DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
MUCHIPARA, BURDWAN.
Consumer Complaint No 25 of 2015
Date of filing: 16.01.2015 Date of disposal: 24.7.2015
Complainant: Amiya Kumar Chowdhury, S/o. Late Gour Chandra Chowdhury, Ranitala, PO: Kulti, District: Burdwan, PIN – 713 343.
-V E R S U S-
Opposite Party: 1. E-Meditek (TPA) Services Ltd., Shri Vishal Plaza, No. 123 (N), G. T. Road (East), Murgasol, PO: Asansol, District: Burdwan – 713 303.
2. Divisional Manager, National Insurance Co. Ltd., Divisional Office XII, 3rd Floor, 6/90 Padam Singh Road, Karol Bagh, New Delhi – 110 005.
3. Vaani Kapoor, Sr. Manager (Mediclaim), Steel Authority of India Ltd., “Ispat Bhawan”, Lodhi Road, New Delhi – 110 003.
Present: Hon’ble President: Sri Asoke Kumar Mandal.
Hon’ble Member: Smt. Silpi Majumder.
Hon’ble Member: Sri Durga Sankar Das.
Appeared for the Complainant: In Person.
Appeared for the Opposite Party No. 1: Chinmoy Bhattacharya, Executive of OP-1.
Appeared for the Opposite Party No. 2: Ld. Advocate, Shyamal Kr. Ganguli.
Appeared for the Opposite Party No. 3 : 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 C. P. Act, 1986 alleging deficiency in service, as well as, unfair trade practice against the Ops as the Ops did not pay his legitimate insurance claim.
The brief fact of the case of the complainant is that being a member of SAIL and its ex-employee he obtained a mediclaim policy by which he is entitled to get cashless treatment. On 12.6.2014 medical investigations were made at B.P. Poddar Hospital & Medical Research Limited, Kolkata where the authority of the said hospital suggested for PTCA with stenting etc. and accordingly an e-mail was sent to the OP-1 on 16.6.2014 for approval of the proposed medical cost amounting to Rs. 2,90,000=00. The OP-1 sent pre-approval certificate on 17.6.2014 stating admissible limit for Rs. 1, 80,000=00 for the proposed hospitalization. Again on 27.6.2014 the OP-1 sent pre-approval certificate stating the admissible limit for Rs. 2, 00,000=00. The complainant got admission at the said hospital on 01.7.2014 and he underwent an operation of PTCA on 02.7.2014 for re-stenosis. Before getting discharge from the hospital on 04.7.2014 the OP-1 sent another pre-approval certificate stating admissible limit for Rs. 1, 66,000=00 whereas the medical bill has been raised by the hospital to the tune of Rs. 2, 54,000=00. Where on earlier occasion on 16.6.2014 the OP-1 approved the medical cost to the tune of Rs. 2,00,000=00 comprising the cost of re-stenosis + hospitalization + balloon, then how the pre-approval cost was reduced at Rs. 1,66,000=00 on 04.7.2014 at the time of his discharge after operation, the picture is not clear at all. Due to such evasive tactics adopted by the OP-1 the complainant had to pay excess amount of (Rs. 2, 00,000 - 1,66,000) Rs. 34,000=00 in addition to other expenses amounting to Rs. 55,000=00 i.e. Rs. 88,000=00 in total. The OP-1 did not pay actual amount of Rs. 1, 86,000=00 for two stents and arbitrarily and whimsically deducted Rs. 86,000=00 at their caprice. In addition the OP-1 did not pay Rs. 2,300=00, incurred by him on account of Doppler and Eco- cardiogram Test, conducted by the same hospital on 12.6.2014, before 19 days of hospitalization. As the patient party was not prepared for making payment of any amount towards hospital bill and could not pay the extra amount of Rs. 34,000=00 on the date of discharge, the complainant was compelled to stay one day in excess at the hospital beyond 04.7.2014 for collection of the excess amount by lending from outside. After making payment of the entire amount the complainant got discharge on 05.7.2014. According to the complainant such attitude of the Ops is an example of deficiency in service as well as unfair trade practice. Though the complainant had to incur medical expenditure to the tune of Rs. 2, 54,000=00 genuinely, but the Ops did not reimburse the entire amount with mal-intention, from which it is clear that the actions of the Ops suffer from deficiency in service and unfair trade practice. Therefore finding no other alternative the complainant has approached before this ld. Forum by filing this complaint praying for direction upon the Ops for making payment to him for Rs. 34,000=00 towards remaining unpaid amount of actual bill for indoor treatment, Rs. 2,300=00 for pre-investigation charge, Rs. 600=00 as doctor’s consultation fee, Rs. 1,00,000=00 as compensation due to harassment, mental agony and illogical deduction, Rs. 5,000=00 towards the cost of stationery, conveyance charge and litigation cost of Rs. 5,000=00.
