SMT.MOLYKUTTY MATHEW : MEMBER

        This  is a complaint filed by the complainant U/S 12 of the Consumer Protection Act 1986  for an order directing  each of the  opposite parties to pay  Rs.1,00,000/- to the complainant towards compensation for the hardship and mental agony  suffered by him for the deficiency of service on their part.

The case of the complainant in brief:

    The  complainant  is an SB account holder of 4^th OP.  The 4^th OP informed the complainant that the health care policy for the needs of the existing and potential customers and it was a co-branded medi care policy with 1^st OP.  Then the complainant took a policy as  No.0726002815P111061962 for the  period from  21/12/2015 to 20/12/2016.  Then  OP issued a certificate to that effect.  The insurance amount will be collected by 1^st OP through 4^th OP. The 1^st OP is having tie up with a list of hospitals to provide cashless claim to the policy holders and 3^rd OP is the hospital which is  opted by the complainant. 2^nd OP is the  TPA agent of  1^st OP and in this cashless claim the 2^nd OP is authorised to pay the bill amount to the  hospital while the policy holder has been  admitted and incurred  bill amount.  Then the complainant was admitted in the hospital on 29/7/2016 and was discharged on 1/8/2016 at 12.51 p.m  At the time of discharge 3^rd OP issued a bill for Rs.4640/- to the complainant and demanded to pay the bill amount  immediately.  At the time of admission the complainant  represented the contract of policy and the mode of payment .  Moreover the complainant was getting SMS from 2^nd OP that they  have received an e mail ,fax from 3^rd OP on 1/8/2016 at 10.42 A.M for pre authorisation  Rs. 28,000/- for cashless claim No.13026212.  The complainant was discharged on 1/8/2016 at 12.51 P.M and he was forced to wait in the hospital corridor for about 7 hours.  The complainant was forced to pay the bill amount  for discharge from the hospital which he ought not to be  paid as per the terms of  policy. . The act of OPs the complainant caused much mental agony and financial loss.  So there is deficiency of service and unfair trade practice on the part of OPs.  Hence the complaint.

       After receiving the notice all OPs entered before the commission  and filed their written version. 1^st  OP contended  that the policy was obtained by the complainant  by suppressing his pre-existing diseases.  While taking policy the insured had the diseases of hypertension, nausea, giddiness and flashes in the eyes.  If the complainant would have disclosed about  his pre-existing diseases in the proposal form, the 1^st OP would  not have issued the policy.  As per the exclusion  clause, 4-1 , the company shall not be liable to make any  payment under  the subject policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of all diseases/injuries which are pre-existing when the cover incepts for the first time.  So there was no deficiency  of service  from the side of  1^st OP.  So  the complaint may be dismissed.

     3^rd OP contended that the complainant had undergone treatment from 3^rd OP and since the complainant wanted to avail cashless facility as per the insurance policy, the matter was referred to 2^nd OP with all the treatment documents and discharge bill for Rs.4640/- of the complainant to 3^rd OP.  But 3^rd OP refused the hospital discharge bill, because the complainant is not eligible for the cashless facility.  The complainant has committed breach of insurance policy and he was having pre-existing deceases  at the time of the inception of the insurance policy.  As per the  exclusion clause 4-1 of the policy and  are not liable to reimburse the medical expenses to the complainant.  So 3^rd OP had no option  to collect the bill amount towards the treatment given to the complainant from the  hospital .  The collection of the discharge bill of the  complainant may not be construed as an act of deficiency of service and 3^rd OP may be exonerated .

      As per the version of 4^th OP is that he is only a facilitator and with respect to the enforcement or claim under the policy  it has no role or liability.  This OP had duly complied with its duty of service under the scheme.  Hence there is no deficiency of service  on its parts and liability to  compensate.

      On the basis  of the rival contentions by the pleadings the  following  issues  were framed for consideration.

1. Whether there is  any deficiency of service   on the part of the opposite party?
2. Whether the complainant is entitled for any relief?
3. Relief and cost.

     The  evidence  consists of the oral testimony of PW 1 and  Exts. A1 to A7 were  marked.  On OP’s side Ext.B1 marked.

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 documents  Exts.A1 to A7 also marked on his  part to substantiate his case.  In Ext.A1 is the policy.  Ext.A2 is the discharge bill and Ext.A3 is the  lawyer notice.  In Ext.A4 to A7 are the reply sent by  OPs 1 to 4.  On 1^st OP’s side  also produced the policy and  marked as Ext.B1.  The complainant was discharged on 1/8/2016 at 12.51 P.M.  But he forced to wait the hospital  upto 1/8/2016 at 7.45 P.M.  So the complainant has got an SMS from 2^nd OP regarding the cashless claim.  But the OPs  not give the cashless benefit to complainant.  The act of  OPs the complainant caused much mental agony and financial loss.   1^st OP stated that as per Ext.B1 the exclusion clause 4.1 states that ,” the company shall not be liable to make any  payment under  the subject policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of all diseases/injuries which are pre-existing when the cover incepts for the first time.  But the complainant taken the policy for medi care policy and cashless claim also.  Moreover the complainant got SMS from 2^nd OP for preauthorization  Rs.28,000/- for cashless claim  No.13026212.  But the 1^st OP refused the claim.  The discharge bill as per Ext.A2 is  Rs.4640/- to  the complainant.  1^st OP is not examined the doctor  to prove the complainant’s disease.  So the 1^st OP  is liable to reimburse the amount to complainant .  Ops 2 to 4 are exonerated  and  there is no deficiency in  service against Ops 2 to 4.  We hold that there is deficiency of service on the part of  1^st opposite party only.  Hence the issue No.1 found in favour of the complainant and  answered accordingly.

Issue Nos.2&3:

        As discussed above the complainant had paid Rs.4640/- to hospital authorities as per the discharge bill.  But at the time of taking policy the TPA assured the  complainant that the medicare policy having cashless claim.  But the 1^st OP  is fails to do so .  According to the complainant the  1^st  OP is  directly bound to pay the discharge bill as per Ext.A2 for Rs.4640/- along with Rs.5000/- as compensation  for mental agony and cost.   Thus issue No.2&3 are also accordingly answered. 

          In the result the complaint is allowed in part  directing the 1^st  opposite party  to pay  the discharge bill of Rs.4640/- to the complainant along with Rs.5000/- as compensation for mental agony  and cost  of the complainant within  30 days of  receipt  of this order. Failing which the  complainant is at liberty to  execute  the  order as  per the  provisions  of Consumer Protection Act 2019.

Exts:

A1- Policy certificate

A2-Discharge bill

A3-Lawyer notice

A4to A7- Reply notice of OPs  1 to 4

B1- Policy

PW1-Suresh Babu Ponon- complainant

Sd/                                                         Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                        /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR