BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
DHARMAPURI AT KRISHNAGIRI
PRESENT: THIRU.S.ARUMUGAM,B.A.,B.L., PRESIDENT
TMT.K.KASTHURI,B.A.,B.L., MEMBER-I
THIRU.M.VISWABHARATHI, M.A.,B.L., MEMBER-II
C.C.NO.66/2010
DATED THIS THE TUESDAY 15th DAY MARCH OF 2011
N.Narayanan,
S/o. R.M. Narayanan,
#H275, TNHB, I Phase,
Krishnagiri – 635001. …Complainant
-Vs-
1.United India Insurane Co.Ltd.,
Senior Divisional Manager,
Divisional Office, M.M. Reddy Complex,
Old Bangalore Road,
Hosur – 635109.
2. TTK Health Care TPA Pvt.Ltd.,
Rep by its Manager,
146, “ Sri Saibab Towers,
Raju Naidu Road, Tatabad,
Coimbatore – 641012.
3. Manipal Hospital,
Rep. By its. Manager – Operational & HR,
Dalmia Board, Salem – Bangalore Highway,
Salem – 636012. …Opposite Parties
This complaint coming on 08/03/2011 for hearing before us, Mr. K.L.Samarasam, Advocate appearing for the complainant, and Mr.M.Jayakumar, Advocate appearing for the Opposite party Nos: 1 & 2, Dr. S.V.Joga Rao, Advocate appearing for the Opposite party No: 3, having heard the arguments, having perused the documents and having stood till this date for consideration this Forum pass the following:
ORDER
The Complainant seeks the compensation of Rs.6,00,000/- as against Opposite party Nos: 1 & 2, the compensation of Rs.6,00,000/- as against the Opposite party No: 3 and the cost of Rs.10,000/-
2. The allegations in the complaint are briefly as follows: The complainant was a mediclaim insurance holder of the Opposite party No: 1, administrated by the Opposite party No: 2, for the past 10 years. For the said insurance the complainant paid a sum of Rs.8,250/- as premium for the year 2009-10. By virtue of the said policy the complainant was eligible for cashless treatment to the extend of Rs.2,00,000/- per year and it was in force for the past year also from 13/10/2008 to 29/10/2009. During December – 2008 the complainant suffered from disease and on 02/01/2009 it was diagnosed by the Opposite party No: 3 as fissure. The Chief Doctor of the Opposite party No: 3 suggested the removal of fissure by operation to which the complainant agreed. The Opposite party No: 3 also accepted the health card and informed the complainant that he is eligible for cashless treatment. The Opposite party No: 3 further assured the complainant to arrange transport after discharge from the Hospital to the Salem town. He also informed the complainant the treatment including operation and medication would cost around Rs.15,000/- only. On 02/01/2009 itself the complainant got admitted as in-patient by 10.30 A.M. The Opposite party No: 3 took the complainant’s health card soon after the complainant was admitted and carried out necessary test for the operation. The complainant was informed by the Opposite party No: 3 that the operation will be conducted on 03/01/2009 at about 10.30 A.M and advised him not to take any food from mid-night onwards till the operation is over. On 03/01/2009 the complainant was on fasting as advised by the Opposite party No: 3 expecting that he will be taken to the operation theatre. But even after 12.00 noon he was not taken to the operation theatre. The complainant was a diabetic patient and he could not withstand hungriness. The complainant asked the Opposite party No: 3 why he was not taken to the operation theatre in time and told him about his vigorous appetite. The Opposite party No: 3 allowed him to take food at 1.00 P.M without stating the reason for the delay to conduct operation and asked him to ready for operation by 3.30 P.M. At about 3.30 P.M the complainant was taken to the operation theatre. Late in the evening, after gaining consciousness, the complainant again enquired the reason for the delay to conduct the operation. Then only the Opposite party No: 3 informed him that his health care card was rejected by the Opposite party No: 2 through fax on the ground that the amount shall not be payable in the first two years of taking the insurance