By Smt. Beena. M, Member:-

            This is a complaint filed under section 35 of the Consumer Protection Act 2019

2.  Facts of the case in brief:  The Complainant had taken Health Policy issued by 4^th Opposite Party through 3^rd Opposite Party. 3^rd Opposite Party had introduced the scheme to Complainant’s family and had offered the policy and explained the terms and specialties of the policy. The agent of 4^th Opposite Party also assured that at the event of any disease to family members, a cashless facilities and treatment at all recognized hospitals would be available and hence the policy was chosen and taken by the Complainant and his family. The period of insurance for policy was one which covers the relevant period of January 2021 and a continuing policy.  On 21.01.2021, the Complainant was admitted in Baby Memorial Hospital with symptoms of Urinary stream, hesitancy, urinary frequency, nocturia (3-4) and on investigation and after taking USG of Abdomen cystitis with significant post void urine residue bilateral mild hydro ureteron ephrosis. Prostatomegaly-Grade-I fatty liver, Renal taren chymal change, and cortical cysts, were detected. The Complainant after admission on 21.01.2021 undergone treatment for 3 days and got discharged on 23.01.2021 who was dealing with health insurance section of the hospital. All the relevant information including the policy copy was entrusted with 2^nd  Opposite Party. The Complainant was given an assurance by 2^nd  Opposite Party that the treatment will be done on cashless facility basis for that purpose they will duly inform the 4^th Opposite Party with regard to the admission of the Complainant in the hospital for treatment.  After 3 days of medicine, procedures and treatment Complainant was discharged with and advise to review in urology OP Department for persisting any further difficulties or on his will. At the time of discharge, the hospital authorities issued a bill to the Complainant to the tune of Rs.15,701/- against the assurance given by Opposite Parties that the treatment will be carried out on cashless basis. Complainant was having no sufficient money to pay the bill at that time hence he contacted with 2^nd Opposite Party and told her that he is entitled for getting cashless facility and hence he is to be discharged. The Hospital Authorities are entitled to get re-imbursement from 4^th Opposite Party. Instead of walking the talk the 2^nd Opposite Party abused the Complainant and ill-treated him and pressurized him to pay the bill then and there. On asking about the insurance facility 2^nd Opposite Party informed the Complainant that as she was under the impression that the Complainant would be discharged after undergoing surgery, she has not forwarded the policy and other details regarding Complainant’s admission and treatment to the 2^nd Opposite Party. The Complainant then informed the other Opposite Party regarding his admission and requested for cashless facility but nothing was done by the other Opposite Parties also.  Thereafter, the Complainant arranged the money from some of his friends and thus with much inconvenience and pain arranged the payment of bill. Even after discharge, the 4^th Opposite Party had not reimbursed the bill and expenses.  After Discharge, the Complainant proposed a claim and all copies of Bills and treatment records were provided to Opposite Parties for the reimbursement of the amount as offered and agreed in the policy. But nothing was done by the Opposite Parties.  The Complainant had spent Rs.15,497/- as hospital Bills. He is advised to take rest for one month and have to spent Rs.15,000/- towards bystander expenses and Rs.10,000/- towards travelling expenses all these amounts are liable to be reimbursed by Opposite Party to the complainant.  There is serious deficiency of service on the part of Opposite Parties in not processing the claim without any reasonable grounds and that caused much mental agony and pain to the Complainant. The Opposite Party is liable to compensate the Complainant to the tune of Rs.20,000/- in that ground also.

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3.  Upon notice, the Opposite Parties appeared and filed version.  The brief averments in the version filed by the 1^st & 2^nd Opposite Parties are as follows:- 

