By Sri. MOHANDASAN.K, PRESIDENT
Complaint in short is as follows:-
1. The complainant is a senior citizen aged 64 years with Robust Health and doing agricultural works and was earning bread for his family. Son of the complainant Mr. Vivek Mathew was a software engineer and employed in Wipro Limited and was working at Bangalore campus. During 2016 son of the complainant availed a Health Insurance policy of Untied India insurance company limited covering insurance benefits from 01/12/2016. As per the policy the parents of the primary beneficiary Vivek Mathew was also covered and they were also entitled to cashless facility for any medical treatment during the period. As per the policy, the policy was issued in the name of Wipro Limited and the primary beneficiary was Vivek Mathew and the employee ID 361733 and insurance member ID was 361733. The Medi assist ID number was 4018772396. The above insurance policy was regularly renewed with second opposite party. The opposite parties promptly collected premium from the primary beneficiary Vivek Mathew. The second opposite party issued policy No. 0703002818P112046827 covering the liability of primary beneficiary Vivek Mathew and his dependents including parents. At the time of colleting the premium the second opposite party under to cash less medical treatment facility to primary beneficiary Vivek Mathew and his dependents including parents. The primary beneficiary had remitted the premium believing the assurance of the second opposite party.
2. The complainant was admitted to Baby Memorial hospital with chest discomfort associated with Sweating and one episode of vomiting. The complainant subjected to several investigation procedures including angiogram and the investigation revealed coronary artery diseases acute inferior wall stimi left main with two vessel disease the complainant was managed with dual anti platelets, statins, angioplasty, and the petitioner was discharged from Baby Memorial hospital on 19/10/2019 with advice to continue regular treatment as outdoor patient. The complainant is undergoing regular treatment for heart disease and also other co morbidity diseases including CA.
3. Soon after the admission at Baby Memorial hospital Kozhikode intimation were given to the opposite parties and the claim was registered as cashless claim refer No.99329418 and as per the request of the opposite parties the primary beneficiary submitted claim form duly filed and signed by the cardiologist doctor John.MD, DM, FSCAaI, FESL, FACL, Senior consultant department of cardiology, Baby Memorial hospital limited Kozhikode. The claim form contains declaration by the hospital also. In short, the son of complainant had submitted all the relevant documents with the opposite party and expected the complainant can enjoy the benefit of cashless medical treatment. But the opposite parties protracted the settlement of claim beyond all reasonable limits. The son of the complainant and also his employer made several attempts to clarify the situation and made several representations through online. The opposite parties were not prepared to see the grievance of the complainant despite all the treatment records the opposite parties repudiated the genuine claim assigning totally false reasons on flimsy grounds and denied the benefit of cash less treatment facility to the complainant. The treated doctor issued medical certificate and stated that the complainant was suffering this disease from 05/10/2019 and there was no past history of illness and also certified that the present ailment is not a complication of any pre existing ailment and the ailment mentioned in the certificate is not a congenital in nature.
4. The complainant submitted that he had to spend 3,00,000/- rupees to this treatment and due to the deficiency of service of the opposite party he had to make arrangements for clearing the medical bills at the hospital and he was driven pillar to post in search of money. Due to the act of opposite party complainant on started to avail a loan and had incurred huge loss by way of interest. The complainant also submit that he had suffered mental agony and pain due to the action of the opposite party and so the claim is to pay compensation of Rs.5,00,000/- and also to pay treatment expense of 3,00,000/- rupees.
5. On admission of the complaint notice was issued to the opposite parties and on receipt of notice the second opposite party entered appearance and filed version denying the entire averments and allegations in the complaint. According to opposite party the complainant is legally not maintainable, devoid of merits and is liable to be dismissed with cost. The first opposite party did not entered appearance and so set exaprte.
6. The second opposite party admit that the son of the complainant had approached through M/s Wipro limited and requested to issue “WT , BPS, KSA, parents, standard policy , group health policy” for 70% share of the liability and the second opposite party had issued the policy conditions of the above policy and son of the complainant had accepted the policy conditions of the above policy and subsequently remitted the policy premium and issued the policy number 0793002818P112046827 for the period commencing form 01/12/2018 to 30/11/2019 for 70% of the liability and the liability of the opposite party is subject to the terms, conditions, exemptions and limitations of the policy . The opposite party submitted that Eco Tokyo general insurance company limited also jointly issued the above said group health policy in favor of son of the complainant and 30% share of the liability is accepted the above insurance company and the above insurance company is a necessary party in the above proceedings for fair disposal of the case and the present complaint is bad for non-joinder of necessary party.