The POC has been contested by the Op-1 by filing written version contending that it is working as third party administrator, who only process the claims as per guidelines of the Insurance Company and recommends the claims for payment/rejection to the Insurance Company keeping in view the specific terms and condition of the policy issued by the Insurance Company. The OP-1 has no pecuniary /financial interest in any of the claims whatsoever, as such, it only recommends the cases to the Insurance Company and liability for reimbursement /repudiation of the claim finally lies upon the shoulder of the Insurance Company, not the OP-1. It is further submitted by the OP-1 that the claim of the complainant has been duly settled in view of the terms and the condition of the policy and it had duly remitted its opinion to the Insurance Company for settlement of the claim as per policy condition and settled amount had duly remitted to the concerned hospital by the OP-2 before his discharge. As the OP-1 has duly discharged its liability, there was no deficiency in service on its part. So it has no liability to make any payment to the complainant as prayed for. Prayer has been made by the OP-1 for dismissal of the complaint with exemplary cost.
The OP-2 has contested the POC by filing written version contending that the complainant obtained a mediclaim policy through SAIL being a retired employee for sum assured of Rs. 2,00,000=00 (self) from the OP-2 for the period from 01.01.2014 to 31.12.2014. On 17.6.2014 the OP-1 informed the hospital authority by authorizing them to admit the complainant suffering from CAD between 17.6.2014 to 19.6.2014 stating admissible limit of Rs. 1, 80,000=00 against estimated expenses forwarded by hospital authority for Rs. 2, 90,000=00 comprising of PTCA for Rs. 45,000=00, medicine Rs. 16,000=00, cost of balloon Rs. 30,000=00 and cost of double stent @Rs. 1, 00,000=00X2=Rs. 2, 00,000=00. Again on 27.6.2014 upon receipt of intimation about proposed date of hospitalization of the complainant on 01.7.2014 to 03.7.2014 (for 3 days) the admissible limit was stated for Rs. 2, 00,000=00. Thereafter, upon receipt of the intimation from hospital authority about final bill they have stated about implanted ‘Pronova’ stent for Rs. 1,00,000=00 in total and stated authorized limit for Rs. 1,66,000=00 against expenditure of Rs. 2,54,361=00. It is further stated that the authorized limit worked out based on full and final bills drawn by hospital authority. The OP-1 was appointed as third party administrator only to process the claim and make recommendation for final payment keeping in view of the policy condition. As per terms and conditions of SAIL mediclaim policy there is a capping in this particular cardiac stent ‘Pronova’ which is Rs. 50,000=00 per stent together with Balloon charges of Rs. 21,000=00 and Angioplasty package of Rs. 45,000=00, thus approved an amount of Rs. 1, 60,000=00 by TPA as per segregation and in light of capping under condition of the said policy. The OP-1 has also confirmed that an amount of Rs. 2,300=00 being Doppler and Eco-cardiogram charges should not be raised by the hospital authority separately, however, TPA has paid package charges of Rs. 11,500=00 as per PPN rates to the Hospital authority along with the amount of Rs. 600=00 as doctor’s fees to the complainant in his previous hospitalization claim. It was also confirmed that further an amount of Rs. 5,000=00 as VAT on stent (which was not paid in the final bill) to be released immediately. Thus differential amount of Rs. 29,000=00 for indoor treatment was not payable because of capping of the said policy. It is submitted by the OP-2 that in the prayer portion the complainant has prayed for release of an amount of Rs. 1, 46,900=00 on five separate accounts including claim of compensation for harassment to a heart patient for Rs. 1,00,000=00 leaving aside the rest amount claimed on other heads of expenses stands for Rs. 46,900=00. The investigation charge of Rs. 2,300=00 is a part of package of coronary Angiogram and hospital should not demand separately and similarly the fees of the treating doctor has already been paid and claim on other two heads are not related to the actual cost of operation. Therefore, it is evident that the OP-2 has fully complied with the recommendation of TPA regarding reimbursement of medical expenses and the same was justified with the terms and the conditions of the policy. According to the OP-2 as there was no deficiency in service on its part, the complaint is liable to be dismissed with cost.
