Karnataka

Bangalore 4th Additional

CC/1267/2018

Pradeep R, - Complainant(s)

Versus

The Manager, HDFC ERGO General Insurance Company Ltd., - Opp.Party(s)

28 May 2019

ORDER

Complaint filed on: 28.07.2018

                                                      Disposed on: 28.05.2019

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

 1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027    

 

 

CC.No.1267/2018

DATED THIS THE 28^th MAY OF 2019

PRESENT

 

 

SMT.PRATHIBHA R.K, BAL, LLM, PRESIDENT

SMT.N.R.ROOPA, B.A., LLB, MEMBER

 

	Complainant/s	V/s	Opposite party/s
	Pradeep.R, Aged 36 years, S/o  Renu.P, # 18, 2nd Cross, L N Reddy Garden, Kariyanapalya, St.Thomas Town Post, Bangalore-084.   In person	1	The Manager, HDFC ERGO GENERAL INSURANCE COMPANY LTD., No.25/1, 2nd Floor, Shankarnarayana Building, Building No.2, M.G.Road, Next to Raheja Tower, Bangalore-01.
		2	The Manager, HDFC ERGO GENERAL INSURANCE COMPANY LTD., 6th Floor, MBC Tower, Old No.90, New No.199, Luz Church Road, Mylapore Chennai-600004.   By.Adv.Prashant T. Pandit

SMT.PRATHIBHA. R.K., PRESIDENT

1.        This complaint is filed by the complainant against the Opposite parties (herein after called as OPs), under section 12 of the Consumer Protection Act, 1986. The complainant prays to direct the OPs to reimburse amount of Rs.15,500/- and to pay Rs.1,55,000/- as compensation.

2. The brief fact of the complaint is as under.          

            The complainant submitted that the complainant had availed a health insurance policy from the Ops Policy bearing No.2952201628336200000/1. The complainant’s father was admitted to the hospital on 21.11.2016 and obtained the treatment due to dehydration and requested for cashless treatment. The Ops have approved the claim on 24.11.2016 and discharged on 28.11.2016.

            2a.      The complainant further submitted that the complainant’s father was again re-hospitalized on the same day i.e.on 25.11.2016 as he was fainted. The complainant requested the Ops for cashless treatment on 25.11.2016. The Ops have approved the claim of the complainant.

            2b.      The complainant further submitted that during the hospitalization, his father was advised to take a CT scan and the doctor also advised to take MRI scan to get more accurate results for further treatment.  Since the CT and MRI facility was not available in that hospital, the complainant was suggested to get it done from some other diagnostic center. Hence, the complainant got the scan done from Santosh Diagnostic and Scan Center.

2c.      The complainant further submitted that during cashless documentation in the hospital, they said only CT scan amount can be claimed via hospital during the full and final settlement and they asked the complainant to send the MRI claim separately. The hospital has already sent all the original CT scan report and investigation reports to the insurance company to get the final bill settled, but the insurance company has intentionally put the claim on hold to delay the payment of Rs.15,500/- as a CT scan amount of Rs.4,500/-, MRI scan amount of Rs.5,000/- and daily cash benefit of Rs.6,000/-.

            2d.      The complainant further submitted that there were no original documents in the hospital. Hence, the photocopy of the CT scan report was sent to the OP Insurance Company for their reference, but they refused to accept the photocopy and also they started asking irrelevant reports from the complainant which clearly shows their intention is to delay the payment or to avoid making the payment for CT scan. Hence, the complainant has filed this complaint.

            3.        The notice was issued to the Opposite Parties. The Opposite Parties have appeared and filed their version by denying the contents of the complaint filed by the Complainant.   The Ops submitted that the complainant alleged that total hospital bill for treatment during 25.11.2016 to 30.11.2016 was raised for Rs.19,900/- and further alleged that total amount to be reimbursed is Rs.15,500/-.  

            3a.      The Ops further submitted that the Ops have settled the cashless claim of the complainant for Rs.14,590/-. The Ops have sent a communication to the complainant on 18.2.2017, 25.2.2017, 7.3.2017 and 7.4.2017 requesting to produce the documents i.e.CT scan report and investigation bills towards the settlement of the reimbursement bills. Inspite of several reminders, the complainant has not submitted the documents. Hence, the claim of the complainant was closed on 15.6.2017. The complaint filed by the complainant is hereby dismissed as there is no deficiency in service on the part of the Ops.  All other allegations prayed in the complaint are denied by the Ops.

4. In the course of enquiry into the complaint, the complainant and the OPs have filed their affidavit and reproducing what they have stated in their respective complaint and objections. Both parties have filed written arguments. The complainant and OPs have produced documents which were marked. We have heard the arguments of both sides and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.  

5.        Based on the above materials, the following points arise for our consideration;  

1) Whether the Complainant prove the deficiency in service on

                the part of the OPs, if so, whether he is entitled for the

                relief sought for?

 

           2) What Order?

 

6. Our findings on the above points are as under:

Point No.1: In the affirmative

 

Point No.2: As per the final order for the following

REASONS

7. POINT NO.1:      On perusal of the pleadings, objections, evidence and documents of both the parties, it is an admitted fact that the complainant had obtained health insurance policy from the Ops bearing Policy No.2952201628336200000/1. It also an admitted fact that the complainant’s father was admitted to the hospital and taken treatment during 25.11.2016 to 30.11.2016 and raised inpatient final bill amount of Rs.19,900/-. The Ops have settled cashless claim of the complainant for Rs.14,590/-.

