State Consumer Disputes Redressal Commission
Star Health And Allied Insurance Co. ... vs Hansraj on 17 April, 2018
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.
First Appeal No.47 of 2018
Date of Institution : 25.01.2018
Order Reserved on: 16.04.2018
Date of Decision : 17.04.2018
Star Health and Allied Insurance Company Ltd., through its Branch
Manager SCO 25, 1st Floor, Ranjit Avenue, District Shopping
Complex Amritsar, India-143001.
.....Appellant/opposite party
Versus
Mr. Hansraj S/o Sh. Brij Lal, #20, Village Chatiwind, Amritsar 143001
Punjab mobile 9530956200.
.....Respondent/complainant
First Appeal against order dated
17.11.2017 passed by the District
Consumer Disputes Redressal Forum,
Amritsar.
Quorum:-
Shri J. S. Klar, Presiding Judicial Member
Smt. Surinder Pal Kaur, Member Present:-
For the appellant : Sh. Rajeev Abhi, Advocate For the respondent : Sh. Updip Singh, Advocate ............................................ J.S. KLAR, PRESIDING JUDICIAL MEMBER :-
Challenge in this appeal by appellant is to order dated 17.11.2017 of District Consumer Disputes Redressal Forum Amritsar (in short the 'District Forum'), directing appellant to allow the cashless claim of respondent of this appeal with the direction to pay compensation of Rs.5000/- and cost of litigation Rs.2000/- to him.
The respondent of this appeal is complainant in the complaint before First Appeal No.47 of 2018 2 District Forum and appellant of this appeal is opposite party therein and they be referred as such hereinafter for the sake of convenience.
2. The complaint has been filed through Dr. Satish Kumar Verma proprietor of complainant hospital U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against OPs before District Forum on the premise that he purchased a medical health care Insurance policy named Family Health Optima Insurance Plan for himself and his wife from OP by paying annual premium of Rs.16,638/- bearing current policy No.P/211111/01/2017/004852 dated 19.11.2014. He further paid two more annual premiums in time. He felt acute pain in his knees in the month of September 2016. He was referred to Dr. Tarandeep Singh and advised x-ray for both knees. On 06.10.2016, he followed it up with the doctor alongwith x-ray report and was diagnosed osteoarthritis knee B/L and changed the medicines. After taking prescribed medicines regularly, he felt no relief and he visited the doctor, who advised him for replacement of knees. Thereafter, he approached Amandeep Hospital and Clinics for second opinion. This hospital was in the list of pre-approved hospitals of OP for cashless treatment under the policy. On reaching the hospital, he explained his health condition to the doctor, who after doing necessary investigations, diagnosed the same problem of B/L O.A. of Knee and advised him for knee replacement. He intimated the hospital authorities that he has been covered under a cashless health care program of OP. Thereafter, First Appeal No.47 of 2018 3 the hospital staff asked him to handover the copies of policy and related documents for online cashless approval from OP. He submitted all the necessary documents to the hospital authorities, upon which the hospital received a communication confirming the receipt of cashless claim and the denial of cashless claim for want of further documents. He again visited Amandeep Hospital and Clinics on 11.02.2017 and expressed his willingness to follow the surgical procedure upon which the doctor concerned checked for the fitness level of the patient. On investigation, the doctor found all parameters well under control and gave a green signal to his surgery. He visited Dr. Tarandeep Singh (MS Orthopaedics) on 01.03.2017 and asked him to prepare a doctor's note for the compliance of cashless claim procedures. The complainant complied with the formalities of the requirement of further documents and submitted all the documents required by OP to them and intimated the concerned staff to send the required information to OP which was complied with. Despite complying with all the formalities, the complainant got a phone call on his mobile regarding the rejection of cashless claim. Despite clear cut medical reports of no previous medical history, OP did not entertain the request of his cashless claim. Thereafter, he visited the office of OP and narrated the entire story to the executive available, but he refused to accept the request of cashless claim and said that he could get the surgery done on his own expenses and send the bills and documents to OP for reimbursement, which would be considered on merits at that time. The complainant alleged that OP First Appeal No.47 of 2018 4 rendered deficient services to him and failed to discharge its responsibility at the time of this occurrence. The complainant prayed that OP be directed to allow the request of cashless claim for complainant with immediate effect; (b) further to pay compensation as well as litigation expenses to the tune of Rs.30,000/-
3. Upon notice, OP appeared and filed written reply by raising preliminary objections that complaint is not legally maintainable. The complainant is estopped by his own act and conduct from filing the complaint and he has no cause of action to file the complaint. He obtained the policy of Family Health Optima Insurance Policy from the OP, covering Mr.Hans Raj self, Mrs. Shakuntla spouse for the sum insured of Rs. 4,00,000/- vide policy N. P/211111/01/2015/003001 from 19.11.2014 to 18.11.2015, policy No. P/21111/01/2016/003659 from 19.11.2015 to 18.11.2016 and Policy No. P/211111/01/2017/004862 from 19.11.2016 to 18.11.2017. The claim was reported in the third year of the policy and the insured was admitted in Amandeep Hospital on 02.02.2017 for the treatment of B/L OA KNEE and submitted pre-authorization request for cashless treatment vide claim No.399061. On perusal of documents submitted by the treating hospital, it was observed that :-
