In the Consumer Disputes Redressal Forum, Burdwan.
(Nivedita Pally, G.T. Road, P.O.-Sripally, Dist.-Burdwan)
Consumer Complaint No. - 93/2014.
Date of filing - 15.05.2014.
Date of final order - 15.03.2016
Present
i) Sri Asoke Kumar Mandal Honorable President.
ii) Sri Pankaj Kumar Sinha Honorable Member.
Bawa Singh
S/O. Gyan Singh,
Resident of QRT. No.HA/8,
(Near Town Puja), P.O.-Burnpur,
Dist.: Burdwan, Pin-713325 (WB) Complainant.
VERSUS
- E-Meditek (TPA) Services Ltd.,
Shri Vishal Plaza, No.-123(N),
G.T.Road (East), Murgasol,
P.O.- Asansol, Dist.-Burdwan,
Pin-713303, Service through its
Manager.
- E-Meditek (TPA) Services Ltd.,
Having its corporate office at Plot No.577,
Udyog Vihar, Phase-V, Gurgaon, Haryana,
Pin-122 016, Service through its Corporate
Officer.
- Bajaj Allianz General Insurance Company Ltd.,
GE Plaza, Opp. Gunjan Cinema, Airport Road,
Blue Hill Society, Yerawada, Pune, Maharashtra,
Pin-411 006, Service through its Chairman. Opposite Parties.
Appeared for the complainant : Ld. Advocate Subrata Ghosh & Others.
Appeared for the Opposite Party No.1 & 2 : Authorized person Chinmoy Bhattacharya.
Appeared for the Opposite Party No. 3 : Ld. Advocate Sourav Kr. Mitra.
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This is a case U/S 12 of Consumer Protection Act, 1986 filed by the Bawa Singh for an award directing the O.Ps. to pay Rs.1,76,503/- towards reimbursement of rest medical expenses incurred by the complainant for the treatment of his wife, to pay Rs.2,00,000/- as compensation towards mental pain, agony and harassment and to pay Rs.30,000/- towards litigation cost.
The complainant’s case in short is that the complainant was an employee of Steel Authority India Ltd.(SAIL), the complainant retired from his service being posted at Burnpur as ‘Assistant Foreman’ on 31.12.2010 at the age of 60 years, after retirement from service the complainant entered into Mediclaim Scheme of E-Meditek (TPA) Service Ltd. specially for the retired employees of SAIL and their spouses, so the complainant and his wife Chiranjeet Kaur became the Mediclaim Members of E-Meditek (TPA) Service Ltd. and covered their Group Insurance Mediclaim Policy of the Insurance Company being Emp. No./ Personal No.55111 and as per Mediclaim Scheme of E-Meditek (TPA) Service Ltd., the policy will be operated through Bajaj Allianz General Insurance Co. Ltd., GE Plaza, Opp. Gunjan Cinema, Airport Road, Blue Hill Society, Yerawada, Pune, Maharashtra-411 006, said policy being No.OG-13-1000-8402-00000001 was commenced on and from 01.01.2011, the son Sarwan Singh Johan of the complainant was the nominee of said policy and the premium of the policy was 3,606/- which the complainant paid in cash to the O.P. No.1. The further case of the complainant is that said mediclaim policy was renewed for the year 2013 by paying the premium of Rs.4,426/- on 17.1.2013 and the mediclaim policy was numbered as MIN Nos. (Mediclaim Index Number)-5908699 for the complainant and 5908700 for his wife Chiranjeet Kaur, the policy was valid for the period from 01-01-2013 to 31.12.2013, during the period of validity of the mediclaim policy the wife of the complainant Chiranjeet Kaur felt pain in her abdomen, she was admitted at Burnpur hospital on 28.10.2013, after examining it was detected that the patient was suffering from Gallbladder Mass, so operation was required, the doctor of said hospital made an attempt for laparoscopic Cholecystectomy Surgery on 29.10.2013 but the doctors stopped the operation as he suspected that there might be cancer in Gallbladder of the patient, the patient was referred from Burnpur Hospital, without any delay, the patient was admitted at Apollo Hospital, Chennai under the treatment of Dr. Manish Ch. Verma, who after some medical tests operated the patient on 11.11.2013. The further case of the complainant is that the complainant incurred all such medical expenses to the tune of Rs.2,21,503/- Chiranjeet Kaur from his own pocket, the complainant submitted his claim along with medical bills connected with said treatment before the O.Ps. with a request to reimburse the entire amount but unfortunately the O.Ps. paid only Rs.45,000/- with the remark that the amount of Rs.45,000/- was the maximum limit in the case of Cholecystectomy as per terms and conditions of Steel Authority India