7. The opposite party submitted that the complainant had admitted at Baby Memorial Hospital Calicut on 05/10/2019 due to “Atherosclerotic heart disease of native coronary artery without angina pectoris “and was discharged on 09/10/2019 and on receipt of the claim document, the claim was reviewed by team of panel doctors and they were with the opinion that the claim should be investigated and accordingly investigation was conducted. The opposite party submitted that claim under health insurance policies is dealing by third party administrators’ company (TPA), holding IRDA licese to perform as third-party administrators. The second opposite party forwarded the claim to Medi Assist insurance TPA private Limited, Bannerghatta Road Bangalore. The claim of the complainant was for cashless claim vide claim No.99329418/99329417 for an amount of 2,02,949/-and on scrutiny. The panel of documents raised certain queries on different dates. On 07/10/2019 requested the complainant to enclose treatment details, enclose investigation report supporting diagnosis and enclose the first consultation paper with exact duration of ailment from the treating doctor and on 08/10/2019 requested the insured to enclose ECG /Echo report along with assessment sheet, the patient is K/C/ DM,HTN and DLP and enclose all previous consultation papers treatment for the same along with duration of the same , old reports and on 10/10/2019 requested the insured that the patient is K/C/O DM, HTN and DLP since three months and enclose consultation papers lab report prior to three months as mandatory to process the case and on 12/10/2019 requested the insured as the same above and requested again on 12/10/2019 to the insured that the initial assessment sheets and case papers for further process of the claim and on the same day sent another request as per prescription dated 11/06/2019 along with exact duration of DM, HTN and DLP and old reports and mandatory to process the claim and on the same day the same request was repeated to the insured and informed that the claim will be denied due to none submission of the same .
8. The opposite party submitted that the claim was repudiated due to non-submission of relevant documents such as details of discharge summary with full pages, the correct duration of HTN and DM, with all consultation papers and investigation reports, detailed case history of patient having previous consultation notes with details of previous clinical findings, history patient details from the time of first diagnosis, certified copy of the operation theater notices and with place and attested copy of the Indore case papers. The opposite party further submitted for the none receipt of the documents; several reminders were sent to the insured and due to none submission of the requested documents the claim was not admitted as per clause 5.6 of the policy condition. The above clause of policy condition says that “ the insured person shall obtained and furnished the TPA with all original bill receipts and other documents upon which a claim is based and shall also give the TPA / company such additional information and assistance as the TPA / company may requiring in dealing with claim ”. It is also submitted by the opposite party that the insured / complainant can submit the documents and for submission of the above documents, as per the quarry / request letter dated 04/11/2019, the opposite party will re-open the claim and asses the same. The opposite party submitted the discharge summary issued from Baby Memorial hospital Kozhikode says that the complainant is aged 64 years, male, a known case of Systemic Hypertension, Type II diabetes mellitus and dyslipidemia was admitted with complaints of chest discomfort associated with sweating and one episode of vomiting. The insured was informed the opposite party that the symptom of the above disease was primarily identify for the first time on 11/06/2019 and the insured / complainant is not willing to submit the previous documents for treatment before the opposite party and so the non production of the requested documents before the opposite party. The opposite party submitted they have got right to repudiate the claim.
9. The submission of the second opposite party is that they have issued the policy condition and the compliant had verified the same and thereafter accepting the conditions remitted the policy premium. Subsequently the second opposite party issued the policy certificate. The submission of the opposite party is that the complaint is filed only for experimental basis and the complainant is not eligible for the compensation as claimed. It is submitted that there is no deficiency in service on the part of the opposite party and so the complaint deserves dismissal with cost
10. The complaint and opposite party filed affidavit and documents. The documents on the side of complainant marked as Ext. A1 to A4. Ext. A1 is copy of voluntary parental insurance policy. Ext. A2 is discharge summary issued from baby Memorial hospital Kozhikode dated 09/10/2019. Ext. A3 is copy of treatment certificate issued by treated doctor. Ext. A4 is copy of communication between the insured and insurer. The opposite party documents marked as Ext. B1 and B2. Ext. B1 is policy copy for the period 01/12/2018 to 30/11/2019 with policy No.0703002818P112046827. Ext. B2 is copy of letter regarding repudiation issued by the insurer to the insured.
11. Heard the complainant and opposite party, perused affidavits and documents. The following points arise for the consideration:
- Whether there is deficiency in service on the part of the opposite party?
