PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding the deficiency in service, unfair trade practices, harassment and mental torture against the Opposite Party.
2) The facts of this case as stated by the Complainant are that, she has obtained a Mediclaim Insurance Policy from the Opposite Party bearing No.112600/34/08/11/19636 valid from 11/03/09 to 10/03/2010. During the validity of this policy she was hospitalized in Bombay Hospital on 20/05/2009 for Acute Appendicitis. The insurance mediclaim policy, being a cashless policy, she submitted the copy of the policy to the Marketing Department of Bombay Hospital who in turn submitted Preauthorization Form No.7 to the TPA of Opposite Party No.1. This preauthorization form stated total estimated amount of expenses of Rs.65,000/- for the hospitalization. The operation of appendicitis was scheduled on 21/05/09. But, the hospital does not act till the authorization comes from the TPA of the Opposite Party. On 20/05/09, at about 3.00 p.m. the TPA informed the marketing Dn. of Hospital on telephone that the authorization was not given because the Complainant was marked as male in the policy. When the TPA was asked to give the reason for not giving authorization in writing, the TPA refused to give the reason in writing. The father of the Complainant who is a Sr. Citizen tried to contact the Opposite Party but in vain. Then he informed the Opposite Party in writing that his daughter Ria is a female & sent I Card, etc. for the proof but there was no response from Opposite Party or the TPA.
3) On 21/05/09, the father of the Complainant went to Opposite Party office and explained the above facts to the Opposite Party Officer, Mr. Ahemed Ali. After some discussion with TPA, he assured about the Authorization, Opposite Party has given the endorsement on 21/05/09 as follows –
“It is hereby agreed & noted that the name and gender of the insured should be read as under right from inception.
Ms. Ria Rajan Alimchandani – female – 23 years SI. 200000 other terms and conditions remain the same.”
4) On 21/05/09, at 1.29 p.m. the Hospital received fax from TPA that they required to see the sonography report before issuing authorization. By that time the Complainant was operated.
5) Further the father of the Complainant was asked to submit an undertaking to Hospital that in the event the T.P.A. fails to make payment, he would make the payment.
6) On 22/05/09, TPA sent a fax informing that an authorization limit of Rs.40,000/- was approved. It is alleged by the Complainant that her sum assured was 2 Lacs, the estimated amount was Rs.65,000/-still the TPA approved only Rs.40,000/-.
7) The TPA still on 22/05/09 labeled the Complainant as male inspite of giving the correct information as stated above.
8) It is further alleged by the Complainant that, though she had a cashless policy she was asked by the Hospital to deposit Rs.5,000/- for Admission Deposit (This is the allegation against hospital and it appears that Opposite Party is not concerned with this allegation).
9) On 23/05/09, the doctor gave ok for discharge. Final bill, prepared by the Hospital was of Rs.81,575/-. Bill was sent to TPA for amendment of authorized amount. It was faxed to TPA Bangalore Office. There was no response from TPA ON 23/05/09 till evening. Marketing department of the Hospital told the father of the Complainant to get the revised bill approved form TPA. Inspite of several calls to Bangalore Office of TPA there was no response.
10) On 24/05/09 in the morning also the required authorization was not received from the TPA. Again the TPA was repeatedly called when one Vijay told that the approval was held up as the TPA wanted the break up of Hospital surcharge of Rs.12,886/-. Then the entire bill was sent to TPA at 10.15 a.m. In this connection the Complainant has brought to the notice of the Forum that as per the policy, 20 % surcharge levied on hospital bill except on medicines is to be paid by the insured and still the approval was delayed by the TPA.
11) The approval was received by hospital on 24/05/09 at 12.12 p.m. by fax approving only Rs.66,000/-. In the said approval also the gender of the insured was shown as male instead of female. The TPA has also not explained about the shortage of Rs.2,689/-.
12) It is alleged by the Complainant that the attitude of the Company & Development Manager was totally un-professional, mindset is arrogant. This caused severe mental strain to the Complainant & her family.
13) Finally the Complainant has prayed for a) compensation of Rs.2 Lacs for mental torture and agony b) Rs.2,689/- the amount deducted from the medical bills without any explanation c) Rs.15,000/- towards expenses incurred for attending Court, communication and correspondence d) Rs.360 as the Opposite Party made the Complainant to stay one day more because it did not sanction the amount claimed on 23/05/09 e) Compensation of Rs.20,000/- towards Legal Consultation.
