Consumer Complaint No.230 of 2015
Date of filing: 04.12.2015 Date of disposal: 14.12.2016
Complainant: Prativa Mukherjee, W/o. R.N. Mukherjee, resident of 3/10, Madhusudan Dutta Path, Durgapur, District: Burdwan, PIN – 713 216.
-V E R S U S-
Opposite Party: 1. E-Meditek (TPA) Services Ltd., represented by its Regional Manager, having its office at Shri Vishal Plaza, No. 123 (N), G. T. Road (East), Murgasol, PO: Asansol, District: Burdwan, Pin – 713 303.
2. E-Meditek (TPA) Services Ltd., represented by its Regional Manager, having its office at Suit No. 6, 8th Floor, Shanty Niketan Building, 8, Camac Street, Kolkata – 700 017.
3. National Insurance Co. Ltd., represented by its Divisional Manager, having its office at Kundu Mansion (1st Floor), 548, G. T. Road, Bhangakuthi, Burdwan, PIN – 713 101.
4. Steel Authority of India, represented by its Manager, having its office at Ispat Bhavan, Lodi Road, New Delhi, PIN – 110 003.
Present: Hon’ble President: Sri Asoke Kumar Mandal.
Hon’ble Member: Smt. Silpi Majumder.
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No. 1&2: Chinmoy Bhattacharya, Autho. Representative.
Appeared for the Opposite Party No. 3: Ld. Advocate, Shyamal Kumar Ganguli.
Appeared for the Opposite Party No. 4: Ld. Advocate, Biswa Ranjan Bhattacharjee.
J U D G E M E N T
This complaint is filed by the Complainant u/S. 12 of the Consumer Protection Act, 1986 alleging deficiency in service, as well as, unfair trade practice against the OPs as the Ops, specially the OP-3 has settled the insurance claim at a very lower amount.
The brief fact of the case of the Complainant is that the husband of the Complainant being a retired employee of the OP-4 obtained one medi-claim policy from the OP-3 for himself and his spouse i.e. the Complainant in the year 2014 by making payment of premium amounting to Rs.5, 670=00 in favour of the OP-1 and 2, who are the marketing agent of the OP-3 and the Op-3 accordingly issued the insurance policy. At the time of issuing the policy the OPs issued MIN no-6500958 in favour of the Complainant and 6500957 in favour of the husband of the Complainant. During continuation of the policy the Complainant felt ill in the month of January, 2015 and took admission at the Apollo Hospital Enterprises Limited, Chennai on 08.01.2015 under Dr. Madan Mohan Reddy, Orthopedic. The Complainant underwent operation in her knee on 09.01.2015 and 10.01.2015. A sum of Rs. 1, 90,487=00 was incurred for her treatment. At the time of admission the hospital authority intimated the OP-1 and 2 and at the time of discharge the hospital authority intimated the said OPs regarding treatment cost. But as the OPs did not take any step for making payment of the bill amount to the hospital directly, the husband of the Complainant being compelled paid the bill amount to the hospital on 15.01.2015. After getting discharge from the hospital the Complainant with the help of her husband reached at the house at Durgapur and on 19.01.2015 received a cheque amounting to Rs.1, 00,700=00 from the Apollo Hospital. After getting the cheque the Complainant and his husband became surprised and the husband of the Complainant contacted with the OP-1 and asked them about such insufficient amount. The OP-1 did not give any reply to his queries, but on 05.05.2015 the Op-1 send a letter to the Complainant from which the Complainant and her husband came to know the OP-1 and the OP-2 lodged their claim as a claim no-100011507816 and deducted a sum of Rs. 89,787=00 as per the terms and condition of the policy. In the said letter the OPs have given a chart of deducted amount and its reason. It is appeared that the OPs deducted the amount arbitrarily, whimsically and on the basis of their self-made story. The husband of the Complainant made several written correspondences with the OPs in this connection for making payment of the entire amount as incurred towards the medical treatment of her wife, being insured, but the OPs did not take any step in favour of the Complainant. As the grievance of the Complainant have not been redressed by the OPs before coming to the Ld. Forum, hence having no alternative this complaint is initiated by the Complainant praying for direction upon the OPs to pay a sum of Rs. 89,787=00 in favour of the Complainant towards the remaining amount of the medical expenditure, to pay compensation for Rs. 25,000=00 due to mental pain, agony and harassment and litigation cost of Rs. 25,000=00 to her.
