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Judgment
Justice A.K. Samantaray, President
The complainant, who is retired IPS officer & former Director General of Police, Orissa has in this consumer complaint alleged serious deficiency in service on the part of the Opp. Parties. The complainant''s case is that he had purchased Indian Overseas Bank Health care Plus of United India Insurance Company Ltd. (for short ''UIIC'') for an assured sum of Rs. 5,00,000 vide No. 2007/484101384/1. The cashless claim for hospitalization of the complainant due to illness clearly falls within the purview of & in all fours of the UIIC Circular containing terms & conditions of the Indian Overseas Bank Healthcare Plus policy. The Complainant had been under Cover of Health insurance policy of Oriental Insurance Company from 1998 to 2007 & thereafter taken over & renewed with UIIC through the Indian Overseas Bank from 2008 without any break in insurance. Being fully satisfied after perusal of all previous policy papers of another Indian Insurance Company, i.e., the Oriental Insurance Company, & on receipt of the prescribed premium amount through the Indian Overseas Bank, the UIIC issued in favour of the complainant the certificate for Indian Overseas Bank Healthcare policy. The complainant having been found eligible for the above cashless benefit for hospitalization in any TTK network hospital in eastern India, the Third Party Administrator of UIIC M/s TTK Healthcare TPA Pvt. Ltd. provided the complainant with UIIC Health Card No. CHE-UI-1801-01-17789 with TTK monogram valid up to 27.02.2009. The complainant''s claim for cashless hospitalization, as promised & guaranteed by the UIIC Ltd. arose within the period of validity of the contractual policy binding upon the UIIC Ltd. & its service provider M/s TTK Health Care TPA Pvt. Ltd. In the morning of 20.11.2008, the complainant, a widower living alone in his residence, felt acute, unbearable & excruciating pain over his left hip joint radiating up to the leg. He was rushed immediately by some of his well wishers & neighbours to the emergency ward of the Ashwini Hospital, Cuttack, which is one of the TTK''s network hospitals, for treatment. On production of TTK''s valid healthcare card entitling the complainant to cashless hospitalization, the said hospital admitted the complainant as inpatient A 1275 & took immediate follow up by way of check up, X-Ray, MRI, blood tests, etc., with due intimation to the TPA in conformity with the formalities, as is the practice in such cases in all network hospitals. The complainant was informed by Shri Bijay Kumar Sahoo, General Manager (Operation) of Ashwini Hospital that he was admitted on emergency after telephonic conservation with TTK''s Bangalore office as the Chennai office of TTK could not be contracted by any means despite repeated efforts. Although the Ashwini Hospital dispatched the authorization application along with requisite investigation reports & complied with all queries of TTK made over phone from time to time, the hospital authorities failed to secure authorization & sanction of advance from TTK, which frustrated the very purpose of TPA Health Card issued to the complainant promising & guaranteeing cashless hospitalization. It is categorically stated by the complainant that the copies of the letters/Fax/e-mails exchanged between the Ashwini Hospital & M/s. TTK Healthcare TPA Pvt. Ltd., which are there in custody of the hospital authorities, are clear proof of TPA''s stubborn attitude & lack of commitment & devotion to duty in total disregard to the safety & security of the customer-patient, that too of senior citizens. Till the date of discharge of the complainant from the hospital, i.e., afternoon of 26.11.2008, the hospital authorities got no response, written or otherwise, from any of the offices of M/s. TTK Healthcare TPA Pvt. Ltd in the matter of approval & sanction of advance towards the cost of hospitalization & treatment of the complainant. Such a sad & painful circumstance created by the TPA compelled him to issue Indian Overseas Bank Cheque No. 122514 for Rs. 19,266 in full settlement of the claim raised against him prior to discharge at 11.00A.M on 26.11.2008. It is also stated that on 22.11.2008, the Specialist of Ashwini Hospital, after control & management of pain of the patient, had ruled out surgery of any Kind on the basis of the findings of the investigations