Date of filing:24.1.2014
Date of Disposal:23.6.2014
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II::
VIJAYAWADA, KRISHNA DISTRICT.
Present: SRI A. M. L. NARASIMHA RAO, B.SC., B. L., PRESIDENT
SMT N. TRIPURA SUNDARI, B. COM., B. L., MEMBER
MONDAY, THE 23rd DAY OF JUNE, 2014.
C.C.No.35 OF 2014
Between :
B.V.N.S. Sarma, S/o Sambasiva Rao, Hindu, 54 years, Advocate, R/o House No.20-2-16, B-2, F-7, Aravinda Apartment, Ayodyanagar, Vijayawada – 520 003
….. Complainant.
And
1. The Divisional Manager, United India Insurance Co., Ltd., D.O. IV, 7th Floor United India Towers, Basheerbagh, Hyderabad.
2. The General Manager (Claims), Good Health Plan Limited, Plot No.49, Nagarjuna Hills, Panjagutta, Hyderabad – 500 082.
3. The Branch Manager, Andhra Bank, S.N.Puram Branch, Vijayawada – 520 003.
…..Opposite Parties.
This complaint is coming before us for final hearing on 12.6.2014 in the presence of Sri S.Chandra Sekhar, advocate for the complainant and Sri N.V.R.Krishna Kumar, Counsel for opposite party No.1 and opposite party No.2 remained absent and Sri Y.S.C.Bose, Counsel for opposite party No.3 and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble Member Smt N. Tripura Sundari)
This complaint is filed under Section 12 of the Consumer Protection Act, 1986.
The averments of the complaint are in brief;
1. The complainant is an account holder of the 3rd opposite party and he obtained medi-claim insurance policy from the 1st opposite party through the 3rd opposite party for himself and his family members in the year 2007 and since then he is regularly renewed the said policy. The 2nd opposite party is the 3rd party’s administrator (TPA) who issued ID card, guide book and list of network hospitals for availing cashless treatment. As the terms of the medi-claim policy the 1st opposite party has to indemnity the medical expenses under the policy. While so on 25.8.2013 the daughter of the complainant joined in Andhra Hospital with Abdomen pain and after getting treatment she was discharged from the hospital on 28.8.2013. The Andhra Hospital Authorities submitted documents for obtaining permission for cashless treatment. The said proposal was rejected by the 1st opposite party and therefore the complainant paid the entire amount to the hospital authorities. Subsequently the complainant received a message from the 1st opposite party stating that his clam record was closed for the reasons best known to them. But inspite of repeated requests made by the complainant the opposite parties did not settle his claim. Thus the complainant got issued legal notice demanding the opposite parties to indemnify the medical expenses under the policy. The 2nd opposite party issued reply requesting the complainant to send the documents for pursuing the data. Accordingly the complainant submitted the same. But the opposite parties failed to settle the claim till today which amounts to deficiency in service on their part. Hence the complainant is constrained to file this complaint against the 1st opposite party praying the Forum to direct the opposite parties to repay the entire claim amount of Rs.10,120/- towards hospital expenses, to pay premium amount with interest, to pay damages of Rs.3,00,000/- for mental agony and to pay costs.