The petition of complaint have been contested by the OP-1 & 2 by filing conjoint written version contending that present complaint is not maintainable against these OPs as there is no privity of contract between the Complainant and these OPs because neither any premium was charged by the OPs nor there is any contract of insurance in which both the Complainant and the OPs have entered. The OP-1 and the OP-2 is merely a Third Party Administrator. These OPs are working as TPA and it only used to process the claims for payment/rejection to the Insurance Company keeping in view the specific terms and conditions of the policy issued by the Insurance Company. These OPs have no financial interest in any of the claims whatsoever, as such the OPs are only recommended the cases to the Insurance Company and the Insurance Company is only entitled to take final decision in respect of reimbursement of any claim or not, so entire liabilities lie on the shoulder of the Insurance Company. These OPs are not entitled to make payment, if any claim, to the insured and as per the Law of this Land the agent is not liable for the acts of the principal. The OPs have further stated that the Complainant had preferred a reimbursement claim in respect of hospitalization/medical expenses incurred on the treatment with effect from 08.01.2015 to 15.01.2015. On scrutiny of the claim papers it was observed that the patient was suffering from B/L O.A. with Synovitis and according to the terms of the policy the OP-1 and the OP-2 have recommended and settled the claim of the Complainant for a sum of Rs. 1,00,700=00. An amount of Rs. 89,787=00 was disallowed on account of GIPSA package. The claim of the Complainant has been settled as per the instructions of the Insurance Company-OP-3. According to the OP-1 &2 as there was no deficiency in service and unfair trade practice on their behalf, the Complainant is not entitled to get any relief from these OPs as prayed for. The OP-1 and the OP-2 have prayed for dismissal of the complaint.
The petition of complaint has been contested by the OP-3 by filing written version contending that the husband of the Complainant being an ex-employee of SAIL was enjoying a medi-claim policy having MIN no-6500957 and in favour of his spouse bearing MIN no-6500958. The Group Medical Insurance Policy for retired employees of SAIL was on the basis of a contract between SAIL and NICL-OP-3 under operation of the scheme based on stipulated terms and condition as per Group Medi-claim Insurance policy entitling the retired employees towards enjoyment of certain treatment facilities according to the terms and conditions of the policy. It is mentioned by the OP-3 that upon receipt of the intimation regarding treatment of the Complainant for her Arthroscopy and knee treatment at Apollo Hospital, Chennai during the period from 08.01.2015 to 15.01.2015 the same was thoroughly scrutinized by the OP-1 and the OP-2 and thereafter Rs. 1, 00,700=00 was released as settlement of claim amount which was reimbursed to the Apollo Hospital authority against total treatment cost of Rs. 1,90,487=00. The hospital bill mentioning the charges for consultation, equipment, investigation, medical administration, non-pharmacy material, OT charges, Physiotherapy, professional charges, profile, room rent, OT consumables, OT pharmacy, nursing and hospital utilities, nutritional and functional assessment charges. Out of the above the permissible charges have been paid to the extent of Rs. 1, 00,700=00 and deducted the amount of Rs. 89,787=00 only. The reason for deduction was also duly intimated by the OP-1 & 2 by issuing a letter dated 05.05.2016 addressed to the Apollo Hospital Credit Sell Department, Chennai in details. According to the OP-3 as the claim of the Complainant has been settled as per the opinion of the OP-1 and 2, who are the claim settling agent of the OP-3, and the settled amount has duly been paid by the OP-3, hence there is no deficiency in service, as well as, unfair trade practice on the part of this OP and for this reason the Complainant is not at all entitled to any amount as sought for. Accordingly prayer is made by the OP-3 for dismissal of the complaint.
Upon receipt of the notice from the Ld. Forum the OP-4 appeared on 04.02.2016, but thereafter the OP-4 chose not to contest the complaint by filing written version inspite of getting such opportunity and ultimately after expiry of the statutory period for filing the written version, the Ld. Forum was pleased to fix the complaint ex parte against the OP-4. So we have heard argument of the complaint case ex parte against the OP-4.
The Complainant has adduced evidence on affidavit. All the contesting parties have filed some documents in support of their respective contentions.
