IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 28th day of October, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 98/2019 (Filed on 24-06-2019)
Petitioner : Sonymon Thomas,
S/o. Thomas Punnoose,
Kochupilaparambil (H)
Eravichara P.O.
Kottayam
(Adv. Rohit Nair)
Vs.
Opposite party : (1) The Divisional Manager,
The Oriental Insurance Co. Ltd.
Divisional Office No.1
P.B. No.1, P.B. No.166
3rd Floor, Mattekara
Buildings, M.C Road,
Baker Jn. Kottayam – 686001
(Adv. P.C. Chacko)
(2) The Divisional Manager.
Medi Assist TPA Pvt. Ltd.
Chicago Plaza, 4th Floor,
Rajaji Road, Cochin – 682035
(3) The Administrator / Medical
Superintendent, Matha Hospital,
Thellakom, Kottayam - 686630
(Adv. M.C. Suresh)
O R D E R
Sri. Manulal V.S. President
Case of the complainant is as follows;
Complainant is the holder of “Happy Family Floater policy” of the first opposite party . The complainant and his family members are insured persons under the policy for the period from 14-10-2018 to 13-10-2019. The total sum assured is Rs.4,00,000 and the policy covers the total expenses for domiciliary hospitalization and other hospitalization expenses as cash less hospitalization. On 3-6-2019 , complainant’s mother Susy Punnose who is also insured under the policy was admitted in the third opposite party hospital with complaint of swelling over face and nose and diagnosed as Cellitius Face with Vertibutities nose Uti Diabetes mellitus. On the date of admission the complainant had informed the third opposite party about the health insurance policy and handed over the documents to the third opposite party. On 4-6-2019 the third opposite party informed the complainant that the second opposite party had rejected the claim stating “Dental Treatment is not covered under the policy. But it was totally different from diagnosis made by the third opposite party. Later a staff from the second opposite party visited the complainant’s mother in the hospital and ensured about the treatment. On 7-6-2019 i.e. the date of discharge the third opposite party intimated the complainant about the total bill amount as 26,716 and the third opposite party also informed the complainant that the second opposite party had only approved Rs.14,993/- against the total bill amount. It is averred in the complaint that from the total bill amount 10% is co-pay which is mentioned in the policy. But an amount of Rs.10,058/- was deducted on baseless ground. The complainant paid the balance amount of Rs.11,723/- to the third opposite party and the third opposite party insisted the complainant to pay Rs.3,000/- as the deposit amount till the realization of the approved amount from the second opposite party. It is further averred in the complaint that though the complainant is entitled for the cashless hospitalization for the total bill, but the third opposite party deducted 50% of the total bill amount for monetary gain and collected Rs.3000/- from the complainant on base less grounds, which is not even mentioned in the policy as a condition and amounts deficiency in service and unfair trade practice from the part of the third opposite party. According to the complainant due to the acts of the opposite parties the complainant had suffered loss and injury due to deprivation, harassment mental agony for which he is entitled to compensation. Hence this complaint is filed by the complaint praying for an order to direct the opposite parties to pay Rs.13,058/- along with compensation Rs.25,000/- and litigation cost of Rs.3000/-.
Upon notice first and third opposite parties appeared before the commission and filed separate version. Though the notice was served to the second opposite party the did not care to file the version, hence the second opposite party was set exparty.
Version of the first opposite party is as follows:
The complainant had availed a Silver Happy Family floater policy for the period from 14-10-2018 to 13-10-2019 for a sum of Rs.4,00,000/- covering himself, his spouse , daughter and mother. Originally he took the policy covering himself and mother for a sum of Rs.2,00,000 for the period from 14-10-2014 to 13-10-2015. He renewed the said policy for the period from 14-10-2015 to 13-10-2016. Again the policy is renewed for the period from 14-10-2016 to 13-10-2017 , but the sum assured was Rs.3,00,000/-. The policy was again renewed policy for the period from 14-10-2017 to 13-10-2018 , by covering the spouse also in the policy and sum insured was enhanced to Rs.4,00,000/ and in continuation of the same , the present policy was taken.
On 3-6-2018 one of the beneficiaries , the mother of the complainant Susy Punnose was admitted in the third opposite party hospital for the complaints of swelling over right side of face since two weeks. The initial requisition for cashless facility for approximate expenses of Rs.30,000/- was received and on perusal of the documents received along with the cashless request it was observed the patient got admitted with the dental related ailment. Since dental treatments are not covered as per policy exclusions clause 4.7 the request for cashless facility was not extended as denied.