policy. The complainant underwent immense mental agony and he was forced to call the Opposite party No: 2 several times. At last the Opposite party No: 2 responded the complainant’s call. The complainant made them clear that he was a policy holder for the past 10 years and the rejection of this health care card was unfair. On 05/01/2009 at about 12.52 P.M the Opposite party No: 2 faxed an approval letter only for Rs.8000/- and not for the full amount as asked for by the Opposite party No: 3. The Opposite party No: 3 after receiving the approval letter for Rs.8000/- started pestering the complainant to pay the remaining amount of Rs.25,425/- and said that till then he will be discharged. Thereafter the complainant with great difficulty arranged only for Rs.14,000/-, which he paid at 7.10P.M, and he was discharged by 7.30 P.M by giving discharge summary. Even after discharge the complainant was not allowed to leave the premises of the Hospital demanding the balance of Rs.11,425/- and thus the complainant was restrained to move out of the premises. He was made to sit in the chairs meant for visitors in lobby till 10.30 P.M. The complainant could not bear with the post operative pain and tiredness. He was not able to sit over there and asked the Opposite party No: 3 to allow him to go atleast to his friend’s house in Salem. The complainant gave the local grantee of his friend’s address. Thereafter the complainant was allowed to leave the Hospital at about 11.00 P.M with a condition that he should report back in the next morning itself and clear the balance. If at all the Opposite party No: 2 did not sanction the bill amount as asked for by the Opposite party No: 3, it is the issue between them governed by the terms and conditions. The Opposite party No: 3 should have sorted it out with the Opposite party No: 2. The Opposite party No: 3 treated the complainant inhumanly and very cheaply with put him to shame before the staffs and others. On 06/01/2009 the complainant went back to the Opposite party No: 3 premises and remained in the visitors lobby. The complainant’s son and wife were trying to arrange the rest of the money to be paid to the Opposite party No: 3. At about 4.00 P.M the Opposite party No: 2 faxed a letter to the Opposite party No: 3 approving the entire amount of Rs.33,425/- . After that, Rs.14,000/- paid by the complainant on 05/01/2009 was refunded to him and he was allowed to go home. It took nearly two months for the complainant to come out of the rut. The very purpose of the surgery was not served and the complainant is now again under going treatment for the same problem. On 14/03/2009 the complainant sent a notice to the Opposite party No: 2 and got a reply dated: 17/03/2009 to the effect that it was the lacunae on the part of the Opposite party No: 3 for not providing vital information. On 18/03/2009 the complainant wrote a letter to the Opposite party No: 2 seeking explanation for the rejection of the cashless treatment and later sanctioning partial amount and subsequently sanctioning the full amount. On 17/07/2009 the complainant sent a legal notice to the Opposite party Nos: 1 to 3. On 14/08/2009 the Opposite party No: 1 sent a reply stating that the Opposite party No: 2 did not do anything intentionally. The Opposite party Nos: 2 & 3 did not choose to reply to the legal notice. The pain and suffering of the complainant, due to the deficiency in service of the Opposite party Nos: 1 to 3, cannot be equated in terms of money. However, the complainant claims compensation of Rs.6,00,000/- from the Opposite party Nos: 1 & 2 and another sum of Rs.6,00,000/- from the Opposite party No: 3. Hence the complainant prays for the compensation of Rs.6,00,000/- from the Opposite party Nos: 1 & 2 for their deficiency in service, the compensation of Rs.6,00,000/- from the Opposite party No: 3 for the deficiency in service by virtue of inhuman ill-treatment and the cost of Rs.10,000/-.