2. The 2nd opposite party called absent and the opposite parties 1 and 3 filed their versions.
The version of the 1st opposite party is in brief:
The 1st opposite party denied al the allegations of the complaint and submitted that the 1st opposite party has not received any claim intimation claim form and other relevant documents from the complainant to process the same. The 1st opposite party is not aware of any correspondence made by the complainant with the 2nd opposite party from time to time as mentioned by him. As per the documents filed by the complainant he made claim with the 2nd opposite party. As per the letter addressed by the 2nd opposite party to the complainant on 22.11.2013 it was clearly mentioned as “cashless facility was denied as the proposed line of management does not warrant”. However he can apply for reimbursement with all relevant documents so that they can process the claim further on merit basis. But the complainant has not responded for the same. The complainant has not submitted all the relevant original documents either to this opposite party or to the 2nd opposite party as per the terms and conditions of the insurance policy. The bill and receipt filed by the complainant dated 28.8.2013 for an amount of Rs.9,500/- are not supported by any separate bills and vouchers. The said B.L.S. Kameswari is not entitled to claim cashless hospitalization and it was clearly mentioned in the ID card as “the issue of this card does not guarantee cashless hospitalization” and the said fact was also confirmed by the 2nd opposite party in his reply notice dated 22.11.2013. There is no deficiency in service on the part of the 1st opposite party towards the complainant and prayed to dismiss the complaint.
3. The version of the 3rd opposite party.
The 3rd opposite party denied all the allegations of the complaint and submitted that M/s United India Insurance Company Limited is doing health insurance business and on its own and also taking the services of other organizations to spread its business. In the process it had introduced group medi-claim insurance AB-Arogyadaan to the account holders of Andhra Bank and it collected premium through Andhra Bank. Therefore the 3rd opposite party is doing service to the medi-claim insurance policy holders of M/s United India Insurance Company Limited by taking proposals from the needy account holders and forwarding them to the insurance company together with collected premium. As per the terms of group medi-claim proposal the 3rd opposite party will not under any responsibility and will not accept any correspondence in the case of claims and the policy holders have to pursue with insurance company/specified TPA for the settlement of claim. Therefore the opposite party is not necessary party to this complaint and prayed to dismiss the complaint against the 3rd opposite party.
4. On behalf of the complainant he gave his affidavit and got marked Exs.A.1 to Ex.A.18 and on behalf of the 1st opposite party Smt U.Bhushanamma, Assistant Manager filed her affidavit and got marked Ex.B.1 to Ex.B.4 and on behalf of the 3rd opposite party Sri P.V.V.Sudhakara Rao, Chief Manager filed his affidavit and got marked Ex.B.5.
5. Heard and perused.
6. Now the points that arise for consideration in this complaint are;
1. Whether there is any deficiency in service on the part of the opposite parties towards the complainant in not accepting the claim of the complainant?
2. If so is the complainant entitled for any relief?
3. To what relief the complainant is entitled?
POINTS 1 AND 2:-
7. On Perusing the material on hand the complainant is an account holder of the 3rd opposite party and he obtained medi-claim insurance policy Ex.A.5 from the 1st opposite party through the 3rd opposite party under Ex.A.5 for himself and his family members in the year 2007 and he has regularly renewed the said policy. The 2nd opposite party is the 3rd party’s administrator (TPA) who issued Ex.A.17 and Ex.A.18 ID cards, guide book and list of net work hospitals for availing cashless treatment. On 25.8.2013 the daughter of the complainant joined in Andhra Hospital with abdomen pain and after getting treatment she was discharged from the hospital on 28.8.2013. Ex.A.7 and Ex.A.8 disclose the above facts. Andhra Hospital authorities submitted documents Ex.A.7 and Ex.A.8 for obtaining permission for cashless treatment. For the said proposal, the 1st opposite party sent a letter Ex.A.9 dated 28.8.2013 to the Andhra Hospital stating that the 1st opposite party authorize and guarantee payment upto Rs.30,000/- and please send the following documents at the earliest possible after discharge of the patient (1) hospital bill summary with the final bill showing itemized details of each service. (2) discharge summary and report of all investigations (original) and prescription of medicines (3) claim form signed by the patient (4) claim documents should be submitted within 7 days from the date of discharge of the patient (5) the claim settlement would be as per the tariff & discounts contracted in the network agreement. The complainant paid the entire amount under Ex.A.10 to the hospital authorities. Inspite of repeated request of the complainant under Ex.A.11 and Ex.A.12 the opposite parties did not settle his claim. Then the complainant got issued a legal notice Ex.A.13 dated 12.11.2013 demanding the opposite parties to indemnify the medical expenses under the policy. The 2nd opposite party issued reply under Ex.A.14 dated 22.11.2013 stating that as per the documents patient was treated and discharged on 28.8.2013 and cashless facility was denied as the proposed line of management does not warrant. However the complainant can apply for reimbursement with all relevant documents to process the claim further on merit basis. The complainant submitted the same under Ex.A.15 dated 29.12.2013.
