OFFICE OF THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAMRUP,GUWAHATI
C.C.74/2013
Present:-
1)Md.Sahadat Hussain, A.J.S. - President
2)Smti Archana Deka Lahkar - Member
Sri Bishnu Ram Patowary -Complainant
R/O House No.5,Bye Lane No.5
Lachit Nagar , Ulubari,
Guwahati-781007
District: Kamrup, Metro, Assam.
-vs-
1) The Deputy Manager - Opp.parties
Aegon Religare Life Insurance Company
Limited, Branch Office.
Ulubari Chariali.Guwahati-7.
District: Kamrup, Metro, Assam.
2) The General Manager
Aegon Religare Life Insurance Company
Limited, Head Office.
Vileparte (East),Mumbai-400057 (Maharastra)
Appearance-
Learned advocate Mr.Subrata Das for the complainant.
Learned advocate Mr.Arup Sarkar for Opp.Parties
Date of argument – 29.3.17
Date of judgment- 16.5.17
JUDGMENT
This is a case u/s 12 of the Consumer Protection Act , 1986.
1) The complaint filed by Sri Bishnu Ram Patuary against Deputy Manager, Aegon Religare Life Insurance Company Limited, Ulubari branch and two others was admitted on 5.8.2013 and notices were served upon them and they also filed written statement on 26.2.2014 and thereafter the complainant filed his evidence on affidavit on 19.9.2014 and he was also cross-examined by Ld counsel of the opp.parties, and thenafter the opp.party side filed evidence of Sri Jitin Parekh on affidavit on 13.5.2015, but his evidence was expunged vide this forum’s order dtd. 20.7.16. After filing written argument by Ld. counsels of both the parties, we, on 29.3.2017, heard the oral argument of Ld.counsel of the complainant , Sri Subrata Das and of Ld. counsel of the opp.parties, Mr. Arup Sarkar; and today we deliver the judgment, which is as below-
2) The crux of the case of the complainant is that, he had insured with Aegon Religare Life Insurance Company Limited, Ulubari branch on 28.9.2011 vide policy No.611090057708 with customer ID No.10000201010402360451 for a sum of Rs.19,904/- ; and during effectiveness of the said policy he had became sick and get admitted at Brahmaputra Nursing Home, Dibrugarh on 13.4.2012 and thereafter he took treatment at Namcare Hospital, Guwahati and he spent a sum of Rs.1,42,000/- at Brahmaputra Nursing Home, Dibrugarh and also spent a huge amount at Namcare Hospital, Guwahati for his treatment; and although he had insured for an amount of Rs.19,904/- only , unfortunately he had to spent a big amount in his treatment and thereby he has to right to claim the said amount from the Opp.party No.1 according to the terms and conditions of the said policy; and he visited the office of the Opp.Party No.1 on several times, but the authorized officers of the said opp.party mis-lead him; and then he served a legal notice on both the opp.parties on 13.6.13, but opp.parties refused to give him relief; and therefore, he prays to this forum to direct the opp.parties to pay him Rs.1,42,000/- as cost of his medical treatment and Rs.50,000/- as compensation for causing or putting him in mental agony and causing harassment to him by the opp.parties.