- Relief and cost
12. Point No.1and 2
It is an admitted fact that the complainant has got insurance coverage as per the policy Ext. B1 document issued by the second opposite party. There is no dispute that the complainant had undergone treatment at Baby Memorial Hospital Kozhikode as per Ext. A2 document. He was admitted in the hospital on 05/10/2019 and treated there as inpatient up to 09/10/2019. He was diagnosed that coronary artery disease acute inferior wall stimi, left main with two vessel disease, S/P PRIMARY PCI To RCA WITH DES (05/10/2019), STGED PCI TO LMCA >LAD (07/ 10/2019) FAIR LV SYSTOLIC FUNCTION, TYPE –2 DIABETES MELLITUS, SYSTEMIC HYPERTENSION, DYSLIPIDEMIA. The clinical history noted that the 64-year-old male a known case of Systemic Hypertension type 2 diabetes mellitus and dyslipidemia was admitted with complaints of chest discomfort associated with sweating and one episode of vomiting. The complainant herein submitted all the treatment records for cashless facility through his son, the insured. But the opposite party repudiated the claim containing want of treatment records. The contention of the opposite party is that there is a reference in clinical history that the complainant is a known case of systemic Hypertension, type 2 diabetic mellitus. The opposite party contended that the complainant had submitted his compliant was detected on 11/06/2019 and so the treatment records for the same and the history of treatments are required for the consideration of claim of the complainant. But on the other hand the complainant submit that he had never undergone for any treatment as alleged by the opposite party in the matter. The second opposite party considering the health claims through the first opposite party Medi assist insurance and they had issued several notices to the complainant producing the treatment records of the complainant. The version 4th paragraph and in affidavit also the 4th paragraph detailed the demands placed by the first opposite party before the complainant about the documents. They issued notices demanding documents on 07/10/2019, 08/10/2019, 10/10/2019, 12/10/2019 and so on. The demand of the first opposite party for the consultation papers prior to 11/06/2019 along with exact duration of DM, HTN and DL P and old reports which are according to them mandatory to process the claim. But the complainant could not produce the same the specific contention of the complainant is that they have not undergone any treatment prior to the admission at baby memorial hospital as stated in Ext. A2 so they are unable to produce the document as demanded by the opposite party. It is evident that the documents produced as A4 series and B2 series regarding the treatments as well as the communications between the insured and the insurer that almost all available treatment records have been produced by the complainant before the opposite party. So, it cannot be treated as a case of none production of documents which are available with the insured and the complainant. But the opposite party insisted for the documents which are really not existence. The perusal of the documents shows that the symptom of the ailment was entitled but no medical check was done by the complainant and so there is no document to produce as demanded by the opposite party. In effects the communication between the insured and the insurer appears a sort of searching black cat in dark room. The attempt of the second opposite party to evade the genuine claim of the complainant contenting baseless averments and demanding which cannot be realized. Hence it is right to hold that the act of the opposite party is deficiency in service and the complainant entitled to insurance coverage as per policy.
13. The claim of the complainant is to reimburse the medical expenses submitted before the opposite party as per the policy coverage. The prayer is to allow three lakh rupees as medical expenses and also 5,00,000/- rupees as compensation on account of deficiency in service on the part of opposite party. The opposite party filed version contenting that as per the policy 75% is the share of the liability of the second opposite party and that is subject to the terms, conditions, exemptions and limitations of the policy. It is also contended that Eco Tokyo General Insurance company limited is also a necessary party in the proceedings since they jointly issued the above said group health policy in favor of the policy holder undertaking 30% share of the liability. But the complainant has not taken steps to implead the said Eco Tokyo General Insurance Company limited in the proceedings. There is no document before the commission to peruse the condition of the liability among insurance companies. It was proper on to implead the Eco Tokyo General insurance company limited as party in the proceedings since there is a contention for the second opposite party. In such situation it appears to find the liability of the second opposite party is up to 70% of the insurance amount. The opposite party submitted that as per the claim of the complainant the amount shown is 2,02,949/- rupees. If the contention of the second opposite party regarding liability is admitted it will be Rs.1,42,064/-. Hence the commission finds that the second opposite party is liable to pay Rs.1,42,064/- that is 70% of the claim amount submitted by the complainant before the opposite party. Though the complainant had prayed for an amount of Rs.3,00,000/- towards the treatment expenses no document has been produced. It is also to be noted that the complainant was admitted in the hospital on 05/10/2019 and treated as inpatient in the hospital up to 09/10/2019. As per the terms of the policy the policy holder is entitled for cashless treatment. But in this complaint the right of the complainant has been denied by the opposite party contenting non production of documents which are in effect not in existence. The opposite party failed to establish the complainant had undergone treatment for the ailment prior to the admission before Baby Memorial hospital on 05/10/2019. Hence, we find there is no justification for the denial of the insurance by the opposite party and so the opposite party is liable to pay interest as well as compensation in favor of complainant. The complainant prayed 5,00,000/ rupees as compensation for the deficiency in service on the part of opposite parties. It appears as fabulous amount without any justification. We find 1,00,000/- rupees will be a reasonable amount as compensation on account of deficiency in service on the part of opposite party. In the light of above fact and circumstance the commission allows the complaint as follows:-
- The opposite parties are directed to pay Rs.1,42,064/- to the complainant towards the treatment expenses with interest at the rate of 12 % per annum from 09/10/2019 till realization.
- The opposite parties also directed to pay Rs.1,00,000/- as compensation on account of deficiency in service and thereby caused inconvenience hardship financial loss and mental agony to the complainant.
- The opposite parties are directed to pay Rs.10,000/- as cost of the proceedings to the complainant.
The opposite party shall comply this order within one month from the date of receipt of copy of this order, failing which the above said entire amount will carry interest @ 9% per annum from the date of filing this complaint till realization.
Dated this 2nd day of August , 2022.
Mohandasan K., President
PreethiSivaraman 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.A1 to A4
Ext.A1: Copy of voluntary parental insurance policy.
Ext.A2: Discharge summary issued from baby Memorial hospital Kozhikode dated
09/10/2019.
Ext A3: Copy of treatment certificate issued by treated doctor.
Ext A4: Copy of communication between the insured and insurer.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 and B2
Ext.B1: Policy copy for the period 01/12/2018 to 30/11/2019 with policy
No.0703002818P112046827.
Ext.B2: Copy of letter regarding repudiation issued by the insurer to the insured.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
VPH
