Date of Filing: 04.10.2016 Date of Final Order: 22.11.2017
Sri Asish Kumar Senapati, President
This is an application U/s 12 of the C.P. Act, 1986.
The sum and substance of the Complainant Case is that Sri Tapas Sen, hereinafter referred as Complainant, filed the Case against Sri S. Mardi, Senior Branch manager, national insurance Co. Ltd., B.S. Road, Cooch Behar, The M.D., MD India Health Care Services (TPA) Pvt. Ltd. and the Director, Dr. P.K. Saha Hospital Pvt. Ltd., hereinafter referred as the O.Ps alleging that one Smt. Sipra Sen, wife of the complainant was covered under the Mediclaim Policy being No.153901/48/16/8500000064 of the national Insurance Co. Ltd and she was admitted at O.P. No.2, Hospital on 27.08.16 due to her sudden illness and discharged on 02.09.16. The Complainant produced necessary documents at the Hospital for availing cashless facility of the Mediclaim policy. The Hospital Authority issued one bill claiming Rs.23,742/- on 02.09.16 but the MD India Health Care Pvt. Ltd. approved Rs.18,894/- only. The MD India Health Care Pvt. Ltd. did not approve Rs.100/- as Registration Charges and Rs.4,748/- as Hospital discount in spite of the fact that the Hospital Authority did not give discount of Rs.4,748/-. The Complainant ventilated his grievances to the O.Ps but of no result. The Complainant claimed Rs.4,800/- which he paid to the hospital Authority, Rs.30,000/- as compensation for mental agony and harassment and cost of litigation against the O.Ps.
The O.P. Nos.1 & 3 contested the case by filing written version. The O.P. No.2 put its appearance through its Ld. Agent on 22.11.16 but did not contest the case by filing W/V.
The O.P. No.1 filed W/V on 30.01.17 contending that the complaint is not maintainable in its present form. That the case is bad for defect of parties. It is true that the O.P. No.1 issued a cashless Mediclaim policy for the period from 28.04.16 to 27.04.17 in the name of Sipra Sen but the dispute as stated is between the complainant and the O.P. No.3 as the O.P. No.3 did not settle the dispute. That the Complaint is liable to be dismissed U/S 26 of the C.P. Act, 1986.
The O.P. No.3 filed W/V on 05.05.17 stating that the allegations against the O.P. No.3 are baseless and far from truth. It is true that Smt. Sipra Sen was admitted at the O.P. No.3, Hospital and submitted all documents for availing cashless benefit and the O.P. No.3 allowed the same properly but 20% Hospital discount was not given as it is not admissible and there is no such agreement between the Hospital and the insurance Company regarding any Hospital discount. The O.P. No.3 prays for dismissal of the Complaint against the O.P. No.3 with cost.
Upon the above versions of the parties, following points are framed for proper adjudication of this Case:
POINTS FOR CONSIDERATION
- Is the Complainant a Consumer in view of Sec 2(1)(d)(ii) of the C.P. Act,1986?
- Has this Forum jurisdiction to entertain the Complainant?
- Have the O.Ps any deficiency in service?
- Is the Complainant entitled to get any relief?
DECISION WITH REASONS
Point No.1.
The Ld. Agent for the Complainant submits that the complainant is a Consumer of the O.Ps as he paid consideration to avail services of the O.Ps. In reply, the ld. Agents for the O.P. Nos.1 & 3 did not say anything on this point.
On going through the materials on record, we find that the Complainant is a Consumer of the O.Ps.
Point No.2.
The Ld. Agent for the Complainant submits that the cause of action of this case arose within territorial jurisdiction of this forum and the claimed amount is also within the pecuniary jurisdiction of this forum.
On a careful consideration over the materials on record, we think that this forum has both territorial and pecuniary jurisdiction to entertain the Complainant.
Point Nos. 3 & 4.
The Ld Agent for the Complainant submits that the O.P. No.3 did not allow the Complainant to get Hospital discount of Rs.4,748/- but the O.P. Nos.1 & 2 did not release the amount in favour of the complainant. He argues that the Complainant had nothing to say if the Hospital discount was received by him. It is urged that the Complainant should not suffer if any guideline of the O.P. No.2 is violated by the O.P. No.3. He submits that the O.P. Nos.1 & 2 had deficiency of service as they did not release the entire amount of the bill for treatment of Smt. Sipra Sen. He prays for refund of Rs.4,800/-, compensation of Rs.30,000/- for mental agony and harassment and cost of litigation from the O.Ps.
