D.O.F:27/06/2017
D.O.O:18/10/2021
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.131/2017
Dated this, the 18th day of October 2021
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
Abdul Mansoor.C.T
S/o Late. Haji. C.T.Abbas Kutty,
Ifan, Post.Vidyanagar : Complainant
Kasaragod Taluk – 671123
(Adv: George John Plamoottil)
And
1. The manager,
Appollo Munich Health Insurance
Company Ltd, 2nd and 3rd Floor,
ILABAS Centre, Plot No. 404-404,
Udyog Vihar, Phase III,
Gurgaon – 122016,
Haryana
: Opposite Parties
2. The Manager,
Canara Bank,
Vidyanagar Branch
ORDER
SRI.RADHAKRISHNAN NAIR.M : MEMBER
The complaint is filed under section 12 of the Consumer Protection Act, 1986 ( as amended)
The facts of the case in brief is that the complainant and his family members are insured with Opposite Party No.1 through Opposite Party No.2 as per the Medi claim policy No. 120 100/12001/2015/4004032/132. The complainant's wife and 4 children are covered by the policy. The policy started on 5.3.2015 and renewed every year up to 2018. Mrട. Fousia, the wife of complainant was admitted in Dr. Paul's Hospital at Kaloor for checkup and underwent a surgery. She had no past history of any diseases. She was admitted on 31.08.2016 and discharged on 01.09.2016 .At the time of admission the complainant furnished the details of health policy. So the claim petition for the bill amount of Rs.1,59,809/- was moved from the hospital to the Opposite Party No. On18.09.2016 the Opposite Party No.1sent a letter to the complainant to submit a passport size photograph, biopsy report, and certificate from doctor and accordingly the complainant furnished all the documents. But the proposal for the cashless facility was rejected by the Opposite Party No.1, without any valid reason.
Inspite of a valid insurance policy, the complainant was put to great trouble
of arranging a huge amount of Rs.1,59,809/- to get discharge from the hospital.
The denial of insurance benefit by the opposite party amounts to gross negligence and service deficiency due to which the complainant suffered great mental agony apart from monetary loss.
The opposite party is to compensate for the loss and sufferings experienced
by the complainant. Hence the complaint is filed for an order directing the opposite party to pay the hospital expence of Rs.1,59,809/-with interest and also Rs.1,00,000/- as compensation and cost.
The opposite parties entered appearance and filed written Version. As per the version of the OP No.1, the main contesting opposite party, the complaint is false frivolous vexatious and maintainable. The Opposite Party No.1 admitted the Policy and the hospitalization of the complainant. It is also admitted that, they received the request for cashless treatment from the Hospital. But they denied that the expense incurred was Rs.1,59,809/-
The complainant obtained Policy by suppressing the past ailment of his wife. On receiving the claim they sent letters to the complainant seeking additional documents but not received. The wife of the complainant had undergone some surgeries recent past and therefore Opposite Party No.1 sought for biopsy report, discharge summary / treatment records etc. along with certificate from doctor. But the complainant had only furnished biopsy report and willfully with held other documents sought for. Hence owing to non compliance of the requested documents the claim was rejected. The insurance is a contract and the Opposite Party No.1 are liable on the basis of the terms and conditions, Iimitations and exclusions of the policy.
The denial of cashless facility does not amount to service deficiency. There is no service deficiency on the part of the opposite party and the complainant is not entitled for any relief and the complaint is liable to be dismissed.
The Complainant filed proof affidavit in lieu of chief examination and documents
Ext. A1 to Ext. A 6 are marked. The Ext - A1 is the Certificate of Insurance. Ext - A 2 is the Closer letter dated 08-11-2016 issued by the Opposite Party, Ext A3 is the Discharge Summary issued by Dr. Paul's Hospital dated 01-09-2016 Ext. A 4 is the Histopathology report dated 10. 9.2016 issued by Lake shore Hospital. Ext. A 5 is the letter issued by the opposite party, Ext. A 6 is the rejection letter dated 12.05.2017 issued by opposite party. The complainant was Cross -examined as PW-1
The opposite party didn't adduce any oral evidence but produced certain documents, which are marked as Ext. B 1 to Ext. B3 ( Series). Ext.B1 is the Enrolment Form, Ext. B2 is the Certificate of insurance. Ext.B3 (Series) are the Query letters issued by Opposite Party No.1 to the complainant.
Based on the pleadings and evidence of the rival parties in this case the following
issues are framed for consideration.
1. Whether there is any service deficiency on the part of any of the opposite party ?
2. If so, what is the relief?
For convenience, both these issues are considered together.
Here the specific case of the complainant is that the complainant and his family members are insured with Opposite Party No.1, through Opposite Party No.2 as per the Medi claim policy No. 120 100/12001/2015/4004032/132. The wife and 4 children are covered by the policy. The policy started on 5.3.2015 and renewed every year up to 2018. Mrട. Fousia, the wife of complainant was admitted in Dr. Paul's Hospital at Kaloor for checkup and underwent a surgery . She had no past history of any diseases. She was admitted on 31.08.2016 and discharged on 01.09.2016.
