Order by:
Smt.Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant availed an health insurance policy bearing no.2952200776122804000 from Opposite Parties, since, 2013 under which his wife namely Asha Gupta and son namely Neelesh Gupta was covered, which was renewed time to time. Lastly the said policy got renewed till 19.06.2023. Alleged that unfortunately, on 14.06.2022, the complainant no.2 fell ill and she got admitted and medically treated from Medanta Hospital and got discharged on 16.06.2022. Thereafter the complainants requested the Opposite Parties to pay the medical bill of complainant no.2 amounting to Rs.1,85,110/-, but the Opposite Parties paid only Rs.1,43,183/- to the hospital and asked the complainant to pay remaining bill from their own pockets. The complainant many times requested the Opposite Parties to reimburse the remaining balance amount, but to no effect. Thereafter, the Opposite Parties told the complainants to send them the claim form. As per the directions of the Opposite Parties, the complainants sent claim form to Opposite Parties, through courier on dated 10.04.2023, but to no effect. Thereafter, the complainant no.2 suffered eye problem and got her surgery done from Thind Eye Hospital on 15.03.2023. At the time of hospitalization, the complainants requested the Opposite Parties to pay all the medical expenses, but they did not pay the expenses of treatment. After discharge from the hospital, the complainants also submitted all the medical record of treatment with Opposite Parties for reimbursement, but they have not paid any amount in lieu of the medical expenses. Thereafter vide letter dated 31.05.2023, the Opposite Parties repudiated the claim of the complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.90,161/- i.e. Rs.41,928/- of Medanta Hospital and Rs.48,233/- of Thind Eye Hospital alongwith interest @ 24% p.a. till its realization.
b) To pay Rs.50,000/- as compensation on account of mental torture and agony.
c) To pay Rs.33,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant had approached the answering Opposite Parties for availing an insurance policy and submitted proposal form for issuance of insurance policy namely My Suraksha Policy Silver Floater policy. Believing the above said declaration, information and details provided by the proposer including the medical history in the PF to be true, correct and complete in all respect, a policy bearing no.2952 2007 7612 2804 000 was issued for the period 20.06.2021 to 19.06.2023. The policy kit containing all relevant documents was duly sent, thereby giving opportunity to complainant to verify and examine the benefits, terms and conditions of the policy taken by the complainant. As no objection was received from the complainant within the free look period, therefore the complainant is strictly bound by the terms and conditions of the policy. The complainant has approached this Commission with unclean hands. The complainant himself violated the terms and conditions of the policy, hence the claim was repudiated by the Opposite Parties after perusal of the submitted claim documents, it was observed that the insured was admitted in an Excluded Provider. As per exclusion 11 of IRD guidelines as mentioned in Chapter 3K (Excluded Providers: Code Excl11 of the Master Circular on Standarization of Health Insurance Products (IRDA/HLT/REG/CIR193/07/2020), the claim is repudiated as expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the insurer and disclosed on its website notified to the policyholder are not admissible. The complainant has approached this Commission with unclean hands and has deliberately not filed the terms and conditions of the policy before this Commission.
Averred that the complainant has no cause of action to file the present complaint; the intricate question of law and facts are involved in this case and the procedure under the Act is summary in nature and complainant may file civil suit seeking the alleged relief; the complainant is stopped from filing the present complaint by their own acts and conduct, omission and acquiescence; the complaint is false, frivolous and vexatious in nature; the complainant has attempted to misguide and mislead this Commission; the complainant has failed to disclose any legal and valid cause of action against the answering Opposite Parties to file the present complaint; neither there is any deficiency in service on the part of the Opposite Parties nor the Opposite Parties have indulged in unfair trade practice. The complainant has tried to challenge the veracity of decision of the Opposite Party to repudiate the claim. By no stretch of imagination the said decision can be brought under the umbrella of Deficiency in Services; the complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified monies from the Opposite Party; this Commission has no jurisdiction to entertain the present complaint. The complainant has failed to demonstrate any deficiency in service on the part of Opposite Parties. In the absence of deficiency in service the aggrieved person may have a remedy under the common law to file a suit for damages, but cannot insist for grant of relief under the act for the alleged acts of commission and omission attributable to the Opposite Party which otherwise do not amount to deficiency in service. In parawise reply, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C8.
4. On the other hand, Opposite Parties has placed on record affidavit of Sh.Amritpal Sandhu, Authorized Signatory, HDFC Ergo Health Insurance Co. Ltd. as Ex.OPs/1 alongwith copies of documents Ex.OPs/2 to Ex.OPs/5.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is admitted and proved on record as averred by the complainant that he availed ‘Suraksha Policy Silver Floater’ covering his wife namely Asha Gupta and son Neelesh Gupta form the Opposite Parties, since, 2013 and lastly the said policy got renewed, vide policy bearing no.2952 2007 7612 2804 000 for the period 20.06.2021 to 19.06.2023 and during this policy coverage, on 14.06.2022, the complainant no.2 got admitted in Medanta Hospital and discharged on 16.06.2022. After discharge from the hospital, complainants requested the Opposite Parties to pay the medical bill of Rs.1,85,110/-, but the Opposite Parties paid only Rs.1,43,183/- to the hospital. Again on 15.03.2023, complainant no.2 suffered from eye problem and got her surgery done from Thind Eye Hospital and discharged on the same day. After discharge from the hospital, the complainants lodged the claim with Opposite Parties for reimbursement of expenses incurred at Thind Eye Hospital, but Opposite Parties have not paid any amount in lieu of the medical expenses. Now, the complainant approached this Commission with a prayer that Opposite Parties may be directed to pay remaining amount of Rs. 41,928/- spent at Medanta Hospital and Rs.48,233/- spent at Thind Eye Hospital.