8.        The contention of the complainant is that the Ops have settled the inpatient final bill amount except CT scan amount of Rs.4,500/-. The complainant further submitted that the Ops have advised to resubmit one more claim for CT scan, MRI scan and daily cash benefit. Hence, the complainant had submitted a claim regarding CT scan amount of Rs.4,500/- and MRI scan amount of Rs.5,000/- and daily cash benefit of Rs.6,000/-.  The claim of the complainant was closed on 15.6.2017 for non-submission of documents. In this regard, the complainant has produced claim form/Ex-A1, inpatient final bill/Ex-A9 and repudiation letter issued by the OP. On perusal of the repudiation letter Ex-B6 dt.15.6.2017 which reads as hereunder:

With reference to the above mentioned claim and deficiency letter sent to you on 1.5.2017 (first letter date), 16.5.2017 (1^st Reminder letter date), 31.5.2017 (2^nd Reminder letter date) and 15.6.2017 (Final Reminder letter date) in which we have asked for following documents/information

Inadequate query reply received: Kindly provide 1) CT report dt.29/11 (Only MRI report in enclosed) (2)  Original bills against investigation bills (radiology)

We regret to inform you that the above mentioned documents have not been received by us in spite of reminders sent to you, till date. Due to non-submission of above said documents, we are constrained to consider your claim as closed.

Kindly quote the Claim Control Number (CCN) for any future correspondence regarding this claim.

The Ops have submitted that they have sent a communication to the complainant on 18.2.2017, 25.2.2017, 7.3.2017 and 7.4.2017 requesting to produce CT scan report and investigation bills for the settlement of the reimbursement. Inspite of several reminders, the complainant has not submitted the above said documents. Hence, the claim of the complainant was closed. Admittedly, the complainant had produced inpatient final bill/Ex-A9 which includes CT scan abdomen report. However, the total bill was Rs.19,990/-. The OP had settled only Rs.14,590/-. Further, the complainant had produced the bill of “Santosh Diagnostic and Scan Center” dt.29.11.2016 which includes CT scan of the abdomen at the cost of Rs.4,500/-. It is evident in the inpatient final bill/Ex-A9. Thereafter, on the advice of the Ops, the complainant further resubmitted one more claim since only Rs.14,590/- was awarded. However, the Ops have repudiated the claim of the complainant only on the ground that the original bill was not produced. The complainant has produced the original bill of Santosh Diagnostic and Scan Center which was included in the inpatient final bill/Ex-A9. Since the original bill of Santosh Diagnostic and Scan Center was produced along with the final bill/Ex-A9, the complainant was unable to produce the original bill. The repudiation made by the Ops on the ground that the original bill was not produced is unsustainable. Since the CT scan report was already included in the final bill/Ex-A9, the Ops cannot once again demand for the original bill since it was already produced and the same was part of the final bill/Ex-A9. Hence, the claim of the complainant is repudiated without any just reasons which amount to deficiency of service by the OPs. On the above said discussions, it is proper to consider the claim of the complainant directing the Ops to settle the claim of the complainant in a sum of Rs.15,500/-.  Further with regard to the compensation is concerned, we come to the conclusion that the Complainant is entitled for an amount of Rs.15,500/-. If interest is imposed at 9% p.a. by way of compensation from the date of payment to till the date of realization, we hope ends of justice would meet sufficiently. Cost of litigation is fixed at Rs.10,000/-Accordingly, we answer the Point No.1 in the affirmative.

9.        POINT NO.2: In the result, we pass the following:

 

 

ORDER

The complaint filed by the Complainant is allowed. The Ops are directed to pay an amount of Rs.15,500/- to the complainant along with interest at 9% p.a. from the date of claim form i.e.30.11.2016 to till the date of realization. Further, the Ops are directed to pay an amount of Rs.10,000/- being  cost of the litigation.

The Ops are directed to comply this order within 6 weeks from the knowledge/receipt of this Order. Failing which, the Complainant is at liberty to take proper steps as per law.

Supply free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the open Forum on 28^th May 2019).

 

 

(ROOPA.N.R)     MEMBER

(PRATHIBHA.R.K)    PRESIDENT

 

 

1. Witness examined on behalf of the complainant/s by way of affidavit:

Pradeep.R., who being the Complainant was examined. 

 

Copies of Documents produced on behalf of Complainant/s:

 

Ex-A1	Claim form
Ex-A2	CT Scan and report
Ex-A3	MRI Scan
Ex-A4	Hospital Department documents
Ex-A5	Postal courier
Ex-A6	Payment details
Ex-A7	Ombudsman complaint
Ex-A8	Insurance policy
Ex-A9	Inpatient bill
Ex-A10	E-mail communication queries on claims

 

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

 

Aneesh Bhaskaran, Manager Legal Claims., who being the Opposite Party/s was examined.

 

Copies of Documents produced on behalf of Opposite Party

 

Ex-B1	Policy and terms and conditions
Ex-B2 – B5	Correspondence letters
Ex-B6	Letter dt.15.6.2017
Ex-B7	Withdrawal Letter
(ROOPA.N.R) MEMBER		(PRATHIBHA .R.K)       PRESIDENT