PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Complaint No.- 209/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Smt. Rita Pansari, aged 62 years,

W/O- Late Ramesh Pansari,

R/O- “Pansari Bhwan” near Balika Vidyalaya, At/PO/Ps-Khetrajpur,

Dist- Sambalpur, Odisha                                                  ………........Complainant

-Vrs.-

1. United India Insurance Company Limited, Divisional office,

At-First Floor, Shivlok Complex, Gaiety Talkies Road,

Sambalpur represented through its Divisional Manager,

2. Heritage Health Insurance TPA Pvt. Ltd.

Nicco House, 5^thFloor, 2 Hare Street,

West Bengal City, Kolkata, PIN-700001.                 .....................Opp.Parties

Counsels:-

1. For the Complainant         :- Miss. P. Mohapatra & Associates
2. For the O.P.No.1                :- Sri. B.K.Purohit, Adv.
3. For the O.P.No.2                :- Ex-parte

Date of Filing:18.11.2023,  Date of Hearing :05.11.2024,  Date of Judgement :16.12.2024

Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The Complainant availed an individual Health Insurance Policy No. 2064002819P-116157244 for Rs. 5.00 Lakhs from O.P.No.1 for the period 24.03.2020 to 23.03.2021. The Complainant had undergone operation for “Intervertebral Disc. Stenosis of Neural Canal of Lumbar Region” in Lilabati Hospital and Research Centre, Mumbai and admitted on 07.01.2021 and discharges on 09.01.2021 with an expenditure of Rs. 3,40,958/-. Claim was made. O.P.No.2 on 07.01.2021 intimated that claim has been received. Complainant submitted claim documents and other required documents on 21.01.2021. The O.P.No.2 further required documents and it was submitted on 23.01.2021 O.P.No.2 on 25.03.2021 informed that Rs. 2,81,535/- claim has been settled.

The deduction details are as follows:-

Surgeon’s Fees as          Rs. 47,961.00

Beyond tariff

Other heads                   Rs. 11,462.00

                             Total Rs. 59,423.00

Clarification was sought for on 25.03.2021 and 21.04.2021. No response came from O.P.No.2 then O.P.No.1 was requested to reimburse Rs. 47,961/- when no response received the Divisional Manager was informed. The Divisional Manager forwarded the email to Deputy Manager on 07.05.2021. Till 06.08.2021 non of the O.Ps clarified the reason of deduction. Then complaint was filed for deficiency in service.

2. The O.P.No.1 submitted that health insurance policy is admitted. The insurer pay the claim through the Third part Administrator(TPA) to the Hospital. In policy exclusion some items are excluded. The insured filled up claim form seeking reimbursement expenses against hospitalisation for Rs. 3,40,958/-. After TPA scrutiny Rs. 2,81,535/- has been paid on 25.03.2021 against Rs. 3,40,958/-.

The deductions made due to :

1. Deduction of Rs. 47,961.00 on Bill No. 1 dated 09.01.2021 was made as per the reasonable and customary clause mentioned in policy condition clause No. 2.41.
2. Rs. 50.00 Bill No. 3 dated 11.12.2020 registration charge.
3. Rs. 50.00 Bill No.5 dated 11.12.2020 registration charge.
4. Rs. 3070.00 Bill No.1 dated 09.01.2021 medicines by hospital are in admissible items.
5. Rs. 4352.00 Bill No.1 dated 09.01.2021. Consumable are not payable.
6. Rs. 90.00 Bill No. 1 dated 09.01.2021 food charge not payable.
7. Rs. 200.00 Bill No. 1 dated 09.01.2021 for registration, Rs. 500/- administrative charges and Rs. 400/- Glucometer is not payable as there was no chart.
8. Rs. 2100.00 on Bill No.6 dated 06.01.2021 home visit charge, Rs. 100/- Routine investigation charge, Rs. 2000/- home visit charges for HIV test not payable as it is not related to diagnosis. Clause 5.12 of the policy condition.
9. Rs. 250/- on Bill No. 1 dated 09.01.2021 in admissible item.
10. Rs. 400/- Bill No. 4 dated 09.01.2021 Hospital Cash not covered.

The claim has been settled following terms and conditions. The complaint is liable to be dismissed.