7. We take up the first grievance of the complainants. The first grievance of the complainant is that in the claim lodged by the complainants for the reimbursement of medical bills of first hospitalization of complainant no.2 for Rs.1,85,110/-, the Opposite Parties paid only Rs.1,43,183/-, they wrongly and illegally not released the remaining payment. Now, the question for determination is that whether the deduction made by the Opposite Parties in the claimed amount is genuine or not?
8. We have carefully perused the record. The Opposite Parties have placed on record Settlement Letter as Ex.OPs/4, vide which, the claimed amount has been mentioned as Rs.1,85,110/- from which they have deducted Rs.3421/- and given discount of Rs.8239.40. Thereafter the total amount comes to Rs.1,73,449.60 and from the said amount Rs.34690/- has been deducted as Zonal Co-Payment and Rs.13,642.80 as TDS. We have also perused the terms and conditions of the policy, vide which definition of ‘Co-Payment’ is mentioned as under:-
On availing this option, Co-Payment as mentioned on the Schedule of Coverage in the Policy Schedule will be applied on each and every admissible claim after Deductible/Excess wherever application under the Policy. Once the Co-payment option is availed by the Insured Person, it cannot be opted out of at subsequent Renewal.
Further in Specific General Conditions at Sr. No.6 Premium Tier, it is mentioned as under:-
Premium Tier:
For the purpose of policy issuance, the premium will be computed basis the city of residence provided by the Insured Person in the proposal form. Classification of cites would be as under:-
Tier 1a: Delhi and NCR region
Tier1b: Mumbai, Mumbai Suburban and Navi Mumbai, Pune, Surat, Ahmedabad, Varodara.
Tier 2: Rest of India
Conditions:-
i. On payment of Tier 1a premiums, as Insured Person can avail treatment all over India without any co-payment.
ii. On payment of Tier 1b premium, as Insured Person can avail treatment as Tier1b cities and Tier 2 cities without any Co-Payment. However, if an Insured Person avails a treatment in Tier 1a cities, 20% Co-Payment shall be applicable on admissible claim amount.
iii. On payment of Tier 2 premium, an Insurer Person can avail treatment at Tier 2 cities without any Co-payment. However if an Insured Person avails a treatment in Tier 1a or Tier1b cities, 20% Co-Payment shall be applicable on admissible claim amount.
As the complainants fall under Tier 2 premium (which is proved on record vide policy document Ex.C2) and taken the treatment as per Tier 2 i.e. rest of India, so the complainant is entitled for the deduction in claim amount with 20% Co-payment. Hence, we are of the view that the Opposite Parties have rightly made the deduction on account of Co-Payment in first claim of the complainant. Further the deduction on account of TDS made by the Opposite Parties is also genuine. So, the complainant is not entitled for remaining amount of his first claim.
9. Now, we take up the second grievance of the complainant. The second grievance of complainant is that the Opposite Parties have not given any amount with regard to second claim lodged for the reimbursement of expenses incurred for the treatment of eyes at Thind Eye Hospital. The perusal of the record reveals that the Opposite Parties repudiated the second claim of the complainant on the ground that complainant has taken the treatment from Excluded Provider Hospital, vide repudiation letter dated 30.03.2023. The contents of said repudiation letters are reproduced as under:-
“We have received your request for reimbursement of claim for the above mentioned hospitalization. We have verified the same with respect to the coverage terms and conditions under the insurance policy plan. And on primary scrutiny of the submitted documents, we regret to inform that your claim is not payable due to the following reasons:-
1. On perusal of the submitted claim documents it was observed that the insured was admitted in an Excluded Provider. As per exclusion 11 of IRDA guidelines as mentioned in Chapter 3K (Excluded Providers: Code- Exc11) of the Master Circular on Standardization of Health Insurance Products (IRDAI/HLT(REG/CIR/193/07/2020); the claim is repudiated as expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website/notified to the policyholders are not admissible.”
However, the rejection of claim on the ground that policy holder got the treatment from excluded provider hospital is totally arbitrary. Sometime it is not possible for the policy holder to approach the listed hospitals due to any reasons. The right to medical claim cannot be denied merely because the name of the hospital is not included in the empanelled list. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned.
10. In the present case, by taking a very inhuman approach, the Opposite Parties have denied the grant of medical reimbursement to the Complainant. There is no denial that taking best treatment is the right of the complainant to which the Opposite Parties cannot deprive the complainant. Moreover, it is admitted on record that the complainants are purchaser of the policy in question since, 2013 and further the policy is admitted, hospitalization/treatment and lodging of claim is admitted. So, the ground taken by the Opposite Parties for repudiation of the genuine claim of the complainants is not genuine.
11. In view of the discussion above, the instant complaint is allowed in part and Opposite Parties are directed to pay the claim amount as per admissible rates of their empanelled hospital for the Cataract surgery in question to the complainant. Further Opposite Parties are directed to pay Rs.5,000/- (Rupees Five Thousand only) as compensation and Rs.5000/-(Rupees Five Thousand only) as litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.5,000/- (Rupees Five Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
