By. Smt. Renimol Mathew, Member:-
The complaint is filed Under Section 12 of the Consumer Protection Act of 1986 for an Order to reimburse an amount of Rs.15,047/- to the complainant as per the terms of health insurance policy from the opposite parties with compensation and cost of the proceedings.
2. Brief of the complaint:- The complainant is the policy holder under the scheme introduced by opposite party as per the policy vide No.101601/48/11/97/00001171 dated 21.10.2011 issued from the opposite parties office. As per the terms of said policy of insurance coverage is effective from the period of 23.10.2011 to 22.10.2012. And the complainant joined and started the health insurance policy from the year 2003 onwards under the opposite party No.1 and renewing the same up to this policy without fail or breakage of insurance coverage period. The complainant's wife Nandini Devi. P. P. covered by the said policy happended to be admitted as inpatient as I.P No.362697 and underwent treatment from Baby Memorial Hospital, Kozhikode from 08.12.2011 to 16.12.2011 due to her serious ailments. As per the diagnosis of diseases from the hospital it is found that she is suffering for disease of Infectious Ezzematoid Dermatitis Secondary and fatty liver, Neurodermatis which was in acute stage at the time of admission. While admitting in hospital being the holder of said health insurance policy the complainant informed the same and asked to make claim from opposite party on usual terms through hospital office. Since the complainant is holding an effective health insurance policy not arranged sufficient amounts to meet the expenses for hospital bills expecting that policy would acted upon as agreed. It is also submitted that even though he requested for medi-calim for hospital bills as agreed in policy through Baby Memorial Hospital office and forwarded but on 15.12.2011 hospital authorities received a reply and informed the complainant that claim for complainant's wife is rejected from opposite party's third party agency Paramount Health Service Private Limited office for the reason stating that “Said procedure does not necessitate hospital management”. Due to the said situations hospital office demanded the complainant to remit the entire bills in lump sum. Hence the complainant put to untold miseries to arrange the huge amount in lump sum which has finally billed and settled for an amount of Rs.15,047/-. Due to the said acts of opposite party the complainant caused financial loss, mental agony and suffering. The said acts from opposite parties part are nothing but unfair trade practice and deficiency in service which are actionable and liable to be compensated to the complainant.
3. Thereafter complainant sent a Registered Lawyer Notice to the opposite party and third party demanding reimbursement of the said hospital bill but opposite party not send any reply or act as demanded. But at the same time third party agency send a reply notice to the complainant counsel stating that cashless access benefit does not imply denial of treatment and does not in any way prevent the insured from seeking necessary medical attention or hospitalization/claiming for reimbursement. And the patient can submit the claim papers for reimbursement after the treatment. As per the said reply the complainant directly approached and submitted another claim application with all documents before the opposite party's office on 25.01.2012. Even though the complainant submitted claim application no amount has reimbursed or any communication received so far from the opposite party till today even though complainant made several enquiries on the same. Hence filed this complaint to get relief.
4. Notice served to opposite parties. Opposite party No.1 appeared and filed version.
5. Opposite party filed version in short it is as follows:- Opposite party admitted the individual Health Insurance Policy. As per the terms of the policy, Paramount Health Service Private Limited is the third party agency to deal the claim arising under the policy. They are not impleaded in this case. The Paramount Health Service Private Limited received an admission request from the hospital for the treatment of the Smt. Nandini Devi noting the date of admission as 08.12.2011. The ailment mentioned on the admission request note was Contract Eczematous Dermatitis. Based on the nature of ailment, some more information were asked from the hospital vide letter dated 13.12.2011 by Paramount Health Services Private Limited. On receipt of the additional information, the cash less benefit was denied to the insured vide letter dated 15.12.2011. The available medical information on the admission request note and further with the additional information received, it was observed by the medical team of Paramount Health Service Private Limited, that the said hospitalization does not necessitate hospital management. Therefore the said cashless facility was denied. Though the cashless facility was denied, the insured can submit the claim documents for consideration in reimbursement. The cashless denial letter dated 15.12.2011 mentioned the following important note mentioned requirements/documents. The case can be decided expeditiously. So the claim of the complainant is not rejected, and the complaint now filed is premature and is liable to be dismissed. The claim at this stage is premature.