3. The averments in the written version filed by the Opposite party No: 1 and adopted by the Opposite party No: 2 are briefly as follows: No allegation in the complaint is leveled as against the Opposite party No: 1. The absence of any averments, no cause of action could be made out as against the Opposite party No: 1. In the absence of any cause of action for deficiency in service, the complaint is liable to be dismissed as against the Opposite party No: 1. It is true that the complainant was a mediclaim policy holder of the Opposite party No: 1 for the past 10 years. For the past two years the Opposite party No: 2 have taken up servicing of policies of the Opposite party No: 1. The delay caused in approving the cashless treatment was only due to non-availability of the policy particulars of the previous years. It is the duty of the complainant to produce the entire policy particulars of the previous years when he submits his claim for cashless treatment. The mistake is only on the part of the complainant in not providing proper policy particulars to the Opposite party No: 2. It is the duty of the Opposite party No: 3 to receive all the particulars relating to the health card of the complainant before giving consent for his surgery by way of cashless treatment. Having prepared the complainant for surgery, it is atrocious on the part of the Opposite party No: 3 to make him wait till the sanction of the amount from the Opposite party No: 2. The Opposite party No: 3 should not have approached the Opposite party No: 2 at the eleventh hour for cashless treatment. The Opposite party Nos: 1 & 2 were not aware of the seriousness of the situation. It is false to state that the Opposite party Nos: 1 & 2 have committed deficiency in service. The surgery was planned on 03/01/2009. The Opposite party No: 2 received a fax message for cashless treatment. After denying the same on the same day by the Opposite party No: 2 due to non-availability of the previous policies, they sought for information regarding previous policies. On furnishing the details of the previous policies by the complainant, the Opposite party No: 2 approved immediately a sum of Rs.8000/- and Rs.33,425/- after verifying the previous policies. The complainant had never communicated to the Opposite party No: 1 prior to the legal notice dated: 17/07/2009. The Opposite party No: 1 has replied for the said notice on 14/08/2009 after getting necessary information from the Opposite party No: 2. The letter sent by the Opposite party No: 1 expressing regret for the inconvenience caused to the complainant will not amount to deficiency in service. In the absence of deficiency in service, no claim either damage or compensation could be sought for as against the Opposite party No: 1. Hence the Opposite party No: 1 prays for the dismissal of the complaint.
4. The averments in the written version filed by the Opposite party No. 3 are briefly as follows: The present complaint pertains to the denial of cashless facility by the third party administrator and the Insurance Company. There is no allegation as against the Hospital as far as the treatment is concerned. On 02/01/2009 the complainant visited the Opposite party No: 3 with the complaints of difficulty in passing motion and pain while passing motion for the past 6 months. He was a diabetic and hypertension for the last 5 years and was on medication. He was advised Colonoscopy to diagnose the problem. The complainant underwent colonoscopy and the report showed chronics fissure in ano with anal stenosis. He was advised lateral internal sphincterotomy and on obtaining consent the said procedure was conducted on 03/01/2009. His condition was fine both pre and post operatively. He was discharged on 05/01/2009 with an advice to come for a review with the treating Doctor at OPD. He was a mediclaim policy holder and had sent his request for cashless through the Hospital. However, the same was rejected. On request made by the complainant and considering his continuous policy renewal, his request was approved partly with a request to the Hospital authorities to collect the balance amount from the patient. Accordingly the balance amount of the total bill amount was to be collected from him after deducting the payment received from the TPA. The complainant was explained about the normal procedure followed by the Opposite party No: 3 to avail the cashless facility and also informed him about the approximate amount that may be incurred for the said treatment. He was not assured any transport or gave an impression that his request for cashless will be approved. Immediately after admission, a request for cashless facility was sent to the TPA with all the details. It is true that the procedure was scheduled on 03/01/2009 and he was advised not to take any food from mid-night till the procedure be completed. Initially the cashless request sent to the Opposite party No: 2 was rejected and the same was informed to the complainant and his relatives. Sincere efforts were made to get an approval from the Opposite party No: 2 by providing all the required documents like previous policy, renewal details, etc., and in the process the operation was delayed awaiting for clarity on the cashless claim approval. Since there was no positive response from the Opposite party No: 2 for quite some time, surgery was taken up even before the approval came through. The complainant needs to pay up if approval did not come through, was clearly indicated to him and the same was accepted by him orally. Only then he was taken up for surgery. Only on 05/01/2009 the Opposite party No: 2 sent its approval for an amount of Rs.8000/- with a note to the Hospital asking to collect the balance from the complainant. Accordingly, the Opposite party No: 3 have requested the complainant to pay the balance amount before discharge. This was as per the rules and regulations and the procedure followed by every Health Care provider. At no point of time the Hospital authorities have pressurized the complainant and it was only a request. The allegation that the complainant was allowed to leave the premises only after getting local guarantee of his friend, etc., is false. The Hospital authorities only requested to pay up the difference amount before discharge as per the standard procedure and the complainant did pay the difference amount and got discharged. The complainant was not treated inhumanly as alleged in the complaint. The staff and the Hospital authorities were polite and tried to explain to the complainant about the procedure followed by the Hospital. It is true that the Hospital authorities received the intimation approving the complainant’s claim for the entire amount towards Hospital charges and immediately refunded the amount collected from the complainant. It is true that the Hospital did receive a legal notice from the complainant. Since the authorities felt that there was nothing in the notice to be responded by the Hospital, a response was not sent to the complainant. The Opposite party No: 3 is not responsible or liable to pay the amount claimed by the complainant. Hence the Opposite party No: 3 prays for the dismissal of the complaint with costs.
