Final Order / Judgement | Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi Complaint Case No. 202/2019 Sh. Neeraj Kumar Sharma H.No.-178, Gali No-16, Village Wazirabad, …Complainant Versus Medi Assist Insurance TPA Pvt. Ltd Branch 88, 2nd Floor, Tej Building, Bahadur Shah Jafar Marg, New Delhi-110002 Bajaj Allianz Insurance Co. Block No-4, Plot No.-4, 7th Floor,DLF Floor, 15-Shivaji Marg, Moti Nagar,New Delhi-110015 ...Opposite Party Date of filing: 06.07.2019 Date of Order: 06.11.2024 Coram: Shri Inder Jeet Singh, President Ms Rashmi Bansal, Member -Female FINAL ORDER Ms Rashmi Bansal, Member -Female By the present order Commission is disposing off complaint of the complainant alleging deficiency in services on the part of OPs in not clearing his insurance claim in full because of which he suffered not only the financial loss but also harassment, mental agony and inconvenience. - It is the case of complainant that he is group C employee in MTNL and under the company’s (employer) cashless treatment agreement with OP2, he was provided a cashless card by OP2 with MID no. 5023930087, policy no. 1000/OG18-1000-8403-0000002 valid for a period from 10.06.2017to 09.06.2018. Complainant submits that except the above stated card he was not provided with any documents not even the copy of the policy or its terms and conditions.
- It is further submitted that in July 2018, complainant has noticed a nodule in his neck region. On 06.07.2018 he visited Parmanand Hospital where he was advised to get FNAC test of the nodule from outside, which he got done from Tirathram Hospital and on receiving report on 13.07.2018, immediately shown to the Doctor in Parmanand Hospital, where cancer was doubted and he was asked to get more tests done. To confirm this, he again got the nodule tested in Ganga Ram Hospital on 16.07.2018 and received the report on 18.07.2018 which though clearly mentioned no evidence of cancer, however, it was advised by the doctor that it should be removed. Therefore, the complainant decided to have the operation done at Ganga Ram Hospital. However,, since the said hospital was not in the empaneled list of the policy, he opted Apollo Hospital instead of Parmanand Hospital or Tirathram Hospital as he has lost his faith in the said hospitals. After some examinations, he was operated on 31.08.2018. The final bill raised by Apollo Hospital was of Rs. 1,79,470.35/-, however, OP2 has paid only Rs. 1,65,079/- and Rs. 14391/- were deducted which is unfair and injustice to the complainant as the policy was cashless policy. Complainant also submits that before operation, certain tests and treatment undertaken by the complainant, which costed him Rs. 23,793/- for which reimbursement was applied with OP2 but only Rs. 13,214/- were paid, which is wrong and arbitrary.
- Complainant submits that he has written to the OP2 on 01.12.2018 to know the reason why the bills were not reimbursed in full but has not received any clear reply from OP2. It is further submitted that he also informed his employer's (department) and requested help, but no help was provided from the them. Complainant pleads that he has undergone to the treatment as per doctor’s advice despite that his bills were not reimbursed in full by OP2 and amount was deducted without any reason. Complainant further submits that OP2 has taken the plea that bed rent of the hospital was more than the prescribed but he has got the treatment from the lowest level of ward (general ward) and there is no bed lower than what he has taken in the Apollo Hospital. Complainant also submits that if this is the situation, then OP2 and department (employer) should not enter into any agreement. Complainant submits that OP2 has violated the terms of agreement by not reimbursing his bill properly and the services provided by the OP2 are deficient because of which he has suffered financial loss, harassment and mental agony, at the hands of the OP2. The complainant prays for Rs. 10,579/- the amount which was not reimbursed, Rs. 14,391/- which was deducted from the final bill by OP2 and Rs. 1500/- which he had spent on online for seeking legal aid from Apki Samasya.com. Complainant also prays for compensation for the sufferings of harassment and mental agony and any other relief. In support of his case, complainant filed documents and bills from Parmanand Hospital and Tirathram Hospital, test reports dated 18.07.2018 of Ganga Ram Hospital, documents of the Apollo Hospital with respect to operation dated 31.08.2018, copy of letter dated 01.12.2018 addressed to OP2.
- Upon notice, OP1 failed to appear and was proceeded ex-parte vide order dated 26.09.2019. OP2 has filed reply along with documents in support of his case, stating that there is no deficiency in service on its part and the complaint is liable to be dismissed as the complainant has not come with clean hands before this Commission and has also concealed the material fact that the claim payable under the policy has been already paid to him.