It is submitted that they are unnecessary parties, since the case is for the reimbursement of medical expense from Insurance Company. The decision of approval or repudiation of the claim is solely vested with the Insurance Company and they have no role in such decisions. Hence, the complaint is bad for mis-jointer of necessary parties.  On 21.01.2021, the Complainant came to the Opposite Party hospital. On the same day at about 15.23 hrs, the Complainant reported to the Insurance Department of the hospital for admission procedure.  As per protocol, he was advised to go to the admission counseling room by the 2^nd Opposite Party for carrying out various admission formalities for which he was provided with the admission slip. He was also requested to return to the insurance office to complete the formalities along with Insurance Card, Id Proof etc.   However, he never returned to the insurance office on that day.  On 22.01.2021, the next day, he came back to the office with his documents and insisted the 2^nd Opposite Party to provide cashless facility. The 2^nd Opposite Party provided him with mandatory forms to be filled by him. But he had not submitted the said forms to the Insurance Department of the 1^st Opposite Party.  As a part of patient care and gesture of goodwill, they had even provided credit facilities to the Complainant. Thereafter, on 23.01.2021 the Complainant once again came to the insurance department of the 1^st Opposite Party and requested not to process his claim since the surgery which was planned for him was not carried out and that he was being discharged. The 2^nd Opposite Party told him to pay Rs.15,701/- being the bill amount and accordingly the Complainant himself suggested that he would go for reimbursement and paid the bill. The allegations that at the time of admission, the complainant consulted with the 2nd Opposite Party and all the relevant information including the policy copy was entrusted with 2nd Opposite Party, that the Complainant was given an assurance by 2nd Opposite Party that the treatment will be done on cashless facility basis on for that purpose they will duly inform the 4^th Opposite Party with regard to the admission of the complainant in the hospital for treatment, that at the time of discharge the hospital authorities issued a bill to the Complainant to the tune of Rs.15,701/- against the assurance given by Opposite Parties that the treatment will be carried out on cashless basis, that the Complainant was not having sufficient money to pay the bill at that time hence he contacted with 2^nd Opposite Party and told her that he is entitled for getting cashless facility and hence he is to be discharge and that the Hospital Authorities are entitled to get re-imbursement from 4^th Opposite Party, that instead of walking the talk the 2^nd Opposite Party abused the Complainant and ill-treated him and pressurized him to pay the bill then and there, that on asking about the insurance facility, 2^nd Opposite Party informed the Complainant that as she was under the impression that the Complainant will be discharged after undergoing surgery, she has not forwarded the policy and other details regarding Complainant’s admission and treatment to the 4^th  Opposite Party that the Complainant then informed the other Opposite Party regarding his admission and requested for cashless facility but nothing was done by the other Opposite Parties also, that thereafter, the Complainant arranged the money from some of his friends and thus with much inconvenience and pain arranged the payment of bill that Complainant had to spent Rs.15,000/- towards bystander expenses and Rs.10,000/- towards travelling expenses. All these amounts are liable to be reimbursed by Opposite Party to the Complainant, that there is serious deficiency of service on the part of Opposite Parties in not processing the claim without any reasonable grounds and that caused much mental agony and pain to the Complainant, that the Opposite Party is liable to compensate the Complainant to the tune of Rs.20,000/- in that ground also are not true or correct.   Besides being thoroughly unfair, uncharitable, and unsustainable and hence denied. They prayed to dismiss complaint with compensatory costs.

4.  The 3^rd Opposite Party filed version stating that the 4^th Opposite Party is an Insurance Company Ltd. having its branches all over India and 3^rd Opposite Party is a Banking company constituted under the Banking Companies Act. These two are separate entities. The role of 3^rd Opposite Party is only an intermediary between the insured and insurer and there is no Privity of contract between 3^rd Opposite Party and the Complainant. Therefore, it is prima facie clear that 3^rd Opposite Party acts just as an agent in fulfilling the insurance services and the 3^rd Opposite Party did not take part directly in any kind of procedures for initiation, issuance or remitting the claim.  The refrainment of Hospital Staff to forward the claim upon which he raised the complaint before the 3^rd Opposite Party, 3^rd Opposite Party has forwarded the complaint to the 4^th Opposite Party.  As an agent to the Insurance Company and Complainant, 3^rd Opposite Party’s obligation is to intimate the insurance Company about the received Claim which was done without any fail at the very first instance for which, the 3^rd Opposite Party has received a reply via mail from the Insurance Company as "No records found in the given Policy Number". Hence, 3^rd Opposite Party would like to inform the Complainant without waiving of its responsibility as an agent to look over the claim forwarded to the Company for any error in details produced or may be the claim was not communicated properly from the side of Hospital Authorities.  3^rd Opposite Party further submitted that the bank’s role in the Contract of Insurance is to furnish a medium to transact the premiums from Insured to the Insurer and the nature of services which can be availed from 3^rd Opposite Party is limited to this. Therefore, no claim regarding the issuance of insurance facility should come under the obligation of 3rd Opposite Party. Therefore, the 3^rd Opposite Party has intimated the Insurance Company about the claim raised and made earnest efforts to get fasten the process of the claim thereby fulfilling its duty absolutely.  3^rd Opposite Party condemn the situation gone through by the complaint but his claim of deficiency of service is not meant for 3^rd Opposite Party as 3^rd Opposite Party has made sincere efforts to intimate and settle the claim and there is no latches or delay or deficiency of service on the part of this 3^rd Opposite Party and the Complainant is not entitled to get Compensation from the 3^rd Opposite Party. Hence the Complaint is liable to be dismissed with the cost to the 3^rd Opposite Party for being falsely dragged into a frivolous litigation like the present Complaint.

5.  The 4^th Opposite Party also filed version denying the statement of Complainant that he had taken a policy as stated in the complaint and as such they have no liability to indemnify the Complainant.  The complaint with regard to reimbursement of the medical expense, the complainant has failed to provide any policy details which is most important to identify the insured and through which we can process our claim if any. It is important to submit here that the present case is premature as the required details to process the claim if any, has not been furnished and same is not annexure with complaint copy. Hence, the complaint is liable to dismiss on this score only.  Therefore, the 4^th Opposite Party prays to dismiss the complaint with cost.