reports & had advised the complainant to undergo physiotherapy immediately on discharge in any out side hospital due to non-availability of the said facility in Ashwini Hospital. Due to the callous & lackadaisical attitude of the TPA, the complainant was forced to stay in the Ashwini Hospital from 22nd to 26.11.2008 with the fond hope of receipt of administrative approval & sanction of fund, although at that point of time, he urgently needed physiotherapy in the Hope Rehabilitation Centre under care of Dr. Sanjay Kumar Sazzan, SCB Medical College & Hospital, Cuttack. The complainant has further averred that in spite of having medi-claim policy running without any break since 1998 & valid healthcare entitling him to cashless hospitalization, he had to be unnecessarily & vexatiously kept confined except for routine check up for four days from 22nd November to the forenoon of 26.11.2008, which delay in absence & default of much needed physiotherapy had serious negative impact on his recovery & convalescence, thereby adversely affecting performance of his duty as External Monitor for Coal India Ltd. & its subsidiary companies across the country. The TTK''s mischievous & inept handling of the complainant''s entitlement to cashless hospitalization ran contrary to & was violative of the TPA''s own Health Insurance Guide Book, where it is mentioned-
Henceforth the insured will not have to pay the network hospital after undergoing treatment. He will have to sign the bills & we will pay the hospital for the treatment undertaken by the insured (subject to authorization being taken bill be settled directly to the hospital up to the authorized amount.
The complainant states in his complaint petition that the rejection letter of TTK Health Care TPA Pvt. Ltd addressed to the Aswini Hospital shown to have been issued on 25.11.2008 at 12.13 P.M. & received much later than the time of discharge of the complainant from the hospital contains the following grounds:-
As per UIIC records policy is fresh, insufficient data received, Possibility of long standing pathology cannot be ruled out. Hence cashless not possible.
According to the complainant, such type of outright rejection of his claim not only indicate non-application of mind & deficiency in service but also are contrary to the facts & circumstances of his case inasmuch as his policy was & old & continuous policy & his disease was newly detected & was not an old one. Since he had never undergone hospitalization & treatment for any kind of disease during the first four years or thereafter from the very inception of his medi-claim policy, he was given cumulative bonus by the former Insurance Company, i.e. the Oriental Insurance Company, which is a matter of record. The TPA unreasonably demanded for being furnished with all previous policy papers during the time of the complainant''s confinement in the hospital, & notwithstanding the fact pointed out through the hospital the UIIC after due perusal of all pro previous policy papers earlier had issued the insurance certificate & the health card, the TTK refused to be convinced. The complainant patient, after being provided with the hospital vehicle, had to go to his residence to fetch copies of all previous papers. He supplied the same to the hospital authorities, who sent those papers immediately to M/s. TTK in compliance with the TTK''s unjust insistence. This is nothing but & instance of deliberate harassment & humiliation to a widower senior citizen staying alone. It is the further case of the complainant that in spite of being furnished with all previous policy papers running from 1998 to 2007, the TPA rejected his claim for cashless hospitalization on quire frivolous & untenable grounds. The complainant has further stated that all these facts & circumstances were duly brought to the notice of the Chairman-Cum-Managing Director of UIIC through a Petitioner dated 01.12.2008 with copy thereof to the Chairman, Indian Overseas Bank followed by reminder dated 24.12.2008 to each of them, but to no result. Having thus failed to get the Chairman-cum-Managing Director, UIIC act on his petition, the complainant had no other means than to issue legal notice on 24.01.2009/27.01.2009 through speed post. On receipt of the legal notice, the Divisional Manager, UIIC replied that when they referred the matter to their TPA, i.e. M/s. TTK Health Care TPA Pvt. Ltd with regard to his claim, the TPA informed