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Ltd.(SAIL), though there was no such limit in terms and conditions of the policy, the complainant several times requested the O.Ps. to pay the rest amount of Rs.1,76,000/- but the O.Ps. did not pay any heed. So, there is clear deficiency in service on the part of the O.Ps., the complainant made an application before the Assistant Director, Consumer Affairs and Fair Business Practices, Durgapur Regional Office but being noticed the O.P. No.1 neglected to appear before the Assistant Director as mentioned, this conduct of the O.P. also shows deficiency in service on his part, for the illegal acts of the O.Ps. the complainant was harassed and he has been forced to come before this Forum to get proper relief. Hence, this case with the prayer as mentioned above.
The O.P. No.1 & 2 contested this case by filing a joint written version while stating inter-alia that the O.P. No.1 & 2 is a third party administrator (TPA) duly licensed by the Insurance Regulatory and Development Authority under the IRDA (Third Party Administrators-Health Services Regulation -2001 under license No.007, the O.P. No.1 & 2 is engaged in making available Health Services with regards to health Insurance Business conducted by insurer, O.P. No.1 & 2 provides third party administration services to many insurance company including O.P. No.3, Bajaj Allianz General Insurance Company Ltd., the O.P. No.1 & 2 is working as third party administrator and it only process the claims as per guideline of Insurance Company and recommend claims for payment/rejection to insurance company and also keeping in view the specific terms and conditions of policies issued by respective insurance company, so the entire payment liability is upon the Insurance Company (O.P. No.3), the O.P. No.1 & 2 are the agents of O.P. No. 3 being a third party administrator (TPA) licensed by the Insurance Regulatory Development Authority to act as a facilitator between the Insurance Company and the insured, the policy in question was issued by the O.P. No.3, Bajaj Allianz General Insurance Company Ltd. and the premium was also collected by it and the O.P. No.1 & 2 being the agents are not liable for the acts of a disclosed principal. The O.P. No.1 & 2 has admitted in their written version the case of the complainant that the complainant purchased a mediclaim policy vide policy No. OG-13-1000-8402-00000001, claim No.100111302950 for the period from 1.1.2013 to 31.12.2013 for a sum of Rs.4,00,000/- (spouse) from the insurer, O.P. No.3 and Chiranjeet Kaur, the wife of the complainant was admitted at Apollo Hospital Enterprises Ltd. And stayed there for the period from 08.11.2013 to 15.11.2013 for her treatment of ‘Chronic Cholecystis’. It is the further case of these O.Ps. that the complainant preferred a reimbursement claim bearing No.100111302950 dated 25.11.2014 in respect of hospitalization/medical expenses incurred for the treatment of his wife made within such period, on scrutiny of the claim papers it was observed that the patient was suffering from chronic Cholecysitis and according to the terms of insurance
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policy, the O.P. No.1 & 2 settled and approved only Rs.45,000/- and as per terms and conditions of the policy the maximum amount payable for chronic Cholecysitis is Rs.45,000/-. It is, therefore, claimed by these O.Ps. that the complaint is liable to be rejected.
