Orissa

Sambalpur

CC/33/2019

Shyam Sundar Pansari - Complainant(s)

Versus

1- United India Insurance Co.Ltd. - Opp.Party(s)

30 Aug 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Case No- 33/2019

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Shyam Sundar Pansari,

S/O-Durga Prasad Pansari,

Baraipali, Sambalpur.                                                    ………..…..Complainant

 

Vrs.

1. United India Insurance Co. Ltd,

Gaity Road, Sambalpur

2. Heritage Health Services Pvt. LTd,

NICCO House, 5^th floor, 2, Hare Street,

Kolkata 700001                                                   . ………..Opp. Parties

Counsels:-

1. For the Complainant                   :-Self
2. For the O.P.No.1                                      :- Sri. B.K.Purohit & Associates
3. For the O.P. No.2                                    :-Third Party Administration(TPA)

 

DATE OF HEARING :13.07.2022, DATE OF JUDGEMENT : 30.08.2022

           Presented by Dr. Ramakanta Satapathy, PRESIDENT,

1. The case of the Complainant is that a Mediclaim Policy No. 2604002817P. 118051695 was taken for the period 23.03.2018 to 22.03.2019 by the Complainant for self and his wife Smt. Prema Pansari. The policy is newed since 1998. On 02.05.2018 Smt. Prema Pansari was operated for cataract on left eye in CARE Hospital, Bhubaneswar. On 01.05.2018 the third part administrator (TPA) approved the claim of Rs. 45,000/-. Again on 02.05.2018 it was increased to Rs. 50,000/- (2.32A.M.) and further on 02.05.2018 it was reduced to Rs. 30,000/-(4.42A.M.). Finally at about 2.56PM approved the claim of Rs. 35,000/-. The Complainant incurred expenses of Rs. 55,720/- for the operation and had to pay Rs. 20,0720/- for relieve of the patient from the hospital. On 28.08.2018 when correspondence was made consultation fees of doctor, the O.P. No.2 remained silent.

Being aggrieved this complaint was preferred.

2. The O.P. No.1 in its version admitted the policy valid from 23.03.2018 to 22.03.2019. The Insurance Company is to pay the insured through T.P.A. to the Hospital/Nursing Home or to the insured person the amount of such expenses as will fall under different heads mentioned in the policy and its conditions. In Exclusion clause 4.7. cost of spectacles contract lenses and hearing aids are excluded.

Registration Fees-Rs. 260/-

Attendee’s Pass-Rs. 90/-

Insurance Documents-Rs. 370/-

Phaco with Multifocal-

Foldable 90L charges     Rs. 55,00/-

•  

          The T.P. A. deducted Rs. 15,720 from the total claim and approved Rs. 35,000/- to-wards cashless facility as per policy conditions. There was mo infirmity in the authorization for which the amount Rs. 45,000/-, Rs. 50,000/- and Rs. 30,000/- varied from time to time. The O.Ps settled the claim at Rs. 35,000/- and paid to the hospital. The complaint is not maintainable.

3. Perused the documents & submission of both the parties. It is the admission of both the parties that the admission of  both the parties that the O.P. No.1 paid an amount of Rs. 35,000/- to the CARE hospital authority as cashless payment. This settled amount of the T.P.A. as it reveals from the documents was the outcome of third decision taken by the T.P.A. which is totally whimsical and not inconsonance with the policy terms. In one hand the O.P. No.1 stated that IOL i.e. cost of spectacles, contact lens charges are excluded. The cost of contract lens in included with Rs. 55,000/- charges. There is no specific rate mentioned by the T.P. A. in all his correspondences nor during the final settlement amount i.e Rs. 35,000/-. It proves the monopolistice attitude of the T.P.A who is appointed by the O.P. No.1 The reply of the O.P. No.1. The reply of the O.P. No.1 in variation on the settlement of claim is not satisfactory. It proves the deficiency in service of the O.Ps.
4. The Complainant has paid Rs. 20,720/- vide receipt No. BC 1800025060 dated 02.05.2018 to CARE Hospital, Bhubaneswar, Post care treatment charges Rs. 210/- consultation fees of doctor, Rs. 377.15P. Patholosy charges total Rs. 587.15P. has been paid to the hospital authority. In this way Rs. 21,307/- was paid by the Complainant which is recoverable from the O.P. No.1.
5. In a contract of insurance, the O.P. No.1 by giving liberty to TPA to settle the claim not only shifting its responsibility but also harassing the consumers, as it is evident in settlement of claim of the present consumer. It is purely an unfair trade practice in providing service.

Taking in to consideration supra facts and circumstances the following order is passed:

6698606.  

The complaint is allowed against the O.P.No.1. The O.PNo.1 is liable to pay Rs. 21,307/- with 7 % interest P.A. w.e.f. 02.05.2018 to the complainant within one month from the date of order. In case of non payment the amount will carry 12% interest P.A. w.e.f. 02.05.2018 till the date of realisation.

The O.P. No.1 is directed to pay Rs. 10,000/- compensation and litigation expenses of Rs. 5000/- to the complainant.

The O.Ps are warned not to commit unfair trade practice in future.

Order pronounced in open court on this 30^th day of August, 2022.

Supply free copies to the parties.