BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SMT. PREETHA G. NAIR                        : PRESIDENT (I/C)

SRI. VIJU V.R                                           : MEMBER

C.C. No. 43/2013 Filed on 30.01.2013

ORDER DATED: 31.01.2020

Complainants:

1. P.R. Sabapathy, E/78 B, Sasthri Nagar, Karamana, Thiruvananthapuram-695 002.
2. P. Geetha, W/o Sabapathy,            ..do..                     ..do..

Addl. Complainants :

3. Sowmya S., D/o Sabapathy,          E11, Xancus, Sasthri Nagar, Karamana, Thiruvananthapuram-2.
4. Prasanth S., S/o Sabapathy,                    .do..                      ..do..

                   (By Adv. Vazhuthacaud R. Narendran Nair)

Opposite parties:

1. M/s United India Insurance Co. Ltd., Divisional Office II, Malankara Church Building, Palayam, Thiruvananthapuram-695 033 represented by its Divisional Manager. 

2. M/s TTK Healthcare TPA Private Ltd., 1^st Floor, Mareena Building, M.G. Road, Ernakulam, Kochi-682 016 represented by its Managing Director.

3. M/s Meditrina Hospitals Pvt. Ltd., T.C. 2/1566, Pattom, Thiruvananthapuram-4 represented by its Managing Director Dr. N. Prathap Kumar.

(By Adv. C.R. Sudheesh for 3^rd O.P)

This case having been heard on 14.11.2019, the Forum on 31.01.2020 delivered the following:

ORDER

SMT. PREETHA G. NAIR : PRESIDENT (I/C)

The case of the complainants is as follows:  The 1^st complainant accompanied by the 2^nd complainant on 11.06.2012 approached the 3^rd opposite party with some chest discomfort.  The Consultant Cardiologist Dr. Prathap Kumar who was also the Managing Director of the 3^rd opposite party advised urgent Angioplasty (CAD/CAG) procedure for the 1^st complainant.  He was admitted in the hospital as per M.R. No. 1556/2012.  The 1^st complainant explained all the details known to him before the doctor concerned about the ailments including previous surgery he had undergone for hernia in 2006.  The complainants also revealed that they are holding a valid medical insurance policy with the 1^st opposite party with policy No. 101400/48/11/4100003125 valid from 24.02.2012 to 23.12.2013.  The 3^rd opposite party agreed to provide cashless treatment to the 1^st complainant under the said medical insurance policy.  It was informed from the hospital that the complainants are entitled for cashless treatment and therefore no need to pay any amount during hospitalization period and also that the insurance company will reimburse the entire treatment expenses incurred on presenting the bill.  After having been admitted in the hospital, CAD/CAG procedure was done on 14.06.2012 and he was discharged on 16.06.2012.  The discharge bill dated 16.06.2012 for Rs. 2,12,953/- was issued to the complainants.  At the time of discharge irrespective of the insurance coverage and contrary to the assurance given at the time of admission, the hospital authorities compelled the complainants either to clear off the bill in cash.  There arose a dispute and finally they agreed to discharge the 1^st complainant after receiving a post dated cheque.  The hospital authorities promised to the complainants that they will not present the cheque for collection and will be kept only for accounting purposes and the same will be returned as and when the policy amount is collected from the insurance company.  Based on the said assurance, the 2^nd complainant issued a cheque for Rs. 2,05,000/- bearing No. 392345 dated 16.07.2012 drawn on the State Bank of Travancore, Vellayani Branch.  The 2^nd complainant issued the cheque on the belief that the hospital authorities will keep the same only for accounting purpose and will be returned after the insurance claim is received.  The 1^st complainant submitted claim form dated 07.07.2012 to the 2^nd opposite party along with a medical certificate dated 07.07.2012 issued by the Consultant Cardiologist with the 3^rd opposite party Dr. Prathap Kumar.  But by letter dated 30.08.2012 the 1^st opposite party rejected the claim put forward by the 1^st complainant on a finding that the 1^st complainant was having CAD/CAG since 2006.  The claim was rejected by the insurance company only due to a false and mistaken entry in the medical certificate issued by the 3^rd opposite party.  The 1^st complainant never had the past history of CAD/CAG.  The complainants never gave such information to the hospital or to the doctor concerned.  The complainants are not aware of such information and ignorant of the fact from where the hospital authorities got such wrong information.  Immediately thereafter the complainants requested the 3^rd opposite party to get the mistake corrected as early as possible so as to facilitate the insurance company to process the claim.  But unfortunately the 3^rd opposite party took a negative attitude in the matter.  It is the primary responsibility on the part of the 3^rd opposite party to rectify the mistake committed by them.  The 3^rd opposite party without inclined to correct the mistake, is on a hasty move to collect the money from the complainants.  Sensing the clandestine attempt by the hospital authorities, the complainants issued a stop memo to the bank.  But the 3^rd opposite party presented the cheque for collection before the bank and issued a notice dated 03.09.2012 to the 2^nd complainant to initiate legal proceedings.  On 19.09.2012 the 3^rd opposite party in collusion with the bank made an attempt to take money from the account of the 2^nd complainant.  The timely intervention of the complainants defeated this illegal attempt.  Thereafter the 3^rd opposite party filed O.S. No. 1291/2012 before the Hon’ble Sub Court, Trivandrum and obtained an exparte order of attachment on the bank account of the 2^nd complainant.  The 1^st opposite party rejected the claim simply based on a false entry in the medical certificate.  These complainants now strongly believe that there is a collusion between the 1^st and 3^rd opposite parties which amounts an unfair trade practice.  The 1^st complainant, being a senior citizen suffered huge financial loss apart from serious mental agony.  All the actions of the opposite parties in this regard amount to unfair trade practice and serious deficiency in service.  The 1^st opposite party is grossly unjustified in repudiating the claim.  The complainants issued a lawyer’s notice dated 15.10.2012 to the 3^rd opposite party calling upon to correct the mistake committed by them so as to obtain the claim amount.  Despite receipt of the said notice, the 3^rd opposite party neither sorted out the issue nor sent any reply.  Hence this complaint.    