14) The Complainant has attached the xerox copies of the following documents alongwith the complaint.
Relevant Mediclaim Policy, Medical papers of Abhishek Day Care & Institute & Medical Research Centre, having date 20/05/09 on last page i.e. on page 8, Preauthorization request form., A note signed by Rajan Alimchandani dtd.20/05/09, Copy addressed to Opposite Party, I Card of the Complainant, Endorsement letter issued by Opposite Party, Fax from TTK Health Care TPA Pvt. Ltd. dtd.21/05/09, 1.29 p.m. asking USG Report, Ultrasonography Report dtd.20/05/09, Letter of Undertaking, Approval letter dtd.22/05/09, Receipt of Admission deposit dtd.22/05/09, Discharge report from Bombay Hospital, (Exh.‘K’ is not a list of telephones but it is approval letter dtd.22/05/09), Final Bill from Bombay Hospital, dtd.23/05/09, Approval letter dtd.24/05/09 for Rs.66,000/- form TTK Healthcare Pvt. Ltd.
15) The complaint was admitted and the Opposite Party was served with the notice, Opposite Party appeared through its Ld.Advocate and filed its written statement, it denied the allegations of unfair trade practice, mental torture and deficiency in service on the part of Opposite Party. However, the Opposite Party admitted that the total estimated cost was approximately Rs.65,000/-. The Opposite Party has clarified that there cannot be any nexus between the treatment of Hospital and authorization of the TPA but the Opposite Party is silent on the allegation of the Complainant that it (Opposite Party held up the approval because the Complainant was marked as a male in the policy instead of female. It is further stated by the Opposite Party that the original policy contained the abbreviation M. for which the Complainant never approached for change only during hospitalization the Complainant moved application for correcting the gender. The allegation of the Complainant that the Opposite Party has wrongly put male gender, was denied by the Opposite Party.
16) The Opposite Party has further submitted that the TPA authorized the payment. TPA is justified in seeking important reports, clarifications from the Complainant to ensure that the payment is made inconsonance with the terms and conditions of the policy.
17) It is also submitted by the Opposite Party that the undertaking referred by the Complainant does not contain the dates & it is sought by the Hospital and not by the Opposite Party or the TPA.
18) The Opposite Party has not given any comment on para 10, 11, 12 & 13 of the complaint inspite of fax approving Rs.40,000/- was attached to the Complaint. The averment of Opposite Party that the Complainant has not produced the details of fax report and therefore, it is unable to comment, is absolutely misleading.
19) Regarding the allegation that the Complainant received Rs.2,689/- less than the actual bill, the Opposite Party’s contention seems absurd and meaningless.
20)It is further denied that the attitude of the Development Manager & the Company was unprofessional etc. Finally the Opposite Party has submitted that the Complainant is not entitled to any relief as prayed by her in her complaint.
21) Thereafter the Complainant’s father, duly authorized by the Complainant, filed his affidavit-cum-rejoinder wherein he denied the averments in the written statement of the Opposite Party and explained how they are not either relevant or false. He also expected certain explanation from the Opposite Party and added certain new things which were not mentioned in the complaint. He has attached the news paper cuttings containing Consumer Fora orders against the insurance companies. The father of the Complainant also attached copy of the letter dtd.05/08/09 addressed to the Opposite Party by the Complainant and a copy of Cheque No.818894 of Rs.5,000/- in favour of the Complainant issued by Bombay Hospital. The Complainant has then filed written argument wherein the facts and points raised in the affidavit of evidence, were reiterated. Thereafter the Opposite Party filed its affidavit of evidence.
22) We heard the Ld. Representative of the Complainant (the father of the Complainant) and the Ld.Advocate for the Opposite Party. We also perused all the documents submitted by both the parties and our findings are as follows.
23) The Complainant has obtained a Mediclaim Policy No.112600/34/08/11/19636 valid from 11/03/09 to 10/03/2010. During the validity of this policy, the Complainant was hospitalized in Bombay Hospital from 20/05/09 to 24/05/09.
