Haryana

Panchkula

CC/381/2020

MR.INDERJEET KHATTAR. - Complainant(s)

Versus

HEALTH INSURANCE TPA OF INDIA LTD. - Opp.Party(s)

IN PERSON.

23 Jan 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

                                                       

 

Consumer Complaint No	:	381 of 2020
Date of Institution	:	10.12.2020
Date of Decision	:	20.01.2023

 

 

Sh.Inder Jeet Khattar, son of Shri Nand Lal Khattar, Resident of Flat No.402, GH-23, Sector-20, Panchkula-134117, Haryana.

 

                                                                           ….Complainant

Versus

1.     Health Insurance TPA of India Ltd., 2^nd Floor, Majestic Omnia Building, A-110, Sector-4, Noida-201301, Uttar Pradesh, through its C.E.& O.

2.     United India Insurance Company Ltd., 24, Whites Road, Chennai-600014, through its Chairman cum Managing Director.

3.     Punjab National Bank, Human Resource Development Division, Head Office: Plot No.4, Sector-10, Dwarka-110075, New Delhi, through its General Manager.

4.     Indian Bank’s Association, 6^th Floor, World Trade Centre Complex, Cuffe Parade, Mumbai-400005, through its Chairman.

                                                                   ….Opposite Parties

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019

 

Before:              Sh. Satpal, President.

Dr. Pawan Kumar Saini, Member,

Dr. Sushma Garg, Member.

 

 

For the Parties:   Complainant in person.

                        Sh. Harinder Kumar, Advocate for OPs No.1 & 2.

                        Sh. Saurav Verma, Advocate for OP No.3.

                        OP No.4 already ex-parte vide order dated 05.08.2021.

 

ORDER

(Per Satpal, President)

1.             Briefly stated, the facts of the present complaint are that the complainant had retired as Assistant General Manager from Punjab National Bank, Sector-5, Panchkula on 31.03.2018; the complainant and his wife, namely, Smt.Savita Khattar, were covered qua health risk under the health Insurance Policy no.5001002818P113013686 and policy no. 5001002818P113016871(Super Top up) w.e.f.01.11.2018 to 31.10.2019. The said policies were issued by OP No.2 appointing the Third Party Administrator(TPA) i.e. OP No.1 for the operation of the said policy. The said policies were purchased by OP No.3 for its retired employees. It is stated that the complainant’s wife, namely, Smt.Savita Khattar was suffering from blood cancer and struggling for her survival and that qua the expenses incurred during her treatment, the following claims were lodged with the OP  No.1:-

Sr.No.	Claim No.	Amount (In Rs.)	Date when the claimed lodged	Name of Hospital where admitted
1	181100204349	2,43,656	20.12.2018	PGI,Chandigarh
2	181100213414	1,91,895	03.01.2019	PGI,Chandigarh
3	191100005924	2,75,072	25.03.2019	Max Hospital, Mohali
	Total	7,10,623

 

        It is stated that all the above claims pertain to indoor treatment and none of the bills pertain to day care. The claim at serial no.1 & 2 pertain to Chemotherapy, which was given indoor. Qua the claim at serial no.3, it is stated that the date of the admission in the hospital was 03.03.2019 and date of discharge was 14.03.2019. The period of policy for employees of Punjab National Bank was from 1^st October to 30^th September of the year and for retired employees, it was from 1^st November to 31^st October for the following years. A sum of Rs.3,142/- for the period 01.10.2018 to 31.10.2018 was debited from the complainant’s account No. 2938009500105679 and there was no break in the policy. Further, the premium of Rs.87,422/-was debited on 30.10.2018 for the period from 01.11.2018 to 31.10.2019 from the said account of the complainant. It is stated that the amount claimed vide said claims as lodged by the complainant have not been reimbursed despite the fact that several emails in the last about 23 months were sent to OPs. It is stated that the complainant’s wife, namely, Smt. Savita Khattar died on 02.11.2020 but the Ops did not release the claim amount thereby compounding the difficulties of the complainant. It is stated that all the claims were paid regularly by the OPs for the same patient i.e wife of the complainant, for the same treatment. Even after the retirement of the complainant, the claims as raised were paid till 31.10.2018. The complainants has forwarded all the necessary papers to OPs qua the treatment of his wife, namely, Smt. Savita Khattar; a legal notice was sent to Ops on 10.08.2020 through registered post but the Ops have not paid the claimed amount. Due to the act and conduct of the OPs, the complainant has suffered financial loss, mental agony and harassment; hence, the present complaint.

