Date of Filing: 20.09.2016
Date of Order: 18.09.2019
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B. PRESIDENT.
HON’BLE Smt. D.NIRMALA, B.Com., LLB., MEMBER
ON THIS THE WEDNESDAY THE 18th DAY OF SEPTEMBER, 2019
C.C.No. 437 / 2016
Between
Sri Suryakanta Guru,
S/o . Dr.(Prof) Sunakar Guru, Aged about 29 years,
Occ:Pvt.Employee R/o. Plot No.2886/4849,
Opp: Rashmi Homes, Nageswar Tangi,
Bhubaneswar – 751002, Odisha. ……Complainant
And
L.V. Prasad Eye Institute,
Rep.by its Director, Sri G.Chandra Sekhar,
Registered Address:
Kallam Anji Reddy Compus, L.V.Prasad Marg,
Banjara Hills, Hyderabad – 500 034,
Telangana ….Opposite Parties
Counsel for the complainant : Mr.B.Sai Kiran.
Counsel for the Opposite Party : Mr Adnan Mahmood
O R D E R
(By Sri. Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
1) This complaint has been preferred under Section 12 of Consumer Protection Act, 1986 alleging that the opposite party by sending incorrect report to the insurer caused deficiency of service. Hence directions to refund the amount at Rs.1,08,000/- spent by the complainant for the treatment of his mother in the opposite party institute with interest at 18% p.a. and to award a compensation of Rs.3,00,000/- for causing mental agony to the complainant and his family members and also to award costs of this complaint.
2) The complaint averments in brief are that :
He had a cashless parental insurance coverage with United India Insurance in MA.ID.4014926518 . His mother Smt.Sulochana Devi had developed Epiretinal Membrane and he took her to the opposite party hospital all the way from Bhubaneswar for treatment of the same. He informed the opposite party institute that he shall apt for cashless surgery to his mother but opposite party insisted to pay for the surgery in cash and advised him to claim the insurance amount from the insurer after surgery. Hence he paid the total cost of the surgery and related treatment at Rs.1,08,900/- to the opposite party and latter submitted claim with insurer for reimbursement of the amount spent.
But the opposite party institute willfully sent wrong and un-verified claim documents containing wrong and baseless medical record of the complainant’s mother to the insurance company. It also advised insurance company to deny the claim. According to the said wrong advise of opposite party institute the insurer denied the parental claim of the complainant.
The complainant’s mother previously had 3 operations for both the eyes of cataract and knee replacement under cashless provision. But this time opposite party institute denied it. The insurer received wrong report of opposite party institute that the complainant’s mother had diminished vision OD in the right eye for 2 years . On the said advice insurer rejected the claim submitted by the complainant . In reality the complainant’s mother diminished vision OD in the right eye has been since 2 months only. As such insurer cannot reject the claim. The insurer also mentioned that the benefit covered from 1.6.2014 i.e. 5 months before operation. But DOV of the patient was intentionally and wrongly mentioned to be 2 years in order to stop the complainant from claiming cashless operation.
The complainant after seeing the discrepancies in the reports submitted of opposite party institute he approached Coordinator of the insurance and inquired with him as to why there have been such gross discrepancies and there has been a refusal for claim. But the said coordinator behaved in a rude manner with complainant and his father who was 75 years of age having chronic ailments. The complainant learnt that the medical record pertaining to his mother’s defect of vision has been manipulated by the insurance coordinator showing as two years prior to ailment instead of recording two months with a mala-fide intention not to allow the complainant to claim parental insurance claim. The medical records preserving procedure of the opposite party institute is defective , erroneous and they were prepared carelessly by hugely irresponsible staff . The complainant had sent standard applications to the opposite party institute and one Dr.Annei Mathaei and said doctor issued correct medical record pertaining to his mother’s discharge summary. But there was no response. Hence he got issued a legal notice on 27.4.2016 to the opposite party institute calling upon to pay an amount of Rs.1,08,900/- with interest at 18% p.a., but for said notice there is no response. Hence the present complaint.