8. The 1st opposite party says that the 1st opposite party has not received any claim intimation claim form and other relevant documents from the complainant to process the same. The 1st opposite party is not aware of any correspondence made by the complainant with the 2nd opposite party from time to time. As per the documents filed by the complainant he made claim with the 2nd opposite party. As per the letter Ex.B.3 addressed by the 2nd opposite party to the complainant on 22.11.2013it was clearly mentioned “cashless facility was denied as the proposed line of management does not warrant. However the complainant can apply for reimbursement with all relevant documents to process the claim further on merit basis. But the complainant has not responded for the same. The complainant has not submitted all the relevant original documents either to the 1st opposite party or to the 2nd opposite party as per the terms and conditions of the insurance policy Ex.B.1. The complainant says that the 1st opposite party has not mentioned any of the stipulated procedure in his leaf supplied by him. The 1st opposite party says that the bill and receipt filed by the complainant dated 28.8.2013 for an amount of Rs.9,500/- are not supported by any separate bills and vouchers. The said B.L.S.Kameswari is not entitled to claim cashless hospitalization and it was clearly mentioned in ID card Ex.B.2 as “the issue of this card does not guarantee cashless hospitalization and the said fact was confirmed by the 2nd opposite party in his reply notice dated 22.11.2013. The 2nd opposite party sent a letter Ex.B.4 dated 27.3.2014. That claim amount is Rs.9,500/-. As member has submitted all photocopy of documents, the processing team has raised query to submit all original documents. 1st letter was sent to complainant on 27.12.2013 and 2nd letter on 12.3.2014 to submit all original documents but required documents not received. If all original documents submitted, claim can be put into further process.
9. The 3rd opposite party submitted that M/s United India Insurance Company is doing health insurance business and on its own and also taking the services of other organizations to spread its business. It had introduced group medi-claim insurance AB Arogyadaan to the account holders of the 3rd opposite party and it collected premium through the 3rd opposite party. The 3rd opposite party is doing service to the medi-claim insurance policy holders of the 1st opposite party by taking proposals from the needy account holders and forwarding them to the 1st opposite party with collected premium. As per the terms of group medi-claim proposal, the 3rd party will not be under any responsibility and will not accept any correspondence in case of claims and the policy holders have to pursue with insurance company/specified TPA for settlement of claim. Ex.B.5 filed by the 3rd opposite party discloses the same.
10. On hearing the parties we, the Forum came to conclusion that the 1st opposite party offered and issued insurance certificate under AB-Arogyadaan medi-claim policy to the complainant. The 2nd opposite party is the third party administrator (TPA) on behalf of the 1st opposite party and it issued ID cards, guide book, and list of net work hospitals for availing cashless treatment. The 1st opposite party has to indemnify hospitalization expenses. On assurance of the policy the complainant’s daughter was joined in the net work hospital i.e., Andhra Hospital on 25.8.2013 and was discharged on 28.8.2013. The claim documents were submitted to the 2nd opposite party by the said hospital but the claim was not settled. The complainant paid the hospital expenses to the hospital to get his daughter discharge. The complainant was informed by 2nd opposite party that his claim record was closed. The 1st opposite party denied the cashless facility as the proposed line of management does not warrant. The opposite party has not mentioned any stipulated procedure in Ex.B.1. Ex.B.4 clearly shows that the 1st opposite party is aware of the all proceedings from time to time. The 1st opposite party stated in his letters sent to the complainant to send the documents to pursue the matter but he did not mentioned to send original documents. After filing the complaint in this Forum, the 2nd opposite party sent a letter to the complainant on 10.3.2014 to send original documents. It is clearly mentioned by the 1st opposite party in the terms and conditions that “for all the grievances, complaints with regard to issuance of cards, settlements contact TPA M/s Good Health Plan Ltd., i.e., 2nd opposite party, further it was mentioned in Ex.B.1 and Ex.A.6 that the claim is cashless. The complainant made several correspondence with the 1st and 2nd opposite parties. Inspite of repeated demands of him the opposite parties did not settle the claim. It seems clearly deficiency in service on the part of opposite parties 1 and 2 towards the complainant and they are liable for compensate the complainant. The complainant is entitled for relief from the opposite parties. Accordingly these points are answered.