The O.P. No.3 contested this case by filing separate written version while stating inter-alia that the case is not maintainable, misconceived and barred under the principles of estoppels, waiver and acquiescence. It has been further claimed by this O.P. that the policy of insurance bearing No.OG-13-1000-8402-00000001 was issued by covering the risk of treatment expenses of the complainant and his wife subject to terms, conditions and stipulation thereof, as per terms of the policy claim will be lodged through the O.P. No.1 and this O.P. No. 1 will indemnify the same in favour of the complainant, the O.P. No.1 will calculate the indemnification amount and this O.P. has no authority to verify & to increase or decrease the amount as settled by the O.P. No.1, a claim was lodged by the complainant for indemnification for the amount incurred by him in the treatment of his wife, after verification of papers the O.P. No.1 and 2 approved a sum of Rs.45,000/- as per Clause-45.1(f) of the terms and conditions and as per said clause, the ceiling for payment is Rs.45,000/- only for Cholecystectomy and said amount was paid to the complainant. So, there is no deficiency in service on the part of the O.P. No.3. Hence, this case is liable to be rejected.
DECISIONS WITH REASONS
In support of his case, the complainant has adduced evidence on affidavit and copies of several documents related to the treatment of his wife Chiranjeet Kaur and related to his claim for reimbursement before the O.Ps. On the other hand the contesting O.Ps. have also adduced evidence on affidavit and the copies of several documents including SAIL Mediclaim Scheme 2013, in which the terms and conditions of the policy has been mentioned.
We carefully perused the evidence adduced by the parties and documents in which the parties have relied upon. From the evidence on record it appears that the case that the complainant was an employee of Steel Authority India Ltd.(SAIL), he retired from service on 31.12.2010, he entered into the Mediclaim Scheme of E-Meditek (TPA) Service Ltd. specially for the retired employees of SAIL and their spouses, the complainant and his wife both are the mediclaim members having the policy No.OG-13-1000-8402-00000001 which was subsequently renewed for the year 2013 and the case that the wife of the complainant was admitted at Burnpur Hospital for her treatment, subsequently she was
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admitted at Apollo Hospitals, she was undergone operation on 11.11.2013 by Dr. Manish Verma and there she stayed for the period from 8.11.2013 to 15.11.2013 for her
treatment and for the treatment of his wife, the complainant was forced to bear the medical expenses amounting to Rs.2,21,503/-, are not disputed. It is further admitted that the complainant made a claim with medical papers for reimbursement of the same but the O.Ps. only relying upon the provisions of clause 45.1(f) of the terms and conditions of the policy only paid Rs.45,000/- as full & final settlement and they have denied to pay the rest amount of Rs.1,76,503/- with the remarks “ admission charges not payable, already settled in main claim as per capping of Cholecystectomy Rs.45,000/-, so cannot be paid here”.
In the above premises, it is essential to see whether the complainant is entitled to get the rest amount of Rs.1,76,503/-. We carefully perused the terms and conditions of the policy as mentioned in part-III of SAIL Mediclaim Scheme-2013. In clause-40.0 of technical specifications of SAIL Mediclaim Scheme-2013, the policy coverage has been mentioned. As per clause 40.0(b) provides “the policy covers reimbursement of Hospitalization and also Cashless Facility and/or Outpatient Department (OPD) expenses within the prescribed limits under the policy for illness/diseases contracted or injury/sustained by the insured person, in the event of any claim becoming admissible under the policy, the Insurance Company will pay to the insured member (Reimbursement)/Hospital (for cashless treatment), the amount of such expenses as reasonably and necessarily incurred anywhere in India and for the purpose of the said Mediclaim Scheme, the ex-employee and his/her spouse, to be treated as two distinct members.” Clause-42.0 describes the hospitalization benefit. Here it has been mentioned that reimbursement of actual charges up to Rs.2,00,000/- per member per policy period (with clubbing facility between employee and spouse) is permissible. So, as per terms of Clause-40.0(b) and Caluse-42.0, the complainant is entitled to get reimbursement up to Rs.2,00,000/- for the treatment of his wife as mentioned in the foregoing line. It is admitted that on recommendation of O.P. No.1 & 2, the O.P. No.3 has only paid Rs.45,000/-. So, the complainant is entitled to get the rest amount of Rs.1,55,000/- (Rs.2,00,000=00 – Rs.45,000=00).
