization expenditure and Rs.1,00,000/- (Rupees One Lakh only) towards compensation for the deficiency in service along with cost of the proceedings.
Complaint was admitted and issued notice to opposite parties and they entered appearance and filed their version.
Opposite parties admitted the policy which was issued to K.V.Madhavikutty with herself as the principal insured and Madhusoodanan, the complainant herein as the other insured member in the policy with an annual premium of Rs.7,500/- (Rupees Seven Thousand Five hundred only) and Hospital cash benefit of Rs.500/- (Rupees Five hundred only) per day for each insure member. As per the policy conditions the policy holder is eligible for two benefits depends on the number of days of hospitalization less than 48 hours and the daily benefit amount chosen at inception. The major surgical benefit is payable for eligible surgeries mentioned in the conditions and privileges of the policy subject to the terms and conditions in the policy. The complainant was admitted in the Nizar Hospital, Valanchery on 11-7-2013 with acute chest pain. He was admitted in the ICU for two days from 11-7-2013 to 13-7-2013. In the discharge card from the Nizar Hospital it is reported that he was undergoing treatment for Bronchial Asthma under aerocort inhaler 15 days prior to the date of admission. Discharge summary shows that his is a diabetic patient under medication. He was discharged from Nizar Hospital, Valanchery with a reference to higher center for coronary Angiogram. On 15-7-2013 he was admitted in the EMS Memorial Co-operative Hospital & Research centre Perinthalmanna and underwent coronary Angioplasty on 16-7-2013. He was discharged on 18-7-2013. For processing claim under LIC’s Health Plus Plan the policy condition specifies that the claimants have to submit the prescribed claim forms ie, Claim intimation form, Claim Form and the Hospital Treatment Form along with discharge summary and the hospital bills. If the treatment involves more than one hospitalization a separate set of claim form and hospital treatment form which should clearly indicates the date and time of admission and discharge, date and time of admission in ICU if any involved has to be submitted by the complainant. LIC settle health insurance claims through Third Party Administrator (TPA) which is a body licensed by IRDA. LIC avail their services to assist in processing health insurance claims. In this case the claim papers submitted by the complainant were forwarded to the TPA, M/S Medi Assist India PVT Ltd. on 16-8-2013. Immediately on 22-8-2013 TPA has sent a letter as document deficiency letter to Madhavikutty, the insured herein to produce the documents which were essential to process the claim. But the complainant has submitted only the inpatient record pertaining to the admission in Nizar Hospital where he has undergone only preliminary investigation checkup along with a letter stating that he had no previous history of diabetes mellitus, CAD, Bronchial asthma. Again on 5-9-2013 a reminder letter was sent by TPA to the insured to produce the said documents. Except a letter dated 27-9-2013 the complainant has not produced the treatment records from EMS Memorial Co-operative Hospital, Perinthalmanna where he underwent the Coronary Angioplasty. During the course of the claim processing TPA has contacted the EMS Memorial Hospital, Perinthalmanna for getting the details of the treatment but the Hospital authorities denied verification of hospital records stating that no one except the patient shall be permitted to verify the hospital records. In spite of all the efforts taken by the opposite parties the claim could not be processed since the complainant was not complying with the required details after repeated reminders. Hence this opposite parties decided to reject the claim instead of keeping it open indefinitely and sent a claim rejection letter on 11-10-2013. Opposite parties has sent a reply to the lawyer notice dated on 22-11-2013. In the reply notice this opposite parties has made it clear that the claim has not been repudiated or denied, the file shall be reopened at any time when the claimant submits the requirements sufficient for deciding the case. Instead of complying the requirements of the opposite parties the complainant preferred to file this complaint. The opposite parties has neither repudiated nor denied the claim. Opposite party submitted that this complaint is premature one. Complainant has no cause of action against this opposite parties for filing this complaint. There is no deficiency of service or unfair trade practice on the part of the opposite parties. After filing the version complainant has given a letter through his lawyer dated 21-3-2014 authorizing the authorized representative of the opposite party to verify the treatment records at EMS Memorial Co-operative Hospital and Research Centre at Perintalmanna. On the basis of that letter Administrative Officer of the opposite party has verified the hospital records regarding the treatment given to the complainant and collected necessary treatment records and forwarded to Third Party Administrator. They after verification made the claim payment of Rs.43,600/- (Rupees Forty Three Thousand and Six hundred only) to the complainant on 20-5-2014 to his account No.1799 in the Punjab National Bank through NEFT. The claim amount payable as per the terms of the policy is only 40% of the sum assured for surgical benefits. In this case the sum assured is Rs.1,00,000/-(Rupees One lakh only) hence Rs.40,000/- (Rupees Forty Thousand only) towards surgical benefit and Rs.3,600/-(Rupees Three thousand six hundred only) towards Hospital cash benefit totalling to Rs.43,600/-(Rupees Forty Three Thousand and Six hundred only) was paid to the complainant. This opposite party has satisfied the claim of the complainant as per the terms of the policy contract.