The 1^st opposite party filed version contending as follows:  The complaint is not maintainable either in law or on facts.  The features, restrictions, limits and benefits of the aforesaid policy have been clearly mentioned in the prospectus and policy.  The complainant suppressed the material facts and hence this is a clear abuse of process of law.  The 1^st opposite party had issued a medi claim policy for the period from 24.02.2012 to 23.02.2013 with inception date 23.02.2009 subject to the terms and conditions envisaged in the policy and prospectus.  As per the terms and conditions of the policy, non-disclosure of any pre-existing ailments and all the material facts thereof entail rejection of any claim.  The 1^st complainant had previous history of cardiology ailment and was under treatment for the same since 2004 duly certified by the doctor who had treated him.  Hence non-disclosure of this pre-existing ailment and the material facts thereof at the time of taking the medi-claim policy resulted in the rejection of the claim of the complainant as per the terms, conditions and exclusion clause of the policy.  This opposite party denies knowledge about any agreement purportedly made by the 3^rd opposite party with the 1^st complainant regarding permission of cashless treatment to him under the aforesaid policy.  This respondent also denies having any knowledge about the litigation pending before the Hon’ble Sub Court, Thiruvananthapuram between the complainants and the 3^rd opposite party regarding return of the cheque issued by the 2^nd complainant and the resultant execution proceedings before the court.  The complainants themselves admit in the complaint that the 3^rd opposite party had mentioned about the pre-existing CAD/CAG ailment of the complainant since 2006 in the medical certificate issued by them.  The opposite party does not commit any unfair trade practice as alleged by the complainant.  There is also no deficiency in service on the part of the opposite party and the opposite party is no way bound to pay any amount or compensation to the complainant.  Hence the complaint may be dismissed with cost to this opposite party. 

2^nd opposite party was set ex-parte. 

The 3^rd opposite party filed version contending as follows:   The complaint is not maintainable under law, facts and equity.  It is true that the 1^st complainant initially visited the 3^rd opposite party’s hospital on 22.05.2012 with a complaint of shortness of breath, climbing uphill, able to walk for 5 kms on level ground without any discomfort and had CAG in 2006 from Sree Chithira Thirunal Institute of Medical Science and Technology and in support of the same 1^st complainant showed some medical records pertaining to the CAG which he underwent.  Further the 1^st complainant was specifically advised to undergo the procedures of CAD and CAG for getting release from the clutches of illness, but he turned down the medical advice.  But on 11.06.2012 the 1^st complainant approached this opposite party’s hospital with the same complaint and the 1^st complainant informed his case history to the duty doctor including the history of CAG in the year 2006-SVD 50%.  The 1^st complainant also disclosed the duty doctor that he had a previous operation with regards to hernia right side in the year 2007.  Accordingly he was admitted in the hospital and underwent CAG on 14.06.2012 and on the same day it was found that he was suffering from OM1 90% disease and also found LAD and LCS has broader line disease.  Accordingly angioplasty was conducted on the 1^st complainant and finally he got discharged on 16.06.2012 with excellent TIMI III flow attained/no thrombus/no edge, in the sense his complete ailments was discarded and removed in the angioplasty conducted by this opposite party with a further advice of continue medical management.  At the time of admitting the patients this opposite party will only inquire whether they are covered by any insurance policy.  But at no point of time this opposite party had informed the complainant he is entitled to cashless treatment because the insurance claim will normally be adjudicated by the 3^rd party advisors of the insurance company and usually the hospital will issue a medical certificate to the insurance company by providing required material as disclosed to the hospital authorities by the insured persons.  It is true that CAD/CAG procedure was done on 14.06.2012 by this opposite party.  It is the bounden duty and liability of the insurer to inform his insurance company/agent for getting the coverage within the time stipulated by the policy conditions.  This opposite party can only provide the medical certificate by the doctor who had treated the patient.  It is true that this opposite party had issued a bill.  Since the 1^st and 2^nd opposite party has not considered the claim raised by the 1^st complainant, this opposite party insisted for the payment for the treatment covered.  Accordingly the 2^nd complainant issued cheque for Rs. 2,05,000/- dated 16.07.2012.  The further averment to the effect that the hospital authorities made believe the complainant that the cheque will be kept with them for the accounting purpose and will be returned once the insurance company will approve the claim and pay the amount towards the treatment is absolutely false.  At the time of the issuance of the cheque, the complainants were fully aware of the fact that the insurer can approach the insurance company by sending a claim for consideration of reimbursement within the time frame fixed in the policy condition.  At the time of issuance of the cheque, the complainants made believe this opposite party that they will set right the dispute within one month’s time with the insurance company and in case the company repudiates the claim, the complainants will pay the amounts, for which only the cheque mentioned therein is issued.  The claim of the 1^st complainant was rejected by the 2^nd opposite party on 16.06.2012.  Thereafter the 1^st complainant issued a letter on 03.07.2012 and therein requested this opposite party to provide data’s enabling the 1^st complainant to avail the insurance coverage in the sense, forward the medical treatment certificate by suppressing the factum of 1^st complainant’s past history of CAG and further requested to recall the discharge summary provided to 2^nd opposite party.  Since the request was illegal, unfair and improper, this opposite party turned down the same.  That is why this opposite party is also made a party in this proceedings.  It is true that this opposite party filed O.S. 1291/2012 for getting a decree to realize the money covered by the cheque aforesaid.  The repudiation of claim is a dispute between the complainants and opposite parties 1 & 2.  This opposite party is an unnecessary party.  This opposite party has not committed any unfair trade practice or deficiency in service.  The complainant does not have a case of medical negligence or any improper service availed by him from this opposite party.  This opposite party is only expected to provide relevant and correct datas to the insurance companies as available in the medical records.  Any deviation from the above norms are illegal and improper.  Hence prayed for dismissal of the complaint with heavy cost. 

