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.44,672/- 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. Then 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 happened to be admitted as inpatient as I.P. No.370932 and underwent treatment from Baby Memorial Hospital, Calicut from 08.03.2012 to 17.03.2012 due to his serious ailments. As per the diagnosis of diseases from the hospital it was found that “Third Degree Haemorrhoids Hypertension”. 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 to meet the same as cashless claim. Since the complainant is a pensioner holding an effective health insurance policy not arranged sufficient amounts to meet the expenses for the hospital bills. Also the complainant submits that even though he requested for medi-claim for hospital bills as agreed in policy through Baby Memorial Hospital office and forwarded, but on 15.03.2012 hospital authorities received a reply and informed the complainant that claim for complainant rejected from opposite party's third party agency, Paramount Health Service Private Limited office for the reason stating that “The prognostic outcome of medical mgnt in asurgical case is not appreciable, pre-operative stay and evaluation is not covered under cashless, claim is declined for cashless at this juncture in view of the same and requested to send fresh request for actual admission for surgery”. Due to the said situations complainant was forced to pay the bill amount of Rs.44,672/-. According to the complainant he is entitled for entire claim as offered and assured by opposite party. The denial of cashless benefit from the part of the opposite parties are to escape from the real liability. The complainant alleges that these act of opposite parties are nothing but unfair trade practice and deficiency of service.
3. Thereafter the complainant directly approached and submitted another claim application with all documents before the opposite parties office on 03.03.2012. 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. Notices served to opposite parties. Opposite party No.1 appeared and filed version.
5. Opposite party No.1 filed version in short it is as follows:- Opposite party admitted the individual Health Insurance Policy and claim. 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 were not impleaded in this case. They are the necessary party in this case and without impleading them, the petition is not maintainable. Again opposite party submitted that Paramount Health Service Private Limited has scrutinized the claim documents of the complainant and they observed that some more documents are required for considering the claim and they have sent a letter dated 18.04.2012 asking the complainant to submit the further documents. The claim is submitted on a belated stage and it is requested to the complainant to submit letter stating the reason for the delay in submission of claim documents required. Also requested to give advance and balance payment receipt of hospital bills and all the original investigation reports required for which bills submitted. And also details item and cost wise break up of consumable and disposable Rs.1,500/- required for which charged in final hospital bill. The above requirements are vital to decide the admissibility of the claim and the party is liable to submit the same. Thereafter a reminder also sent on 05.05.2012. The party has not complied so far and at last the claim was closed due to non fulfillment of deficiency of the above said document on 05.07.2012 by Paramount Health Service Private Limited, the above case was closed and not rejected. Once on receipt of the above mentioned requirements/documents the case can be decided expeditiously. So the claim of the complainant is not rejected and the complainant now filed is premature and is liable to be dismissed. The claim at this stage is premature. According to opposite party 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.
6. Thereafter as per the Order in I.A No.237/2012 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 complainant filed chief affidavit and examined as PW1, Exts.A1 and A2 series were marked. Ext.A1 is the copy of the Health Insurance Policy. Ext.A2 series are the true copies of the claim letter with forms and accompanying documents. Opposite party No.1 is examined as OPW1. This complaint is filed to reimburse the hospital bill along with reasonable cost and compensation. The opposite party denied the cashless benefit, again complainant submitted another claim form with documents on 30.03.2012 in opposite party's office but they were not allowed the claim. According to complainant he submitted all the hospital bills and related documents to opposite parties along with claim form. The opposite party admitted the claim and insurance coverage during the admission period and opposite party stated that the third party agency that is the Opposite party No.2, on scrutiny of the claim documents, it is observed that the following documents/information were asked vide deficiency letter dated 18.04.2012 followed by the reminder on 15.05.2012 but still documents are not received. (1). A letter from the insured stating the reason for the delay submission of claim documents. (2). Require advance and balance payment receipt of hospital bills. (3). All original investigation reports required for which bill submitted. (4). Details item and cost wise break up of consumable and disposal of Rs.1,500/- required for which charged in final hospital bill. The above requirements are vital to decide admissibility of the claim. At last the claim was closed due to non fulfillment of deficiency of above said documents on 05.07.2012. The claim is closed and not rejected. Once on submission of the above mentioned documents/requirements, the claim can be decided expeditiously. The complainant denied all these contention in the witness box and complainant submitted that he had produced all bills along with claim form but in order to substantiate opposite party's contention that they had sent deficiency letter demanding the documents, they were not produced anything before this Forum but complainant produced Ext.A2 series documents that is the photo copy of the bills of Rs.44,672/- before the Forum. The complainant argued that the original bills along with the claim form submitted in the opposite parties office on 30.03.2012.
9. On going through the evidences and records we are in the opinion that complainant submitted entire bills related to this claim with opposite party. The claim and policy is admitted by both the parties and no dispute regarding the hospitalization. Opposite parties main contention is that complainant not submitted the required documents to opposite parties but complainant denied the acceptance of deficiency letter dated 18.04.2012. But opposite parties were not produced the photo copy of the same or any supporting documents before this Forum. So we are in the opinion that denial of cashless benefit and 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.44,672/- (Rupees Forty Four Thousand Six Hundred and Seventy Two) only as per the terms of Health Insurance Policy with 12% interest from 17.03.2012 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(Series). Copy of Claim Letter with forms and accompanying documents (17 Nos).
Exhibits for the Opposite Parties:
Nil.
Sd/-
PRESIDENT, CDRF, WAYANAD.
