O R D E R
By Dr.K.Radhakrishnan Nair, Member :
Complainant’s case is that he is a mediclaim policy holder with the opposite parties covering his family consisting of himself, his wife Bindu Roby and two children namely Master Ryan Roby and Ian Francis Roby. Policy details are as follows: Policy No.441106/48/2009/908, Period of Insurance – 8/7/2008 to 7/7/2009. The above policy had been timely renewed also. Complainant’s son Ryan Roby was hospitalized in Trichur Heart Hospital on 6/7/2009 for high fever and cough and discharged on 11/7/2009. Necessary application was made before TPA M/S M.D.India Health Care Services on 7/7/2009 by the hospital for cashless facility. This preauthorization request was denied by the TPA on the basis that the eligibility of the claim under the policy cannot be ascertained. An amount of Rs.6,468/- was paid towards hospitalization expenses. Further Rs.809/- was also spent towards medicines and miscellaneous items. It is alleged that the denial of cashless facility tantamount to deficiency in service. Therefore the complaint may be allowed granting Rs.7,277/-, Rs.15,000/- compensation and cost Rs.5,000/-.
2. Case was admitted. Issued notice to opposite parties. 1st and 2nd opposite parties appeared through counsel and filed their version. 3rd and 4th opposite parties were set exparte being absent and unrepresented. In the objection 1st and 2nd opposite parties reiterates that there is no deficiency in service in denying the cashless facility since the required information was not furnished to the TPA. The furnished information was not sufficient to allow the cashless facility. Condition No.6.6(2) of the policy very clearly provides that denial of cashless authorization should in no way be construed as denial of the claim. In cases where cashless authorization could not be extended, the insured person may avail treatment as per attending doctor’s advice and later on submit the full claim papers to the TPA for reimbursement within seven days of discharge from the hospital. Condition No.5 of the policy stipulates that the insured should submit the claim form along with hospital bills, medical bills, pathological test reports, discharge summary, attending doctor’s certificate etc. to the TPA, within seven days of discharge form the hospital. These opposite parties submit that the petitioner had not preferred his claim before the TPA subsequent to the discharge of the patient on 11/7/2009. Condition No.5.5 of the policy casts a duty as well as a right upon the insured to prefer the claim along with all necessary documents in order to avail a benefit under the policy. Complainant, by choice, has decided not to put up a formal claim before the TPA, on reimbursement basis and instead thought it fit to approach this Hon’ble Forum with a complaint. In doing so, the complainant has denied an opportunity to the opposite parties to consider his claim, subject of course, on its merits. Since the complainant has not preferred his claim for reimbursement of hospitalization expenses before the TPA, at all after the discharge of the patient from the hospital, as stipulated under condition No.5.5 and condition No.5.6(2) of the policy, this complaint is premature and is liable to be dismissed. In the absence of any deficiency in service the complaint may be dismissed with costs.
3. The case then posted for evidence. The points for consideration are the following :
1) Is there any deficiency in service on the part of opposite parties ?
2) If yes, what are the reliefs and costs ?
4. Complainant filed proof affidavit along with 9 documents that are marked as Exts.P1 to P9. Ext.P1 is the Individual Medi claim policy with terms and conditions of 2008-09, Ext.P2 is the policy for 2009-10, Ext.P3 is the prescription of Thrissur Heart Hospital Ltd., Ext.P4 is the inpatient bill of Thrissur Heart hospital, Ext.P5 is the discharge summary, Ext.P6 is the investigation details, Ext.P7 is the radiographical reports, Ext.P8 is X-ray film and Ext.P9 is medical bills. From the side of Complainant depositions were marked as PW1 and PW2. Deposition of opposite parties is marked as RW1. Four documents were produced, which are marked as Ext.R1, Ext.X1, X2 and X3. Ext.R1 is the mediclaim policy, Ext.X1 is the discharge summary, Ext.X2 is the payment receipts and Ext.X3 is the hospital file.
5.Appreciation of Evidence : The bone of contention is that the cashless facility was not allowed. If it is so, onus of proof lies on the complainant to establish that sufficient information and details of treatment have been furnished to allow the facility. In the instant case the complainant had miserably failed to establish the same. The documents produced by both parties will clearly establish that the complainant is eligible to get the medi claim through proper process. This eligibility is obtained not at the time of admission stage but through different stage of treatment in the instant case. Ext.X3 clearly shows the same. Denial of cashless facility is not in any way affect the right to claim the benefits under the policy. Cashless facility is extended in appropriate cases where the insured is in urgent need of such assistance for which the admissibility of a claim needs to be established prima facie. In cases where cashless authorization could not be given, the insured person can very well avail the reimbursement facility by submitting all the relevant documents within seven days of discharge from the hospital. This Commission fails to understand that what prevented the complainant in adopting that mode of claim settlement. However, in the deposition of PW1 a question was asked him to explain the reason for not submitting the claim for reimbursement? It was answered that “ഓഫീസുമായി ബന്ധപ്പെട്ടപ്പോൾ ക്ലെയിം സംഖ്യ കിട്ടുവാൻ സാധ്യതയില്ലെന്ന് ഇൻഷുറൻസ് കമ്പനി പറഞ്ഞതിനാലാണ് ക്ലെയിം അപ്രകാരം നൽകാതിരുന്നത്. കമ്പനിക്ക് വക്കീൽ നോട്ടീസ് അയച്ചിട്ടുണ്ട്” . This Commission is convinced that the denial of cashless facility and further statements of the company dissuading the complainant from submitting the claim may be a reason for such inaction on the part of the complainant. While examining the documents, proof affidavits, depositions and argument notes besides the points raised during final hearing, we have found that there is no deficiency in service on the part of 1st to 4th opposite parties. The denial of cashless facility is rightly done. The nonappearance of opposite parties 2 and 3 is noted with displeasure. They have an ardent and pious duty to enlighten this Commission the way in which the cashless facility was administered. Both opposite parties (3&4) have to realize their mistakes and have to pay for the same.
6. Reliefs and costs: We are convinced and inclined to dismiss the complaint and direct both parties to ensure that the reimbursement claim is settled within thirty days from the receipt of a copy of this order. All required documents need to be produced before the opposite parties within 15 days from the receipt of this order. The Commission finds that the claim is admissible for reimbursement settlement. We pronounce an exparte order against 3rd and 4th opposite parties to pay Rs.1,000/- (Rupees one thousand only) each to the Legal Benefit Fund of this Commission against their noncooperation. A copy of this order may be forwarded to them. Complaint is dismissed accordingly.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission this the 30th day of October 2020.
Sd/- Sd/- Sd/-
Sreeja.S Dr.K.Radhakrishnan Nair C.T.Sabu
Member Member President
Appendix
Complainant’s Exhibits
Ext.P1 Individual Medi claim policy with terms and conditions
Ext.P2 policy for 2009-10,
Ext.P3 prescription of Thrissur Heart Hospital Ltd.,
Ext.P4 Inpatient bill of Thrissur Heart hospital,
Ext.P5 Discharge summary,
Ext.P6 Investigation details,
Ext.P7 Radiographical reports,
Ext.P8 X-ray film
Ext.P9 Medical bills
Complainant’s witnesses
PW1 – Roby Davis
PW2 – Dr.Shameem
Opposite Parties Exhibit
Ext.R1 Mediclaim policy
Ext.X1 Discharge summary,
Ext.X2 payment receipts
Ext.X3 Hospital file
Opposite Parties witness
RW1 - Santhoshkumar
Id/-
Member