Hence there is no deficiency of service on part of these opposite parties. The allegation that the petitioner has suffered mental agony and trauma etc, are untrue and hence denied. The complaint is liable to be dismissed with cost.
Both parties filed their chief affidavit. Ext.A1 to A4 marked from the side of complainant. Ext. B2 to B6 marked and B1 and B7 marked with objection on the side of opposite parties. 1st opposite party is examined as DW1.
The following issues are considered.
1. Whether there is any deficiency in service from the part of opposite parties?
2. If so what is the relief and cost?
ISSUES 1 & 2
Both parties heard: - We have perused the documents on record. The opposite parties admitted the policy. As per Ext.B5 complainant admitted in Nizar Hospital, Valanchery on 11/07/2013. But complainant submitted in the complaint that he was admitted in EMS Memorial Co-operative Hospital & Research Centre, Perinthalmanna. It is not true as per Ext.B5. On 22-8-2013 Opposite parties sent Ext.B2 letter to the complainant to forward the treatment records for processing the claim. But complainant submitted the documents pertaining to the Nizar Hospital, Valanchery. On 2-9-2013 Dr.Sajesh Kumar from the TPA Medi Assist went to the EMS Hospital to verify the treatment records of the complainant kept in the hospital. But he has not permitted to verify the records because the hospital authorities told him that according to the hospital policy nobody will be allowed to verify the case sheets and treatment details except the patient. Again on 5-9-2013 another letter Ext.B3 was sent to the complainant for producing the documents. But on 27-9-2013 complainant sent a letter Ext.B5 with treatment records of Nizar hospital, Valanchery where he took only a preliminary checkup and treatment. The complainant has not produced the treatment records from EMS Memorial Co-operative hospital & Research Centre, Perinthalmanna where he underwent the Coronary Angioplasty. After filing the complaint the complainant has given a letter dated 21-3-2014 Ext.A8 authorizing the authorized representative of the opposite parties to verify the treatment records at EMS Memorial Co-operative hospital, Perinthalmanna. On the basis of that the opposite parties verified the hospital records and collected necessary treatment records and settled the claim by making the payment of Rs. 43,600/- ( Rupees Forty Three Thousand and Six hundred only ) on
20-5-2014 to his bank account. As per the terms and conditions of the Ext.A1 the insured has to submit the required documents for settle the claim. After the repeated requests of the opposite parties the complainant did not take any initiative to produce the documents before the opposite parties. There are some negligence from the part of complainant. In this case complainant has instead of providing the relevant records to opposite parties, opted to file this complaint. There is no willful latches or delay from the part of the opposite parties. After considering the above facts we are not in a position to attribute the deficiency in service on the part of opposite parties.
In the view of above discussions, we are of the opinion that no deficiency in service from the part of opposite parties. Hence complaint is dismissed.
Pronounced in the open court on this the 24th day of November, 2014
Sd/-
Smt. Seena. H
President
Sd/-
Smt. Shiny. P.R
Member
Sd/-
Smt.Suma K.P Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 - LIC’s Bond in the name of complainant’s wife Madhavikutty (Original)
Ext.A2 - Regd. With A/D lawyer notice sent to 1st opposite party dtd.02/11/2013
Ext.A3 - Reply notice to the complainant sent by the 1st opposite party (Original) dtd.11/11/2013
Ext.A4 - Reply notice to the complainant sent by the 2nd opposite party (Original) dtd.22/11/2013
Exhibits marked on the side of the opposite parties
Ext.B1 - Policy copy and Conditions and privileges referred in the policy document (Photocopy)
Ext.B2 - Document Deficiency Letter dtd.22/08/2013 sent by Medi Assistant India TPA to the insured.
Ext.B3 - Information Reminder1 dtd.05/09/2013 sent by Medi Assistant India TPA to the insured.
Ext.B4 - Investigation report dtd 02/09/2013 by Medi Assistant India TPA (P) Ltd.
Ext.B5-Reply letter dtd.27/09/2013 by the complainant to Medi Assistant India TPA(P) Ltd.
Ext.B6-Claim Rejection letter dtd.11/10/2013 by the opposite party to insured
Ext.B7- Reply notice dtd.22/11/2013 sent to Adv.Sri.A.V.Ravi
Ext.B8-Authorization letter dtd.21/03/2014 given by the complainant (Photocopy)
Witness examined on the side of complainant
Nil
Witness examined on the side of opposite parties
DW1 - G.Rani
Cost allowed
No Cost Allowed