5. In Proof of the allegations made in the complaint, the complainant filed proof affidavit and marked Ex.A1, the copy of the rejection letter dated: 03/01/2009 sent by the Opposite party No: 2,Ex.A2, the copy of the approval letter dated: 05/01/2009 sent by the Opposite party No: 2, Ex. A3, the copy of the receipt dated: 05/01/2009 issued by the Opposite party No: 3 for the payment of Rs.14,000/-, Ex.A4, the copy of the discharge summary dated: 05/01/2009 issued by the Opposite party No: 3,Ex. A5, the copy of the approval letter dated: 06/01/2009 sent by the Opposite party No: 2, Ex.A6, the copy of the letter dated: 14/03/2009 from the complainant to the Opposite party Nos: 1 & 2, Ex.A7, the copy of the acknowledgement from the Opposite party No: 2, for the receipt of Ex.A6, Ex.A8, the copy of the acknowledgement from the Opposite party No: 1, for the receipt of Ex.A6, Ex.A9, the copy of the reply dated: 17/03/2009 from the Opposite party No: 2, Ex.A10, the copy of the letter dated: 18/03/2009 from the complainant to the Opposite party No: 2, Ex. A11, the copy of the legal notice dated: 17/07/2009 from the complainant to Opposite party Nos: 1 to 3, Ex.A12, the copy of the acknowledgement for receipt of Ex.A11 from the Opposite party No: 1, Ex.A13, the copy of the acknowledgement for receipt of Ex.A11 from the Opposite party No: 2, Ex.A14, the copy of the acknowledgement for receipt of Ex.A11 from the Opposite party No: 3, Ex.A15, the copy of the reply dated: 14/08/2009 from the Opposite party No: 1, Ex.A16, the copy of the prescription dated: 06/08/2010, Ex.A17, the copy of the Health card and Ex.A18, the copy of the Insurance policy for the period from 30/10/2008 to 29/10/2009. In proof of the averments in the written version the Opposite party Nos: 1 to 3 filed proof affidavit. Opposite party Nos: 1 & 2 have not filed any documents. The Opposite party No: 3 marked Ex.B1, the copy of the admission form, Ex.B2, the copy of the discharged summary, Ex.B3, the copy of the History and physical examination, Ex.B4, the copy of the pre operative check list, Ex.B5, the copy of the Pre Anesthetic evaluation, Ex.B6, the copy of the Operation report, Ex.B7, the copy of the consent letter given by the complainant, Ex.B8, the copy of the consent for Anaesthesia Services, Ex. B9, the copy of the progressive sheet, Ex.B10, the copy of the Diabetic chart, Ex. B11, the copy of the Intake and Output chart,. Ex.B12, the copy of the Nurses record, Ex. B13, the copy of the Graphic (T.P.R) Chart, Ex.B14, the copy of the Blood pressure chart, Ex.B15, the copy of the Regular Drug Prescription, Ex.B16, the copy of the Pre Authorization request far, Ex.B17, the copy of the rejection letter dated: 03/01/2009 sent by the Opposite party No: 2, Ex.B18, the copy of the approval letter dated: 05/01/2009 sent by the Opposite party No: 2, Ex.B19, the copy of the approval letter dated: 06/01/2009 sent by the Opposite party No: 2 and Ex.B20, the copy of the consent for admission given by the wife of the complainant.