The OP-3 has contested the complaint by filing written version wherein it is stated that this OP has been impleaded by name, followed by description of the post earlier held by her, which is uncalled for as she has no personal involvement in the dispute raised by the complainant. So the OP-3 has been wrongly and unnecessarily impleaded, who is entitled to the discharged from the above case. The complainant has made allegations regarding deficiency in service against the OP-1&2 as the TPA and the Insurance Company did not make payment of the entire amount as incurred by him towards medical expenditure. No allegation has been made out by the complainant against the OP-3 within the fourcorners of the complaint. Moreover, no relief has been sought for against the OP-3 in the complaint. Therefore, the complainant has made her as a party unnecessarily with a view to harass her only. Prayer has been made by the OP-3 to dismiss the complaint against her with cost.
The complainant has filed affidavit along with several medical documents, treatment papers, bills raised by the concerned hospital where he was operated upon, policy certificate etc. The OP-2 has filed written notes of argument and placed reliance on the documents filed by the complainant. The complainant has also filed his written argument.
We have carefully perused the record, documents and papers 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 complainant being a retired employee of SAIL obtained one mediclaim policy, the policy was valid for the period from 01.01.2014 to 31.12.2014, policy sum assured was for Rs. 2,00,000=00 for the complainant, the complainant was admitted at the hospital on 01.7.2014, where he underwent balloon surgery, two stents implanted, got discharge on 04.7.2014, the OP-2 paid Rs. 1,66,000=00 towards his treatment cost keeping in view of the terms and the conditions of the mediclaim policy, VAT was not paid by the OP-2 inspite of making payment of the same by the complainant to the Hospital Authority as per the bill raised by it. The allegation of the complainant is that though he had to incur medical expenditure to the tune of Rs. 2, 54,361=00 but the Insurance Company paid only Rs. 1, 66,000=00 and for this reason he is entitled to get the balance amount from the Insurance Company. Further allegation of the complainant is that as the action and activity of the OP-1&2 suffers from deficiency in service, as well as, unfair trade practice, being compelled he has approached before the court of law for redressal of his grievance. On the other hand, the contention of the OP-1 is that being TPA, it has no right to make payment of any amount towards insurance claim and it only used to process the claim file and remit the opinion to the Insurance Company either to settle or reject the claim. The submission of the OP-2 is that as the claim of the complainant has already been settled by making payment of Rs. 1, 66,000=00 in view of the terms and the conditions of the policy, hence there was no deficiency in service and unfair trade practice on its part.
At the very outset we are to adjudicate as to whether there was any deficiency in service or not on behalf of the OP-3. It is seen by us that within the fourcorners of the complaint no allegation has been made out by the complainant against the OP-3. There is no pleading that the activity of the OP-3 suffers from any deficiency in service and/or unfair trade practice. Moreover, in the prayer portion also no relief has been sought for by the complainant from the OP-3. As we cannot travel beyond the pleadings of the complainant, hence in our view this complaint does not stand against the OP-3. Accordingly, the complaint is dismissed on contest without any cost against the OP-3.