3) Opposite party in the detailed written version admitted issuance of parental policy to the complainant and submission of the claim by the complainant after expenditure incurred for the treatment of his mother. The stand of the opposite party in the written version is that complainant brought his mother to M.Sulochana Devi to opposite party institute on 6.11.2014 with a complaint of diminished vision in the right eye for the past 2 years. The information provided by the said Sulochana Devi was recorded by them on the same day. At that point of time the fact of duration of the vision loss has not been brought to the notice of opposite party by the patient or her family members. The patient was checked in for LVPEI, Bhubaneswar campus and she came to opposite party hospital for further management and surgery on her own accord. As per the prescriptions with the patient she had undergone cataract surgery for the right eye at Kar Vision Eye Hospital at Bhubaneswar on 5-8-2013 for reduced vision since one year in her right eye. The discharge summary clearly states that even after the cataract surgery there was no improvement in the vision following post operative check-up her vision recorded was poor at 6/36 and same 6/36 vision they have been recorded at her first visit to the opposite party hospital. Complainant’s mother herself stated that she had poor vision since one year i.e. from August, 2012. The opposite party hospital has correctly mentioned that the patient had problem since 2 years as per the information received from the patient only. Since there was no record of good vision after cataract surgery, it is obvious vision that the patient had before the surgery is continuing even after surgery also as per the record. The complainant’s mother Smt.Sulochana Devi was seen by Dr. Annie Mathai, Retina consultant on 7.11.2014. Her vision acuity was 20/100 (6/36) in the right eye and 20/20 in the left eye. Fundus examination of the right eye showed epiretinal membrane and left eye showed RPE changes Cellophane maculopathy. Patient was advised 25G Parsplana Vitrectomy + membrane pelling in the right eye under local anesthesia and same was performed on 10.11.2014. The said surgery was as per the international standards and patient does have any complaint to the treatment provided to her. Complainant was not forced to pay the amount in cash. In fact complainant choose to get the surgery done and claim insurance as per his own free will. The allegation that opposite party hospital sent wrong and unverified documents and medical reports is absolutely false and baseless.
The opposite party mailed the details to the Insurance company. The denial of the claim by insurance company and the reasons, the opposite party unaware of it and same was conveyed to the complainant. But the complainant on his own volition, still preferred to go ahead with the surgery by bearing the complete cost. Complainant could have chosen a package that was affordable when the insurance was denied or could have done surgery later on or at another place as per his choice as it was an elective procedure and not an emergency.
Opposite party hospital is not for profit organization and is governed by two trusts it has served 15 million people with more than 50% services were provided free of cost, regardless of complexity. The hospital has been running noble services without any profit. As such the allegation levelled by the complainant are of false and created up for the purpose of this complaint.
If`the complainant is aggrieved by the insurance agency refusing his claim unauthorizedly, he could have filed the case against insurance agency. But filed against opposite party institute. The opposite party hospital received two letters and the dates in the medical records are corrected and kept ready for collecting the same, which is not collected till date. The concerned tried calling the complainants mother for post surgery check up but there was no response to those calls. By not coming for post operative check-ups the complainant’s mother has flouted the Doctors advice . The complaint is devoid of merits and is liable to be dismissed..
4) In the enquiry the complainant got filed his evidence affidavit and substance of the same is in tune with the complaint averments. To support the same he has got exhibited 8 documents. For the opposite parties evidence affidavit of its Area Service Executive is got filed and this evidence is nothing but replica of written version. 1 document is exhibited for the opposite party. Both sides filed written arguments.
5) On a consideration of the material brought on the record the following points have emerged for consideration :-
1. Whether the complainant could make out the case of deficiency of service on the part of opposite parties?
2. Whether the complainant is entitled for the claim made in the complaint?
3. To what relief?
6) Point No.1:- The essence of complainant’s case is the opposite party institute having refused to prove cashless treatment, in spite of having insurance coverage, after surgery and necessary treatment to his mother had sent a false and incorrect statement to the insurer advising to reject the claim to be considered by the insurer post operatively . Basing on the said advice and reports submitted by the opposite party institute the insurance company rejected the claim. Complainant having alleged that opposite party Institute has sent wrong information and advised to reject the claim failed to substantiate the same. It is pertinent to note that the opposite party institute has nothing to do with the insurance company since complainant has parental insurance coverage. That apart insurance company will have a 3rd party advisor for processing the claim received from the insured people. No hospital will advise insurance companies not to honour the claim submitted by insured people for the treatment rendered in the hospitals. It has been categorically stated by the opposite party that whatever information furnished by the patient was recorded in admission register and same was sent to the insurance company. It is also mentioned by the opposite party that complainant informed that he got medical insurance with United India Insurance Company. Since the opposite party Institute provided the complete information of surgical procedure and the details of patient and information provided by the patient to the insurance company for a cashless facility. It is for the insurance company either to provide or reject people cashless treatment. The opposite party hospital has no say of whatsoever. When the insurer of the complainant refused for cashless treatment same was conveyed to the complainant and the complainant on his own accord that proceed for surgery.