6. The points that arise for consideration in this complaint are:
1. Whether the allegation of deficiency in service is proved?
2. To what relief the complainant is entitled?
Point No : 1
7. The learned counsel for the complainant would contend that the complainant was a mediclaim insurance holder of the Opposite party No: 1, continuously for the past 10 years, and he was issued the Health card Ex.A17. On payment of regular premium the Opposite party No: 1 issued Ex.A18, the Health Insurance policy, for the period from 30/10/2008 to 29/10/2009. The complainant suffered difficulty in passing motion and also pain while passing motion during December – 2008 and on 02/01/2009 it was diagnosed by the Opposite party No: 3 as chornic fissure in ano with anal stenosis. The Opposite party No: 3 suggested for the removal of fissure to which the complainant agreed. On 02/01/2009 at 10.30 A.M, the complainant was admitted in the Hospital of the Opposite party No: 3 and soon after admission the complainant handed over the Health card to the Opposite party No: 3 to avail cashless treatment. The Opposite party No: 3 informed the complainant that he would be operated on 03/01/2009 at about 10.30A.M and advised him not to take any food from mid-night onwards till the operation is over. The complainant was observing fasting, as advised by the Opposite party No: 3, but he was not taken to the operation theatre even after 12.00 noon. Since he was a diabetic patient he could not withstand hungriness. When he enquired, the Opposite party No: 3, allowed him to have food at 1.00 P.M without stating the reason for delay for the operation. The Opposite party No: 3 asked him to be ready for the operation by 3.30 P.M. At about 3.30 P.M the complainant was taken for operation and he regained consciousness late in the evening. Then only he was informed that his Health care card was rejected by the Opposite party No: 2 as per Ex.A1. The complainant was forced to contact Opposite party No: 2 to inform that he was a policy holder for the past 10 years. Only thereafter on 05/01/2009 at about 12.52 P.M the Opposite party No: 2 approved Rs.8000/- alone as per Ex.A3. The Opposite party No: 3 insisted the complainant to pay the remaining balance amount of Rs.25,425/-. The complainant with great difficulty paid a sum of Rs.14,000/- by 7.10P.M as per Ex.A3 and he was discharged by 7.30 P.M. Evenafter discharge the complainant was not allowed to leave the premises of the Opposite party No: 3 and he was insisted to pay the remaining balance of Rs.11,425/-. He was made to sit in the chairs meant for visitors till 10.30 P.M. He was not able to sit over there and requested the Opposite party No: 3 to allow him to go atleast to his friend’s house in Salem and after giving local guarantee of his friend’s address the complainant was allowed by the Opposite party No: 3 to go out of the Hospital at about 11.00 P.M with a condition to report on the next day morning itself and clear the balance. The Opposite party No: 3 treated the complainant inhumanly and very cheaply. On the morning of 06/01/2009 the complainant went back to the premises of the Opposite party No: 3 and remained in the visitor’s lobby. The complainant’s son and wife were trying to arrange for the rest of the money to be paid. At about 4.00 P.M the Opposite party No: 2 approved the entire amount of Rs.33,425/- as per Ex.A5 and thereafter the Opposite party No: 3 refunded Rs.14,000/- paid by the complainant on 05/01/2009. Thereafter the complainant was allowed to go home. The complainant issued the legal notice Ex.A11 to the Opposite party Nos: 1 to 3 to which the Opposite party No: 1 alone replied stating that it was not the intention of the Opposite party No: 2 to delay the approval. Hence according to the learned counsel for the complainant, the Opposite party Nos: 1 to 3 committed deficiency in service. On the contra the learned counsel for the Opposite party Nos: 1 & 2 would contend that the delay caused in approving the cashless treatment was only due to the non-availability of the policy particulars of the previous years. It is the duty of the complainant to produce the entire policy particulars of the previous years while submitting his claim for cashless treatment. The mistake is only on the part of the complainant in not providing proper policy particulars to the Opposite party No: 2. It is also the duty of the Opposite party No: 3 to receive all the particulars relating to the Health card before giving consent for the surgery. There is no allegation as against the Opposite party No: 1. The Opposite party No: 2 have taken up servicing of the policies of the Opposite party No: 1 only for the past 2 years. On furnishing the detail of the previous policy, the Opposite party No: 2 had approved immediately a sum of Rs.8000/- and Rs.33,425/- after verifying the previous policies. According to learned counsel there was no deficiency in service on the part of the Opposite party Nos: 1 & 2. The learned counsel for the Opposite party No: 3 would contend that sincere efforts have been made to get the approval from the Opposite party No: 2 by providing all the required documents. The operation was delayed awaiting for clarity on the cashless claim approval. Since there was no positive response from the Opposite party No: 2 quite for some time, surgery was taken up. The complainant was