DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

Complaint Case No : RBT/CC/2018/364

Date of Institution : 22.05.2018/29.11.2021

Date of Decision : 06.09.2022

Shri Anil Sharma son of Late Shri Madan Mohan, resident of H. No. 1246/6, Gali Jarhu Wali, Chowk Phullan Wala, Amritsar. …Complainant

Versus

1. BOI National Swasthya Bima Policy, Division-II, D-26, Court Road, Amritsar through its Manager/Authorized Officers. 

2. Safeway TPA Services Private Limited, 815, Vishwasadan, District Centre, Janakpuri, New Delhi.

3. Shoor Hospital, Khazana Gate, Amritsar through its Partner/Prop/ Manager. 

…Opposite Parties.

Complaint U/S 12 (1) read with Section 2 C z (i), (ii) and (iii) of The Consumer Protection Act, 1986.

Present: Sh. Sumant Tuteja Adv counsel for complainant.

Sh. PK Mody Adv counsel for the opposite parties No. 1&2.

Opposite party No. 3 exparte. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 12 (1) read with Section 2 C z (i), (ii) and (iii) of the Consumer Protection Act 1986 against BOI National Swasthya Bima Policy, Amritsar and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant is son of Late Smt. Santosh wife of Late Shri Madan Mohan who was died on 12.4.2018 and is only legal heir of his mother. 

3. It is further alleged that the late mother of the complainant during her lifetime purchased a medical health care insurance policy bearing No. 401900501710000765 for herself from the opposite party by paying annual premium of Rs. 1,836/- valid from 25.1.2018 to 24.1.2019. But no terms and conditions of the said policy was supplied to the mother of the complainant during her lifetime. 

4. It is further alleged that in the month of March 2018 the mother of the complainant fell seriously ill and taken to Shoor Multi Super specialty Hospital on 8.3.2018. The doctors of said hospital diagnosed that the mother of the complainant is suffering from Esophageal Varices with Fundal VX with Col with Portal HTN. The mother of the complainant told them that she is having a health insurance policy of amount of charges of the treatment shall be paid by the opposite party No. 1 and after verifying the said policy the opposite party No. 3 started giving treatment to the mother of the complainant but the opposite party No. 2 being TPA firstly allowed authorized limit of Rs. 10,000/- vide their letter dated 10.3.2018 and thereafter authorized Rs. 74,490/- vide letter dated 13.3.2018 but vide their letter dated Nil denied the genuine medical claim of the complainant mentioned that Cashless Denied. As per the investigation by the TPA the relevant documents were not provided by the hospital. Patient was not found in the hospital. As per hospital patient left against medical advice but in case file no such doctor's remarks available. Then the complainant and his mother paid the charges of treatment to the tune of Rs. 1,34,936/- to the opposite party No. 3 when treatment of Smt. Santosh was fully covered under the said insurance policy. She was eligible medical claim of Rs. 1,00,000/- out of which earlier she obtained a medical claim of Rs. 25,000/- so now she was eligible for the medical claim of Rs. 74,490/-. Then complainant and his mother visited the office of the opposite party No. 1 and met the Sub Divisional Manager many a times but he refused to accept the request of cashless claim of the complainant and said that he will not reimburse the claim of the complainant at any cost. In the meantime mother of the complainant died on 12.4.2018 leaving behind the complainant as her only legal heir. The act of the opposite parties is deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party No. 1 may be directed to release the medical claim of the mother of the complainant to the tune of Rs. 74,490/- in favour of complainant alongwith interest at the rate of 18% per annum from March 2018 till actual realization. 

2) To pay Rs. 22,000/- on account of compensation and litigation expenses.

3) Any other relief to which the complainant is found entitled. 

