By Jayasree Kallat, Member:
The petition was filed on 27-10-2006. Complainants Celin James and E.S. James have filed this petition under Sec. 12 of the Consumer Protection Act alleging deficiency in service on the part of the opposite parties. The second complainant had availed a medi claim policy from the second opposite party covering the period from 27-9-2006 to 26-9-2007. The policy covers treatment expenses of the policy holder and his family members. The complainant was made to believe that if admission of any of the beneficiaries under the policy in any of the approved hospitals of the first opposite party the treatment expenses will be met by the opposite party. The opposite parties had collected 5% extra premium as service charge. The first complainant was admitted in Malabar Institute of Medical Sciences at Calicut, On 10-10-2006. MIMS hospital is an approved hospital of the opposite party. The first complainant was admitted due to severe back pain. Doctor advised to admit the patient and treatment started. Complainant had immediately given intimation to the second opposite party. First complainant was discharged from the hospital on 12-10-2006. The complainants were under the impression that the opposite parties will meet the treatment expenses in the hospital. But on discharge from the hospital the complainants were required to make payment of the hospital bills as there was no conformation from the opposite parties in this regard. The complainant had to remain in the hospital till the payment is made. Complainants had to wait from 5 P.M. to 7 P.M. but they did not get any information regarding the payment from the opposite parties. So the second complainant had to arrange cash at odd hours in order to make hospital bills payment. Complainants had to suffer mentally and financially due to the negligence of the opposite parties. Hence this complaint is filed seeking compensation.
O.P.1 filed a version denying all the allegations in the complaint except those that are expressly admitted. First opposite party is a third party administrator who is licensed, governed and regulated under the insurance regulatory and development authority regulations 2001. O.P.1 admits that complainant No.1 was admitted in the MIMS hospital on 10-10-2006 and discharged on 12-10-2006. O.P.1 received a requisition for cashless facility from the 3rd opposite party hospital on 12-10-2006 at around 13:11 hours ie. 1.11 P.M. Upon scrutiny of the requisition form it was found that the information available was in sufficient to authorize any amount to the hospital for the treatment as there was no mention of the line of treatment given to the complainant. The additional information sought for by the opposite party-1 was furnished by the hospital at around 6.28 P.M. and the requisition for free authorization was approved by this opposite party at around 6.50 P.M. At around 7.03 P.M. on 12-10-2006 O.P.1 sent a letter of approval to the hospital. O.P.-1 submits that the time taken for processing the request for cashless facility was reasonable as additional information was required for processing. The request was granted immediately on getting the additional information. There has been no delay or deficiency of service on the part of O.P.1. If O.P.1 had received full information at the time of request all the complications could have been avoided. The complainant No.1 was intimated regarding the reimbursement of Rs.6000/- on 18-11-2006. O.P.1 is not liable for the delay and the alleged mental agony suffered by the complainants.
Opposite party-2 filed version denying the averments in the complaint except those that are admitted. O.P.2 admits that on 25-9-2006 a medi claim insurance policy was issued to the complainant covering the period from 27-9-2006 to 26-9-2007. As per the policy the insureds were entitled for the expenses that incurs as hospitalization expenses for medical or surgical treatment at hospitals. This opposite party was not informed about the claim by the complainant. The allegation that O.P.2 had collected 5% extra premium as service charges and had assured additional service is denied by O.P.2. As per the policy agreement between O.P.1 and O.P.2 in case of any claim the notices for communication shall be delivered at the 3rd party administrator ie. O.P.1. As per information it is revealed that the pre authorization request for cashless hospitalization facility from the hospital reached O.P.1 very late and also information provided was in sufficient. So O.P.2 could not arrive at rough estimate for authorizing any amount to the hospital. All these complications could have been avoided if the complainants had been cautious in getting informed the opposite parties about the information immediately. The inconvenience suffered by the complainants is due to their negligence only. O.P.1 had settled the hospital amount for Rs.6000/-. The complainant can claim the amount from the hospital. There was no negligence or deficiency in service on the part of O.P.2. Hence O.P.2 prays to dismiss the petition with cost to O.P.2.
