O R D E R<br /> <br /> <br /> <br /> SRI.D. KRISHNAPPA, PRESIDENT:<br /> <br /> <br /> The brief facts of the complaint filed by the complainants against the Ops are that he is the beneficiary of the Ops insurance scheme called individual medishield policy. That policy was availed commencing from 01/03/2006 and it has been regularly renewed every year and was in effect as on 23/12/2008. That policy covered himself and his spouse up to Rs.2.00 lakhs for himself, and Rs.1.00 lakh for his wife which covered hospitalization expenses, ICU charges and other tests also. That Op No.3 is the 3rd party administrator of Ops No.1 and 2. That he underwent hospitalization treatment in Sagar Apolo Hospital from 01/10/2009 to 03/10/2009 for diagnosed disease called acute vertigo VBI, hypertension. At the time of admission to the hospital he had produced all the relevant records for treatment under cashless hospital benefit guaranteed under the policy. Ops were liable to provide him cashless treatment but he received communication from Op No.3 on 02/10/2009 informing their inability to consider his case for cashless benefit without assigning any reason. Then Op No.3 also sent communication to the hospital declining cashless facility on technical grounds and informed that hospitalization will be considered on medical and clinical ground on production of documents. That he incurred Rs.13,665/- for his treatment and made a claim with ops by enclosing all the relevant bills and documents but Op No.3 has unreasonably withheld his claim and thereby caused deficiency in their service as such has prayed for direction to Ops to reimburse Rs.13,665/-, to award compensation of Rs.25,000/- and to grant such other reliefs. <br /> <br /> 2. Op No.3 who is served with the notice of this complaint remained absent as such is set ex-parte. Ops No.1 and 2 have filed their common version through their advocate contending that mere denial of hospitalization for cash less access does not imply denial of treatment and prevent the complainant from seeking necessary medical attention and claiming for reimbursement by furnishing necessary documents and stated that the complainant is not entitled for reimbursement as the complainant has not given complete documents while seeking reimbursement. That during October 2009 they sought documents from the complainant like previous consultation slip, investigation report, duration of diabetes, duration of hypertension and past history related to many ailments duly certified from treating doctor. Such information though was sought repeatedly was not given. Therefore, claim was not settled. Contending that he has no knowledge of the complainant had given all necessary documents at the time of admission to the hospital has stated that facility of cashless treatment was denied on technical ground and further reimbursement was not given for non production of documents and therefore by denying other allegations have prayed for dismissal of the complaint. <br /> <br /> 3. The complainant along with the complaint has produced a copy of policy, condition of policy, copy of letter of Op No.3 denying cash less access, then a copy of letter of Op No.3 refusing to reimburse medical expenditure for want of documents with copies of bills evidencing hospital expenditure. Op No.1 and 2 have not produced any documents. Complainant and the authorized signatory of Ops 1 and 2 have filed their affidavit evidence in the course of enquiry reiterating what they have stated in their respective complaint and version. We have heard the counsel for both parties and perused the records.<br /> 4. On the above contentions, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that the Ops No.1 to 3 have caused deficiency in their service in not extending cash less facility for the treatment of the complainant and in not reimbursing his medical expenditure?<br /> 2. To what relief the complainant is entitled to?<br /> <br /> 5. Our findings are as under:<br /> <br /> Point No.1 : In the Affirmative<br /> Point No.2 : See the final order.<br /> <br /> REASONS:<br /> <br /> 7. Answer on point No.1: As we have seen from the rival contention of the parties, we do not find much dispute between the parties in connection with the issues involved in this case. Because ops No.1 and 2 have admitted that the complainant had effective medical insurance policy as on 23/12/2008 and during the treatment of the complainant for his ailment. Ops have also not denied that the complainant under the policy conditions was entitled for cashless hospital facility and if it was not granted, for reimbursement of medical expenditure. Therefore, we shall consider whether refusal by the Ops to extend such facilities was justified or not.<br /> <br /> 8. Ops have not denied that the complainant within the time provided with intend to avail cash less medical facilities applied to Ops for extending cash less facility so that he without bothering for meeting medical expenditure could come out of the hospital with that assure facility under the policy he had got admitted hospital but for misfortune the 3rd Op who had received the claim, through his letter dated 02/10/2009 refused to extend that facility for the following reasons, which is reproduced.<br /> <br /> “We have received the request for pre-authorization for the above mentioned hospitalization, we have verified the coverage terms and conditions under insurance plan. On primary scrutiny of the request we are unable to sanction cashless benefits for the said hospitalization for the following reasons. As per available information, we are unable to consider this case for cashless benefit, send all claim documents for consideration for reimbursement”.