By Smt. PREETHI SIVARAMAN.C, MEMBER
1.The complaint in short is as follows:-
Complainant is a Sales Executive of Bisleri water supply. Complainant purchased one Health Insurance policy of opposite parties from them on 2022 April. Complainant had obtained the policy on 03/04/2022. While complainant contacting the executive of opposite parties, they explained the different schemes of opposite party’s Group Health Insurance Policy and they assured to complainant that they will provide cashless treatment to complainant when he admitted to any of the hospitals listed by them in the list of hospitals for more than 24 hours. Moreover they assured that if complainant had admitted in the hospital where opposite parties not listed in their list of hospitals, then they will reimburse the full amount which complainant had paid as hospital bill. As per the assurance given by the executive of opposite parties, complainant propose a Medi Claim Insurance Policy and complainant‘s friend Rahees paid the amount of Rs.6,232/-through e-payment to the bank account of opposite parties on 04/04/2022. The above said insurance policy covers Rs.5,00,000/- as medical insurance and complainant paid Rs.6,232/- as premium of the above policy and tax. Thereafter one person from opposite party insurance company approached complainant for verification and after verification complainant got the certificate and other letters regarding the insurance policy on 30/04/2022 by post. The details of the above said policy is master policy No. 71-20-00040-01-00, GHI –BT-22-2000583 which provides a personal insurance coverage to complainant from 04/04/2022 to 03/04/2023.
2. On 14/07/2022 complainant had fallen down from the staircase of his house and his knee joint of right leg had a fracture and he approached an Ayurvedic expert for treatment. But pain of his leg has not subsidised, hence on 22/07/2022 he approached Dr. Rajanish of Baby Memorial Hospital, Kozhikode and as per his direction he had taken an MRI scan of his right knee and it is revealed that there is fracture on the meniscus of knee and doctor advised for a surgery.
3. Before admitting the hospital for surgery, complainant approached the insurance section of the said hospital and showed his health insurance policy and requested for the cashless scheme of treatment. Thereafter he had signed so many forms and papers for cash less treatment as per the direction of hospital authority and they sent that forms to opposite parties .Then hospital authority told to complainant that the approval will sanctioned by opposite parties within one week and complainant can take admission for surgery in the hospital as per the approval sent by the opposite parties. Thereafter one agent of opposite parties from Ernakulum approached the complainant and enquired about the surgery and other details of complainant and he told to complainant that the cash less claim of complainant will surely approved and directed the complainant to take the necessary steps for surgery.
4. As per his direction complainant admitted Baby Memorial Hospital, Kozhikode on 29/07/2022 and surgery done on 30/07/2022 and he was discharged from the hospital on 02/08/2022. But he did not get the benefit of cash less claim offered by opposite parties and he paid the full amount at the hospital. Thereafter, hospital offered to complainant that, if they got the amount of cash less claim of complainant, they will repay the amount to complainant. For settling the bill of the hospital, complainant had taken a loan from Bajaj Finserv, Private Finance Company and he is paying Rs.12,000/- per month for a period of 8 months. But complainant did not get the claim amount from opposite parties yet. When complainant called the opposite parties for enquiring about the claim amount, they always saying that claim is in ‘’processing ‘’. Then complainant approached the hospital insurance section, he realised that his claim was not approved by opposite parties and they sent a letter to hospital stating that the claim is not eligible for approval. Complainant was expecting the claim amount for settling the matter, then opposite party No.2 sent the claim repudiated letter to the hospital on 01/08/2022. Complainant alleged that, opposite party repudiated the claim of complainant because complainant has pre-existing diseases. But that allegation is not true. Moreover opposite parties did not sent any letter to complainant to inform him that his claim is repudiated and the reason for repudiation But they sent the letter to hospital. It is clear deficiency in service and unfair trade practice from the side of opposite parties.
5. The prayer of the complainant is that, he is entitled to get Rs. 1,52,000/-, the amount he had spent for surgery and other treatment at hospital with 12% interest from the date of filing of complaint, Rs. 30,000/- as compensation on account of deficiency in service and unfair trade practice on the part of opposite parties and thereby caused mental agony, physical hardships and sufferings to the complainant and Rs. 10,000/- as cost of the proceedings.
6. On admission of the complaint notice was issued to the opposite parties and notice served on them and they did not turn up. Hence opposite parties set exparte.
7. In order to substantiate the case of the complainant, he filed an affidavit in lieu of Chief examination and the documents he produced were marked as Ext. A1 to A5 series. Ext.A1 is the copy of Group Activ Health - Certificate of insurance. Ext.A2 is the copy of discharge summary issued from Baby Memorial hospital, Kozhikode to complainant dated 02/08/2022. Ext.A3 is the copy of claim form for Cash less hospitalisation for Health Insurance Policy. Ext.A4 is the copy of repudiation of cash less claim letter issued by opposite parties to complainant dated 01/08/2022. Ext. A5 series are the copies of Inpatient bills.
8. Heard the complainant and perused the affidavit and documents filed by complainant. The allegations against opposite parties are proved by the unchallenged evidence of complainant. There is no contra evidence in this matter. Moreover complainant produced five documents which are very supportive to prove his case. Complainant had fallen down from the stair case of his house and had fracture at his knee joint on 14/07/2022 and his surgery conducted on 30/07/2022 and he was discharged on 02/08/2022 which is during the policy existing period. Complainant’s Health insurance policy valid from 04/04/2022 to 03/04/2023. Complainant submitted all the relevant documents for its treatment before the Commission. So we are on the opinion that complainant may have submitted all the documents before the insurance company for cash less approval. Insurance Company without any reason rejected the cash less claim of complainant . As per the documents from Baby Memorial hospital it is seen that complainant admitted for surgery on 29/07/2022 and he was discharged on 02/08/2022. Complainant fell down from the stairs on 22/07/2022 and Dr. Rajanish clearly stated in the treatment plan and doctor’s instruction that “fall from stairs’’. The treatment bills also submitted by the complainant before the Commission. So rejection of cash less claim is a deficiency in service and unfair trade practice from the side of opposite parties. Hence the Commission finds that there is deficiency in service and unfair trade practice on the part of the opposite parties as alleged in the complaint. Hence complainant is entitled to get the amount spent by him for his treatments and compensation and cost. Hence we allow this complaint holding that opposite parties are deficient in service.
9. We allow this complaint as follows:-
- The opposite parties are directed to pay Rs.1,46,945/-(Rupees One lakh fourty six thousand nine hundred and fourty five only) to complainant , the amount he had spent for his treatments with 12% interest from the date of order.
- The opposite parties are directed to pay compensation of Rs.1,00,000/-(Rupees One lakh only) to the complainant on account of deficiency in service on the part of opposite parties and thereby caused mental agony, physical hardships and sufferings to the complainant.
- The opposite parties are also directed to pay Rs.10,000/-(Rupees Ten thousand only) as cost of the proceedings.
If the above said amount is not paid to the complainant within 30 days from the date of receipt of copy of this order, the opposite parties are liable to pay the interest at the rate of 12% per annum on the said amount from the date of receipt of the copy of this order till realisation.
Dated this 19th day of July , 2023.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A5
Ext.A1 : Copy of Group Activ Health - Certificate of insurance.
Ext.A2 : Copy of discharge summary issued from Baby Memorial hospital, Kozhikode
to complainant dated 02/08/2022.
Ext.A3 : Copy of claim form for Cash less hospitalisation for Health Insurance Policy. Ext.A4 : Copy of repudiation of cash less claim letter issued by opposite parties to
complainant dated 01/08/2022.
Ext. A5 : Series are the copies of Inpatient bills.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Nil
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
