ORDER

 SRI.VIJU.V.R          : MEMBER

         1. The complainant has presented this complaint before this Commission under section 12 of the Consumer Protection Act 1986. The facts of the case is that the complainant availed a Health Care Insurance Policy namely IOB- Health Care Pulse Policy  bearing number 2817/50329558/03/B00 dated 08/12/2012 which was renewed timely and the same was issued by the first opposite party through the second opposite party as its intermediary.  At the time of availing the policy the complainant was assured that all his health conditions will be covered in a cash free treatment or through reimbursement without any hustle. The policy was renewed by the second opposite party from the account of the complainant on instruction. On 3/6/13 the complainant was admitted at S.K.Hospital due to severe back ache.  The complainant was advised for an MRI test and the same was conducted by the hospital as part of treatment. The complainant was discharged on 05.06.2013. The complainant borne expenditure of Rs.1610/- for the treatment at the hospital. On completion of treatment, the complainant preferred the claim in the address of the third opposite party along with original bills, case sheet, OP ticket, investigation results and the same was replied by the third opposite party on 15.07.2013 seeking clarification regarding the treatment given in hospital.  The complainant is only a patient, hence cannot provide clarification for the treatment given by the doctor, whereas the opposite parties are bound to obtain it from the necessary sources. But to the surprise, the third opposite party further demanded clarification as his query is not cleared, by a letter dated 31.07.2013. The request for reimbursement continued and as demanded by the third opposite party in the letter dated 30.08.2013 the complainant forwarded the hospital treatment records whatever original available with him. Thereafter, instead of settling the claim the complainant received a letter on 20.09.2013 as final reminder for clarification. Constrained by the act of the opposite parties the complainant issued a notice to the third opposite party on 24.01.2014. There after the complainant received a rejection letter of the claim from the third opposite party on 20.02.2014 with unsustainable reasons. The complainant and his family had to suffer untold hardships due to the act of the opposite party. Hence this complaint.

      2. The Opposite parties 1 to 3 received notice. Third opposite party did not appeared before this Commission, hence third opposite party was set-exparte.The first opposite party has averred that the complainant is not maintainable either in law or on facts. The IOB- Health Care Plus policy was issued by the first opposite party in the name of complainant. A claim was preferred by the complainant for expenses for treatments undergone by complainant for Lumbar Disc Disease with mild compression of L4-5. The claim for reimbursement of expenses for treatments undergone was repudiated as the treatment does not require any in-patient admission. This fact was informed by letter dated 17.12.2013 repudiating the claim. The claim of the complainant is for oral medication and investigations for Lumbar disc disease with mild compression L4-5. The treatment documents submitted by the complainant shows that the treatment given during hospitalization is possible on outpatient basis also. There is no active treatment given and the same is not admissible under the clause no.12 of the policy. What we Exclude: - (The Clause no.12) : Any expense on treatment of insured persona as an outpatient in a hospital. The claim is not legally payable and the repudiation is genuine and as per the policy conditions. The complainant was admitted as inpatient unnecessarily. The procedures done were only investigations which can be done on OP basis and no in patient admission is necessary. The complainant was not able to give any sufficient explanation for the genuine requirement as the same was unnecessarily done by the hospital to help the complainant for availing claim.  The opposite parties have acted only in terms of policy conditions. There is no deficiency in service from the side of first opposite party. Hence the complaint may be dismissed with cost.

       3.  Second opposite party in their version has stated that the complaint is not maintainable either in law or on facts. The complainant availed a Health Care Policy Viz. Indian Overseas Bank Health Care Plus Policy. The complainant admits that the second opposite party is only an intermediary.  The complainant also admits that, the policy was renewed by the second opposite party from the account of the complainant on instruction. The power to redress the grievances of insurance policy holders is vested with Insurance Ombudsman. Hence this complaint is not maintainable before this Commission against the second opposite party. IOB Health Care Plus Policy is a contract entered into between the complainant and the first opposite party. As per the stipulation in the said policy the information furnished by the petitioner in the proposal form and the declaration signed by the petitioner forms the basis of this contract. No contract is existing between the petitioner and the second opposite party. There is no averment against the second opposite party for the rejection of the claim by the first and third opposite party. The first and third opposite party rejected the claim of the complainant as per stipulation in the rejection clauses of the contract. The complainant had not suffered any monetary loss or mental agony due to any act of Commission or omission on the part of the second opposite party. There is no deficiency in service on the part of the second opposite party as alleged. The second opposite party is not liable to compensate the complainant. Hence the complaint may be dismissed with cost to the second opposite party.

Issues to be ascertained:

1. Whether there is any deficiency in service from the side of opposite parties 1to 3?
2. Whether the complainant is entitled to get the reliefs?

Issues (i) & (ii):- Both these issues are considered together for the sake of convenience. The complainant has filed affidavit in-lieu of chief examination and was examined as PW1 and has produced 10 documents which were marked as Exts. P1to P10. The first opposite party was examined as DW1. One witness was examined as DW2 from the side first opposite party. The complainant & opposite parties 1 and 2 filed argument notes.