that they had already sent pre-authorisation approval for Rs. 26,500. The said approval letter is dated 30.01.2009 at 5.39 P.M. addressed to the Ashwini Hospital of M/s TTK Health Care TPA Pvt. Ltd., a unit Cuttack Hospital Pvt. Ltd., which clearly mentions authorization date/time as 26.11.2008 at 3.41 P.M. The complainant states that it is crystal clear that the defaulter TPA approved authorization & commutated the same to the Ashwini Hospital long after he left the hospital being harassed, disgusted & humiliated inasmuch as he was discharged only after due settlement of the hospital expenses from his own pocket. It is finally clarified by the complainant that the TPA clandestinely misled the Divisional Manager to believing that they had already sent the pre-authorisation approval for Rs. 26,500 to the Aswhini Hospital whereas the actual fact was that despite best of efforts from 22.11.2008 to 26.11.2008 by his brother & the Ashwini Hospital authorities, no authorisation, let alone pre authorisation approval was sent & received, or else the complainant would not have been compelled to issue cheque in order to secure his discharge from the hospital at 11.00 A.M. on 26.11.2008. Thus, summing up his immense physical, mental & psychological torture & the agonizing circumstances the complainant, a widower & senior citizen, had to undergo for not fault of his, he has put forth his prayer of direction to the Opp. Parties to make payment of the hospital expenses of Rs. 19,266 & also make payment of compensation of Rs. 40,00,000 & any other direction as this Commission may deem just & proper to impart.
In response to the notice issued by the Commission after admission, all the Opp. Parties except Opp. Party No. 3 entered appearance & filed separate written versions.
Opp. Party No. 1, the Insurance Company has specifically averred that the complainant had not shown his previous policies before taking the present policy, i.e., the medi-caim policy. It is at the instance of the Indian Overseas Bank that the policy in question was issued. According to the Insurance Company, the benefit guaranteed under the medi-claim policy is subject to certain terms & conditions, & if there is any breach thereof, the insured is not entitled to get any compensation. In paragraph 10 of the written version, it is stated that the Ashwini hospital authorities reported the case of the complainant to M/s. TTK Health Care TPA Pvt. Ltd., but they did not intimate about the previous policies of the complainant, which he had obtained from the Oriental Insurance Company. There was requirement of certain processing work for the claim for which the few days delay occurred, It has been repeatedly stated that as per the condition, if any cashless benefit is claimed by the insured, he has to intimate about the previous policies, but the insured, the complainant in the instant case, had not intimated the same to M/s TTK Health Care TPA Pvt. Ltd., & the disease suffered by the complainant was a pre-existing disease for which the TTK Health Care TPA Pvt. Ltd. rejected the claim resorting to the exclusions clause of the policy. But, subsequently the same was rectified & as such the TTK Health Care TPA Pvt. Ltd. is not at fault. It is also in the said written version that after getting information from the medical authorities, Opp. Party No. 3 asked for the required documents, which were not supplied by the complainant, for which, at the initial stage, the claim was rejected. After supply of the same by the complainant, the claim was approved by the said Opp. Party on 26.11.2008, which was intimated by the Insurance Company to the complainant on 03.02.2009. It is further stated that Opp. Party No. 3 directly deals with medi-claim policies & they have their panel of doctors & once a claim is registered, it is scrutinized by the said Opp. Party as to whether the claim should be approved or rejected, If the claim is approved, the agency deposits the claim amount with the hospital authorities deducting the same from the insurance Company. Towards the last part of the written version, it has been stated by the Insurance Company that the claim of Rs. 40,00,000 for mental agony, physical & psychological torture for an expenditure of Rs. 19,266 is absolutely vexatious. It is a frivolous claim & it does not attract the pecuniary jurisdiction this Commission. Therefore, the Commission should have rejected the complaint.
Opp. Party No. 2 the Indian Overseas Bank in its written version has stated that the Bank is providing insurance coverage to their clients having tie up with UIIC with regard to health policy. The complaint for the first time made medi-claim policy through the Bank where Opp. Party No. 1. UIIC was the insurer & the policy was for the period covering from 28.02.2008 to 27.02.2009 M/s. TTK Health Care Tpa Pvt. Ltd is an organisation duly approved by the Insurance Regulatory & Development Authority. The said organisation has direct dealing with the medi-claim polices, hospital authorities & clients. They have their panel of doctors & hospitals. Once the claim is registered. The same is scrutinized by them either to approve or reject the same. Opp. Party No. 3 has been authorized by the Insurance Company to extend third d party administration services to the insured & they are to process all queries & claims relating to medi-claim policies, such as cashless access to network hospitals in case hospitalization & reimbursement of hospitalization claims subject to the terms & conditions of the policy. In case the claim is approved, the aforesaid agency is to deposit the claim amount with the recognized hospital authority deducting the same from the insurance Company. It is further stated that the complainant for the first time in his registered letter dated 02.12.2008 & letter 24.12.208 brought to the notice of the chairman of the Bank at Chennai that the cashless facility has been denied by the TPA & the Insurance Company Accordingly, the head office of the Bank enquired from the Insurance Company. The Insurance Company informed the Bank that the TPA has approved the cashless facility to the tune of Rs. 26,500 to the insured on 26.11.2008 This Opp. Party has pleaded that in the aforementioned circumstances it has committed no deficiency in service & as such it is in no way liable.
Opp. Party No. 4, the General Manager of the network hospital i.e., the Ashwini Hospital has in his written version admitted that the complainant was admitted to the hospital & remained as an indoor patient & all possible care & treatment had been rendered to him to his best Satisfaction. It is also stated that the complainant was discharged from the hospital on 26.11.2008 &, in fact, he had paid Rs. 19,266 through cheque in full & final settlement of the bill raised against him by the hospital. The TTK Health Care TPA Pvt. by letter dated 25.11.2008 had rejected the claim of the complainant & the said communication received by the hospital much after discharge of the complainant from the hospital. It is specifically stated that the hospital-Opp. Party No. 4, has nothing to do with the activities of the TPA & the hospital is in no way responsible for the action/inaction of the TPA With such averments, it has been stated that impleadment of Opp. Party to the complaint is without any basis & its name should be struck off from the cause title of the complaint.
We have heard Learned Counsel for the parties. The admitted position, as we gather are as follows:-
The complainant purchase Indian Overseas Bank Health Care Plus medi-claim policy of UIIC for an assured sum of Rs. 5,00,000/-. The said policy was valid from 28.02.2008 to 27.02.2009. On 20.11.2008, the complainant felt intolerable & excruciating pain over his left hip joint radiating up to the leg. Immediately he was rushed to the emergency ward of the Ashwini Hospital, one of the TTK''s network hospitals, for treatment & was admitted there as an indoor patient on production of TTK''s health card. Till 26.11.2008, the hospital authorities got no response from the TTK Health Care in matter of approval & sanction of advance towards the cost of hospitalizations & treatment of the complainant. The complainant getting frustrated over the action/inaction of TTK Health Care issued a cheque for Rs. 19,266 in full & final settlement of the claim of the hospital & left he hospital at 11.00 AM. on 26.11.2008.
Mr. Mohanty, Learned Counsel appearing for the Insurance Company submitted that the delay was caused as because Opp. Parties 1 & 3 are having two different offices & at least 2 to 3 days are required for processing a claim. The claim of the complainant was finally approved on 26.11.2008, i.e., within 6 days out of which 22nd & 23rd were holidays being Saturday & Sunday respectively. In this connection, Mr. Pattnaik, Learned Counsel for the complainant drew our attention to paragraph 4 of the Health Care Guide Book of TPA, wherein it has been stated thus:
EMERGENCY HOSPITALIZATION.
The policyholder is advised to get admitted. In case of admission to a Network Hospital the Hospital will admit the patient as per the procedure of the Hospital. The hospital will then contact TTK & send us a request for authorization. At times the policyholder may be required to contact TTK of authorization. The policyholder must send the pre-authorisation request completely filed. TTK will revert within 6 hours of receipt of the request.
Mr. Pattanaik submitted that the Health Care Card was issued in favour of the complainant, each by the UIIC & the TTK. When the guidelines specifically state that within 6 hours from receipt of the request TTK would revert back, proceeding of file between the parties inter se should have been completed within 6 hours from the time of receipt of the request. It was argued by Mr. Patanik that the plea taken by the Insurance Company that Saturday & Sunday were holidays & for that these two days should be overlooked is not at all tenable in view of the over all scheme of the TTK'', which comes under essential service of cashless treatment. Referring to the Health Insurance Guide Book, he submitted that when a request is made for authorisation & there is stipulation that TTK shall revert back within 6 hours, if there is no response for six days, the object of the scheme, i.e., cashless emergency hospitalization, which is meant to treat the patient immediately when he is admitted to the hospital, gets totally frustrated. He further submitted that the condition incorporated in the Health Insurance Guide Books is to complete the formalities within the specified period of six hours, which is mandatory in nature & is meant to protect the insured from any harassment. Mr. Pattnaik submitted that it is not the case of TTK or UMC that the hospital (Ashwini Hospital) dispatched the authorisation application at a belated stage & did not send the same after hospitalization of the complainant, for which there was delay in disposal of the authorisation & approval.
The complainant has categorically stated in the complaint petition that TTK issued a letter to Ashwini Hospital on 25.11.2008 at 12.30. P.M. stating that as per United Insurance Company Ltd., the policy record is fresh, insufficient data received, possibility of long standing pathology cannot be ruled out, hence cashless is not possible. The UMC has stated in its written version that as per the condition, if any cashless benefit is claimed, the insured has to intimate about the previous policies & whether the disease was pre-existing. For that, TTK is not at fault in rejecting the claim. Taking exception to this. Mr. Pattnaik argued that such a stand/contention of the Insurance Company is contrary to the condition of the policy & the proposal from. Referring to the copy of the proposal from, which is the basis of the contract/policy, he stated that in case of renewal of insurance, photo copy of previous insurance policy/certificate is to be attached. Stamp size photographs are to be affixed for renewal. If photographs are not attached, original IP card from the TPA under the previous policy is to be attached Renewal from any insurance Company is accepted & continuity benefit is available if renewal is made before expiry. Mr. Pattnaik, referring to the record took us through the previous policies of the complainant, which he had been taking the Oriental Insurance Company, submitted that there is absolutely no doubt that there was continuity is obtaining the policies & it is nobody''s case that the present policy within Opp. Party No. 1. UIIC was taken after expiry of the previous policy. In Such circumstance as per the condition in the proposal from, the benefit of continuity is available to the complainant in respect of the present policy. We have ourselves examined the previous policies of the complainant taken from the Oriental Insurance Company right from the year 1998 up to 2007, whereafter he renewed the policy with UIC through the Indian overseas Bank from 2008. There is no break in the policies at any point of time. It is the categorical case of the complainant that being fully satisfied after perusal of all previous policy paper of another Indian Insurance Company, i.e. Oriental Insurance Company, & on receipt, of the prescribed premium amount through the Indian Overseas Bank, the UIIC issued in his favour the certificated of the Indian Overseas Bank Health Card Policy. Besides, as we find, there is not condition whatsoever in the policy compelling the insured to provide the previous policy details after the issuance & receipt of the policy in case of a renewal policy at the time of admission to a network hospital. The insured is also under no obligation to intimate about the previous policies either to the TTK or to the Insurance Company at any point of time after issuance of renewal policy, more specifically for settlement of cashless benefit, it is specific cases of the complainant & it was vehemently argued by Mr. Pattnaik, Learned Counsel appearing for him that in spite of repeated reminders to TTK as well as UIIC, the claim was not settled, for which lawyer''s notice dated 24.01.2009/27.01.2009 was served on the Chairman-cum-Managing Director of UlIC & the claim was approved on 03.02.3009 by the Insurance Company-Opp. Party No. 1, as intimated to the complainant. It was also submitted by Mr Pattnaik that at no other point of time the Insurance Company had contacted the complainant regarding approval or otherwise of his claim. We have referred to the rejection letter of the TTK dated 25.11.2008 time 12.13 PM & approval letter said to be dated 26.11.2008 time 3.14 PM mentioning that the denial was reconsidered in view of continuous policy. The Insurance Company has put much stress on the latter letter to escape its liability. But, the said letter appears to have been issued on 30.01.2009 at 5.30 PM. If any letter was issued on 26.11.2008 stating that after reconsideration approval was accorded of cashless benefit, why no intimation was received by the network hospital, i.e., Ashwini Hospital, makes the matter dubious & suspicious. We consider such a plea to be nothing but afterthought & conctee.