24) The medical insurance policy being a cashless policy, the Marketing Department of the Bombay Hospital, where the Complainant was hospitalized, submitted a pre-authorization form 7 to the TPA of the Opposite Party. The estimated expenses for hospitalization were Rs.65,000/-. Here the Complainant has alleged that the hospital does not act till the authorization comes from the TPA. But there is no substance in this averment as the Complainant has herself stated in the subsequent paras, that she was operated even though the authorization was not received by 21/05/09 (para 8 of the complaint). As per the Complainant’s averment only she was operated on 21/05/09 and authorization of Rs.40,000/- was received on 22/05/09.
25) The next allegation of the Complainant is that on 20/05/09 at about 3.00 p.m. the TPA informed the Marketing Division (Dn. in short) of the Hospital on telephone that the authorization was not given because the Complainant was marked as a male in the original policy. This must have certainly upset the Complainant and her family. From the record it is seen that the father of the Complainant who is a Sr. Citizen has to run from pillars to pole and brought to the notice of the Opposite Party as well as the TPA that the patient i.e. the insured is a female. He had to submit the relevant papers in this respect and obtain an endorsement from the Opposite Party that Ms. Ria Rajan Alimchandani – Female – 23 years, etc. (Exh.‘E’ to the complaint). This endorsement was effected on 21/05/09 but still the authorization reached on the next day i.e. on the 22/05/09. In this case the policy document is prepared by the Opposite Party. The name of the insured is Ria. Before the name Ria the word Ms. is put. This clearly shows that the insured is a female. Still the Opposite Party marks the insured as male. This is nothing but a shere negligence on the part of Opposite Party. This does not stop here. On the said ground the TPA objects and does not approve the authorization of expense and for that, the Sr. Citizen, the father of the Complainant has to run from Opposite Party to TPA. This is certainly a deficiency in service on the part of Opposite Party. When a service provider i.e. the Opposite Party takes an handsome amount of premium for its service, it should be given smoothly particularly when its consumer is on bed undergoing an operation, when he/she cannot move from his place, his/her family members have to take the brunt of consequences of the deficiency in service of the Opposite Party.
26) It is further alleged that the TPA required sonography report of the patient. In this connection, in our view we do not think that the TPA has erred by asking such a report. After all the TPA is reimbursing the expenses of the hospitalization and it has all the rights to verify the papers pertaining to the hospitalization. But at the same time, it should not delay the matter and the authorization.
27) It is further alleged by the Complainant that her father was asked to submit an undertaking to the hospital. It is an undertaking to make payment of the expenses towards hospitalization if the TPA fails to make payment. This is the undertaking, asked by the hospital to ensure the payment of the hospitalization expenses. We have perused this undertaking produced by the Complainant. There is no name on this paper. It is a printed form with one signature dtd.22/05/09. It is not understood as to when the authorization was received on 22/05/09. Still it is because of the deficiency in service of the Opposite Party, that it did not approve the expenses and hence, the hospital has obtained this undertaking from the father of the Complainant.
28) The next allegation of the Complainant that the TPA approved authorization of only Rs.40,000/-. The estimated amount of expenses was Rs.65,000/-. The insured sum was Rs.2 Lacs, still the TPA approved only Rs.40,000/-. We carefully examined this allegation. The Complainant has not directly mentioned that this is the deficiency but she only stated the facts and left for the Forum to decide whether it is deficiency. Though the Complainant has not directly averred that it amounts to deficiency, we examined this fact from that point of view and to our candid opinion, the estimate given by the hospital is only an estimate and not the actual expenditure incurred in hospitalization of the Complainant. Therefore, the TPA also sanctioned the amount which it felt, was appropriate. Even in such circumstances these transactions are not the final transactions. The final settlement would be after the discharge of the patient from the hospital. Therefore, it would be a pre-matured averment that the TPA sanctioned less amounts than the estimated amount.
29) The next allegation of the Complainant is that the TPA has again labeled the Complainant as male inspite of brining the fact to its notice as stated earlier. This is again a deficiency on the part of TPA that inspite of the endorsement correcting the gender of the insured it marked the Complainant as male. The act of the TPA is absolutely negligent.
30) The next allegation of the Complainant is that she was having a cashless policy but she was asked by the hospital to deposit Rs.5,000/- for admission deposit. The hospital has asked the deposit and not the Opposite Party. Hospital is not a arty before this Forum. There is no any obligation on the Opposite Party to do certain things in this behalf. Therefore, this cannot be termed as a deficiency against the Opposite Party.