"As per Pre-Auth Form, the insured was admitted with the complaints of pain and unable to walk properly and the provisional diagnosis was OA Knee Bilateral. -X-ray image showed severe osteoarthritis - As per the letter of treating doctor, which was submitted in response to the query dated 01.02.2017 of OP, the insured was first diagnosed First Appeal No.47 of 2018 5 as OA Knee Bilateral on 06.10.2016, whereas the X-ray was taken on 04.10.2016. From the above findings, it was observed that there was discrepancy in the onset and the duration of above disease in the current claim. Due to this reason, the cashless authorization was denied and complainant was requested to approach for reimbursement of medical expenses, vide letter dated 02.02.2017. OP sent the claim form to the insured to approach for reimbursement of medical expenses, vide letter dated 04.02.2017 and it was followed by reminders dated 19.02.2017, 06.03.2017 and 21.03.2017, but the insured has not submitted the claim records for reimbursement of medical expenses. The complainant was again admitted in Amandeep Hospital on 05.02.2017 for the treatment of B/L OA Knee and submitted pre authorization request for cashless treatment, vide claim No.403292. On perusal of the documents submitted by the treating hospital, it was observed that :- As per Pre- Auth. Form, the insured was admitted with the complaints of pain and unable to walk properly and the provisional diagnosis was OA Knee Bilateral. X-ray image showed severe osteoarthritis -with the available documents, it was unable to ascertain the onset of disease. OP was unable to authorize cashless and as such the complainant/insured was requested to approach for reimbursement of medical expenses and the same was communicated to the insured and the treating hospital, vide letter dated 03.02.2017. But the insured has not submitted the claim records for reimbursement of medical expenses for both the claims, as such the complaint of the First Appeal No.47 of 2018 6 complainant being pre-mature is liable to be dismissed. OP controverted the other averments of the complainant and prayed for dismissal of complaint.
4. The complainant tendered in evidence his duly sworn affidavit Ex.CW1/A alongwith copies of documents Ex.C-1 to Ex.C-12 and closed the evidence. As against it, OP tendered in evidence affidavit of Sh. P.C. Tripathy, Zonal Manager Ex.OP-1 and copies of documents Ex.OP-2 to Ex.OP-22 and closed the evidence. On conclusion of evidence and arguments, the District Forum Amritsar accepted the complaint of the complainant, as referred to above. Aggrieved by above order, OP now appellant has directed this appeal against the same.
5. We have heard the learned counsel for the parties and have also examined the record of the case. The solitary contention raised by counsel for respondent in this appeal is that the appeal as presented by the appellant is not competent and merits dismissal for want of authorization to file it. The forceful submission of counsel of respondent in this appeal is that there is no proper resolution passed by the appellant, a corporate body, to institute this appeal against the impugned order. Even this appeal is not filed by any Director, Secretary or Principal Officer of the above Insurance Company. On the other hand, Sh. Rajiv Abhi, counsel for appellant argued that the appeal is maintainable, because P.C. Tripathy, Zonal Manager is the Principal Officer of the appellant insurance company and is competent to file it. The stamp fixed on it recorded him as Zonal First Appeal No.47 of 2018 7 Manager only. Counsel for appellant submitted that Managing Director of Star Health appointed P.C. Tripathy as his attorney. This document has further shown that the Managing Director of appellant company was conferred the power by the resolution of board of Directors of appellant company in their meeting held on 3rd April 2006. On the basis of this document, the contention of Sh. Rajiv Abhi counsel for appellant is that P.C. Tripathy is, thus, competent to file the appeal having been appointed by the Managing Director as his attorney. On this point, the counsel for the respondent relied upon law laid down in "State Bank of Travancore Vs. Kingston Computers India Private Limited"2011(II) Supreme Court Cases-
524. In this authority, it has been held that respondent neither produced any evidence to prove that he was appointed as Director of the company nor there was any resolution by Board of Directors of respondent company authorizing him to file suit against appellant. Further, letter of authority issued by R was nothing but a scrap of paper, as no resolution was passed by Board of Directors delegating its powers to R to authorise another person to file suit on behalf of the company. We find that this authority is distinguishable from the fact situation of the case. The Managing Director has been authorized by the Board of Directors of the appellant to do the needful and he further appointed P.C. Tripathy as his attorney holder and as such the submission of respondent is without consequence. Allahabad High Court has held in "M/s Northland Traders Vs. Bank of Baroda" 1995(2)Civil Court Cases-467 that an agent of the bank First Appeal No.47 of 2018 8 signing and verifying the contents of the plain, as an authorised agent or being acquainted with the facts of the case on behalf of the bank need not be authorised by written authority. Reference be further made to law laid down by our own Hon'ble High Court in "Ismail Khan Vs. Bir Singh and another" 2015(4) Civil Court Cases-28. Consequently, this contention raised by counsel for respondent is not acceptable.