<br /> <br /> 9. Again the 3rd Op through another communication on the same day has stated that cashless facility is declined on technical ground. On perusal of these two letters we do not understand the reason for the third Op administrator for declining to extend cashless benefit. The Ops have not denied that the complainant had forwarded all requisite information and documents for pre-authorization, through the hospital, when that is not in dispute why and what made Op No.3 to decline pre-authorization is not understandable. In addition to this, Op No.3 in the second letter of that date has further stated that policy confirmation is not yet received from insurance company and therefore stated to had refused pre-authorization. This reason for denial of cashless facility is not only surprising but shocking one. Because the complainant is having insurance right from 01/03/2006 and it is being renewed from time to time and the complainant had valid policy as on the date of treatment but despite that if Op No.3 to say on 02/10/2009 that they have not received policy confirmation from Ops 1 and 2 speak on the efficiency of these Ops and cast doubt on the genuine concern of these Ops to the insured. We should bear in mind here that Ops No.1 and 2 who have issued policy from March 2006 if have failed to inform their third party administrator about eligibility of the complainant that itself is sufficient to doubt the functioning of Ops No.1 and 2 and the object of the insurance. This aspect cast doubt on co-ordination of Ops 1 to 3 in each of them keeping themselves under ignorance which cannot be visualized. Thus we find no legality or justification for the Ops in denying cash less facility and pushing the complainant to the unnecessary anxiety and tension for arranging money to get himself discharged from the hospital for which act deficiency and negligence, ops are accountable to the complainant.<br /> <br /> 10. Then coming to the Ops in not reimbursing the medical expenditure of the complainant is concerned we should bear in mind that the complainant is entitle for reimbursement of medical expenditure up to Rs.2.00 lakhs. The complainant had incurred a total expenditure of Rs.13,665/- only for his treatment. Ops No.3 who had in his early repudiation letter assured the complainant for considering the case for reimbursement has again adopted dubious method to taunt the complainant to reimburse his legal medical claim. The complainant after dischargel from the hospital made a claim for reimbursement of his medical expenditure. The 3rd Op again through his letter dated 09/12/2009 and 16/12/2009 refused to consider the claim and requested the complainant to produce the following documents.<br /> <br /> 1. All previous consultation slip and investigation records.<br /> 2. To be certified from treating doctor<br /> a) Duration of diabetes<br /> b) Duration of hyper tension<br /> c) Past history relating to many ailment.<br /> <br /> For non-production of these documents Ops have not considered reimbursement of the complainant’s claim.<br /> <br /> 11. On perusal of these letters of Op No.3 it is clear that the 3rd Op has not asked for any particulars, information or documents pertaining to treatment for which the claim is made. The complainant has categorically stated that he is enclosed all the documents and furnished all information required by the Ops for reimbursement of his money and that is not denied by the Ops, but the 3rd Op by asking these documents appears to had entertain a doubt whether this complainant had pre-existing disease and it is for that pre-existing disease, the complainant underwent treatment from 01/10/2009 to 03/10/2009. Here the Ops are again exhibited their reluctance in honouring legitimate claim of the complainant. If Ops had doubt that the complainant had any such ailment prior to the inception of the policy it is for them to lay their hands and find out whether the complainant had suppressed certain facts and obtained policy. But even for that we do not find any reasons or justification for these Ops to doubt it. Further it is too much for Ops to ask the complainant himself to produce certain documents in proof of his earlier ailment. As that is not the case of the complainant we cannot understand how he can produce such documents and the Ops can ask the complainant to produce documents against his interest. Even this act of asking for documents in respect of previous treatment of the complainant when the previous treatment was not in existence how the complainant can comply the request. This attitude of the Ops in not honouring the claim of the complainant in our view is nothing short of unfair trade practice. The Ops 1 and 2 by floating the policy received premiums but denied their liability which sends wrong message to the insured and the persons who are intending to have medical insurance. This attitude of Ops attendance shall have to be curbed by imposing punitive damages against Ops 1 and 2 besides granting substantive relief asked by the complainant. With the result, we answer point No.1 in the affirmative and pass the following order.<br /> <br /> O R D E R<br /> <br /> 1. Complaint is allowed. Ops 1 to 3 are jointly and severally are held as deficient in not extending cash less hospital facility to the complainant and therefore are ordered to pay compensation of Rs.10,000/- to the complainant.<br /> 2. Ops 1 to 3 are jointly and severally are ordered to reimburse Rs.13,665/- to the complainant and they shall also pay Rs.5,000/- towards hardship, uncertainty, tension and mental agony caused to the complainant.<br /> 3. Ops 1 and 2 are ordered to pay punitive damages of Rs.20,000/-, out which Rs.10,000/- be paid to the complainant and remaining amount of Rs.10,000/- be remitted to the legal aid account of this forum.<br /> 4. Ops 1 to 3 shall pay the amount as ordered above within 60 days from the date of this order failing which they shall pay interest @ 9% p.a from the date of this order till the date of payment.<br /> 5. Ops 1 to 3 shall pay cost of Rs.3,000/- to the complainant.<br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the Open forum on this the 25th June 2010.<br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />