Date of filing :23.3.2017
Judgment : Dt.12.3.2018
Mrs. Balaka Chatterjee, Member
This petition of complaint is filed under section 12 of C.P.Act, 1986 by Bhaskar Saha alleging deficiency in service on the part of the opposite parties (Referred OPs hereinafter) (1) General Manager, M/s Star Health & Allied Insurance Co. Ltd., (2) The Chief Marketing Manager, (3) The Branch Manager and (4) The Claim Officer.
Case of the Complainant in brief is that Complainant’s mother namely Sandhya Saha obtained a mediclaim policy being Policy No.P/191117/01/2016/006227 issued by the OP Insurance Company Ltd. which was a special type of policy known as Red Carpet Mediclaim Policy issued for the Senior Citizens on 21.11.2012. Subsequently, the said policy used to be renewed every year till 2016. The Complainant have stated that on 8.4.2016 the said Sandhya Saha became ill and was admitted at Behala Balananda Brahmachari Hospital and Research Centre being referred by her family Physician Dr. Subrata Roy. The Complainant have further stated that on 22.4.2016. The Hospital Authority informed that Authorization for being covered under Mediclaim Policy by the patient had been withdrawn and stood null and void since the patient had been being bedridden since 7 years and on a further ground of age discrepancy. The Complainant have specifically stated that the patient was not bedridden since 7 years rather it was written in the prescription issued by family physician Dr. Subrata Roy, wherein he prescribed for 7 days bed rest for the patient’s respiratory problem but owing to his hand writing style the doctors of Balananda Brahmachari Hospital took it ‘Bedridden for 7 years’ which was outcome of misinterpretation of handwriting of Dr. Subrata Roy. The Complainant have specifically mentioned that he had deposited the premium for last five years (which means from the date of inception of the policy till Hospitalization of the insured patient) regularly but in spite of that the OP Insurer withdrawn authorization of Insurance on vague grounds. Accordingly, the Complainant has prayed for direction upon the OPs to compensate the Complainant by paying sum assured plus a certain sum for causing mental agony and pain and also to pay cost of litigation.
The Complainant have annexed following documents with the petition of complaint:-
Photocopy of Policy No.P/191117/2016/006227, Premium Receipt dt.23.11.2015, Hospitalisation Benefit Policy dt.09.12.2015, Discharge Certificate issued by Behala Balananda Brahmachari Hospital and Research Centre, Money receipt dt.2.5.2016, Prescription dt.10.4.2016, 11.4.2016,. 14.4.2016, 18.4.2016, 19.4.2016, 20.4.2016, 2.5.2016 issued by Behala Balananda Brahmachari Hospital, Voter Identity Card and Customer Identity Card, Certificate issued by Dr. Subrata Roy dt.25.4.2016, Authorization for cashless treatment, withdrawal of Authorization letter dt.22.4.2016, rejection of Pre-authorisation for cashless treatment, letter dt.21.6.2016 issued by Star Health to Bhaskar Saha, Letter dt.6.7.2016 issued by Star Health, Advocate’s letter dt.7.9.2016, letter dt.23.9.2016 issued by Star Health Advocate’s letter dt.18.11.2016, OPD Patient Card issued by Department of Health & Family Welfar to the Govt. of West Bengal, Death Certificate of Sandhya Saha.
The OP contested the case by filing written version denying and disputing all the material allegation made out in the petition of complaint stated inter alia, that the Insured namely Sandhya Saha obtained a policy namely Red Carpet Policy for a sum of Rs.1,00,000/- only which came into force on 21.9.2012 for one year and thereafter renewed the same for further 3 years in continuation to that. It is stated by the OPs that in one of the special privileges was given to the senior citizen was that no pre-insurance medical examination had been taken place. It is stated by the OP Insurer that the Insured patient was admitted to the Behala Balananda Brahmachari Hospital and Research Centre on 8.4.2016 for treatment of “lower respiratory tract infection (LRTI) septicemia with hyponatricimia with Cronic Kidney Disease (CKD) of recent outset” and hence a pre-authorisation of Rs.6,45,001/- was raised and sent by the Hospital for availing cashless facility which was recorded by the respondent as claim intimation No.CLI/2017/19117/0010587. It is further stated by the OP Insurance Company that it was informed by the Behala Balananda Brahmachari Hospital in the case history of the insured that she had been bed ridden for 7 years and was suffering from bed sore. The OP Insurance Company specifically stated that the said fact was not disclosed at the time of inception of the policy and hence pre-authorisation was rejected. The responding OP further stated that the Complainant, thereafter, submitted a claim for reimbursement of medical expenses under claim No.CLI/2017/191117/0010587 and on scrutiny of the medical documents it was observed that the patient was admitted with the history of Ischemic Stroke with right NOF (Old) and the OP in order to settle the claim requested the Complainant vide query letter dt.21.6.2016 to furnish the following documents in original (1) Previous Hospitalisation information any, (2) Discharge Summary of old neck of Femur fracture and CEREBROVASCULAR accident (CVA), (3) Agre Proof Certificate of Insured patient, which was unreplied and, therefore, further query letters dt.6.7.2016 & 21.7.2016, which was also remained unheeded which resulted in repudiation of the claim vide rejection letter dt.5.8.2016. Accordingly, the OP prays for rejection of the complaint.