2.             Upon  notice,  OPs No.1 & 2 appeared through counsel and filed  written statement  raising  preliminary objections qua complaint is not maintainable  being false, frivolous and baseless; complicated question of facts and laws are involved, wherein elaborate evidence involving examination and cross-examination of witness is required, which is not permissible under the summary procedure being adopted under the C.P.Act. No prior notice as required under the terms and conditions of the insurance policy was given by the complainant. It is stated that the complainant is liable to be dismissed as hospitalization must be for treatment and not for the OPD/ follow up treatment, which is clearly excluded as per exclusion Clause no.4 as well as clause 3.3 of the policy. On merits, the averments made by the complainant in all the paras of the complaint have been denied being incorrect except that the contents of para no.9(i) to 9(iii) & (vi) have been stated as matter of record. It is stated that there is no deficiency in service on the part of the OPs No.1 & 2 and thus, prayed for dismissal of the present complaint.

                Upon notice, OP No.3 appeared through counsel and filed written statement raising preliminary objections qua complaint is not maintainable as complainant has no locus standi to file the same; the complainant is not covered under the definition of consumer as given in Section 2(7) of the CP, Act. It is submitted that the OP No.3 has no role in the present dispute. It is the sole responsibility of the OP No.2 and its TPA i.e. OP No.1 to settle the claim of the concerned employee under the existing policy as per the extent terms and conditions. The complainant is retired officer of the bank i.e. OP No.3. For the welfare of its employees, the OP No.3 has bargained with the Insurance Company i.e. OP No.2 to float a Corporate group health Insurance Policy. It is open to all retired employees to opt for the said scheme and pay premium as per their eligibility. For purchasing of this exclusive policy for the retired employee, option rests with the retired employee concerned and OP no.3 has no say in his option. It is the complainant himself who has lodged claim before OP No.1 for processing the insurance claims. The OP No.1 process the claims on behalf of the OP no.2 and final payment of claims are made by the OP No.2, therefore, the present complaint against OP No.3 is liable to be dismissed in liminie. The complainant is estopped by his own act and conduct against the OP No.3. On merits, it is stated that the OP No.3 has acted as facilitator in getting the policy from OP No.2 for larger interest of its employees. It is stated that settlement of insurance claims are done by OP No.2 and for this purpose, the OP No.2 has engaged the OP No.1 for the processing of insurance claims. The OP no.3 has no say in the processing of the settlement claim. It is admitted that the complainant was covered under the policy by making of insurance premium from his own account from 01.11.2018 to 31.10.2019. It is denied that the insurance policy was ever purchased by OP No.3. Infact, the policy was purchased by the complainant himself and the premium amount was also paid by him from his own account. It is submitted that OP no.3 is not a service provider. The OP no.3 has bargained with the Insurance Company i.e., OP No.2 to float a Corporate group health insurance policy. It is open to all retired employees to opt for the said scheme and pay premium as per their eligibility. It is submitted that policy for the retired employee is purchased by the retired employee himself and the OP No.3 has no say in this decision of the retired employee and if option of purchasing the policy is exercised by the retired employee, the contractual agreement is entered between OP No.2 and the complainant. It is submitted that the claims are submitted to OP No.2 through OP No.1 and OP No.3 has no say in the process of claim settlement. There is no deficiency in service on the part of the OP No.3 and thus, prayed for dismissal of the present complaint.

                Notice was issued to the OP No.4 through registered post, which was not received back either served or unserved despite the expiry of 30 days from the issuance of notices to OP No.4; hence, it was deemed to be served and thus, due to non appearance of OP No.4, it was proceeded ex-parte by this Commission vide its order dated 05.08.2021.

3.             Separate replication to the written statement of the OPs No.1 & 2 as well as OP No.3 was filed by the complainant reiterating the contents of the complaint while controverting the contentions of the OPs No.1 & 2 and OP No.3.        

4.             To prove his case, the complainant has tendered his affidavit as Annexure C/A along with documents Annexure C-1 to C-10 in evidence and closed the evidence by making a separate statement. On the other hand, the ld. counsel for the OPs no.1 & 2 has tendered affidavit Annexure R1/A along with documents Annexure R/1 to R/5 and closed the evidence. The ld. counsel for the OP No.3 has tendered affidavit Annexure R3/A and closed the evidence.

5.             We have heard the complainant and the learned counsel for the OPs No.1 to 3 and perused the written arguments filed by the complainant as well as OPs No.1  & 2  and gone through the entire record available on file minutely and carefully.

6.             The grievances of the complainant are that the claim lodged by him seeking reimbursement of the expenses incurred during the hospitalization of his wife, Smt.Savita Khattar(since deceased)  have been repudiated by OP No.1 on baseless, flimsy and frivolous grounds. During arguments, the complainant reiterating the averments made in the complaint contended that said Smt.Savita Khattar(since deceased) was hospitalized for more than 24 hours and thus, the treatment obtained by her cannot be treated under the category of day care treatment. It is vehemently contended that all the claims were previously paid by the insurance company for the same patient i.e. his wife  and for the same treatment till 31.10.2018 and thus, for the complainant has prayed for the acceptance of the complaint by granting the relief claimed for in the complaint.