           4. The main allegation raised by the complainant is that his medical expenses incurred for the treatment was repudiated by the third opposite party without any valid reason. The first opposite party has taken the contention that the claim was repudiated as per clause No.12 of the policy. On going through clause No.12 in Ext P1 it can be seen that ‘’ what we exclude: Any expense on treatment of insured person as outpatient in a Hospital’’. But it can be seen from Ext P2 series that the complainant was admitted as inpatient on 4/6/2013 and was discharged on 5/6/2013. Further it was deposed by DW2 during chief-examination that 2013 കാലഘട്ടത്തിൽ താങ്കൾ ഈ patient നെ treat ചെയ്‌തിട്ടുണ്ടോ (Q) ഉണ്ട് (A) patient നെ 04/06/2013 ൽ  admit ചെയ്യുകയും   05/06/2013 ൽ discharge ചെയ്യുകയും ചെയ്തു (Q) Ext.P2 പ്രകാരം 03/06/2013  ലാണ് patient കണ്ടതായി  മനസിലാവുന്നത്. 05/06/2013 ലാണ്  discharge ആയതായി കാണുന്നത് . So it is admitted by the doctor (DW2) that the complainant was admitted in the hospital. The complainant has claimed Rs 6500/- as per Ext.P5.But it can be seen from Ext P5 that the scan was conducted on 3/6/2013, which is prior to the admission of the complainant in the hospital, hence it cannot be allowed.

          5. Another contention raised by first opposite party is that the hospital with an intention to help the complainant has unnecessarily admitted the complainant for availing the claim. It has been deposed by DW1 that  പരാതിക്കാരൻ  treatment എടുത്ത  hospital ഞങ്ങളുടെ  company empanel ചെയ്തിട്ടുള്ള hospital ആണ്.  Treat  ചെയ്ത doctor panel  ൽ ഉള്ളതാണോ  (Q) അതെ (A). So it is clear that the S.K.Hospital is an empanelled hospital of first opposite party and the doctor was also in their panel. If the doctor has done anything with a view to help the complainant for getting the claim, it is the duty of the first opposite party to take necessary action against the hospital & the doctor. Second opposite party bank is only a facilitator, hence complaint against second opposite party is not maintainable.

              6.   In this case, the claim was rejected by opposite party No.3- TPA, as per Ext P10. Admittedly, the complainant was insured with opposite party No.1. Opposite party No.3-TPA is acting like agents, which identify the Preferred Provider Network (PPN) list of hospitals, which offer cashless claim settlement. The same is done on behalf of the Insurance Company. TPAs have no authority to reject the claim. Such power lies, exclusively with the Insurance Companies. The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. Their only job is to serve and process the claims. Accepting and rejecting the claims at their own by the TPAs is illegal, arbitrary, null & void and is not sustainable in the eyes of law.

             7. So we find that there is deficiency in service from the part of opposite parties 1 & 3, hence opposite parties 1 & 3 are liable to compensate the complainant.

              In the result, the complaint is partly allowed. The first opposite party is directed to pay an amount of Rs.1610 to the complainant along with 9% per annum from 5.6.13 till the realization and third opposite party is directed to pay Rs 5000/- as compensation to the complainant, as opposite party No.3. has exercised the jurisdiction without any authority and opposite parties 1 & 3 are jointly & severally directed to pay Rs 2500/- towards the cost of proceedings within one month from the date of receipt of this order, failing which the amount of Rs.5000/- carries interest @ 9% per annum from the date of order till realization.

                  A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

                      Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Court, this the 28^th day of January 2022.

                                                                                          Sd/-

P.V.JAYARAJAN : PRESIDENT

                                                                                           Sd/-

PREETHA G NAIR : MEMBER

                                                                                            Sd/-

Be/

List of witness for the complainant

PW1                      - Sanu.S.S

Exihibits for the complainant

Ext.P1         - Copy of IOB Health Care Pulse Policy dated 08.12.2012

Ext.P2         - Copy of the medical records (Admission note)

Ext.P3           - Copy of discharge bill on 05.06.2013

Ext.P4         - Copy of report of MRI

Ext.P5         - Copy of MRI bill dated 03.06.2013

Ext.P6         - Copy of e-mail dated 15.07.2013

Ext.P7         - Copy of e-mail dated 31.07.2013

Ext.P8          - Copy of letter on 20.09.2013

Ext.P9         - Copy of notice dated 24.01.2014

Ext.P10       - Copy of the rejection letter of the claim from the third opposite party  dated 20.02.2014

List of witness for the opposite parties       

DW1           - Dibumon

DW2           - Dr.Sreejith Babu.V.S

Exhibits for the opposite parties                 NIL

Court Exhibits                                            NIL

                                                                                Sd/-

                                                                           PRESIDENT