5. Upon notice of this complaint, the opposite parties No. 1 and 2 filed written reply taking preliminary objections that there is no privity of contract between the complainant and the answering opposite parties for the alleged claim so the present complaint is not maintainable. Further, there is no juristic person under the provisions of any law named as BOI National Swasthya Bima Policy and complaint against the arrayed opposite party before this Forum is not maintainable. Further, the complainant has not come to this Forum with clean hands. The complainant deliberately not mentioned that fact that the cashless treatment since was refused to Santosh mother of the complainant as intimated to the alleged hospital authorities vide communication dated 13.3.2018 for the reason that since as per the investigations by the TPA the relevant documents were not provided by the hospital and moreover patient was not found in the hospital as per hospital patient left against medical advice but in case file no such doctors remarks found available. Such communication of the TPA to the hospital authority dated 13.3.2018 is very vital and shows the act of the complainant and her mother at the relevant time. Even the death of the insured has not been reported to the insurance company or the TPA abovesaid. The right of succession cannot be adjudged by the Forum which can alone be decided by the Civil court under the law of succession for entitlement of the insured or that of the complainant for alleged reimbursement as claimed by the complainant which otherwise is denied. The TPA concerned vide letter dated 16.4.2018 addressed to Santosh in reference to claim intimation dated 7.4.2018 called certain informations and documents to be furnish within ten days from the receipt of letter which since was never replied by the insured Santosh or complainant. The insured or the complainant did not  submit the original discharge summary and the details of the payment alleged to have been made to the stated hospital from time to time with room number mentioned on it. The original discharge summary duly signed and stamped by the treating doctor with the registration number and proof of alleged payments made to the hospital have not been provided by the insured or the complainant for processing the claim file of the alleged claim by the TPA. The opposite party No. 2 is working as agency of the Principal National Insurance Company Private Limited having not been arrayed in the array of opposite party and also the Bank of India under whose arrangement the alleged policy stood issued through whom the claim was to be processed having not been arrayed as opposite party so in the absence of these parties the present complaint is not maintainable. This Forum has got no jurisdiction to try and entertain the present complaint and complainant has no cause of action to file the present complaint. Further, the complainant has no locus standi to file the present complaint and not maintainable for non impleading of necessary parties. 

6. On merits, it is denied that Smt. Santosh died on 12.4.2018 as no intimation stood rendered either to the opposite party No. 2 or any competent authority under whom the alleged policy obtained in the name of Smt. Santosh. The alleged Santosh as an account holder of the Bank of India and through Bank of India purchased some insurance policy from the insurance company who neither has been arrayed as opposite party nor any attribution of its name and style has been mentioned in the complaint itself. Further, on receipt of request through opposite party No. 3 the opposite party No. 2 provisionally allowed authorized limit of Rs. 10,000/- for treatment of Santosh on 10.3.2018 subject to furnishing the requisite documents by the hospital authorities and verification of facts by the TPA. The TPA opposite party No. 2 in the course of investigation for cashless entitlement of treatment found on the visit of his representative in the hospital concerned on 13.3.2018 that the patient for whom the cashless treatment facility was reported to have left the hospital against the medical advice as disclosed by the hospital authorities but no such entry in the record or remarks of doctors concerned were available in the hospital records. So, the cashless treatment was denied by revoking the earlier provisional sanction accorded by the opposite party No. 2. The hospital authorities even failed to furnish the required documents for the provisional sanction limit. The alleged claim of Rs. 74,490/- in the name of Santosh is not sustainable as no documents as called vide letter dated 16.4.2018 has been furnished to the opposite party No. 2. Further, all the submissions mentioned on merits are the same as submitted in the preliminary objections so there is no need to repeat the same. The non compliance of terms and conditions on the part of the insured is a reason for non processing the claim. Moreover the conduct of the insured or her attendants leaving the hospital under lama dis-entitled for any reimbursement or cashless for any treatment. The complainant never reported the death of his mother to the opposite parties as after the death of Santosh present dispute is not maintainable as successor or legal heir of Smt. Santosh. Complainant is not entitled for any claim. There is no deficiency in service or unfair trade practice on the part of the answering opposite parties. Lastly, the opposite parties No. 1 and 2 prayed for the dismissal of the present complaint with costs.

7. The opposite party No. 3 preferred to remain exparte. 

8. To prove his case the complainant filed affidavit Ex.CW-1/A and documents Ex.C-1 to Ex.C-7. To rebut the case of the complainant the opposite parties No. 1 and 2 filed affidavit Ex.OP-1.2/A and documents Ex.OP-1.2/1 to Ex.OP-1.2/5.   