7.             On the other hand, the learned counsel appearing on behalf of the OPs No.1 & 2 has contended that the complainant has lodged four claims with the insurance company, which are as under:-

1. Dated 20.12.2018 for Rs.2,43,656/-
2. Dated 03.01.2019 for Rs.1,91,895/-
3. Dated 25.03.2019 for Rs.2,75,072/- (Already paid)
4. Dated 25.07.2019 for Rs. 2,36,500/- (Already paid)

8.             It is contended that the amount qua claim mentioned at serial no.4 has already paid before filing of the present complaint and the claim qua dated 25.03.2019 has been settled, during the pendency of the present complaint, on 04.02.2021, by paying a sum of Rs.2,71,169/- against the amount of Rs.2,75,072/-. The learned counsel argued that the claim dated 20.12.2018, for a sum of Rs.2,43,656/-and the claim dated 03.01.2019 for a sum of Rs.1,91,895/- were rightly repudiated as per the terms and conditions of the insurance policy as the treatment taken was not covered in day care list. It is contended that Smt.Savita Khattar(since deceased) wife of the complainant was hospitalized on 18.12.2018 and discharged on 19.12.2018, and thus, her treatment was not covered in day care list. Further, it is contended that said Smt.Savita Khattar (since deceased) was hospitalized on 01.01.2019 and discharged on 02.01.2019; thus, it is contended that her treatment was not covered in day care list; hence, it is asserted that the repudiation of the claims was valid and legal. Reliance has been placed upon the law laid down by Hon’ble Apex Court in Civil Appeal No.6739 of 2010 titled as “Oriental Ins. Co. Vs. Parvesh Chander Chadha. The learned counsel also took the plea that no prior notice was given by the complainant and thus, the complainant is liable to be dismissed.

9.             The learned counsel appearing on behalf of the OP No.3 reiterated the averments made in its reply and contended that the OP No.3 has no role to play in the present dispute as it is the sole responsibility of the OP No.2 and its TPA i.e. OP No.1 to settle the claim of the concerned employee under the existing policy as per the terms and conditions of the insurance policy and thus, prayed for dismissal of the complaint qua OP No.3.

10.            Undisputedly, Smt.Savita Khattar(since deceased) wife of the complainant was covered qua health risk amounting to Rs.4,00,000+ 5,00,000/- vide insurance policy(Annexure C-1 & C-2). It is also not in dispute that the claims dated 20.12.2018 & 03.01.2019 amounting to Rs.2,43,656 & Rs.1,91,895/- respectively were lodged by the complainant during the subsistence of the health insurance policy (Annexure C-1 & C-2).  The OPs have repudiated the claim taking the shelter of Clause 3.3 of the insurance policy(Annexure C-1 & C-2) stating that the treatment taken by Smt.Savita Kattar(since deceased) wife of the complainant was not covered under the day care list. The relevant part of repudiation letter dated 28.03.2019(Annexure R-1/5) for the sake of clarity and convenience is reproduced as under:-

1. As per submitted documents it is evident that patient is admitted for Multiple Myeloma and underwent adjuvant chemotherapy(inj Darzalex). As per policy terms and conditions, this treatment is not covered in Daycare list. Hence we recommend the claim for repudiation under clause 3.3.

11.            As per insurance policy(Annexure C-1 & C-2), the day care treatment is defined as under:-

“2.10   DAY CARE TREATMENT-Day care treatment means the medical   treatment and/or surgical procedure which is-(i) Undertaken under General or local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement and (ii) which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an outpatient basis is not included in the scope of this definition”.

                From above, it is evident that the treatment taken in a hospital for less than 24 hours is termed as day care treatment.

12.            Further, as per Clause 2.19 of the insurance policy(Annexure C-1 & C-2),  hospitalization  is defined as under:-

“Hospitalization

          Means admission in a Hospital/Nursing Home for a minimum period of 24 in-patient care consecutive hours except for the specified day care procedures/treatment, where such admission could be for a period of less than 24 consecutive hours”.

        As per clause 2.23 of the insurance policy(Annexure C-1 & C-2),  in-patient care  is defined as under:-

                “In-Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event”.

                From the above definition of the “hospitalization” as well as “in-patient care”, it is evident that admission in a hospital for more than 24 hours is categorized as treatment taken as in patient care.