At the time of admission the complainant furnished the details of health policy. So the claim petition for the bill amount of Rs.1,59,809/- was moved from the hospital to the Opposite Party No.1 . On 18.09 2016 the Opposite Party No.1 sent a letter to the complainant to submit a passport size photograph, biopsy report, and certificate from doctor and accordingly the complainant furnished all the documents . But the proposal for the cashless facility was rejected by the Opposite Party No.1, without any valid reason.
Inspite of a valid insurance policy, the complainant was put to great trouble
of arranging a huge amount of Rs.1,59,809/- to get discharge from the hospital.
The denial of insurance benefit by the opposite party amounts to gross negligence and service deficiency due to which the complainant suffered great mental agony apart from monetary loss.
The opposite party is to compensate for the loss and suffering experienced by the complainant.
As per the version of the Opposite Party No.1, the main contesting opposite party, the complaint is false frivolous vexatious and maintainable. The Opposite Party No.1 admitted the Policy and the hospitalization of the complainant. It is also admitted that, they received the request for cashless treatment from the Hospital . But they denied that the expense incurred was Rs.1,59,809/-.
The complainant obtained Policy by suppressing the past ailment of his wife.
On receiving the claim they sent letters to the complainant seeking additional documents but not received. The wife of the complainant had undergone some surgeries recent past and therefore Opposite Party No.1 sought for biopsy report, discharge summary / treatment records etc. along with certificate from doctor .
But the complainant had only furnished biopsy report and willfully with heldother documents sought for . Hence owing to non compliance of the requested documents the claim was rejected.
The insurance is a contract and the Opposite Party No.1 are liable on the basis on the terms and conditions, Iimitations and exclusions of the policy.
The denial of cashless facility does not amount to service deficiency. There is no service deficiency on the part of the opposite party and the complainant is not entitled for any relief and the complaint is liable to be dismissed. The opposite party No. 1 admitted the Policy and the hospitalization of the complainant's wife.
It is also admitted that they received the request for facility of cashless treatment
from Dr. Paul's Hospital.
The wife of the complainant had undergone some surgeries recent past and therefore Opposite Party No.1 sought for biopsy report, discharge summary / treatment records etc. along with certificate from doctor. But the complainant had only furnished biopsy report and willfully with held other documents sought for. Hence owing to noncompliance of the requested documents the claim was rejected.
The insurance is a contract and the Opposite Party No.1 are liable on the basis on the terms and conditions, Iimitations and exclusions of the policy.
So the cash less request was rejected. In order to check the viability of the claim complete set of the documents are required.
From the above discussion it can be seen that admittedly the complainant was having a valid insurance policy at the time of hospitalization and treatment. Ext. A1 (and Ext B2) is the Certificate of insurance which show that the complainant, his wife and 3 children were covered by the insurance policy and it was valid for the period from up to 03-03-2018. Ext.B2 is the Policy wording of Easy Health Group Insurance showing the term and conditions of the policy.
Contentions of Opposite Party is that the complainant is not entitled for getting
the insurance benefit. According to them, the denial of the cashless facility at the time of discharge from the hospital was correct.
The policy holders are entitled for insurance benefit unless their case is under exclusion clauses. Here also, the attempt of Opposite Party was to allege that the complainant’s case is under exclusion clauses. As per the Exclusion Clause attached to the policy conditions their stand is that among other things, "they will not make payment for any claim in respect of any insured person directly or indirectly for ,caused by, arising from or in any way attributable to any pre - existing condition or any complication arising from the same, after 48 months of continues coverage have lapsed, since inception of the first Easy Health policy with them unless expressly stated to the contrary to the policy. "Interestingly, the Opposite Party have not pleaded and proved that the ailment of the complainant for which he was treated would come within the list of the excluded ones. They have not adduced any evidence to prove that aspect.
The Opposite Party No.1 argue that the claim was rejected due to non production of the documents sought as per the Ext. B3 (series) letters . But the complainant's case is that he had produced all the required documents and inspite of that the claim was rejected without any justifiable reason. Therefore in the absence of any rebuttal evidence, this Commission is of the view that the complainant is entitled for the entire insurance amount claimed.
Therefore considering circumstances and available evidence in this case , this commission is of the view that the Opposite Party No.1 and 2 are liable to pay the entire hospital bill of the complainant's wife and as such there is deficiency of service on the part of Opposite Party No.1 and 2 in denying the cashless facility at the time of discharge from the hospital, due to which the complainant suffered several hardships
The Opposite Party No.1 and 2 are liable to compensate for the mental agony and sufferings .
ln the result , the complaint is allowed and the Opposite Party No.1 and 2 are directed to pay the entire claim amount of Rs.1,59,809/- to the Complainant with 8% interest per annum from 27.06.2017,the date of complaint till payment. The opposite parties are also directed to pay Rs.15,000/-(Rupees Fifteen thousand only) towards compensation and Rs.5,000/- (Rupees Five thousand only), towards the costs.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Certificate of insurance
A2- closure letter
A3- Discharge summary
A4- Histopathology Report
A5- Query letter
A6- Rejection letter
B1-Enrolment form
B2- Certificate of insurance
B3- Query letters
Witness Examined
Pw1- C.T Abdul Mansoor
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
