Punjab

Ludhiana

CC/22/269

Harsimran Singh - Complainant(s)

Versus

Manipal Cigna Health Insurance Co.Ltd - Opp.Party(s)

S.S.Bhatia

14 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  269 dated 08.07.2022.                                       Date of decision: 14.11.2024. 

 

Harsimran Singh aged 48 years son of Shri S.P.S. Walia, resident of House No.2, Maple Manor, Adjoining Flower Enclave, Gurudwara Baba Deep Singh, Village Phullanwal, Basant Avenue, Ludhiana. Mob. No.94170-06150.                                                                                           ..…Complainant

                                                Versus

1. Manipal Cigna Health Insurance Company Ltd., Regd. Office 401/402, Fourth Floor, Raheja Titanium, Office Western Express Highway, Goregaon East Mumbai-400063 through its Director/Managing Director.
2. Manipal Cigna Health Insurance Company Ltd., First Floor, Sandhu Tower-I, Gurdev Nagar, Ferozepur Road, Ludhiana-141001 through its Manager/Branch Head.                                                                                                                                                       …..Opposite parties 

Complaint Under Section 35 of Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. S.S. Bhatia, Advocate.

For OPs                          :         Sh. Vyom Bansal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant availed a family floater health insurance policy from the OPs vide policy No.PROHLN000294429 having validity from 26.05.2020 to 25.05.2021 covering the complainant and his family members Divjot Kaur, Prabh Simran Singh and Gursimran Singh.  The complainant paid premium of Rs.18,592.43P. The complainant stated that he suffered from COVID-19 pandemic for which he remained admitted in Deep Hospital, Ludhiana from 27.08.2020 to 10.09.2020 for which the complainant spent an amount of Rs.4,36,078/- out of which only Rs.1,27,867/- was approved and disbursed by the OPs and the remaining amount of Rs.3,08,211/- was not disbursed. The complainant had to pay the remaining amount from his own pocket at the time of discharge from the hospital. The complainant further stated that he many times requested the OPs to disburse the remaining amount of medical treatment expenses and he also fulfilled all the requisite formalities but the OPs lingered on the matter on one pretext or the other. The complainant wrote a letter dated 29.03.2020 to the OPs with request to reimbursement of his claim and also sent an Email dated 08.04.2022 but no response was received from the OPs. The complainant again wrote a letter dated 16.04.2022 to the OPs but his claim amount was not sanctioned. The complainant claimed to have suffered mental tension, mental agony, harassment etc. due to deficiency in service and unfair trade practice on the part of the OPs The complainant sent a legal notice dated 07.06.2022 but to no effect. Hence this complaint, whereby the complainant has prayed for issuing directions to the OPs to disburse the claim amount of Rs.3,08,211/- along with interest and also to pay compensation  and punitive damages of Rs.3,00,000/- as well as litigation expenses of Rs.55,000/-.

2.                Upon notice, the OPs appeared and filed written statement and under the column factual submission & objections, assailed the complaint on the ground of maintainability; the complainant being not a Consumer; the complaint being frivolous one; suppression of material facts etc. The OPs stated that they issued a policy No. PROHLN000294429  to the Complainant under the Manipal Cigna Prohealth Insurance Policy. The benefits under the policy are governed by the terms and conditions of the Policy and the liability of the Opposite Party is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and condition of the Policy. The OPs further stated that they received a request for reimbursement claim for hospitalization vide reimbursement claim form dated 19.09.2020 for treatment of COVID and the same was allotted to Medi Assist Insurance TPA Pvt. Ltd. for assessment & investigation of genuinity of the claim and confirms the admissibility of the claim as per policy term & conditions. Their officials their mind to the available documents and settled the claim as per the authorized rates of GIC for Rs.1,27,367/-. Further the OPs re-evaluated the claim decision and are ready to settle the claim as per the policy terms & conditions. The payable amount as per the policy terms & conditions is Rs.2,14,264/ in toto and they have already paid amount of Rs.1,27,867/- earlier and are ready to pay additional amount of Rs.86,397/- as full and final settlement of the claim.