We have perused the documents filed & annexed. From the pleading of the complainant, we find that since repeated reminders to TTK as well as UlIC his claim was not settled, lawyer''s notice dated 24.01.2009/27.01.2009 was served & thereafter the claim was approved 03.02.2009 by the Insurance Company & this fact was intimated to the complainant. This itself goes to show that the plea taken by the Insurance Company as well as TTK that reconsideration authorisation was approved on 26.11.2008 is based on blatant falsehood. We have perused the TTK''s Health insurance Guide book where the TTK assures the highest quality of service, which commitment is backed its 78 year-old TTK group. These assurances are only to lure customers, but when actual question of service arises, all tricks are applied to avoid such assured service, which ultimately frustrates the very purpose of the scheme. The instant matter is glaring example of such calculated design to evade payment at the time of dire need of a customer. The complainant, who is a retired Director General of Police of this State & tripura, is a widower & senior & senior citizen staying alone. He is also acting as Independent External Monitor of Coal India Ltd. He is also a member or the Rotary Club & it also associated with many other organisations & commands respect in the society. His legal & genuine claim was turned down & the same was called to be vexatious & frivolous. His non-acceptance of the so-called approved amount of Rs. 26.500 by not signing the discharge voucher, according to the insurance Company is due to his stubborn attitude.
The network hospital bill was for Rs. 19,266, which was paid by the complainant through cheque to get himself discharged from the hospital. It is not understood how a sum of Rs. 26,500 was approved towards the claim of the complainant. Learned Counsel for the Insurance Company could not explain the same to us. This approval appears to be the outcome of letters addressed to the Chairman-cum-Managing Director of the Insurance Company, Head Office at chennai, with intent to cover up to the blatant deficiency in service, which is apparent on record. The deficiency delayed the discharge of the complainant from the network hospital after the aliment was diagnosed. It also delayed the physiotherapy course, which was not available in the network hospital & the complainant had to spend some more days in the process for the complete recovery from agonizing & painful Lumber Spondylitis. Considering the situation to which the complainant was put, keeping in mind his status in the society & the humiliation & harassment he had undergone, which were due to the utter negligence & deficiency in service on the part of UIIC & TTK on the face of his being in possession of valid policy health card, etc., entitling him to cashless benefit of treatment, we have no hesitation to hold that Opp. Parties 1 & 3 jointly & severally liable to reimburse the medical expenses incurred by the complainant & pay him adequate compensation & cost. This, in our view, shall deter them from repeating exhibition of callous & negligent attitude while dealing with such delicate matters in future. We, however, find no material; as against Opp. Parties 2 & 4 so as to fasten any liability to them as, in our considered view, they had no art & part in the matter. In the result, therefore, we allow the complaint & direct Opp. Parties 1 & 3 to jointly & severally reimburse to the complainant an amount of Rs. 19,266 (rupees nineteen thousand two hundred & sixty-six), which he has spent for his treatment in the Ashwini Hospital. They are also directed to they compensation of Rs. 5,00,000 (rupees five lakhs) towards the mental agony suffered by him & Rs. 50,000 (rupees fifty thousand) towards cost of litigation. The aforesaid amounts shall be paid within 60 days from the date of receipt of our order.