13.            The hospitalization of Smt.Savita Khattar(since deceased) wife of the complainant reflecting the date and time of admission and discharge in PGI, Chandigarh is given tabular form as under:-

Sr.No.	Name of the patient	Date of admission with time	Date of discharge with time	Claim no.	Date when claim lodged
1.	Smt.Savita Khattar	18.12.2018 at 11:29:59	19.12.2018 at 12:31P.M.	181100204349	20.12.2018
2.	Smt.Savita Khattar	01.01.2019 at 11:20	02.01.2019 at 15:30P.M.	181100213414	03.01.2019

 

14.            A bare perusal of above would make it evident that Smt.Savita Khattar(since deceased) wife of the complainant was hospitalized for more than 24 hours and thus, by no stretch of imagination, it can be said that she had taken the treatment as day care patient. Therefore, the repudiation of the claims made by the Ops was neither valid and legal nor justified. In view of the aforementioned factual position, we have reached at the irresistible conclusion that OPs No.1 & 2 were deficient while rendering services to the complainant for which they are liable, jointly and severally, to compensate the complainant for which they are liable, jointly and severally, to compensate the complainant.

15.            Coming to the relief, it is found that claim dated 25.03.2019 for a sum of Rs.2,75,072/- has already been settled on 04.02.2021 by the Ops No.1 & 2 during the pendency of the present complaint. Now, the claim no.181100204349 dated 20.12.2018 and claim no.181100213414 dated 03.01.2019 remains to be settled by the Ops No.1 & 2. Qua the claim dated 20.12.2018, the following bills are available on record:-

Sr.No.	Bill issued by	Date	Amount(Rs.)
1	PGIMER, Chandigarh	18.12.2018	800
2	Gupta Agencies	18.12.2018	241351
3	Shri Kumar Chemist-III	18.12.2018	670
	Total		242821

 

16.            With regard to the claim dated 03.01.2019, the bills amounting to Rs.1,91,895/- are available on record as Annexure C-5(colly).

                Therefore, the complainant is entitled to the payment of Rs.4,34,716/-(Rs.242821+191895) along with interest after the expiry of 45 days from the date of lodging of the respective claims till its actual realization. 

17.            As a sequel to above discussion, we partly allow the present complaint against OPs No.1 & 2 with the following directions:-

1. The OPs  No.1 & 2 are directed to make the payment of Rs.2,42,821/-qua claim dated 20.12.2018 and Rs. 1,91,895/- qua claim dated 03.01.2019 along with interest @ 9%(S.I.) p.a. after the expiry of 45 days from the date of lodging of the respective claims till the actual realization. 
2. The OPs No.1 & 2 are directed to pay the interest on the amount of Rs.2,71,169/-, which has been paid to the complainant on 04.02.2021, after the expiry of 45 days from the date of lodging of the claim till 04.02.2021.
3. The Ops No.1 & 2 are also directed to pay an amount of Rs.35,000/- to the complainant on account of mental agony and harassment.
4. The Ops No.1 & 2 are further directed to pay an amount of Rs.5,500/- as litigation charges.

 

18.            The OPs No.1 & 2 shall comply with the order within a period of 45 days from the date of communication of copy of this order, failing which the complainant shall be at liberty to approach this Commission for initiation of proceedings under Section 71/72 of CP Act, against the OPs No.1 & 2. A copy of this order shall be forwarded, free of cost, to the parties of the complaint and file be consigned to record room after due compliance.

 Announced on:20.01.2023

 

 

Dr.Sushma Garg          Dr. Pawan Kumar Saini         Satpal          

        Member                           Member                               President

 

Note: Each and every page of this order has been duly signed by me.

 

                                                 Satpal,                              

        President

 

 

 

 

 

CC. No.381 of 2020

 

 

Present:             Complainant in person.

                        Sh. Harinder Kumar, Advocate for OPs No.1 & 2.

                        Sh. Saurav Verma, Advocate for OP No.3.

                        OP No.4 already ex-parte vide order dated 05.08.2021.

 

Arguments heard. Now, to come upon for 20.01.2023 for orders.

 

Dated: 10.01.2023

 

 

  Dr.Sushma Garg        Dr. Pawan Kumar Saini           Satpal

              Member                  Member                           President

 

                       

Present:             Complainant in person.

                        Sh. Harinder Kumar, Advocate for OPs No.1 & 2.

                        Sh. Saurav Verma, Advocate for OP No.3.

                        OP No.4 already ex-parte vide order dated 05.08.2021.

 

Vide a separate order of even date, the present complaint is hereby partly allowed against Ops No.1 & 2 with costs.

A copy of the order be sent to the parties free of costs and the file be consigned to the record room after due compliance.

Dt.20.01.2023

 

 

                Dr.Sushma Garg          Dr. Pawan Kumar Saini           Satpal

              Member                  Member                           Presiden