2^nd complainant filed chief affidavit and documents.  After the death of 1^st complainant, complainants 3 & 4 were impleaded and 3^rd complainant filed chief affidavit as the daughter of 1^st and 2^nd complainants.  But the complainant is not present for cross examination and for making the documents.  Thereafter 1^st opposite party filed chief affidavit along with documents.  Ext. D1 marked from the side of 1^st opposite party.  3^rd opposite party not filed chief affidavit.   

Issues to be considered are:

1. Whether there is any deficiency in service on the part of opposite
2.  

(ii)      If so, what is the relief and cost?    

Issues (i) & (ii):- We perused the relevant documents on record.  2^nd complainant is the wife of 1^st complainant.  But the 2^nd complainant or her daughter not present for cross examination.  1^st opposite party present for cross.  Admittedly 1^st and 2^nd complainants had a valid insurance from 24.02.2012 to 23.02.2013 from 1^st opposite party.  The discharge bill No. 1839 dated 16.06.2012 for Rs. 2,12,953/- was issued to the complainants 1 & 2.  According to 1^st opposite party non-disclosure of the pre-existing ailment and the material facts thereof at the time of taking the medi-claim policy by the complainants resulted in the rejection of the claim.  The 1^st opposite party stated that 1^st complainant had previous history of cardiology ailment and was under treatment for the same since 2004 and it was duly certified by the doctor who had treated him.  But 1^st opposite party had not produced evidence to show that at the time of taking the insurance 1^st complainant had pre-existing disease.  The complainants stated that he had undergone treatment for hernia in 2006.  The complainants had not produced documents and marked for their evidence.  The 3^rd opposite party admitted that they filed O.S. 1291/2012 for getting a decree to realize the money covered by the cheque.  The complainants not produced documents or evidence to show that 1^st complainant had no pre-existing disease.  The 3^rd opposite party filed O.S. 1291/2012 before the Hon’ble Sub Court, Trivandrum and obtained an ex-parte order of attachment on the bank account of 2^nd complainant.  The complainants had not produced evidence to show the case pending before the Sub Court.  During the pendency of the complaint, the 1^st complainant died and 3^rd and 4^th complainants were impleaded as legal heirs.  But the complainants not present for cross examination.  The complainants had not produced evidence to prove their case.  Also the complainants not present for cross examination of 1^st opposite party.  Hence the complainants miserably failed to prove their case. 

In the result, the complaint is dismissed. 

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 Forum, this the 31^st day of January 2020.   

        Sd/-

PREETHA G. NAIR  : PRESIDENT (I/C)

       Sd/-

                                                                        VIJU V.R                               : MEMBER   

jb        

C.C. No. 43/2013

APPENDIX

  I      COMPLAINANT’S WITNESS:

                             NIL

 II      COMPLAINANT’S DOCUMENTS:

NIL  

III      OPPOSITE PARTY’S WITNESS:

                             NIL

 IV     OPPOSITE PARTY’S DOCUMENTS:

          D1     - Copy of policy schedule

                                                                                                      Sd/-

PRESIDENT (I/C)

jb