- It is further submitted that a policy bearing number OG – 19–1000–8403–00000001 was issued in the name of the complainant along with his wife and two daughters valid from 10.06.2018 to 09.06.2019, for a sum of Rs. 2,00,000/-. It is submitted that complainant planned hospitalisation in the Apollo hospital for the treatment of tumour and on 18.08.2018, hospital sent pre-authorisation request for planned admission with the estimated bill of Rs. 2,50,700/- which was processed by the panel of experts as per terms and conditions of the policy and an initial approval of Rs.75,100/- was sanctioned. On 29.08.2018 the complainant underwent surgery. In addition to initial approval, final enhancement request was sent by the hospital for Rs. 1,79,470/- on 03.09.2018, for which the final approval was given for an amount of Rs. 89,979/-under pre-authorisation claim. Hence, a total bill of Rs. 1,65,079/- was sanctioned against the total bill of Rs. 1,79,470/-. On receipt of cashless claim documents, the claim was processed and settled to the hospital.
- OP2 submits that the deduction under the cashless claim stands corrected as per policy conditions. It is submitted that as per customized policy conditions of the company, the complainant is eligible for the room rent of Rs. 2250/- per day as per his employee grade (NEZ/2/18) but he has availed higher room rent @ rate of Rs. 5300/- per day because of which, a different amount of Rs. 9950/- was deducted with non-medical expenses of Rs. 4841/-. Therefore, out of total bill of Rs. 1,79,470/-, a sum of Rs. 14,391/- was deducted.
- It is further submitted that after the discharge from the hospital, the complainant submitted a claim of pre and post-hospitalisation expenses for the above stated hospitalisation which was received under the claim number 17970223 for a sum of Rs. 23,793/-, which was also settled for a sum of Rs. 13,214/- after disallowing amount of Rs. 10,579/- as expenses were beyond the pre and post hospitalisation limit of 30 – 60 days. OP2 submits that all the claims of the complainant were settled as per the terms and conditions of the policy and no claim remains thereafter, therefore, the present complaint liable to be dismissed. OP2 has filed policy along with its terms & conditions in support of its case.
- Complainant filed the rejoinder negating contentions of the OP2 and reiterated his version of the complaint, by submitting that so far as room rent entitlement is concerned, the complainant has not requested to hospital for any room and stayed at the lowest price accommodation i.e. general ward during the treatment. Complainant submits that when there was no alternative price below the general ward at the hospital, deduction on this ground is not acceptable. Further, deduction of Rs. 4841/- on the ground of being the non-medical expenses is concerned, it is submitted, that during the treatment, whichever material was used, was necessary for the treatment and nothing special has been asked for by the complainant without prescription of the doctor. Even also, the information provided to him by the OP2, with respect to details of non-medical expenses, comes to Rs. 3749/- instead of 4841/-. The complainant also submitted that the deduction of Rs.10,579/- from the total expenses of Rs. 23,793/- based on the pre and post hospitalisation limit is also not acceptable to him in the circumstances where he was advised to be suspected with cancer by Tirath Ram Hospital and just to confirm the same, the said delay in operation has taken place.
- Complainant and OP2 have submitted their respective evidence with support of documents filed with complaint and written statement by endorsing them as per their respective evidences. Both the parties have filed their written arguments.
- The Commission heard the arguments and perused the documents on record filed by both sides.
- The documents on record show that policy number OG – 19–1000–8403–00000001, issued in the name of the complainant for the period 10.06.2018 to 09.06.2019. Complainant has filed claim for Rs. 1,79,470/- with OP2. the settlement claim letter, dated 24.09.2018, as filed by the OP2, shows that the claim of Rs. 1,66,171/- was paid to the complainant after deducting Rs. 13,299/- stating that the payment is done as per the detailed bill filed by the complainant vis -a -vis the terms of the terms & conditions of the policy. The said settlement letter has dealt in detail under different heads as to how and why the deduction of Rs. 13,299/- was made. Since the complainant belongs to the employee grade NE9/2/18 and as per documents, he was eligible for room rent of Rs. 2250/- per day, (which fact is not denied by the complainant), therefore the room rent was restricted to Rs. 2250/- per day and claimed room rent @Rs. 5300/- per day was declined by deducting the difference as the same was beyond eligibility of the complainant and in total the excess room rent of Rs. 9550/- was deducted after considering a discount of Rs. 2650/- given by the hospital and balanced amount of Rs. 18,550/- was paid to the complainant. (Rs. 21,200/- for 4 days – Rs. 2650/ discount given by the hospital = Rs. 18,550/-). Complainant’s plea that he has availed lowest price accommodation i.e., general ward during the treatment and that when there was no alternative price below the general ward at the hospital available, he had no option but to take that, which does not entitle him for more than his rank in the department. The investigation and lab charges of Rs. 7340/- were paid in full without any deduction. Miscellaneous charges of Rs. 823/- were not paid as they pertain to medical record charges, dietician charges and food charges which were non payable. Surgery charges of Rs. 1,04,900/- were paid in full without any deduction. Consultation charges of Rs. 23,500/- also were paid in full without any deduction. Pharmacy and medicine charges, as claimed by the complainant of Rs. 24,357/- were paid of Rs. 21,431/- after deducting an amount of Rs. 2926/- towards non payable items.