We have carefully perused the record; documents filed by the parties and heard argument at length advanced by the Ld. Counsel for the parties. It is seen by us that there are some admitted facts in the case in hand i.e. the husband of the Complainant being a retired employee of SAIL obtained one medi-claim policy for himself and his wife in the year 2014 from the OP-3, the premium amount is of Rs. 5,670=00 paid by him in favour of the OP-1 & 2, MIN nos-6500958 and 6500957 were issued in favour of the Complainant and her husband respectively, during validity of the insurance policy the wife of the retired employee got admission at the Apollo Hospital, Chennai on 08.01.2015 due to her illness under Dr. Madan Mohan Reddy, Orthopedic, she underwent Arthroscopy in her knee on 09.01.2015, she got discharge from the hospital on 15.01.2015, she had to incur medical expenses to the tune of Rs. 1,90,487=00, the Insurance Company did not make payment the medical expenses directly to the hospital, during discharge the Complainant being compelled to make payment of the entire bill amount to the Hospital, after reaching at their residence the Complainant received a cheque amounting to Rs. 1,00,700=00 from the Apollo Hospital, upon receipt of the same the Complainant became surprised and contacted with the OP-1 asking it about such insufficient amount, the Complainant received one letter from the OP-1 & 2 dated 05.05.2015, from the said letter she came to learn that as per the terms and conditions of the policy they have deducted a sum of Rs. 89,787=00 and provided a chart deducting the amount and its reason, thereafter the Complainant has made several correspondences with the OP-1 & 2, but to effect and being dissatisfied with such action of the Ops, the Complainant has initiated this complaint praying for certain reliefs. The allegation of the Complainant is that the OPs have deducted legitimate insurance claim arbitrarily and whimsically.
The contention of the OP-1 and 2 is that they have no authority to make payment of any amount towards the reimbursement of any claim lodged by the insured as they are only claim settling agent. Their duty is to examine the papers and documents submitted by the insured in respect of any claim and being agent of the OP-3 they only use to refer any claim either allowing or repudiating the same. According to the OP-1 & 2 the complaint should be dismissed against them being devoid of any merit.
The contention of the OP-3 is that it has settled the claim of the Complainant as per the terms and conditions of the policy. A sum of Rs. 89,787=00 has been deducted as per policy condition because the Complainant is not entitled to get the entire medical expenses incurred by her due to the terms and conditions. As at the time of taking out the policy the Complainant has admitted the said terms and conditions by putting her signature in the proposal form, now she cannot travel beyond the same. According to the OP-3 as there was no deficiency in service on its part, it is not liable to make payment of any amount to the Complainant as sought for. Moreover, the Complainant was not intimated the cause for deduction of the above-mentioned amount.
During hearing the Ld. Counsel for the OP-3 has argued that the claim of the Complainant has neither been settled entirely nor repudiated till filing of this complaint and as the claim is still pending, hence the complaint is premature. It is further submitted by the OP-3 that if it is found that the Complainant is entitled to get further amount, then it will disburse the amount in favour of the Complainant. Further it is mentioned by the OP-3 that the deduction was made as per the policy terms and the conditions and same was duly intimated to the Complainant along with reasons for deduction. In respect of such argument we are of the view that the OP-3 has failed to corroborate its argument by filing cogent documentary evidence. From the record and the documents it is appeared that the OP-1 and 2 have referred for Rs. 1, 00,700=00 towards the claim of the Complainant to the OP-3 and accordingly the OP-3 has issued a cheque for the said amount and remitted the same to the Hospital and as in the meantime the Complainant left the Hospital by getting discharge, hence the Hospital authority send the cheque at the address of the Complainant. In the written version no where it is mentioned by the OP-3 that the claim of the Complainant is still pending, the OPs are processing the same till date, but failed to come to a conclusion. If that be so or if we accept the contention of the OP-3 for the sake of argument, then one question is cropped up in our mind as to why the OP-3 did not intimate the Complainant by issuing letter that the claim is still under process. Therefore such submission of the OP-3 does not bear any merit at all.