6.  The Complainant filed chief affidavit and examined as PW1 and the documents produced were marked as Ext.A1 and A2.  On behalf of the 1^st  and 2^nd Opposite Party, one Mohanan, AGM, BMH, Kozhikode filed chief affidavit and examined as OPW1 and documents produced were marked as Ext.B1 and Ext. B2. Marking of Ext.B1 objected. On behalf of the 4^th Opposite Party, Ann Mary Francis, senior legal executive filed chief affidavit and examined as OPW2 and the document produced were marked as Ext.B3. 

7.  The points for consideration are as follows:

1. Whether there is any deficiency in service on the part of Opposite Parties?
2. Whether the Complainant is entitled for the reliefs as prayed in the complaint?

8.  For the sake of brevity and convenience point No.1 and 2 are considered together. 

9.  As per the records of the case i.e., pleadings of the parties and evidence produced on record by both the parties, it is clear that the Complainant insured with 4^th Opposite Party.  According to the Complainant, he was admitted in the hospital of 1^st Opposite Party due to the diseases stated in the complaint on 21.01.2021 and discharged on 23.01.2021.  He alleges that the 1^st and 2^nd Opposite Party failed to forward the claim application along with medical records to the 4^th Opposite Party. After the Discharge from the hospital the Complainant submitted all medical reports for reimbursement. But the 4^th Opposite Party had not reimbursed the bill and expenses.   Here, the 4^th Opposite Party in its version stated that they have not provided with any claim details by the Complainant with regard to indemnify the insured. Though the Complainant alleges that after discharge from the hospital he proposed a claim with all copies of bills and treatment records for reimbursement, no proof for the same is produced.  There is no document to show that the claim was made before the 4^th Opposite Party.  It clearly shows that the Complainant herein without approaching the 4^th Opposite Party had filed the complaint by alleging that there is deficiency in service on the Part of 4^th Opposite Party.  Since the Complainant had failed to prove his case against 4^th Opposite Party, we are coming to the conclusion that there is no deficiency in service on the Part of 4^th Opposite Party. 

            10. As far as the reimbursement of medical expenses is concerned, there is no dispute regarding the treatment taken by the Complainant and the expenses incurred by him for that treatment.  The responsibility for non-processing of the claim for cashless treatment of the Complainant is on the 1^st Opposite Party. Hence there is no fault on the part of the Complainant.  Therefore, on considering the nature of the grievance and on humanitarian ground this Commission feels that the 4^th Opposite Party may consider his claim after routine scrutiny.  The Complainant is directed to make fresh application with necessary original documents and after evaluating all the aspects. The Complainant may be provided with the medical reimbursement amount for which he is entitled for.  The 4^th Opposite party is directed to process the fresh application from the Complainant and to pay the claim amount of Rs.15,701/-.  As no evidence is adduced by the complainant to show the proof of bystander expenses and transportation expenses, it cannot be allowed. 

            11.  In the present case, it is apparently clear that there is serious lapse on the part of the 1^st Opposite Party hospital in directly charging from Complainant the expenses of medical treatment and not sending the claim file of the Complainant to 4^th Opposite Party within 30 days from the discharge of Complainant as per terms and conditions of the scheme.  This act of 1^st Opposite Party hospital amounts to deficiency in service on the part of 1^st  Opposite Party.  Therefore, the 1^st Opposite Party hospital is liable to pay the compensation to the Complainant.  The present case against 2^nd and 3^rd Opposite Parties stands dismissed because they have no role in cashless/reimbursement of the claim of the Complainant.  In view of the discussion, this complaint is accepted against 1^st Opposite Party hospital with a direction to pay to the Complainant Rs.10,000/-  towards compensation and Rs.5,000/- as cost of the proceedings. 

            In the result the Complaint is partly allowed, and the 4^th Opposite Party is directed to process the fresh application from the Complainant and to pay the claim amount of Rs.15,701/- (Rupees Fifteen Thousand Seven Hundred and One Only).   The 1^st Opposite Party is directed to pay Rs.10,000/- (Rupees Ten Thousand Only) as compensation and Rs.5,000/- (Rupees Five Thousand Only) as cost of the proceedings to the Complainant. 

            The above Order shall comply within 30 days from the date of receipt of this Order, failing which the Complainant is entitled to get 9% interest per annum till realization.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 12^th day of August 2024.

Date of Filing:-02.02.2022.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

MEMBER       : Sd/-

APPENDIX

Witness for the Complainant:-

PW1.              Muraleedharan. P. P.                                Retired Teacher.

Witness for the Opposite Party:-

OPW1.          Mohanan. A.                                               AGM, BMH, Kozhikode.

OPW2.          Ann Mary Francis.                                     Senior Legal Executive.

Exhibits for the Complainant:-

A1.                  Copy of Medi-claim Insurance Policy Schedule for the period of

28.12.2020 to 17.12.2020.

A2(Series).   Bills (4 numbers).                          

Exhibits for the Opposite Party:-

B1.                  Authorization Letter (Marked with Objection).       

B2.                  Copy of Discharge Summary.

B3(Series).    Medi-claim Insurance Policy Schedule and details (28 pages).    

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-