Now we are to see as to whether there was any deficiency in service or nor on behalf of the OP-1&2. The complainant has stated that as he had to incur medical expenditure towards his medical treatment along with operation and implantation of two stents to the tune of Rs. 2, 54,361=00, the Insurance Company is liable to make payment of the said amount against the mediclaim policy. In this respect we are to say that as the policy sum assured is for Rs. 2, 00,000=00, the complainant is not entitled to get any amount beyond sum assured. Therefore, the claim for Rs. 2, 54,361=00 does not stand at all. Further submission of the complainant is that as the Insurance Company paid Rs. 1,66,000=00, now he is entitled to get remaining Rs. 34,000=00. In this regard we cannot travel beyond the policy terms & conditions wherein it is stated that for implantation of stent, the insured is entitled to get Rs. 50,000=00 per stent. Admittedly, two stents were implanted. Therefore, the complainant is entitled to get Rs. 1, 00,000=00 (Rs. 50,000 X 2 = Rs. 1, 00,000) towards the cost of implantation of two stents. It is seen by us that in this respect the Insurance Company has paid Rs. 1, 00,000=00 in to to keeping in view the terms and the conditions of the policy. Be it mentioned that the complainant had to make payment Rs. 1, 77,142.86 towards the cost of stent, i.e. Rs. 88,571.43 per stent. But as per policy condition the complainant is entitled to get Rs. 50,000=00 per stent and the Insurance Company had complied with the terms and conditions of the policy. We have noticed that the OP-2 paid Rs. 21,000=00 towards Balloon charges and Rs. 45,000=00 as Angioplasty package. In this way Rs. 1, 66,000=00 was paid by the Insurance Company towards the medical expenditure of the complainant. But it is noticed by us that at the time of payment of the bill the complainant had to pay VAT @5% over the total amount. The complainant paid VAT to the tune of RS. 8,857.14 over the amount of Rs. 1, 77,142.86. We have further noticed that as per policy condition the insured is entitled to get VAT. As the OP-2 inspite of making payment of Rs. 1, 00,000=00 towards the cost of two stents, VAT @5% did not pay and for getting the said amount the complainant has approached before this Ld. Forum by filing this complaint, the complainant is entitled to get compensation due to deficiency in service on the part of the OP-2. In our view the complainant is entitled to get VAT @5% over Rs. 1, 00,000=00 i.e. Rs. 5,000=00 from the Insurance Company. Though the complainant filed this complaint personally and did not engage any Ld. Advocate, inspite of this he had to incur some amount towards litigation cost.
Admittedly, the OP-1 has no authority for making any payment to the insured as being Third Party Administrator it is empowered to process any claim of the insured and remit the opinion in respect of either admissibility or rejection of the same to the Insurance Company. In this respect there exist a MOU by and between the OP-1 and the OP-2. It is well known that principal is liable to make payment, not the agent. Here being the agent/TPA the OP-1 has no liability for making any payment as prayed for by the complainant. Therefore, this complaint does not stand against the OP-1 and hence it is dismissed on contest without any cost against the OP-1.
Now we turn up our eyes to the most vital question that as admittedly there is deficiency in service on behalf of the OP-2, then how much amount it is liable to pay to the complainant as compensation. In the prayer portion of the complaint the complainant has prayed for Rs.1, 00,000=00 towards compensation due to unnecessary harassment, mental agony etc. but in our view where there is a question of Rs. 5,000=00 which has not been paid as yet by the OP-2 towards VAT to the complainant, the complainant cannot be entitled to get the above-mentioned hefty amount as compensation. But of course, the complainant is entitled to get some amount towards compensation, as well as, litigation cost as he had to approach before the court of law for redressal of his grievance. Though it is submitted by the Ops that he is not entitled to get any litigation cost as the complainant personally adjudicate his case and did not engage any ld. Advocate. But inspite of this the complainant had to incur some expenses due to such litigation and if the OP-2 paid Rs. 5,000=00 as VAT before coming to the ld. Forum, then payment for litigation cost will not be raised.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is allowed on contest with cost against the OP-2 and dismissed against the OP-1&3 on contest without any cost. The OP-2 shall pay a sum of Rs. 5,000=00 to the complainant towards VAT @5% on the amount of Rs. 1,00,000=00 within 45 days from the date of passing of this order, in default of making payment of Rs. 5,000=00 the amount shall carry penal interest @9% p.a. for the default period. The OP-2 is also directed to pay an amount of Rs. 1,000=00 as compensation due to unnecessary harassment and mental agony and Rs. 500=00 as litigation cost to the complainant within 45 days from the date of passing of this order. In default, the complainant will be at liberty to put the entire decree into execution as per provisions of law.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Durga Sankar Das) (Silpi Majumder)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
