SMT. MOLYKUTTY MATHEW : MEMBER
This is a complaint filed by the complainant U/S 35 of Consumer Protection Act 2019 for an order directing the opposite party to pay Rs.21,306/- , the hospital expense of the complainant with interest @12% per annum from the date of claim till realization and to pay Rs.1 lakh as compensation for mental agony and cost of litigation for the deficiency of service on the part of opposite party.
The case of the complainant in brief
The complainant is a civil engineer by profession and also conducting his own construction work. He had availed a health insurance policy of the OP, namely ‘Care freedom care shield’ in the year 2021 with client ID: 95137668 which was renewed in the subsequent year and the present one having number 34950624 valid from 21/10/2021 to 20/10/2023. The complainant was admitted at Dhanlakshmi hospital, Kannur due to fever and diarrhea on 02/06/2023. He was treated there as in patient till 07/06/2023 as he was found having severe respiratory infection. Immediately on admission to the hospital it was informed to OP for cashless treatment as per terms and condition of the policy. But the OP denied the pre-authorization request for cashless treatment offered by them saying that “Admission not justified and permanent exclusion admission primarily for investigation and evaluation. Even after producing all the documents with respect to his treatment, the OP rejected the application for cashless treatment dated 03/06/2023 by stating false reasons. The OP says the admission not justified and also states that permanent exclusion admission primarily for investigation is not applicable to the case of complainant. The complainant had spend Rs.21,306/- for his treatment expenses in the hospital. Being the insurer the OP is liable to reimburse the amount to complainant as per policy terms and conditions. The OP is repudiated the claim with wrong findings. The act of the OP the complainant caused much mental agony and financial loss. So there is deficiency of service and unfair trade practice on the part of OP. Hence the complaint.
After filing this complaint notice issued to OP. OP received the notice and appeared before the commission and filed his written version. He contended that the medical documents of the complainant shows that the body vitals of the complainant were found to be normal without necessitating any need for hospitalization and vitals does not fulfill the criteria of admissibility. He was admitted due to high grade fever however no temperature spikes were noted during his hospitalization. The insured was treated conservatively without any surgical intervention as he was managed through medicines. It is pertinent to mention that no hospitalization was required and the insured could have been managed on OPD basis and admission for 5 days was not justified. The expenses related to any admission primarily for diagnostic and evaluation purpose only are excluded. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded. The cashless claim is rejected on the ground that “the admission not justified, permanent exclusion admission primarily for investigation and evaluation”. So there is no deficiency of service and unfair trade practice on the part of OP and the complaint may be dismissed.
On the basis of the rival contentions by the pleadings the following issues were framed for consideration.
- Whether there is any deficiency of service on the part of OPs?
- Whether the complainant is entitled for any relief?
- Relief and cost?
The evidence consists of the oral testimony of Pw1 and Ext. A1 to A6 were marked. On OP’s side no oral or documentary evidence on complainant side produced the argument note also.
Issue No.1
The complainant adduced evidence before the commission by submitting his chief affidavit in lieu of his chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. The complainant was cross examined as Pw1 by OP. He relied upon Ext.A1 to A6 documents. According to the complainant Ext.A1 is the policy schedule Ext.A2 is the premium acknowledgment. Ext.A3 is the discharge summary. It clearly shows that the complainant was admitted for treatment. Ext.A4 is the discharge bill issued by the hospital dated 07/06/2023 for an amount of Rs.21,306/-. It shows that after completing all the investigations the doctor decided to admit him to the hospital. It was come out in evidence that the admission for the purpose of treatment and not for investigation. Ext.A5 is the preauthorization denial letter dated 03/06/2023 and Ext.A6 is the reimbursement rejection letter. The treatment of the complainant was covered by the policy schedule “After discharging from the hospital that the complainant made a claim for re-imbursement with the OP. But the OP rejected the claim stating the “admission not justified and permanent exclusion admission primarily for investigation and evaluation”. The complainant had spent Rs.21,306/- for his treatment expenses in hospital. The OP is directly bound to redressal the grievance caused to the complainant. The act of the OP the complainant caused much mental agony and financial loss. So there is deficiency of service on the part of OP. Hence the issue No.1 found in favour of the complainant and answered accordingly.
Issue No.2 and 3
As discussed above the OP is not ready to refund the medical bill to the complainant. But the OP is admitted the policy and the bounden duty of OP to redress the grievance caused to the complainant. So the OP is liable to refund the bill amount of Rs.21,306/- to the complainant. There is deficiency of service and unfair trade practice on the part of OP. So the complainant is entitled to get the cash bill of Rs.21,306/- along with Rs.8,000/- as compensation for mental agony caused to the complainant and Rs.4,000/- as litigation cost. Thus the issue No.2 and 3 are also accordingly answered.
In the result the complaint is allowed in part directing the opposite party to refund Rs.21,306/- the cash bill to the complainant along with Rs. 8,000/- as compensation for mental agony caused to the complainant and Rs.4,000/- as litigation cost within 30 days of receipt of this order. In default the amount of Rs.21,306/- carries 12% interest per annum form the date of order till realization. Failing which, the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.
Exhibits.
A1- Policy schedule
A2- Premium receipt
A3- Discharge summary
A4-Discharge bill issued by Dhanalakshmi hospital
A5-Pre authorization denial letter dated 03/06/2023
A6-Re-imbursement rejection letter.
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forwarded by order/
Assistant Registrar