On denial of the cashless request, the third opposite party submitted one more pre-authorization request for the same for an estimated bill of Rs.26,716/- for diagnosed ailment on 4-6-2019 as Cellulitis face with Vestibulitis nose UTI Urinary tract infection, diabetes mellitus etc. Request for claim was authorized
and approved for Rs.14,993/- by disallowing Rs.10,058/- as insured opted for a higher room rent for Rs.3120/- per day as insured is a known case of diabetes mellitus and the condition is pre-existing to the policy, as the current ailment is related to diabetes and sum insured is restricted to Rs.2,00,000/-. Hence excess Room rent of Rs.4480/-, investigation and lab charges of Rs.2344/- consultant charges of Rs.1,077/- and discharge medicine for Rs.407/- are deducted and proportionate deduction has been applied on all related expenses other than medicines. As per policy 10% co-pay of Rs.1,665/- is disallowed along with non-admissible amount of Rs.1,750/-. Thus the claim was processed legally and there is no deficiency in service on the part of the first opposite party. The first opposite party is not aware that any amount of Rs.3,000/- was insisted to be paid by the third opposite party as alleged.
Third opposite party filed version contending as follows:
There is no consumer relationship between the complainant and the third opposite party. The complainant’s mother was the patient who underwent treatment in the third opposite party hospital and she paid the hospital bills and the complainant has no locus standi to make any claim against the third opposite
party in respect of her treatment. The mother of the complainant was treated with third opposite party’s hospital from 3-6-2019 to 7-6-2019 for the diagnosed cellulitis face with vestibulitis nose.
The insurance department of the third opposite party had promptly proceeded with the claim and obtained pre- authorization for cashless treatment. The patient was specifically informed that in case any amount was not payable
by the insurance company as per terms and conditions of the policy, the same would be payable by her and she agreed to it.
The total bill amount was Rs.26,716/- and out of which the insurance company had approved only Rs.14,993/- after deducting some amount as allegedly as per policy conditions. The third opposite party informed the patient about the deduction of the Rs.11,723/- made by the insurance company and without raising any objection , the patient remitted the same and got discharged . At the time of discharge the insurance company did not pay the approved amount and hence the third opposite party had also collected an amount of Rs.3,000/- as caution deposit and she was informed that the same would be refundable if the insurance company make full payment of the approved amount lest it would be adjusted towards the bill amount and she would be entitled only for the balance if any is due at the time of final settlement. The insurance company settled the account on 4-7-2019 and paid the approved amount of Rs.14,993/- to the third opposite party without any deduction. After getting the amount from the insurance company, the patient was telephonically informed the same from the hospital and asked to furnish her account details for making refund of the caution deposit or else could collect the amount directly from the hospital. But since there was no response from the patient the third opposite party sent Rs.3000/- vide D.D taken in the name of the patient on 23-7-2019. The patient received the D.D and Complainant is not entitled to claim the amount from the third opposite party. The deduction of 50 %of the total bill amount was done by the first and second opposite parties. There was no deficiency in service or unfair trade practice on the part of the third opposite party.
Evidence of this case consist of deposition of PW1 and DW1 and exhibits A1 to A11 and B1 and B1(a). Sabu Sebastian who is the managing director of the third opposite party filed proof affidavit for and on behalf of the third opposite party.
On evaluation of complaint version and evidence on record we would like to consider the following points.
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties?
- If so what are the reliefs and cost?
Point number 1 and 2 together
Before dealing with the rival submissions and contentions advanced by the learned advocate appearing for complainant as well as opposite parties, it will be pertinent to point out certain undisputed facts. There is no dispute that the complainant had availed a Silver Happy Family floater policy for the period from 14-10-2018 to 13-10-2019 for a sum of Rs.4,00,000/- covering himself, his spouse, daughter and mother. There is also no dispute that the on 3-6-2018 the mother of the complainant. Susy Punnose was admitted in the third opposite party hospital for the complaints of swelling over right side of face since two weeks and diagnosed ailment on 4-6-2019 as Cellulitis face with Vestibulitis nose UTI Urinary tract infection, diabetes mellitus.
It is an undisputed fact that the third opposite party informed the complainant that the second opposite party had only approved Rs.14,993/- out of the total bill amount of Rs.26,716/-
Complaint was resisted by the first opposite party stating that insured opted for a higher room rent for Rs.3,120/- per day as insured is a known case of diabetes mellitus and the condition is pre existing to the policy, as the current ailment is related to diabetes and sum insured is restricted to Rs.2,00,000/-.