3) The gist of the pleading of the opp.parties is that there is no cause of action of filing the complaint; the complainant filed the complaint by concocting and distorting the facts and circumstances of this case. The complainant had submitted a proposal for health insurance on 28.9.2011 in his own name and paid yearly premium of Rs.19,904/- and he signed in the terms and condition of the agreement for the policy and, on receipt of his application, policy bearing No.600090057798 dtd.19.10.2011 was issued to him and at the time of issuance of the said policy a health insurance guide book published by Paramount Health Services Pvt. Ltd., which is a third party administrator with the opp.party was also given to the complainant and the said guide book contains various instructions and explanations as to what is third party administrator service (TPA) is and how to access cashless facility and what are the benefits, and billing and discharges, reimbursement in case of treatment in non-network hospital as well as the grievance cell to be addressed. The complainant was admitted at Namcare Hospital, Guwahati in the month of August, 2012, for treatment of Bilateral Maxillary Sinusitis with hypertrophied inferior turbinates Mild DNS (left). The complainant intimated TPA (Paramount Health Service) for the claim benefits and the said TPA vide their letter dtd. 4.8.2012 requested the hospital to provide additional details of the treatment of the complainant to ascertain the coverage, but the said hospital failed to provide them additional documents as sought and then said TPA vide their letter dtd. 9.8.2012 again requested the said hospital to provide additional details to ascertain the coverage of cashless benefits and requested them to provide said details within a period of 24 hours or before discharge, whichever is earlier, else the case to be considered as denied for cashless benefits. In cashless service the insured cannot paid hospitalization expenses and to get cashless service he needs to get authorization from TPA and the network will co-ordinate the facilities of cashless service with the TPA on the matter of the insured; and cashless service is available only at Namcare Hospital and authorization from T.P.A. alongwith copy of Health ID card issued by the opp.party, vide I.D. age proof certificate has given to the network hospital at the time of admission . The cashless access at the network hospital is merely a facility extended to the insured, but, it does not guarantee the availability, quality and outcome of treatment, and the choosing of network or non-network hospital is the prerogative of the insured. TPA, who is licensed by the Insurance Regulatory and Development Authority (I.R.D.A.), is engaged for a fee or remuneration with the insurance company for administration of health insurance policy. Network hospitals and nursing homes who had contract with the TPA are to provide cashless service for treatment of insured for suffering from ailment , disease and medical condition covered under the Aegon Religare Health Plan, and the list of network hospitals is provided in a booklet along with policy documents; and the TPA may add or delete network hospitals regularly and hence to get the most recent list of network hospitals, the insured is to call at TPA toll free line at 1800-22-6655 or log on to their website http://www.paramounttpa.Com /Aegon Religare. TPA is to give written approval for cashless service to the network provider for the covered expenses and the insured or his representative has to communicate with TPA appointed by the opp. party for a prospective claim or treatment mentioning the details of treatment, estimated cost, place of treatment, date and duration of treatment. The policy holder who has paid for treatment specially at non-network hospital and has not availed cashless service at network hospital, then the policy holder can claim for reimbursement of the eligible expenses up to the limit of the plan and within the terms and condition of the policy and they are also to intimate the company as early as possible for plan hospitalization to avoid delays and to ensure smooth processing, as a quoted hospital has failed to provide details sought by the TPA, vide their letter dtd. 4.8.2012 and 9.8.2012, the said TPA has closed the case for providing cashless benefits to the complainant. The complainant was admitted in Namcare Hospital for the treatment of Bilateral Maxillary Sinusitis with hypertrophied inferior turbinates Mild DNS (left). But neither he, nor his representative has got the authorization from the TPA for cashless service as per terms and condition of the policy. As per the cashless service, the insured does not have to pay hospitalization expenses or the hospital bill at the end of treatment/discharge except for the non-medical and un-covered items; and this facility is available at the network hospital only; and the insured has to get authorization from the TPA and the network hospital will coordinate with TPA for cashless service. As the complainant has not got authorization from TPA for availing cashless facility as per terms and condition of the policy, as the TPA requested the hospital to provide details of the treatment of the complainant and for non-receipt of said details from the said hospital the T.P.A. closed the case. The complainant has not provided the bills/ medical prescriptions issued by the hospitals to the opp.parties. It is not true that complainant visited the office of the opp.party and the authorization officer of the opp.party misled him. The complainant never approached the opp.party at any point of time, and no communication had taken place between him and the opp.party except the legal notice., the contents of which are false and frivolous . The complaint is false, frivolous and concocted one and no cause of action had ever arisen in favour of the complainant . The complaint is liable to be dismissed.
4) We have perused the pleading of the parties as well as argument of their Ld counsels. We have also perused the evidence adduced by the parties. It is found that both sides admit the complainant did a health insurance policy with the opp.party vide policy No. 611090057798 and customer ID No. 10000201010402360451 on 28.9.2011 at the Ulubari branch of the opp.party after paying yearly premium of Rs.19,904/- and during effectiveness of said policy the complainant had became sick and admitted in Brahmaputra Nursing Home, Dibrugarh on 13.4.2012, where he was treated as indoor patient, but discharged on 22.4.2012 and thenafter he again took treatment at Namcare hospital on 1.8.2012 and he was also admitted in the said hospital on 3.8.12 . The complainant in his complaint as well as in his evidence states that he had spent Rs.1,42,000/-at Brahmaputra Nursing Home, Dibrugarh for his treatment and also spent a huge amount at Namcare hospital, but he has failed to produce any bill, cash memos and voucher of payment of said amount . It is also seen that in no-where in the complaint and in the affidavit, the complainant states that he had informed the opp.party or its T.P.A. about his hospitalization or he had taken authorization from the TPA from the opp.party for hospitalization or he had requested the opp.party to make payment of bills of the treatment at the said hospitals directly to the said hospitals as per cashless service. The complainant also adduce no document as to said facts. So, it is found that the complainant had not taken authorization either from the TPA or from the opp.party for hospitalization in the said hospitals and that he never informed either the opp.party or its TPA about hospitalization and also he did not request the opp.party or its T.P.A. to pay the bills of his treatment in the said hospitals. Thus, it is found that the complainant has failed to comply with the terms and condition of the policy to get the cashless service from the opp.party for his treatment in the said hospitals. Secondly, it is also found that the complainant has totally failed to prove that he had paid Rs.1,42,000/- or any amount to Brahmaputra Nursing Home, Dibrugarh and in Namcare hospital, guwahati.