As per the version of the opposite party the complainant’s mother came to the hospital on 6.11.2014 with a complaint of diminished vision in the right eye for 2 years and same was recorded. Earlier the patient was checked up in LVPI Bhubvaneswar campus and latter came for further management and for surgery at opposite party institute . As per the record the patient had undergone cataract surgery for the right eye at Kar Vision Eye Hospital in Bhubaneswar on 5.8.23013. The discharge summery from the said hospital reveals that even after surgery there was no improvement in the vision. The complainant mother herself informed that she has poor vision since one year i.e. from August, 2012 and same fact was mentioned in the record. The complainant alleged that the opposite party institute deliberately mentioned incorrect version in the record and submitted the same to the insurer to deny claim what is the necessary for the opposite party institute to send incorrect and false information to the insurer of the complainant is not explained . As rightly pointed out by the opposite party if the complainant is of the view that the rejection of claim by the insurer is not reasonable , illegal and not valid he ought to have filed complaint against the insurer itself. That apart the report submitted by third party to insurer in Exhibit A3 does not disclose that basing on the advise of the opposite party report the claim is rejected. Exhibit A5 is the discharge summary from Kar Vision hospital and it shows complainant’s mother was having poor vision since one year before the surgery on 4.1.2013. 2nd surgery was conducted on 5.8.2013. So even by the date of surgery complainant’s mother was having poor vision for one year. The admission of the complainant’s mother in opposite party hospital was on 6.11. 2014 so by then she was having poor vision for 2 years and same was conveyed by her to the opposite party institute when she visited on 6.11.2014. In Exhibit A3 the reasons mentioned for treatment of the claim are Foreign body sensation in OS since one year. The reason given for rejecting the claim reads as under:
“On perusal of the claim document submitted, the claim pertains to 64 years old with complaint of Diminished vision in OD since 2 years & C/o., Heaviness foreign body sensation in OS since 1 year diagnosed as right eye pseudophakia with epiretinal membrane undergobe Right eye Membrane peeling, sutureless vitrectomy , Benef covered from 1.6.2014 hence this claim is not admissible since the ailment is pre-existing prior to policy inception”
Since the policy coverage was from 1.6.2014 the claim was not admissible. Ailment is pre-existing prior to the taking of policy. So the complainant’s allegation that the opposite party institute deliberately mentioned the incorrect information in the records and forwarded the same to the insurer and basing the advice of the opposite party institute the insurer repudiated the claim has no legs to stand. Thus the complainant has miserably failed to substantiate the allegation that the opposite party institute either caused deficiency of service or indulged in unfair trade practice. Accordingly the point is answered against the complainant.
7) Point No.2:- In view of the above findings of this Forum that there is no deficiency of service or unfair trade practice on the part of the opposite parties, the complainant is not entitled for any of the claims.
8) PointNo.3:- In the result the complaint is dismissed . NO order as to costs.
Dictated to steno transcribed and typed by her and pronounced by us on this the 18th day of September, 2019.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1 - Copy of identification of the insured i.e. the complainant
Ex.A2 – Copy of bill/receipt showing an amount of Rs.1,08,900/- dt.10.11.2014.
Ex.A3 – Copy of breakup of final bill charged by respondent institute
Ex.A4 – Copy of letter sent by respondent institute to complainant’s insurer
Ex.A4 – Copy of discharge summary issued by Kar vision hospital,
Bhubaneseswar, dt.14.1.2013
Ex.A5 – Copy of discharge summary issued by Kar vision eye hospital,
Bhubaneseswar, dt.5.8.2013
Ex.A6 – Copy of check-up consultation of complainant’s mother at Kar vision
Eye hospital dt.27.9.2014
Ex.A7 - Copy of medical report of complainant’s mother issued by L V Prasad
Eye Institute, Bhubaneswar dt 15.10.2014
Ex.A8 – Copy of medical record of complainant’s mother issued by Kar Extension
LVPEI, Hyderabad.
Ex.A9 – Copy of subject explaining about “Vitreous Surgery for Macular
Disorders”
Ex.A10 - Copy of medical report of complainant’s mother issued by L V Prasad
Eye Institute, Bhubaneswar dt 20.02.2015
Ex.A11 – Copy of surgery charges of L V Prasad Eye Institute, Bhubaneswar
Ex.A12 – Copy of surgery estimate given by respondent institute dt. 17.11.2014
Ex.A13 – Copy of legal notice sent to respondent dt. 27.4.2016.
Exhibits filed on behalf of the Opposite parties:
Ex.B1 – Entire medical record of the complainant
MEMBER PRESIDENT