The Ld. Agent for the O.P. No.1 submits that the O.P. No.1 is an unnecessary party and it has nothing to do. He argues that the O.P. No.2 has settled the claim according to the terms and conditions of the Policy and the O.P. No.3 is liable to refund the Hospital discount to the Complainant. He contends that the O.P. Nos.1 & 2 have no deficiency of service as the Complainant had received cashless benefit for treatment of Smt. Sipra Sen.
The Ld. Agent for the O.P. No.3 submits that the O.P. No.3 provided service to the patient, Smt. Sipra Sen and allowed cashless benefit to the tune of Rs.18,894/- as per authorization of the O.P. No.2 and received the rest amount of Rs.4,800/- including Rs.100/- as Registration Charges. He argues that there is no agreement between the O.P. Nos.2 & 3 to the effect that 20% discount is to be given to the patients at the time of allowing cashless benefits. He prays for dismissal of the Complaint against the O.P. No.3.
We have gone through the written Complainant, written version, evidence and documents submitted by both sides.
Admittedly, the Complainant is the consumer under the O.Ps and his wife Sipra Sen was covered under Mediclaim policy No.153901/48/16/ 8500000064. Admittedly, Sipra sen was admitted at Dr. P.K. Saha Hospital Pvt. Ltd. On 27.08.16 for her illness and was discharged on 02.09.16 and the said Hospital is one of the enlisted Hospitals of MD India Health Care Services (TPA) Pvt. Ltd. Admittedly, the Complainant produced required documents to avail cashless benefit for treatment of Sipra Sen. Admittedly, the Complainant got cashless benefit to the take of Rs.18,994/- out of total bill of Rs.23,742/-. Admittedly, the hospital allowed discount of Rs.48/- only and the Complainant had to pay Rs.4,800/-including Rs.100/- as Registration Charges. The O.P. Nos.1 & 2 did not allow Rs.100/- which is for Registration Charges and Rs.4,748/- as hospital discount in spite of the fact that the O.P. No.3 realised Rs.4,800/- from the Complainant.
The O.P. Nos.1 & 2 have not produced any document to establish that the O.P. No.3 is bound to give Hospital discount to the patient who avails cashless benefit under Mediclaim policy. In the present case, the complainant paid Rs.4,700/- excluding registration charges after availing cashless benefit for treatment of Sipra sen under Mediclaim Policy. The reason for repudiation of claim of Rs.100/- as Registration charges being non medical charges is understood but repudiation of the claim of Rs.4,700/- on the ground of Hospital discount, especially when the Hospital has not given discount of the said amount is groundless.
In our considered view, the O.P. No.1 & 2 had no reason to repudiate the claim of Rs.4,700/- and it is nothing but deficiency in service on the part of the O.P. Nos.1 & 2. We think that the O.P. Nos.1 & 2 may be directed to pay Rs.4,700/- to the Complainant as he paid the said amount to the O.P. No.3 and to pay Rs.10,000/- to the Complainant for deficiency in service. The Complainant is also entitled to get Rs.1,000/- as litigation cost against the O.P. Nos.1 & 2.
No deficiency in service is proved against the O.P. No.3. We hold that the Complainant is not entitled to get any relief against the O.P. No.3.
In the result, the Case succeeds.
Fees paid are correct.
Hence,
it is Ordered,
That the Complainant Case be and the same is hereby allowed on contest against the O.P. Nos.1 & 2 with cost of Rs.1,000/- and dismissed on contest without cost against the O.P. No.3.
The O.P. Nos.1 & 2 are directed to pay Rs.4,700/- to the Complainant (as he paid the said amount excluding Registration charges to the O.P. No.3 at the time of discharge of Sipra Sen). The O.P. Nos.1 & 2 are directed to pay Rs.10,000/- to the Complainant for deficiency in service and Rs.1,000/- as litigation cost.
The O.P. Nos.1 & 2 are further directed to comply the above mentioned order jointly and severally within 45 days, failing which the O.P. Nos.1 & 2 shall have to pay Rs.50/- for each day’s delay and the accumulated amount shall be deposited in the Consumer Legal Aid Account.
Let plain copy of this Order be supplied to the parties concerned by hand/by Post forthwith, free of cost for information & necessary action. The copy of the Final Order will also be available in the following Website:
confonet.nic.in.
Dictated and corrected by me.