clearly informed that if the approval did not come through he needs to pay up and the same was accepted by him orally. He was also informed about the approximate amount that may be incurred for the treatment and then only he was taken up for surgery. As per Ex. B18, the Opposite party No: 2 approved only Rs.8000/- and asked the Hospital to collect the balance from the complainant. As per the rules and regulations and also the procedure followed by the Health care provider the Hospital authorities requested the complainant to pay the balance amount before discharge. At no pint of time the Hospital authorities pressurized the complainant and it was only a request to make balance payment. The Hospital authorities requested to pay up the difference amount before discharge but he did not pay the difference amount and got discharged. The complainant was not treated inhumanly as alleged by the complainant. Once the hospital authorities received the entire payment as per Ex. B19, refunded the amount collected from the complainant immediately. Hence according to the learned counsel, there was no deficiency in service on the part of the Opposite party No: 3.
8. On 02/01/2009 the complainant was admitted in the Hospital of the Opposite party No: 3 to remove the fissure in ano. The operation was originally fixed at 10.30 A.M on 03/01/2009, as stated by the complainant, and the complainant was advised not to take any food from mid-night till the operation is completed. The complainant was admitted in the Hospital with the hope that he will be given cashless treatment since he was a mediclaim Insurance holder of the Opposite party No: 1, managed by the Opposite party No: 2, for which the complainant was issued the Health card Ex.A17. The complainant also handed over the Health card to the Opposite party No: 3 for the purpose of claiming cashless treatment at the time of his admission itself. Hence the complainant was having the knowledge that whatever services to be rendered by the Opposite party No: 3 will be paid service and not the free service. The expected cost of hospitalization was also mentioned in Ex.B16, the pre-authorization request form, to be filled by the complainant and the Opposite party No: 3, for claiming approval from the Opposite party No: 2. Admittedly when the complainant was on fasting since the mid-night on 02/01/2009 till 10.30 A.M on 03/01/2009, the time fixed for operation, the approval was not obtained from the Opposite party No: 2. The Opposite party No: 3 admits that the operation was delayed awaiting for clarity on the cashless claim approval. The claim was rejected by the Opposite party No: 2 by 1.00 P.M on 03/01/2009 as per Ex. A1 = Ex. B17. The complainant himself admits that he contacted the Opposite party No: 3 and enquired the delay for operation. He also informed the Opposite party No:3 that he being a diabetic patient could not withstand hungriness for which the Opposite party No: 3 allowed him to have food at about 1.00 P.M and asked him to be ready for operation by 3.30 P.M . Evenafter rejection letter Ex. A1 = Ex. B17 admittedly the Opposite party No: 3 conducted operation between 4.20 P.M and 4.45 P.M as per the entry in Ex.B5. Considering the facts and circumstances of this case, the said action on the part of the Opposite party No: 3, shows that the complainant could have the knowledge of the rejection letter and after obtaining his consent to pay the expenses of the operation, the operation was conducted between 4.20 P.M and 4.45 P.M. The delay for operation was to obtain payment guarantee without affecting the health of the complainant and without postponing the operation to some other date. Such an action on the part of the Opposite party No: 3 cannot be termed as deficiency in service. After completion of the operation on 05/01/2009 by 12.52 P.M, the Opposite party No: 2 approved a sum of Rs.8000/- as per Ex.A2 = Ex.B18. After giving credit to the said sum of Rs.8000/- the Opposite party No: 3 demanded the balance payment of Rs.25,425/- out of which the complainant was able to pay only Rs.14,000/- by 7.10 P.M on 05/01/2009 as per Ex.A3. On receipt of said sum the complainant was admittedly discharged by 7.30 P.M on 05/01/2009. The complainant says evenafter discharge he was not allowed to leave the Hospital premises till 10.30 P.M demanding the balance payment of Rs.11,425/-. However, later he was allowed to go with a condition to come on the next day morning itself and pay the balance. The Opposite party No: 3 was undoubtedly entitled to the total cost of Rs.33,425/- out of which Rs.8000/- was sanctioned as per Ex.A2 = Ex.B18 by 12.52 P.M on 05/01/2009 and Rs.14,000/- was paid as per Ex.A3 by 7.10 P.M on 05/01/2009. The complainant was bound to pay the balance sum of Rs.11,425/- even before discharge, but he was discharged and he was given time till next day morning. The said act of the Opposite party No: 3 shows the humanitarian approach made by him and it will not be termed as deficiency in service. On 06/01/2009 the complainant was unable to pay till 4.50 P.M and by that time the Opposite party No: 2 approved the total sum of Rs.33,425/- as per Ex.B19. Immediately thereafter, admittedly, the amount paid by the complainant viz., Rs.8000/- was refunded to the complainant. Hence we are of the view that the Opposite party No: 3 has not committed any deficiency in service.