6. Now, we touch the merits of the case. Affidavit of complainant Hansraj is Ex.CW1/A in support of his case. Ex.C-1 is the policy taken by him for the period from 19.11.2016 to 18.11.2017. This is family health optima insurance plan for the sum assured of Rs.4,00,000/- for to adults. Ex.C-2 is the copy of another policy document for the period from 19.11.2015 to 18.11.2016 and Ex.C-3 is the copy of advance premium receipt of Rs.16,784/-. Ex.C-4 is the copy of prescription slip issued by Dr. Tarandeep Singh (MS Orthopaedics) to complainant dated 03.10.2016 and Ex.C-5 is the copy of another prescription slip dated 06.10.2016. Ex.C-6 is the photocopy of X-ray. Ex.C-7 is the copy of another prescription slip Dr. Tarandeep Singh (MS Orthopaedics) to complainant dated 01.11.2016 showing diagnosis High Grade Osteo Asthritis of both knees (grade IV). Ex.C-8 is the copy of OPD receipt issued by Amandeep Hospital and Clinics dated 28.01.2017. Ex.C-9 is the copy of claim form Part-A. Ex.C-10 is the copy of denial of pre- authorizations for cashless treatment dated 03.02.2017. Certificate issued by Dr. Tarandeep Singh (MS Ortho) is Ex.C-12 dated First Appeal No.47 of 2018 9 01.03.2017 to the effect that Hans Raj insured was under his treatment from 03.10.2016 on OPD basis and he has been suffering from bilateral Osteo Arthiritis Knee, as is evident from Xrays also. On the basis of this evidence, the submission of counsel for complainant is that complainant took cashless policy from OP and doctors recommended him for knee replacement and preauthorization has been denied to him by OP vide Ex.C-10 without any reason.
7. To counter this evidence of complainant, OP relied upon Ex.OP-2, policy documents with detailed terms and conditions. Ex.OP-3 is the copy of proposal form of complainant filled in by the complainant for taking the policy. The complainant has been taking the policies since 2014 from OP, which fact is not in dispute in this case and finds force from Ex.OP-4, OP-5 and Ex.OP-6. Ex.OP-7 is copy of receipt dated 28.10.2016 of Rs.16,784/-. Ex.OP-13 is the copy of medical examination report of complainant.
8. The bone of contention in this case between the parties is that the requirement of the policy has not been fulfilled in this case by the complainant. The submission of counsel for insurance company is that knee problem degenerates after a long period of time and hence it is not covered under the policy. He relied upon law laid down by this Commission in "New India Insurance Company Limited Vs. K.K. Kohli" I(2006)CPJ-123. It has been held in this authority that disease of degenerative joint of knees at advance stage requiring immediate replacement of both knees. Need for replacement of knees does not arise overnight. It is a long drawn First Appeal No.47 of 2018 10 process. On the other hand, counsel for complainant argued that there is no evidence on the record that complainant suffered from this knee problem before taking the policy. We find weightage in submission of counsel for complainant. The OP company undertook to give the cashless treatment to complainant in case he contracted any disease or suffer from any illness or sustained any bodily injury through accident and if such disease or injury is in the currency of the policy. No evidence has come forth on the record that complainant has been earlier suffering from this knee problem and hence his case is not covered under the cashless insurance policy. The complainant submitted all the necessary documents to OP at the instance of the Hospital authority. Despite compliance with all the formalities, the OP rejected the insurance claim of complainant. The insurance companies run after collecting the premium and showed reluctance in honoring the insurance claims. The District Forum has, thus, correctly arrived at the conclusion in giving direction to OP to provide cashless treatment facility to complainant. We have not come across any illegality or material infirmity in the finding of the District Forum. The order of the District Forum needs affirmance in this appeal.
9. As a result of our above discussion, we find no merit in the appeal and the same is hereby dismissed.
10. The appellant had deposited the amount of Rs.25,000/- at the time of filing the appeal. This amount with interest, which accrued thereupon, if any, be remitted by the Registry to the First Appeal No.47 of 2018 11 respondent being complainant by way of crossed cheque/demand draft after expiry of 45 days from the date of this order, subject to stay order, if any.
11. Arguments in this appeal were heard on 16.04.2018 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.
12. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(J. S. KLAR) PRESIDING JUDICIAL MEMBER (SURINDER PAL KAUR) MEMBER April 17, 2018 MM