Exhibit A1 is the policy issued by the first opposite party in the name of the complainant for the period from 14-10-2018 to 13-10-2019 for a sum of Rs.4,00,000/- covering himself, his spouse, daughter and mother. On perusal of exhibit A1 we can see that the complainant took the policy for a sum of Rs.2,00,000 for the period from 14-10-2014 to 13-10-2015 and renewed the said
policy for the period from 14-10-2015 to 13-10-2016. It can be seen from exhibit A1 that the complainant renewed the policy for the period from 14-10-2016 to 13-10-2017 and the sum assured was enhanced to Rs.3,00,000/-. It is further proved by exhibit A1 that the policy was again renewed for the period from 14-10-2017 to 13-10-2018, and the sum insured was enhanced to Rs.4,00,000/.
It is proved by Exhibit A8 that Susy Punnoose was treated in Caritas hospital as inpatient from 3-6-2018 and got discharged on 7-6-2018 and incurred Rs.26,716/- towards the treatment expenses. The first contention of the 1st opposite party that Susy punnose is a known case of diabetes mellitus and the condition is pre-existing to the policy, as the current ailment is related to diabetes and sum insured is restricted to Rs.2,00,000/-. Pw1 who is non other than the complainant would deposed that the said Susy has been consuming medicines for diabetics over last five years. However the first opposite party failed to prove that the diabetes mellitus has correlation between Cellulitis face with Vestibulitis nose UTI Urinary tract infection, the ailment for which the said Susy punnnose undergone the treatment.
The Hon’ble Supreme Court of India,Hon’ble High Court of Delhi andHon’ble NCDRC in various cases have held that the diabetics is not at all diseases.
The Honible Supreme Court in Manmohan Nanda vs United India Insurance Co. Ltd. . on 6 December, 2021 held that “ the object of seeking medi-claim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent which may occur if the insured suffers a sudden sickness or ailment which is not expressly excluded under the policy. A duty is caste on the insurer to indemnify the complainant thereon”
Thus the first opposite party have no right to take Rs.2,00,000/- as sum insured to process the claim of the Susy Punnoose. We already found that during the period of treatment the sum assured was Rs.4,00,000/-. Admittedly the first opposite party has made deduction in.
Therefore we are of the opinion that the first opposite party had committed deficiency in service by considering the sum assured as Rs.2,00,000/- instead of Rs.4,00,000/- as sum assured.
The first opposite party had made deductions from the total bill amount considering the sum assured as Rs.2,00,000/. The first opposite party made deductions based on the presumption that Susy Punnoose is entitled only for Rs.2,000/- per day towards the head of room rent and nursing expenses. The first
opposite party has made deduction from the admissible amount as per the entitled room category based on the room rent limit .
It is proved by the Exhibit A11 that the room rent was 2250 per day and nursing charge was 850 per day. Thus it is proved that the total amount for room rent and nursing care was Rs.3100/- per day. As per policy condition the insured in entitled for one percent of the sum assured towards Room rent, boarding and
nursing expenses per day. Here in case the insured is entitled for Rs.4000/- per day towards room rent and nursing care. Thus the first opposite party is not entitled to make any deductions based on entitled room rent category. Admittedly the first opposite party had deducted Rs,4,480/- from the room rent, Rs.2344 from the investigation and lab charges , Rs.1,077/- from the consultant charges. The act of the first opposite party deducting the amounts from the total bill amount by violating the provisions of the policy amounts to imperfection and inadequacy in service and amounts to deficiency in service.
It is pertinent to note that the first opposite party had made deduction of Rs.407/- as the expenses for discharge medicines. On a mere reading of the policy condition it can be seen that medical expenses is defined as those expenses that an insured person has necessary and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner as long as theses are more than would have been payable if the insured person had not been insured and no more than the other hospitals or doctors in the same locality would have charged for the same medical treatment. Therefore we are of the opinion that the first opposite party is liable to reimburse the expenses for the medicines which were incurred at the time of discharge of the patient from the hospital. On
going through the evidence the first opposite party is entitled to deduct Rs.1750/- from total amount of Rs.26,716/- which is the expenses for admission charge, bio-medical waste charges and diet charges which are not admissible as per the condition of the policy .Thus the admissible amount of treatment expenses is 24,966/-.
As per the policy condition the insured is bound to bear 10% of the treatment as co-payment condition. Here in case in hand the complainant is bound to bear Rs.2,496 as co-payment. Hence the first opposite party is liable to reimburse Rs.22,470/- to the insured.