- However, this is noticed that the actual amount towards non – payable items, which is deducted from claim amount is Rs. 14,391/- instead of Rs. 13,299/- and thus Rs. 1092/- are deducted in excess. OP2 has not provided any justification towards the excess deduction of Rs. 1092/- made by it nor has explained how the amount of Rs. 4841/- was calculated. Therefore, OP2 is negligent in settling the claim amount of complainant by deducting excess amount of Rs. 1092/- and is held liable to pay the difference of Rs. 1092/- to the complainant. Further, the said amount is retained by OP2 since 24.09.2018, the same is liable to be paid to the complainant with interest, which, this Commission deems fit to be paid with interest at the rate of 6% per annum from 24.09.2018, (the date of the settlement of the claim) till its final realization by the complainant.
- Complainant submission with respect to pre – post hospitalisation claims of Rs. 23,793/- where Rs. 13,214/- were paid by OP2 and Rs.10,579/- were deducted, not acceptable to him because delay in operation has taken place for getting confirmation from other hospitals, cannot be accepted in terms of the terms and conditions of the policy, which, vide its clause A(2) provides for pre-hospitalisation medical expenses specifies immediately 30 days before the insured person is hospitalised and vide clause A(3) provides for post hospitalisation expenses incurred immediately 60 days after the insured person discharge from the hospital. The complainant was discharged from the hospital on 02.09.2018. The details of the payment and deductions as per settlement letter dated 10.10.2018 filed by the complainant has detailed the limit of pre – post hospitalisation as exhausted. The bills filed by complainant were also calculated and found to include expenses beyond the pre and post hospitalisation limit of 30 – 60 days respectively amounting to Rs. 10,579/- were deducted from the claim amount of Rs. 23,793/-. The circumstances as narrated by the complainant, may have caused certain delay in getting himself operated, but that does not justify to go beyond the pre and post hospitalisation limit of 30–60 days respectively as per policy terms and condition, and therefore this contention of the complainant is rejected and it is found by the Commission that the claim amount of Rs. 13,214/- is rightly paid by the OP2. Therefore, the prayer of the complainant for the payment of Rs. 10,579/- is rejected.
- Further, because of the miscalculation on the part of the OP2, in settling his claim as per settlement letter date 24.09.2018, the complainant has suffered mental harassment and agony as well as the financial loss for which OP2 is liable to compensate the complainant which this Commission deems fit and appropriate to the tune of Rs. 5000/- under the circumstances of the case. Complainant is also entitled for litigation cost as he has to file the present complaint for redressal of his grievances before this Commission, which is awarded as Rs. 2500/- to be paid by OP2.
- OP1, being the TPA, has no role except a facilitator in processing the insurance claim. Therefore, the complaint against OP1 is dismissed.
- Therefore, the complaint is partially allowed with the following direction to the OP2:
- To pay an amount of Rs. 1092/- with interest at the rate of 6% p.a. from the date of settlement of the claim, which is 24.09.2018 till its realization by the complainant;
- To pay an amount of Rs. 5000/- towards compensation for causing mental harassment and agony to the complainant;
- To pay an amount of Rs. 2500/- towards the Litigation cost;
The above - stated amount be paid to the complainant by OP2 within 45 days from the date of passing of the order, failing which the OP2 shall be liable to pay the interest on Rs. 1092/- at the rate of 9% p.a. calculated from 24.09.2018, besides the payment of compensation of Rs. 5000/- and Litigation cost of Rs. 2500/-. The OP2 is at liberty to deposit the above stated amount in this Commission by way of a valid instrument in favor of the complainant. - The copy of the order be given to the parties, free of cost as per rule applicable for compliances, and order to be uploaded on website and thereafter, the file be consigned to record room.
- Announced on this 6th day of November 2024.
[Rashmi Bansal] Member (Female) [Inder Jeet Singh] President | |