D.O.F:31/08/2019
D.O.O:11/04/2022
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.174/2019
Dated this, the 11th day of April 2022
PRESENT:
SRI.KRISHNAN.K : PRESIDENT
SRI.RADHAKRISHNAN NAIR.M: MEMBER
SMT.BEENA.K.G : MEMBER
Bino Joseph
Chennithala House,
Anandasramam. P.O
Mavungal : Complainant
Kasaragod (Via)
(Adv: P. Mohanan)
And
1. The Manager
Star Health and Allied Insurance Co. Ltd
Behind Axis Bank,
Near Police Station, Kasaragod. : Opposite Parties
2. Star Health and Allied Insurance Co.Ltd,
Sri Balaji Complex, 15,
White Road, Chennai – 600014
(Adv: C. Damodaran)
ORDER
SRI.KRISHNAN.K : PRESIDENT
The Facts of the case in brief is as follows:-
The complainant and his family joined the insurance scheme of Opposite Party. Its beneficiaries are himself, his wife and three children. Its duration was donation from 22/10/2018 till 22/10/2019. His minor daughter aged 14 year by name Devin Bino suffered so much of pain to his left leg knee. She was admitted in Father Muller’s Hospital Managalore, as an impatient and on 14/08/2019 under gone surgery. He claimed Rs.68565/- as hospital bill and Rs. 50,000/- for mental tension mental tension and litigation expenses. Hence the complaint.
2. The Opposite Party filed their written version. Insurance is admitted. They received the claim. Opposite Party demanded further details, hospital records, which are forwarded. Then it is understand that patient was on treatment with Homeopathic medication for few years ago and complaint of episodes of consciousness. Complainant did not approach with a claim with documents with original bills, receipts or other documents as required. And prayed to dismiss the complaint.
3. The complainant filed chief examination affidavit. Marked documents Ext A1 to A3. Ext A1 is the repudiation letter, Ext A2 is discharge bill, Discharge summary is Ext A3, Opposite Party produced Ext B1 to B5 documents. B1 is copy of the policy, Ext B2 is request for cashless hospitalization Ext B3 is query for details, Ext B4 is copy of denial letter, and Ext B5 request for cashless treatment. Opposite Party cross examined complainant in lengthy.
Considering the rival contentions, documentary as well as oral evidence following points arise for consideration.
a) Whether the denial of insurance policy benefits by Opposite Party is justifiable?
b) Whether there is any deficiency in service of Opposite Party? And whether complainant is entitled for compensation? If so for what reliefs?
5. The fact remains that Opposite Party admitted the policy claim also admitted except the fact that Opposite Party did not receive it in proper claim form but admit request for cashless insurance claim suggestion is made to Pw1 that claim with supporting documents are not submitted direct to the company for re-imbursement. Opposite Party did not dispute that she is not entitled to insurance benefits, no case that Opposite Party is not liable to re-imburse the claim is unenforceable for any other genuine reasons.
Now it is to be seen whether the insurance company was justified in pressing into service, the exclusion No: 4 of the policy terms and conditions to avail the claim. The answer is negative.
In the case titled IV (2014 (CPJ) 14 A (CL) HAR oriental Insurance co Ltd Vs Vivek Rekhan, the claim filed on the basis of the medical claim policy was repudiated by the insurance company on the basis of exclusion clause. The court held that the insurance company vaguely denied without pointing out as to in which manner and on which date terms and condition were supplied to the company. Therefore, unless the terms and conditions have been supplied to the complainant before taking a policy, exclusion clause cannot be enforced.
The undisputed facts are, the complainant availed a medi claim policy from the insurance company and thereafter was admitted to the hospital during the tenure of coverage of the insurance policy. The complainant paid an amount of Rs.68565/- to the hospital in lieu of medical expence which was claimed under the medi claim policy.
Therefore refusal by insurer to process and reimburse petitioners claim is unjustifiable and unreasonable. The object of the insurance policy is to cater to medical expenses incurred by the insured. That is the main purpose of the contract of insurance.
In a cashless policy the insurance company directly settle the bill with the health care institution, that is empanelled itself with the insurance company. A cashless medi claim is one such advantage that it offered today by most insures. It helps avoid the reimbursement formalities by taking care of the treatment cost. The cashless facility will be available only in net work hospitals. A company representative or TPA (Third party administrator) will be responsible for coordinating with the hospital and settling all the claim (both cash and cashless claims) between the insurance company, the hospital and policy holder.
In this case complainant claims that despite having a medi claim policy which promised cashless treatment, the insurance company had refused cashless payment and did not settle the claim. The Opposite party denied cashless treatment on the reason that required details are not produced which is not true.
The Opposite party has no case complainant is not entitled to the policy benefits for any valid since except not claiming reimbursement which is found to be not justifiable as above some complainant has claimed cashless policy benefits. Thus there is serious deficiency in service on the part of Opposite party. The complainant suffered mental tension and agony for which he is entitled to medical expense and compensation. Considering the nature and circumstances of the case a sum of Rs. 10,000/- is found reasonable and complainant is also entitled for cost of the litigation.
In the result complaint is allowed in part and Opposite party is directed to pay Rs. 68565/-towards till payment medical bills/claim with 6% interest from date of complaint compensation of Rs. 10,000/- (Rupees Ten thousand only) and litigation cost of Rs. 5000/- (Rupees Five thousand only) within 30 days of receipt of the order.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Repudiation letter.
A2- Discharge bill
A3- Discharge summary
B1- Copy of policy
B2- Copy of the request for cashless hospitalization
B3- Copy of the query on authorization Dt.15/08/2019
B4- Copy of the denial of pre authorization request for cash less treatment
B5- Denial of preauthorization request for cashless treatment
Witness Examined
PW1- Bino Joseph
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