9. We have heard the learned counsel for the parties and gone through the record on the file.  

10. It is admitted fact between the parties that the mother of the complainant was the account holder of the Bank of India and purchased the insurance policy valid from 25.1.2018 to 24.1.2019 for sum assured of Rs. 1,00,000/- vide copy of policy Ex.C-1. It is also not disputed that the mother of the complainant has taken the treatment from the opposite party No. 3 within the currency of the insurance policy. It is also admitted by the opposite party that when the mother of the complainant admitted in the hospital of the opposite party No. 3 and cashless request was sent to the opposite party No. 1, they firstly sent a limit of Rs. 10,000/- vide Ex.C-2, then sent a sanction of Rs. 74,490/- vide Ex.C-3 and ultimately denied the claim vide Ex.C-4. The reason for cashless request was denied vide Ex.C-4 that as per the investigation by the TPA the relevant documents were not provided by the hospital and patient was not found in the hospital. Further, as per hospital patient left against medical advice but in case file no such doctors remarks available. 

11. The claim reimbursement also denied by the opposite party No. 2 vide letter dated 16.4.2018 Ex.OP-1.2/1. In this letter the opposite parties No. 1 and 2 mentioned that the claim papers received by them on 7.4.2018 in respect of hospitalization of Santosh mother of the complainant but vide letter dated 16.4.2018 Ex.OP-1.2/1 the opposite parties No. 1 and 2 demanded some more papers i.e. original discharge summary with sign and stamp of treating doctor, IPD Papers and original payment receipt against hospital final bill. The complainant has filed the final bill Ex.C-6 and history sheet Ex.C-7 in which the history of his mother's disease and treatment is mentioned in detail and if the complainant filed these documents on the file then there is no hitch for him to supply the same to the opposite parties or even the opposite parties can take copy of the same from the file to settle the claim of the complainant but the opposite parties not done the same which proved that the opposite parties not interested to settle the claim of the complainant. 

12. The opposite parties No. 1 and 2 themselves admitted in their letter Ex.C-4 and written version that as per hospital patient left against medical advice but in case file no such doctor's remarks available so it is proved on the file they have no written proof that the mother of the complainant left the hospital against medical advice. However, if it is presumed that the mother of the complainant left the hospital against medical advice even then the insurance company cannot deny the claim of the complainant as they proved on the file the expenses of treatment of his mother. Moreover, in the present case the claim was repudiated the Safeway TPA Services Private Limited vide Ex.OP-1.2/1 whereas the only duty of the TPA is to investigate the matter and to report the same to the insurance company and it is only the insurance company who can repudiate the claim of the consumer. 

13. The Hon'ble Punjab and Haryana High Court, at Chandigarh in case titled The Oriental Insurance Company Limited Versus Sh. RK Dogra alias Rajinder Kumar through his LRs and another bearing FAO No. 4020 of 2015 (O&M) decided on 18.5.2016 held that a decision to get discharged even against medical advice at the terminal stage of life shall not be likened to an invitation to be assisted suicide. It is embracing dignity in death. So, in the present case also if the mother of the complainant left the hospital against medical advice does not effect the insurance claim in any way. 

14. In view of the above discussion, there is deficiency in service and unfair trade practice on the part of the opposite party No. 1 by not paying the genuine claim of the complainant. The complainant filed the final bill of Rs. 1,34,936/- Ex.C-6 but he claimed only Rs. 74,490/- as balance amount of sum insured. So, the present complaint is partly allowed against the opposite parties No. 1 and 2 and opposite parties No. 1 and 2 are directed to pay the amount of Rs. 74,490/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite parties No. 1 and 2 are also directed to pay Rs. 5,500/- to the complainant as compensation for mental tension and harassment and Rs. 3,300/- as costs and litigation expenses. The opposite parties No. 1 and 2 are directed to pay the above mentioned amounts to the complainant only against the indemnity bonds with regard to other Legal heirs, if any. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Both the opposite parties No. 1 and 2 jointly and severally liable to comply with the above mentioned order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        6th Day of September 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member