                   The OPs further stated that the deductions were made in accordance with the Clause - VI.30 of policy terms and conditions- All non-medical expenses including convenience items for personal comfort not consistent with or incidental to the diagnosis and treatment of the disease/illness/injury for which the Insured Person was hospitalized, Ambulatory devices, walker, crutches, belts, collars, splints, slings, braces, stockings of any kind, diabetic footwear, glucometer/thermometer and any medical equipment that is subsequently used at home except when they form part of room expenses. For complete list of Non-medical expenses, Please refer to the Annexure IV "Non-Medical Expenses". The list of the deductible items is reproduce as under:-

"admission-1000, miscellaneous-86400(no breakup), MRD-500, mask=450, gloves-250, goggles 450, thermometer-230, max shield=495+330, goggles 450, face mask=15, mask=450, gloves=160, mask=629+450, gloves-128, mask-450, gloves-128,m face mask=15, mask=450, gloves=147, mask=629, gloves=250, mask=600+20, mask=450, gloves=147+64, cotton-55, shield=660, mask=600, goggles-600, mask-600+20, gloves-64, goggles-600, shield=660, mask=600, gloves=196, mask=20, gloves=250, mask=600, mask=1500. Total-102762"

The OPs further stated that in the final bill an amount of Rs.86,400/- was charged against the head 'miscellaneous charges', but no such clarification was provided as to what miscellaneous charges are incurred by the hospital. The OPs during investigation tried to make its best efforts in finding out the reason for the same, however neither the hospital nor the complainant provided any clarification in this regard.  Further in addition to the above deductions, the OPs were also constrained to make deductions on the room rent part as the hospital did not provide the room tariff to the company even upon repeated requests. Hence, the company was left with a blinded fold and could not assess the claim on merits. Later, the company verified the tariffs basis the other claims from the same hospital and arrived at amount of Rs.5,400/- which is being charged by the hospital against the other patients. Hence, the amount was calculated basis that calculation of which is pasted- Excess of room rent-99400(considered 5400/day for 14 days). According to the OPs, the proportionate deductions were made against nursing, doctor and oxygen charges as well of Rs.19,652/- (56.8% on 34600).  On the basis of the above calculations, the company derived the payable amount basis the said calculations: 436078 (Claimed amount) 221814(102762+99400+19652) (Deductions)= Rs.2,14,264/- (Payable amount in total). Already paid Rs.127367; Balance payable- Rs.86,397/-. As such, the complainant is only entitled to balance payment amount of Rs.86,397/- from the OPs.

                   On merits, the OPs reiterated the crux of averments made in factual submission. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 to Ex. C9 and closed the evidence.

4.                On the other hand, the counsel for the OPs tendered affidavit Ex RA of Sh. Jaswinder Singh Shekhawat, Senior Manager Legal of the OPs along with documents Ex. R1 to Ex. R3 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statement, affidavit and documents produced on record by both parties.

6.                By filing the present complaint, the complainant is seeking reimbursement of amount of Rs.3,08,211/- and is aggrieved of partial payment of a sum of Rs.1,27,867/- out of total medical expenses of Rs.4,36,078/-  incurred by him. In his complaint and the affidavit, the complainant has not referred to any policy terms and conditions which entitles him to seek the reimbursement of entire amount of Rs.4,36,078/-. The allegations of alleged deficiency on the part of the OPs are bald and non-specific.

7.                On the other hand, the OPs have exhaustively dealt the grievance of the complainant and have categorically admitted that an additional sum of Rs.86,397/- is still payable to the complainant out of the total approved amount of Rs.2,14,264/-. The OPs have referred to clause VI.30 of the policy terms and conditions along with Annexure-IV under the head “Non-Medical Expenses”  and have detailed the non-medical expenses which were not payable.

8.                While preferring the claim, the complainant claimed an amount of Rs.86,400/- under the head 'miscellaneous charges' but despite seeking clarification by the OPs, the complainant did not provide its requisite particulars. As such, due to non-furnishing of the particulars and explanation on the part of the complainant, the said claim of the complainant was declined by the OPs. However, this Commission is of the view that in the interest of justice, another opportunity be afforded to the complainant for supplying necessary particulars/clarifications with regard to 'miscellaneous charges'  of Rs.86,400/- So in the given facts and circumstances of the case, it would be just and appropriate if the OPs are directed to pay the additional amount of Rs.86,397/- to the complainant along with interest @8% per annum from the date of filing of the complaint till its actual payment within 30 days from the date of receipt of copy of order and further the complainant will submit the bifurcation/clarification regarding 'miscellaneous charges' of Rs.86,400/- with the OPs within 30 days from the date of receipt of copy of order and then the OPs shall decide such 'miscellaneous charges' within 30 days from the date of receipt of bifurcation/clarification from the complainant. The OPs are further burdened with composite costs of Rs.10,000/-.

9.                As a result of above discussion, the complaint is partly allowed with direction to the OPs to pay the additional amount of Rs.86,397/- to the complainant along with interest @8% per annum from the date of filing of the complaint till its actual payment within 30 days from the date of receipt of copy of order Further the complainant will submit the bifurcation/clarification regarding 'miscellaneous charges' of Rs.86,400/- with the OPs within 30 days from the date of receipt of copy of order and then the OPs shall decide such 'miscellaneous charges' within 30 days from the date of receipt of bifurcation/clarification from the complainant. The OPs shall also pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.     

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:14.11.2024.

Gobind Ram.