SHRI SUJIT KUMAR CHATTERJEE, IPS (RETD.) FORMER D.G. OF POLICE, ORISSA Vs. CHAIRMAN-CUM-MANAGING DIRECTOR, UNITED INDIA INSURANCE CO.

JUDGEMENT

(1.) THE complainant, who is a retired IPS officer and former Director General of Police, Orissa, has in this consumer complaint alleged serious deficiency in service on the part of the opposite parties.

(2.) THE complainant's case is that he had purchased Indian Overseas Bank Healthcare Plus policy 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 and in all fours of the UIIC Circular containing terms and 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 and thereafter taken over and 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, and 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 Complainants claim for cashless hospitalization, as promised and guaranteed by the UIIC Ltd. arose within the period of validity of the contractual policy binding upon the UIIC Ltd. and 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 and excruciating pain over his left hip joint radiating up to the leg. He was rushed immediately by some of his well wishers and 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 and 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 contacted by any means despite repeated efforts. Although the Ashwini Hospital dispatched the authorization application along with requisite investigation reports and complied with all queries of TTK made over phone from time to time, the hospital authorities failed to secure authorization and sanction, of advance from TTK, which frustrated the very purpose of TPA Health Card issued to the complainant promising and guaranteeing cashless hospitalization. It is categorically stated by the complainant that the copies of the letters/Fax/e -mails exchanged between the Ashwini Hospital and M/s TTK Healthcare TPA Pvt. Ltd., which are there in custody of the hospital authorities, are clear proof of TPA's stubborn attitude and lack of commitment and devotion to duty in total disregard to the safety and 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 and sanction of advance towards the cost of hospitalization and treatment of the complainant. Such a sad and 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 11.00 A.M. on 26.11.2008. It is also stated that on 22.11.2008, the Specialist of Ashwini Hospital, after control and management of pain of the patient, had ruled out surgery of any kind on the basis of the findings of the investigations reports and 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 and lackadaisical attitude of the TPA, the complainant was forced to stay in the Ashwini Hospital from 22nd to 26th November, 2008 with the fond hope of receipt of administrative approval and 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 and Hospital, Cuttack. The complainant has further averred that in spite of having medi -claim policy running without any break since 1998 and valid healthcare entitling him to cashless hospitalization, he had to be unnecessarily and vexatiously kept confined except for routine check up for four days from 22nd November to the forenoon of 26th November, 2008, which delay, in absence and default of much needed physiotherapy had serious negative impact on his recovery and convalescence, thereby adversely affecting performance of his duty as External Monitor for Coal India Ltd. and its subsidiary companies across the country. The TTK's mischievous and inept handling of the complainant's entitlement to cashless hospitalization ran contrary to, and 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 and 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 Ashwini Hospital, shown to have been issued on 25.11.2008 at 12.13 P.M. and 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 and deficiency in service but also are contrary to the facts and circumstances of his case inasmuch as his policy was an old and continuous policy and his disease was newly detected and was not an old one. Since he had never undergone hospitalization and 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 for 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, and notwithstanding the fact pointed out through the hospital that UIIC after due perusal of all previous policy papers earlier had issued the insurance certificate and 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 the 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 an instance of deliberate harassment and 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 quite frivolous and untenable grounds. The complainant has further stated that all these facts and circumstances were duly brought to the notice of the Chairman -cum -Managing Director of UIIC through a petition dated 01.12.2008 with copy thereof to the Chairman, Indian Overseas Bank followed by reminder dated 24.1 2.2008 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 of Cuttack Hospitals 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 and communicated the same to the Ashwini Hospital long after he left the hospital being harassed, disgusted and 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 Ashwini Hospital whereas the actual fact was that despite best of efforts from 22.11.2008 to 26.11 .2008 by his brother and the Ashwini Hospital authorities, no authorization, let alone pre -authorisation approval was sent and 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 and psychological torture and the agonizing circumstances the complainant, a widower and senior citizen, had to undergo for no fault of his, he has put forth his prayer for direction 'to the opposite parties to make payment of the hospital expenses of Rs.19,266/ - and also make payment of compensation of Rs.40,00,000/ - and any other direction as this Commission may deem just and proper to impart.

(3.) WE have heared learned counsel for the parties. The admitted position, as we gather are as follows: - The complainant purchased 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 and 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 and 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 the matter of approval and sanction of advance towards the cost of hospitalisation and 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 and final settlement of the claim of the hospital and left the hospital at 11.00 A.M. on 26.11.2008.