6. Again opposite parties submitted that the complainant is not entitled to get any amount as compensation. There is no deficiency of service on the part of this opposite party as alleged in the complaint. Thereafter as per the Order in I.A No.236/2012 opposite party No.2 impleaded and notice served to opposite party No.2 but no version filed. Hence the opposite party No.2 is set ex-parte and proceeded with the case.
7. On considering the complaint, affidavit, documents and version the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service on the part of the opposite party?
2. Relief and Cost.
8. Point No.1:- The complaint filed chief affidavit and examined as PW1. Exts.A1 to A4 documents were marked. Opposite party is examined as OPW1 and Ext.B1 marked. This complaint is filed to reimburse the hospital bill along with reasonable cost and compensation. The opposite parties contented that the admission was for the investigation only. So as per the Clause 4.11 of exclusions charges incurred at Hospital or Nursing Home primarily for diagnosis are excluded from payment under this policy. On verification of Ext.A2 document it is clear that claim for cashless benefit for hospitalization was denied for the under mentioned reason “said procedure was not necessitate hospital management”. As per clause 4.11 admission for inspection is the said procedure mentioned in the claim rejection letter. On thoughtful examination of evidence and documents we are in the opinion that the treated Doctor is the authorized person to say whether hospitalization is necessary or not. In this case the complainant was admitted in Baby Memorial Hospital from 08.12.2011 to 16.12.2011. The admission was in accordance with the direction of the consultant Doctor and investigation was done as a part of the treatment. Finally diagnised the decease as “ Contact Eczematous Dermatitis”
9. More over that in Ext.A4 it is clearly mentioned that although the cashless facility was denied, the insured can submit the claim documents for consideration in reimbursement. The cashless letter dated 15.12.2011 mentioned the following important note. “please note that the denial of authorization for cashless access does not imply denial of treatment and does not in any way prevent you from seeking necessary medical attention or hospitalization/claiming for reimbursement”. From this it is clear that the denial of cashless benefit does not imply denial of treatment. The patient can submit the claim papers for reimbursement after the treatment. As per the said reply the complainant directly approached and submitted another claim application with all documents before the opposite party's office on 25.01.2012. Even though the complainant submitted claim application no amount has reimbursed or any communication received so far from the opposite party. In this case claim and policy is admitted by both the parties and not dispute regarding that and complainant is admitted in the hospital as per the request of the consultant Doctor. So we are in the opinion that denial of cashless benefit and inordinate delay in allowing the claim from the part of the opposite party is deficiency of service. So the complainant is entitled to reimburse the hospital bill. The Point No.1 is decided in favor of the complainant.
10. Point No.2:- The Point No.1 is found in favor of the complainant. Hence the complainant is entitled to get cost and compensation.
In the result the complaint is partly allowed and the opposite party No.1 is directed to pay Rs.15,047/- (Rupees Fifteen Thousand and Forty seven) only as per the terms of Health Insurance Policy with 12% interest from 16.12.2011 till the payment. The opposite party No.2 is also directed to pay Rs.2,000/- (Rupees Two Thousand) only as cost and compensation for the proceedings. This Order must be complied by the opposite party within 30 days from the date of receipt of this Order.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 28th day of May 2014.
Date of Filing:23.05.2012.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. K. P. Bhaskaran Nair. Complainant.
Witness for the Opposite Parties:
OPW1. Naveen Palliyath. Branch Manager, United India Insurance
Company, Kalpetta.
Exhibits for the complainant:
A1. Copy of Policy.
A2. Copy of Claim Letter with forms and accompanying documents (11 Nos).
A3. Lawyer Notice with Postal Receipt and Acknowledgment Card(5 Nos).
A4. Reply Notice. Dt:12.01.2012.
Exhibits for the Opposite Parties:
B1. Individual Health Insurance Policy.
Sd/-
PRESIDENT, CDRF, WAYANAD.