The OP annexed photocopies of documents including Policy document, Pre-authorisation request, Authorisation for cashless treatment of Insured patient dt.11.4.2016 issued by the OP Insurer, query on pre-authorisation dt.11.4.2016, withdrawal of authorization letter dt.22.4.2016, letter dt.21.6.2016 for requirement of additional documents/information from the OP Insurer, First reminder to the same dt.6.7.2016, 2nd reminder to the same dt.21.7.2016, letter dt.5.8.2016 as to rejection of reimbursement claim, some treatment sheets as well as clinical test reports.
In course of argument Ld. Advocate for the Complainant put much stress on the point that had the patient bed ridden for 7 years i.e. at the point of time of inception of the instant policy then how did the OP Insurer issued policy in favour of her? In this regard Ld. Advocate for the OP Insurer has submitted that the OP Insurer facilitated the provision for non-premedical examination the prospective Insured at the point of time of inception of the policy and as such they accepted the statement furnished by the prospective Insured/Proposer on good faith.
Main points for determinations
- Whether there is deficiency in service on the part of the OPs?
- Whether the Complainant is entitled to the reliefs as prayed for?
Decision with reasons
Both points are taken up together for comprehensive discussion and decision.
Admittedly, Sandhya Saha (since deceased) obtained a mediclaim policy namely Red Carpet Policy meant for senior citizen issued by the OP Insurer on 21.11.2012 with assured sum of Rs.1,00,000/- under certain terms and conditions. It is alleged by the Complainant who is the son of deceased insured that being referred by the family physician the insured was admitted to Behala Balananda Brahmachari Hospital on 8.4.2016 and to avail a cashless facility applied to the OP for pre-authoristion of the same but vide letter dt.22.4.2016 the OP insurer withdrew the ‘pre-authorisation’ under a misconception that the insured had been bed ridden for 7 years but the matter, in reality, was that the patient (insured) was advised for bed rest for 7 days. It appears from the documents on record that the OP Insurer rejected the claim submitted by the Complainant vide rejection letter dt.5.8.2016. Now, the moot point is whether the Insurance Company rejected the claim on the basis of misinterpretation of bed rest for 7 days as bed ridden for 7 years.
The Complainant has reiterated that initially his family physician Dr. Subrata Roy referred the insured patient with advise for bed rest for 7 days which was interpreted by the treating Hospital (Behala Balananda Brahmachari Hospital) as bedridden for 7 years and the same was recorded in the case history of the Insured patient which was shared to the Insurer. However, no copy of the prescription issued by their family physician which was misinterpreted by the treating hospital has been filed before us wherefrom it would have been evident what was actually written by the said Doctor. However, the Complainant filed a certificate issued by the said physician Dr. Subrata Roy dt.25.04.2016 wherein he had certified to that effect that the patient had not been bed ridden for 7 years as per his knowledge. Though the Complainant has filed the said certificate before this Forum but did not take any initiative to make necessary connection in the treatment sheet issued by the treating Hospital which shared its data with the insurance company so that the Insurance Company could be able to take necessary steps in the matter of settlement of his claim. It further appears from the documents on record that the OP Insurer sent letter as to query of the actual physical state of the Insured patient and requested the Complainant to file some documents to that effect a letter dt.21.6.2016 and subsequently sent two reminders (upon which the Complainant relied also, i.e. letter dt.21.7.2016) but failed to take any initiative for filing the required documents with the OP Insurer. It also appears from the documents on record that ultimately the OP Insurer rejected the claim vide letter dt.5.8.2016 on the ground of “Even after reminders, you have not sent us the above documents, we therefore, presume that you are not interested in your claim, we have therefore closed your claim . ” Considering such state of affairs specially inaction on the part of the Complainant as to furnish the required documents as per letter dt.21.6.2016 and two subsequent reminders of the same and also inaction towards informing the treating Hospital regarding certification of the Dr. Subrata Roy dt.25.4.2016 to enable the said hospital for making necessary correction in the treatment sheet we are inclined to hold the OP Insurance Company was justifiable in rejection of the claim submitted by the Complainant.
Point Nos.I & II are decided accordingly.
In the result, the Consumer Complaint does not succeed.
Hence,
ordered
That CC/173/2017 is dismissed on contest but without any order as to cost.