Moreover it is evident from the records that the first claim application filed by the complainant was rejected by the first opposite party on the ground that the patient got admitted with the dental related ailment. This shows the negligent and careless manner in which the first opposite party processed the claim of the complainant.
In case New India Assurance Company Limited Versus Smt. Usha Yadav & others 2008(3) R.C.R. (Civil) 111, the Hon’ble PunjabHaryana High Court expressed its anguish and observed as follows:-
“It seems that the Insurance Companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the affected people to fight for getting their genuine claims. The insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus, pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”
Another contention of the complainant that though the complainant is entitled for the cashless hospitalization for the total bill, but the third opposite party collected Rs.3000/- from the complainant on baseless grounds. It is admitted by the third opposite party that at the time of discharge the insurance company did not pay the approved amount and hence the third opposite party had also collected an amount of Rs.3,000/- as caution deposit. After getting the amount from the insurance company, the third opposite party sent Rs.3000/- vide D.D taken in the name of the patient on 23-7-2019. Clause 3.31 of the exhibit B1 defines the network provider as a hospital or healthcare providers enlisted by an insurer or by a TPA and insurer together, to provide medical services to an insured on payment by a cashless facility. Herein case on hand the opposite parties have no case that the third opposite party is not enlisted by the insurance company as net work provider to render cashless facility to the complainant. Admittedly the first opposite party provided cashless facility of Rs.14,993/- to the complainant through the third opposite party hospital and the same was informed to the third opposite party on 7-1-2019 vide exhibit A5. Thus the third opposite party is well aware of the fact that Rs.14,993/- would be remitted by the first opposite party to the third opposite party. The complainant who is the policy holder of the first opposite party in order to avail the cashless facility for the treatment of his mother who is a co-insured in the policy availed service of the third opposite party. Being a net work hospital enlisted by the first opposite party the third opposite party is bound to render the service to the complainant as offered and undertaken by the first opposite party. Therefore we are of the opinion that the third opposite party has committed deficiency in service by receiving a deposit of Rs.3000/- against the amount which was pre - authorised by the first opposite as cashless facility.
We already found that the first opposite party has committed deficiency in service by illegally deducting Rs.7,447/- from the amount which was entitled buy the complainant for his mother’s treatment as per terms and conditions of the policy. The deficient act of the first and third opposite parties caused much mental agony and hardship to the complainant. And the first and third opposite parties are liable to compensate the same. On a close evaluation of evidence we are of the opinion that the complainant had succeeded to prove his case and the complaint is to be allowed.
In the circumstances we allow that complaint and pass the following order.
- We hereby direct the first opposite party to pay Rs.7,447/- which is the amount illegally deducted by the first opposite party from
the total treatment expenses of Susi Punnoose to the complainant.
- We hereby direct the first opposite party to pay Rs.20,000/- to the complainant as compensation for the deficiency in service committed by the first opposite party.
- We hereby by direct the third opposite party to Pay Rs. 5000/- to the complainant as compensation for the deficiency in service committed by the third opposite party.
We hereby direct the first and third opposite parties to pay Rs.1500 each to the complainant as cost of this litigation.
Order shall be complied within 30 days from the date of receipt of Order. If not complied as directed, the award amount will carry 9% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 28th day of October, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Witness from the side of complainant
Pw1 – Sonymon Thomas
Witness from the side of opposite party
Dw1- Nina George
Exhibits marked from the side of complainant
A1 – Policy No.441300/48/2019/1473 issued by 1st opposite party
A2 – Copy of policy conditions by 1st opposite party
A3 – ID card (MA-ID :5016524138) by 1st opposite party
A4- Copy of letter dtd.04-06-19 by 2nd opposite party to 3rd opposite party
A5- Copy of letter dtd.07-06-19 by 2nd opposite party to 3rd opposite party
A6- Letter dtd.10-06-19 by Matha Hospital
A7 – Receipt dtd.07-06-19 for Rs.11,723/- by Matha Hospital
A8- Copy of final bill dtd.07-06-19 for Rs.26,716/- by Matha Hospital
A9 – Copy of discharge summary
A10- Copy of letter dtd.13-06-2019 from complainant to 1st opposite party
A11 –Break up bill dtd.11-06-19 by Matha Hospital
Exhibits marked from the side of opposite party
B1 – Copy of DD
B2 – Copy of policy with terms and conditions
By Order
SD/-
Assistant Registrar