9. So far as the Opposite party No: 1 is the concerned, admittedly he is an insurer in respect of the mediclaim policy issued to the complainant for nearly 10 years and the Opposite party No: 2 is the third part administrator in respect of the servicing the policies of the Opposite party No: 1. It is not in dispute that the complainant was having the mediclaim insurance making him eligible for cashless treatment to the extent of Rs.2,00,000/- per year at the time of operation and medical treatment given to the complainant by the Opposite party No: 3. Admittedly the pre-authorization request for approval was forwarded to the Opposite party No: 2 by the Opposite party No: 3 even before the operation. However the Opposite party No: 2 rejected the same on 03/01/2009 by 1.00 P.M as per Ex. A1 = Ex. B17. The reason mentioned in Ex. A1 = Ex. B17 is that the amount was not payable in first 2 years of taking an insurance policy. When the complainant was in Hospital and all preparations were made to conduct the operation awaiting approval from the Opposite party No: 2, the rejection made by Opposite party No: 2 as per Ex. A1 = Ex. B17 without asking any clarification in this regard either from the complainant or the Opposite party No: 3 or the Opposite party No: 1 will amount to deficiency in service. After rejection, the complainant while he was in bed after operation contacted the Opposite party No: 2 with great difficulty and thereafter the Opposite party No: 2 approved Rs.8000/-. Even by that time also the full amount was not sanctioned. Because the full amount was not sanctioned, the complainant suffered a lot and he was able to make only a part payment for getting the discharge. Thereafter alone the Opposite party No: 2 approved the full claim on 06/01/2009 by 4.50 P.M as per Ex.B19. The said act on the part of the Opposite party No: 2 will come with in the purview of deficiency in service. Admittedly Opposite party No: 1 is an insurer and the same is also mentioned in the complaint. The Opposite party No: 1 also admits that the Opposite party No: 2 is its third party administrator for servicing the policies of the Opposite party No: 1. Hence the failure on the part of the Opposite party No: 1 to give proper instruction to the Opposite party No: 2 to follow certain essential things before rejecting the claim will amount to deficiency in service. Hence we are of the view that the allegation of deficiency in service on the part of the Opposite party Nos: 1 & 2 is proved and the allegation of deficiency in service on the part of the Opposite party No: 3 is not proved and we answer this point accordingly.
Point No: 2
10. In view of the finding given on point No: 1 the complainant is entitled to get compensation for the mental agony suffered by him due to the deficiency in service committed by the Opposite party Nos: 1 & 2, which we, considering the status of the complainant and the facts and circumstances of the case, assess at Rs.30,000/- in addition to the cost of Rs.5000/- as relief and we answer this point accordingly.
