By. Sri. Jose. V. Thannikode, President:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to declare that complainant is entitled for cash less claim and to declare the statement of opposite party that the disease of the complainant is 'pre-existing disease' is null and void and to pay the medical expenses, cost and compensation due to the denial of cashless benefit.
2. Brief of the complaint:- The complainant took mediclaim policy from opposite party No.1 through opposite party No.2 from Sulthan Bathery, the policy period is to expire on January 2016. While so the complainant admitted in Vinayaka Hospital in the month of November 2015 and consulted Dr. Omana Madhusudhanan due to the pain in her uterus. Due to the heavy pain and bleeding, she was admitted and done diancy and sent for Biopsy. Since the complainant got mediclaim policy it was intimated to the hospital authorities and requested for cash less claim. But the opposite parties has rejected the claim and also declared that her disease is pre-existing disease without any bonafide. The opposite parties done so without enquire in the hospital and without any basis. The complainant further stated that the opposite parties has done so to deny the entire claim of the complainant in future. This complaint was reported to the opposite party No.2 also, so the opposite party No.2 requested the complainant to contact the opposite party No.1 for relief but no relief has been received so far. The complainant further stated that the denial of claim alleging the pre-existing disease is a clear case of deficiency of service and unfair trade practice from the side of opposite parties. Hence filed this complaint.
3. Notices were served to opposite parties on 10.12.2015 and 09.12.2015 respectively but they have not appeared before the Forum. Hence they set ex-parte and proceeded with the case.
4. The complainant filed proof affidavit and stated as stated in the complaint and he is examined as PW1 and Ext.A1 to A6 documents were marked and evidence closed and heard the complainant. Ext.A1 is the Authorization letter given by the complainant to V. K. Saji, husband of the complainant to conduct this case. Ext.A2 is the copy of policy for the period from 10.01.2014 t0 09.01.2015 and 10.01.2015 to 09.01.2016. In Ext.A2 the condition No.5 is that “Cashless hospitalization in network hospital can be obtained in conjunction with this card, an authorization letter issued by the TPA and photo identification such as voters ID, driving license, Passport etc...”. Ext.A3 is the Discharge Summary of complainant dated 25.11.2015 to 26.11.2015. Ext.A4 is the copy of the Application for cashless authorization dated 25.11.2015, wherein on a question whether present complaint/ailment is a complication of pre-existing disease/surgery, answer given by Dr. Omana Madhusudhanan is 'No'. Ext.A5 is the denial of cashless service, wherein the reason stated by the opposite party is “cashless facility cannot be extended as possibility of the present ailment being of pre-existing nature cannot be rules out based on the available/provided documents”. Ext.A6 series are the Bills 11 numbers.
5. On perusal of complaint, affidavit and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Relief and Cost.
6. Point No.1:- As per the policy condition No.5, the complainant is entitled for cashless claim (benefit). Ext.A4 document is the copy of cashless claim application form, wherein the Doctor certified that the present complaint/ailment is not a pre-existing disease. In Ext.A5 the opposite parties stated the reason that “Cashless facility cannot be extended as possibility of the present ailment being of pre-existing nature cannot be ruled out based on the available/provided documents. However, insured can file the claim for reimbursement post completion of the treatment with all medical and financial records. The admissibility of the claim would be decided post review of the documents and policy conditions”. The complainant taken the health policy for getting cashless claim/benefit for all medical expenses. When an application for cashless benefit is received, denying the claim by stating “as possibility of the present ailment being of pre-existing nature cannot be ruled out based on the available/provided documents” and more over the opposite parties has denied the claim without any documentary evidence or medical certificate or evidence is a clear case of deficiency of service and unfair trade practice. Here the treating Doctor clearly stated that the present ailment is not a pre-existing disease. This is a clear case of deficiency of service and unfair trade practice from the part of opposite parties. The Point No.1 is found accordingly.
7. Point No.2:- Since the Point No.1 is found against the opposite parties, they are liable to pay the cashless medical claim and also liable to pay cost and compensation. The Point No.2 is decided accordingly.
In the result, the complaint is partly allowed and the opposite parties are jointly and severally directed to declare the complainant is entitled for cashless claim and also directed to declare the present ailment is not a pre-existing disease and also directed to pay Rs.8,500/- (Rupees Eight Thousand and Five Hundred) which is spent by the complainant for treatment and also directed to pay Rs.5,000/- (Rupees Five Thousand) as compensation and Rs.1,000/- (Rupees One Thousand) as cost of the proceedings to the complainant within 30 days from the date of receipt of this Order, failing which the complainant is entitled for an interest at the rate of 15% per annum till the realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 16th day of February 2016.
Date of Filing:02.12.2015.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Sweety Saji (Affidavit). Complainant.
Witness for the Opposite Parties:-
Nil.
Exhibits for the complainant:
A1. Authorization Letter. Dt:05.01.2015.
A2. Copy of the Policy.
A3. Copy of the Discharge Summary.
A4. Copy of Application for cashless Authorization.
A5. Letter of Denial of Cashless service.
A6(Series). Bills(11 numbers).
Exhibits for the opposite parties:-
Nil.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