O.P.3 was included in the party array as supplemental opposite party. O.P.3 appeared before the Forum and filed a version denying the allegations in the complaint except those that are expressly admitted. O.P.3 is an unnecessary party. O.P.3 admits that the first complainant came to the O.P.3 hospital on10-10-2006 with complaints of severe back pain. The complainant was admitted in the hospital as inpatient. Second complainant had informed the opposite party that they are covered under the medi claim insurance policy issued by the second opposite party for cashless treatment. Complainants had asserted that due intimation was given to the opposite parties for rendering cashless treatments to the patients by 3rd O.P. required the confirmation from the side of insurer. Till the time of discharge O.P.3 did not receive any confirmation from first O.P. As no confirmation was received from the side of first opposite party till the time of discharge O.P.3 was constrained to request the complainant to make the payment. There after O.P.3 received confirmation from the first opposite party. Immediately 3rd O.P. had contacted the complainants and intimated about the facts. The second complainant had collected the amount through cheque. There was no negligence as alleged by the complainant. Hence O.P.3 prays to dismiss the petition.
The only point for consideration is whether the complainant is entitled to get any relief.
Second complainant the husband of the first complainant was examined as PW1 and Ests. A1 to A5 were marked on complainant’s side. RW1 was examined and B1 to B6 were marked on O.Ps side.
The case of the complainant is that he had joined a medi claim policy of O.P.2. which covers treatment expenses from approved hospitals of first opposite party. First complainant was admitted in the O.P.3 hospital on 10-10-2006 due to severe back pain. The doctor advised treatment as inpatient and admitted her in the hospital. According to the complainant information was immediately given to the second opposite party. the second complainant was discharged from the hospital on 12-10-2006. But the complainants did not get the cashless facility. They had to pay the hospital bills as there was no confirmation from the first opposite party. The complainants had to remain in the hospital on the day of discharge until 7 P.M. According to the complainants they had to suffer because of the negligence from the part of the opposite parties. Even though the complainants had a medi claim policy by which they could have availed cashless hospitalization, the complainants did not get this facility. Complainants had to arrange money hastily as it was unexpected. Complainants had to make arrangements for paying the bills before leaving the hospital. The complainants agree that opposite parties had reimbursed the amount later. The case is filed before the Forum because of the unnecessary sufferings they had to undergo due to the negligence of the opposite parties. Opposite party-1 in their version had stated in para-4 that O.P.1 had received requisition for cashless facility from the hospital on 12-10-2006 at around 13:11 hours ie.1.11 P.M. Upon scrutiny of the requisition form it was found that the information available in it was insufficient to authorize any amount to the hospital for the treatment as there was no mention of the line of treatment given to complainant No.1 based on which the opposite party-1 could have processed the same. Additional information with regard to the requisition or copy of the discharge summary was sought from the hospital at 5.41 P.M. From the version of O.P.1 it reveals that the additional information from the hospital was received at around 6.28 P.M. and sent a letter of approval at around 7.03 P.M. on 12-10-2006. This delay in processing could have been avoided if the full information had been furnished by the hospital in the first stage itself. It is true that the opposite parties had reimbursed an amount of Rs.6000/- at later stage. Here the point to be considered is if a person takes a medi claim policy to avail cashless facility for hospitalization whether he should get the facility on time. In this case it has been brought out from the evidence and records and statement of opposite parties that the facility for which the complainants had paid money and taken the policy was not made available at the proper time. Hence we are of the opinion that the complainants are entitled for compensation.
According to the version of the opposite parties it is clear that O.P.3 had failed to give the correct information, so that the complainants could have availed the facility on time. In such a circumstance the Forum is of the opinion that O.P.3 is liable to pay the compensation to the complainants.
In the result petition is allowed and O.P.3 is directed to pay an amount of Rs.3000/- as compensation and Rs.500/- as costs to the complainants within one month from the date of receipt of copy of the order.
Pronounced in the open court this the 6th day of April 2011.
Date of filing:27.10.2006.
SD/-PRESIDENT SD/-MEMBER SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
A1. Photocopy of policy of the New India Assurance Company Ltd.
A2. Copy of the ID card issued by OP. No.1
A3. Copy of the hospital bill dtd. 12.10.2006.
A4. Hospitalisation benefit policy of the new India assurance company Ltd
A5. Hand book of Medi Assist India Pvt Ltd.
Documents exhibited for the opposite party:
B1. Request for cashless Hospitalisation claim form for medical insurance policy.
B2. Request for further information for claimant of Medi Assist India Pvt Ltd.
B3. Photocopy of medicine details.
B4. Photocopy of patient bill
B5.Discharge summary of MIMS Hospital
B6.Approval letter dt.12.10.2006 of Medi Assist.
Witness examined for the complainant:
PW1.James. E.S.(Complainant)
Witness examined for the opposite party:
RW1.Asok kumar, Sreelakshmi,Eroor. (S)PO, Thripunithura.
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