POINT No.3:-
11. In the result, the complaint is allowed in part and the opposite parties 1 and 2 are jointly and severally directed to pay medi-claim amount of Rs.10,120/- towards hospital expenses with interest at the rate of 12% per annum from the date of discharge of the complainant’s daughter, i.e., 28.8.2013 till realization, to pay Rs.10,000/- towards compensation for causing inconvenience and mental agony and costs of Rs.2,000/- to the complainants. Time for compliance one month. The claim against the 3rd opposite party is dismissed. Rest of the claims of the complainant are rejected.
Typewritten by Stenographer K.Sivaram Prasad, corrected by me and pronounced by us in the open Forum, this the 23rd day of June, 2014.
PRESIDENT MEMBER
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For the complainant: For the opposite parties:-
P.W.1 B.V.N.S. Sarma D.W.1Smt U.Bhushanamma,
Complainant Assistant Manager,
(by affidavit) of the 1st opposite party
(by affidavit)
D.W.2 P.V.B.Sudhakara Rao,
Chief Manager of the 3rd opposite party, (by affidavit)
DOCUMENTS MARKED
On behalf of the Complainant:
Ex.A.1 . . Bill & Receipt issued by Andhra hospitals, Vijayawada.
Ex.A.2 25.08.2013 Cash receipt issued by Andhra Hospitals, Vijayawada.
Ex.A.3 25.08.2013 Cash receipt issued by Andhra Hospitals, Vijayawada.
Ex.A.4 07.09.2013 Ramana Gastro & Laparoscopy Centre Pharmacy bill.
Ex.A.5 . . Mediclaim policy.
Ex.A.6 . . Andhra Bank pamphlet.
Ex.A.7 . . Request for pre-authorization issued by Good Health Plan Ltd., along with photocopies of prescription, consultant notes and ID card of the complainant’s daughter.
Ex.A.8 . . Photocopy of Clinical Examination and Investiagations of Andhra Hospitals, Vijayawada.
Ex.A.9 28.08.2013 Authorization letter to the Hospital for Treatment and as a guarantee of payment.
Ex.A.10 28.08.2013 Discharge summary issued by Andhra Hospitals,
Vijayawada.
Ex.A.11 . . E-mail letter.
Ex.A.12 14.09.2013 Letter from complainant to the 2nd opposite party and 3rd opposite party.
Ex.A.13 12.11.2013 Letter from the complainant to the opposite parties.
Ex.A.14 22.11.2013 Letter from the 2nd opposite party to the complainant.
Ex.A.15 29.11.2013 Letter from complainant to the 2nd opposite party.
Ex.A.16 . . Andhra Bank pamphlet
Ex.A.17 . . Mediclaim policy.
Ex.A.18 . . Letter from the United India Insurance Co., Ltd., to the complainant.
For the opposite parties:-
Ex.B.1 . . Mediclaim policy.
Ex.B.2 . . ID card
Ex.B.3 22.11.2013 Photocopy of Letter from the 2nd opposite party to the complainant.
Ex.B.4 27.03.2014 Letter from the 2nd opposite party to the 1st opposite party.
Ex.B.5 . . Specimen copy of proposal Form.
PRESIDENT