11. In the result the Opposite party Nos: 1 & 2 are jointly and severally directed 1) to pay a sum of Rs.30,000/- towards compensation for the mental agony suffered by the complainant and 2) to pay the cost of Rs.5000/- to the complainant within two months from the date of receipt of copy of this order by the Opposite party Nos: 1 & 2.The failure to do so will entail the Opposite Party Nos: 1 & 2 to pay the said amounts along with interest at 6% p. a thereafter till the date of payment and accordingly this complaint is allowed as against Opposite party Nos: 1 & 2 with costs. The complaint as against Opposite party No: 3 is dismissed, but without costs.
Dictated by the President to Assistant Programmer who directly typed the same and corrected and pronounced this the Tuesday the 15th day of March 2011.
Sdxxx Sdxxx Sdxxx
Tmt.K.Kasthuri Thiru. M.Viswabharathi Thiru.S.Arumugam
MEMBER-I MEMBER-II PRESIDENT
List of Documents filed by the Complainant:
Ex.A1, the copy of the rejection letter dated: 03/01/2009 sent by the Opposite
party No: 2
Ex.A2, the copy of the approval letter dated: 05/01/2009 sent by the Opposite
party No: 2
Ex.A3, the copy of the receipt dated: 05/01/2009 issued by the Opposite party
No: 3 for the payment of Rs.14,000/-
Ex.A4, the copy of the discharge summary dated: 05/01/2009 issued by the
Opposite party No: 3
Ex.A5, the copy of the approval letter dated: 06/01/2009 sent by the Opposite
party No: 2
Ex.A6, the copy of the letter dated: 14/03/2009 from the complainant to the
Opposite party Nos: 1 & 2
Ex.A7, the copy of the acknowledgement from the Opposite party No: 2, for the
receipt of Ex.A6
Ex.A8, the copy of the acknowledgement from the Opposite party No: 1, for the
receipt of Ex.A6
Ex.A9, the copy of the reply dated: 17/03/2009 from the Opposite party No: 2,
Ex.A10, the copy of the letter dated: 18/03/2009 from the complainant to the
Opposite party No: 2
Ex.A11, the copy of the legal notice dated: 17/07/2009 from the complainant to
Opposite party Nos: 1 to 3
Ex.A12, the copy of the acknowledgement for receipt of Ex.A11 from the
Opposite party No: 1
Ex.A13, the copy of the acknowledgement for receipt of Ex.A11 from the
Opposite party No: 2
Ex.A14, the copy of the acknowledgement for receipt of Ex.A11 from the
Opposite party No: 3
Ex.A15, the copy of the reply dated: 14/08/2009 from the Opposite party No: 1,
Ex.A16, the copy of the prescription dated: 06/08/2010
Ex.A17, the copy of the Health card
Ex.A18, the copy of the Insurance policy for the period from 30/10/2008 to
29/10/2009
List of Documents filed by the Opposite party No.3:
Ex.B1, the copy of the admission form
Ex.B2, the copy of the discharged summary
Ex.B3, the copy of the History and physical examination
Ex.B4, the copy of the pre operative check list
Ex.B5, the copy of the Pre Anesthetic evaluation
Ex.B6, the copy of the Operation report
Ex.B7, the copy of the consent letter given by the complainant
Ex.B8, the copy of the consent for Anaesthesia Services
Ex.B9, the copy of the progressive sheet
Ex.B10, the copy of the Diabetic chart
Ex.B11, the copy of the Intake and Output chart
Ex.B12, the copy of the Nurses record
Ex.B13, the copy of the Graphic (T.P.R) Chart
Ex.B14, the copy of the Blood pressure chart
Ex.B15, the copy of the Regular Drug Prescription
Ex.B16, the copy of the Pre Authorization request far
Ex.B17, the copy of the rejection letter dated: 03/01/2009 sent by the Opposite
party No: 2
Ex.B18, the copy of the approval letter dated: 05/01/2009 sent by the Opposite
party No: 2
Ex.B19, the copy of the approval letter dated: 06/01/2009 sent by the Opposite
party No: 2
Ex.B20, the copy of the consent for admission given by the wife of the
complainant.
Sdxxx Sdxxx Sdxxx
Tmt.K.Kasthuri Thiru. M.Viswabharathi Thiru.S.Arumugam
MEMBER-I MEMBER-II PRESIDENT
C.C.NO.66/2010
DATED:15.03.2011