31) It is further alleged by the Complainant that the treating doctor gave Ok for the discharge on 23/05/09. Final bill was prepared by the hospital on 23/05/09 for Rs.81,575/-. This bill was sent to TPA for amendment of the authorized amount. But inspite of several efforts to contact the TPA there was no response on 23/05/09. Hospital told the father of the Complainant to get the revised bill approved. Therefore, it is the contention of the Complainant that her stay was in the hospital was delayed by one night. On the next day i.e. on 24/05/09, it was clarified that the TPA wanted to know the breakup of surcharge levied by the hospital. Therefore, the whole hospital bill was sent to the TPA. As the surcharge levied by the hospital was paid by the insured and not by the insurer, this cannot be the reason for upholding the approved of the revised bill. In this connection there is nothing on record that the treating doctor had given discharge on the 23/05/09. Even the hospital has not certified that the patient was to be discharged on 23/05/09 but due to the approval, and non receipt of the expenses from TPA, the patient was not discharged on 23/05/09. It is the fact that the bill of Rs.81,575/- was dtd.23/05/09. Even there is nothing on record to show that the hospital had asked the father of the Complainant to get the bill approved. There is no document to show that the TPA wanted the breakup of surcharge levied by the hospital. Therefore, in our view, this allegation is not substantiated.
32) It is the next allegation of the Complainant that the TPA on 24/05/09 approved the expenses of Rs.66,000/-. The expenses incurred as per the bill were of Rs.68,889/- but the TPA sanctioned only Rs.66,000/-. There was a shortage of Rs.2,689/-. In this connection it appears from the record that the bill was of Rs.81,575/- less the surcharge of Rs.12,868/- which was to be borne by the Complainant. Therefore, the TPA was to sanction Rs.68,689/- but it approved expenses of Rs.66,000/- only thereby sanctioning less Rs.2,689/-. But from the record it is also seen that the Complainant has not paid this amount to the hospital, neither the Complainant has averred in the complaint that the said amount was paid by her to the hospital authorities still in the prayer clause, she has prayed for this amount. Under such circumstances it would be the Complainant to show that the hospital has asked her to pay this amount and she had paid this amount. Therefore, the prayer for Rs.2,689/- made by the Complainant is a pre-matured prayer which cannot be granted.
33) The next allegation of the Complainant is that the attitude of the Company & Development Manager was totally unprofessional and mindset was arrogant which caused mental strain to the Complainant and her family. In this respect when we see the entire facts of this case, it is seen that the TPA of the Opposite Party has delayed the approval of the bill sent by the hospital by one day and during the period i.e. from 20/05/09 to 24/05/05 the TPA has raised some points like the questioning of gender, USG Report, etc. which has certainly caused a mental agony to the Complainant & her family.
34) Therefore, as discussed above, there is a deficiency in service provided by the TPA which has acted on behalf of the Opposite Party, as specifically mentioned in para 25 and 29 above only. However, the compensation as prayed by the Complainant is exorbitant, when we see the nature of the deficiency proved. Therefore, the compensation of Rs.10,000/- would be the proper amount for the mental agony and physical harassment caused to the Complainant. It would also be proper to make further order in this case that the compensation will be first paid to the Complainant by the Opposite Party but, thereafter the Opposite Party should hold enquiry to find out, who had committed a mistake by putting a wrong gender in the original policy and fix the responsibility on a concerned employee. The whole company should not suffer for the mistake of one person.
35) The prayer for Rs.2,689/- cannot be granted as discussed above.
36) Prayer for the expenses in attending Court, communication and correspondence legal consultation is exorbitant and no proof has been submitted by the Complainant in this respect.
37) In view of the above observation we pass the order as follows -
O R D E R
i.Complaint No.262/2009 is partly allowed.
ii Opposite Party is directed to pay the compensation of Rs.10,000/- (Rs. Ten Thousand Only)to the Complainant
for the mental agony, inconvenience and physical harassment caused to the Complainant and her family due to
the deficiency in service as discussed in para 25 & 29 above. The Opposite Party shall hold enquiry in order to
find out the defaulting employee and fix up the responsibility. Thereafter the Opposite Party shall recover the
above amount of compensation from the salary of the concerned employee.
iii.Opposite Party is also directed to payRs.5,000/- (Rs. Five Thousand Only) to the Complainant towards the cost
of this complaint.
iv.Opposite Party is directed to comply with the above order within 60 days from the receipt of this order.
v. Certified copies of this order be furnished to the parties.