3. Perused the documents filed by the Complainant. The O.P. has only filed the Health Insurance Policy with all condition and limitations.
4. The Complainant filed the complaint when she found that Rs. 59,423/- has been deducted from the claim. The O.Ps deducted Rs. 47,961/- from Surgeon’s fees and Rs. 11,462/- from other heads totalling Rs. 59,423/-. The O.P.No.1 submitted that deduction of Rs. 47,961/- was made as per the reasonable and customary clause mentioned in policy condition clause 2.41. The Complainant submitted that there is no specific guideline to any charges as reasonable and customary. The Complainant submitted the bills in respect of charges taken by hospital authority and accordingly entitled for Rs. 47,961/- from O.P.No.1. The deduction of the amount in pre-hospitalisation period is not proper as all the expenses are incidental to the same problem which was during the currency of the policy and the same is not beyond the insured amount.

The O.P.No.1 contended that the Complainant had undergone treatment as Lilavati Hospital, Mumbai, standard fees of doctors are acceptable in every locality and it is fixed by doctors themselves in a particular geographical area. When there is deviation in professional fees, the insurer do not allow more amount than the standard and reasonable charges. Under that head the TPA deducted excess amount of charges of the doctors taking into account their visits and treatment to insured. The deduction is proper. The O.P.No.1 cited the policy condition clause No. 2.41 as follows:

“2.41: RESONABLE AND CUSTOMARY CHARGES.

Reasonable and customary charges mean the charges for services or supplied, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involves.

5. From bill of supply invoice No. II/20/009284 dated 09.01.2021 it reveals that Lilabati Hospital and Research Centre charges the following amount from the Complainant.
6.  

Operation theatre & SurgeryRs. 2,92,050.00

Visit/consultation FeesRs. 2150.00

Pathology                    Rs. 7500.0

Pharmacy                     Rs. 7558.00

Materials                      Rs. 5925.00

Misc. Charges              Rs. 790.00

                          Total Rs. 3,29,473.00

Out of operation theatre and Surgery charges of Rs. 2,92,050/- the O.Ps have deducted Rs. 47,961/- and submitted that the surgeon’s fees is beyond tariff. The policy condition clause No. 2.41 expresses the reasonable and customary charges which are to excluded from the claim. There is no any standard prescribed in the policy conditions. The TPA simply deducted Rs. 47,961/- from the claim amount but failed to explain through the insurer under which circumstances and head the amount was deducted. The O.P.No.1 explained why registration charges, medicines by hospitals, non-payable consumable, food charge, routine investigation charges, visit charges etc. accordingly this commission do not feel proper to probe into the amount of Rs. 11,462/- paid by Complainant for the deduction of Rs. 47,961/- the Complainant has every right from the O.Ps to know the basis of deduction. The O.Ps failed to establish the deductions are proper.

From the correspondences of the Complainant from 25.03.2021 till 06.08.2021 it reveals that the O.P.No.1 has shifted the responsibility to O.P.No.2 and the O.P.No.2 remained silent. Even the O.P.No.2 remained absent in the Commission to explain the basis of deduction.

A consumer has every right to know the details of information on the subject where the consideration is paid. In the present case the O.Ps till filling of complaint not explained the basis if deduction and when appeared also failed to explain the same, which amounts to deficiency in service of the O.Ps. Failure to prove the basis of deduction amounts to unfair trade practice also on the part of the O.Ps. The TPA whimsically to benefit the insurer can not deduct any amount from the claim.

6. The O.Ps till 27.11.2021 could not provide information sought for and resolved the grievance of the Complainant. Ultimately on 18.11.2023 complaint was filed within the period of limitation. Accordingly, the complaint is maintainable.

Taking into consideration the circumstances of the case following order is passed.

ORDER

The complaint is allowed on contest against O.P.No.1 and ex-parte against O.P.No.2 The O.Ps are jointly and severally liable to pay Rs. 47,961/- to the Complainant. The O.Ps are directed to pay Rs. 47,961/- with 7% interest P.A. w.e.f. 09.01.2021 within one month of this order. The O.Ps are liable to pay compensation of Rs. 50,000/- and litigation expenses of Rs. 20,000/- to the Complainant.

Order pronounced in the open court on 16^th day of Dec., 2024.

Supply free copies to the parties.