Now we are to see as to whether the deduction was made arbitrarily and illegally or as per the terms and conditions of the policy or not. From the document no-3 as annexed by the Complainant it is evident that the TPA by issuing a letter dated 05.05.2015 had intimated the Apollo Hospital, where the Complainant was treated, that the claim of the Complainant has been settled for Rs. 1, 00,700=00 and deduction was made for Rs. 89,787=00 and the cause for such deduction was also assigned in the said letter. We have noticed that deductions were made in respect of room rent for Rs. 15,000=00, pharmacy charges for Rs. 16,719=00, consultant charges of Rs. 600=00, food charges for Rs. 370=00, Rs. 4,950=00 for surgical appliances, Rs. 2,800=00 for nursing charges, consumables for Rs. 30,726=00, assistant surgeon charges for Rs. 2,000=00, Rs. 4,009=00 for OT charges, Rs. 605=00 for physiotherapy, Rs.1 ,700=00 for Anesthesia, X-ray for Rs. 1,650=00, cardiology for Rs. 6,208=00, Medical records for Rs. 650=00 and Rs. 1,890=00 for Misc. charges. In the booklet of Group Medi-claim Insurance Policy there is an important exclusion clause. We have carefully gone through the same as the OP-3 has claimed that deduction was made as per the terms and conditions of the policy concerned. But it is seen by us that apart from food charges the aforementioned deduction heads are not mentioned in the exclusion clause. In respect of food charges it is mentioned in the said clause that the ‘attendant food charges’ falls under the exclusion clause, but in the final bill as issued by the Hospital Authority there is no mentioning of ‘attendant food charges’. Not only that on several heads the OP-1 & 2 have deducted the claim, which are not at all claimed by the Hospital Authority from the Complainant and the Complainant also did not make payment the said heads i.e. surgical appliances, assistant surgeon charges, anesthesia, X-Ray, cardiology, medical records and miscellaneous charges etc. Therefore it is clear that the OP-1 & 2 have deducted the amount regarding claim of the Complainant neither based on the terms and the conditions of the policy nor as per the claim of the Hospital Authority. During hearing the Ld. Counsel for the OPs has failed to convince us as to on what basis deduction was made. In our considered view as the deduction has no basis at all, such deduction can be termed as deficiency in service on behalf of the OPs.
Therefore, it is clear to us that in an arbitrary and whimsical manner the OP-1&2 settled the insurance claim of the complainant at a lower amount and the OP-3 has blindly supporting the opinion of OP-1&2 issued a cheque in favour of the complainant to the tune of Rs. 1, 00,700=00. As the complainant has successfully proved the deficiency in service of the OP-1, 2 & 3, hence in our opinion the complainant is entitled to the balance amount of the expenses as incurred by her towards her medical treatment. On the other side, the Ops have failed to show us any provision from the terms and the conditions of the policy that they are entitled to deduct the amount as deducted by them as per the terms and the conditions of the policy. It is the settled principle of law that the insurance policy is based on utmost good faith. As the terms and the conditions of the instant policy has reached its finality after offer and acceptance of both the parties by putting their independent signatures, hence neither the complainant nor the Ops can travel beyond the terms and the conditions of the policy. It is seen by us that due to such deficiency in service of the OP-1, 2 & 3 the complainant had to run from pillar to post for getting reimbursement in respect of the policy, but to no effect. For such deficiency in service in our view the complainant is entitled to get compensation from the Ops. As her grievance have not been redressed by the OP-1, 2 & 3 before coming to the court of law and by filing this complaint she had to incur some expenses, in our considered view the complainant is also entitled to get litigation cost from the OP-1, 2 & 3.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is allowed on contest against the OP-1, 2 & 3 with cost and dismissed ex parte against the OP-4 without any cost. The OP-1, 2 & 3 are directed to pay Rs. 89,787=00 either jointly or severally within 45 days from the date of passing of this award along with interest @6% per annum for the period from 04.12.2015 till realization, in default, entire decreetal amount along with interest shall carry penal interest @8% per annum for the default period. The OP-1, 2 & 3 are further directed to pay either jointly or severally Rs. 5,000=00 as compensation for mental harassment, pain and agony and Rs. 2,000=00 as litigation cost to the complainant within 45 days from the date of passing of this award, failing which, the complainant is at liberty to put the entire award in execution as per provisions of law.
Let plain copies of this order be supplied to the parties free of cost as per provisions of Consumer Protection Regulations, 2005.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