It is essential to mention that the O.Ps. relying upon the provisions of Clause-45.1(f) has claimed that the complainant is entitled to get reimbursement of Rs.45,000/-only as his wife was treated for her disease Cholecystectomy. We carefully perused all the relevant clauses of terms and conditions, it appears that 45.1(f) was included in addition to the capping of the facilities as mentioned in Clause-40.0, 42.0 etc. It is not the case of the complainant and the O.Ps. that the complainant accepting the package system made treatment of her wife at Apollo Hospital, Chennai. There is no evidence on record
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showing that there was package system in Apollo Hospitals, Chennai. So, we hold that in this case Clause-45.1(f) of the terms and conditions is not applicable.
In view of our above discussions, we are of the opinion that the complainant is entitled to get reimbursement of such rest amount of Rs.1,55,000/- from the O.P. No.3, who is the insurer of the wife of the complainant.
In para-15 of its written version the O.P. No.3 has stated that as per terms of the policy any claim is lodged through the O.P. No.1, the O.P. Nos. 1&2 will indemnify the same in favour of the complainant, the O.P. No.1 will calculate the indemnification amount and this O.P. has no authority to verify and increase or decrease the amount as settled by the O.P. No.1 & 2. This case of the O.P. No.3 has not been challenged by the O.P. No.1 & 2. Moreover, the O.P. No.2 in para-10 of their written version have admitted that they settled the accrued claim of the complainant for a sum of Rs.45,000/- disallowing the claim of Rs.1,76,503/-. So, the settlement of the claim of the complainant was made by the O.P. No.1 & 2 and O.P. No.3 paid such settled amount of Rs.45,000/- to the complainant. From this fact it is clear that there was no negligence or deficiency on the part of the O.P. No.3 in the matter of settlement of the claim of the complainant. But the O.P. No.1 & 2 committed wrong in the calculation and by approving only Rs.45,000/- in favour of the complainant. So, we are of the opinion that there was deficiency in service and negligence on the part of the O.P. No.1& 2. In the above premises the O.P. no.1 & 2 are liable to pay compensation to the complainant for his harassment.
For deficiency in service and negligence on the part of the O.P. No.1&2 the complainant was forced to make several correspondences with the O.Ps. and to lodge written complaint before the Assistant Director, Consumer Affairs and Fair Business Practices, Durgapur Regional Office and lastly he was forced to come before this Forum. For the fault on the part of the O.P. No.1 & 2 the complainant was forced to bear the litigation cost, so the complainant is entitled to get litigation cost from the O.P. No.1 & 2.
In view of our above discussions the complaint case succeeds.
Fees paid is correct.
Hence, it is
Ordered
that the complainant’s case be and the same is allowed on contest against the O.Ps.,
that the complainant do get an award directing the O.P. No.3 to pay an amount of Rs.1,55,000/- as rest medical expenses to the complainant and directing the O.P. No.1 &2
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to pay Rs.20,000/- as compensation for harassment and mental agony of the complainant and to pay Rs.3000/- as litigation cost to the complainant within 45 days from this day, failing which the amount of Rs.1,55,000/- payable by the O.P. No.3 will carry interest
@ 9% p.a. for the default period and the complainant will be at liberty to put this order in execution in accordance with law.
Let the copies of this order be supplied to the parties free of cost.
(Asoke Kr. Mandal)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
(Asoke Kr. Mandal)
President
D.C.D.R.F., Burdwan
(Pankaj Kr. Sinha)
Member
D.C.D.R.F., Burdwan