5) It is also found from the evidence of the complainant that he states that he had visited the branch office of the opp.party in several times, but found no positive result, but he fails to adduce any evidence to show that he had approached the branch office of the opp.party at Ulubari for giving him benefits as per the policy for the said treatment . So, in such situation, the plea of Ld.counsel of the opp.party, Mr.Arup Sarkar that the complainant had never approached the opp.party or its TPA for giving him benefit under his policy for taking treatment in the said hospitals, is factually true. Thus, it is held to have been established that the complainant had never approached the opp.party or its TPA for giving him benefit under his policy for his treatment taken in Brahmaputra Nursing Home, Dibrugarh and in Namcare hospital, guwahati.
6) In this case, the opp.party side version is that their TPA (Paramount Health Service Pvt. Ltd.) by sending letters on 4.8.2012 and 9.8.2012 to the hospitals where the complainant had taken treatment asked the said hospitals to give them additional details about the fact of treatment of the complainant . The said assertion of the opp.party infers that the complainant had requested them giving cashless service for his treatment, but they denied to give him cashless service. The opp.party side does not say that Brahmaputra Nursing Home, Dibrugarh and Namcare hospital, guwahati are not network hospital of their company. So, it shall be presumed that the said hospitals are network hospitals of the opp.party .
7) In this case it is found, the opp.party did not pay the bills of expenses of treatment of the complainant in the Brahmaputra Nursing Home, Dibrugarh and Namcare Hospital, Guwahati. Now , question is that what amount is the actual expenses of his treatment and what amount he had paid to the hospital. We have also found that the complainant has failed to produce copy of the bills and the money receipt of the payment of the bills in this case. Therefore, his version that he had paid Rs.1,42,000/- to Brahmaputra Nursing Home, Dibrugarh from his treatment cannot be believed to be a true version. In the cross-examination the complainant states that he was admitted at Brahmaputra Nursing Home, Dibrugarh for treatment of gall bladder stone, but in his affidavit he does not say so, nor he states that he was operated at Brahmaputra Nursing Home, Dibrugarh for gall bladder stone. Thus, it is found that the complainant had not taken any active treatment at Brahmaputra Nursing Home, Dibrugarh for removal of his gall bladder stone. And in result his version that he had paid Rs.1,42,000/- to Brahmaputra Nursing Home, Dibrugarh as expenses of his treatment cannot be believed at all. Secondly, the complainant abstains himself from about total amount he had paid to Namcare hospital, Guwahati for his treatment. Therefore, his version that he had to spent a huge amount at Namcare hospital also cannot accepted as a true version. It is also found that the complainant has not exhibited the original discharge certificate issued by Brahmaputra Nursing Home, Dibrugarh. So ,in such situation, it cannot be believe that he had taken treatment at Brahmaputra Nursing Home, Dibrugarh being hospitalization therein. Thus, it is crystal clear that the complainant has failed to establish that he had taken treatment at Brahmaputra Nursing Home, Dibrugarh being hospitalized therein and also being hospitalised at Namcare hospital, Guwahati. It is also found that the complainant has failed to prove that he paid Rs.1,42,000/- or any amount to Brahmaputra Nursing Home, Dibrugarh and also paid a huge amount to the Namcare hospital, guwahati for his treatment. So, on that count , we must hold that the complaint has no merit and therefore, the complaint is liable to be dismissed . Accordingly, the complaint is dismissed on contest.
Given under our hand and seal of the District Forum, on this the 16th day of May, 2017.
(Mrs. A. D. Lahkar) (Md.S.Hussain)
Member President
