DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

                                      Consumer Complaint No. 373 of 29.9.2017

                                      Decided on:         4.3.2021

Bhupinder Singh aged about 64 years son of Mukand Ram r/o 6003/3, Gobind Nagar, Sheran Wala Gate, Patiala

                                                                   …………...Complainant

                                      Versus

1. M/s Medi Assist India TPA Pvt. Ltd., having its head office No.4/1.IBC Knowledge Park Tower-D,4^th Floor, Bannerghatta Road, Bangalore,Bangalore-560029.
2. M/s Medi Assist India TPA Pvt. Ltd.,having its Regional Office Cabin No.207, Second Floor, SCO-19, Sector 7C, Chandigarh-160019.
3. The Oriental Insurance Co.Ltd. having Regional office SCO-109-110-111,Surindra Building, Sec. 17-D, Chandigarh-160017.
4. The Oriental Insurance Co. Ltd. having its branch office at sai Market, Lower Mall, Patiala.
5. Oriental Bank of Commerce,The Mall, Patiala-147001.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. Jasjit Singh Bhinder, President

                                      Sh.Vinod Kumar Gulati,Member

                                      Sh.Y.S.Matta, Member 

ARGUED BY

                                      Sh.Gaurav Bansal, counsel for complainant.

                                      OPs No.1&2 exparte

                                      Sh.D.P.S.Anand, counsel for OPs No.3&4.

                                      Sh.Dhiraj Puri, counsel for OP No.5.

 ORDER

                                      JASJIT SINGH BHINDER,PRESIDENT

1. This is the complaint filed by Bhupinder Singh  (hereinafter referred to as the complainant) against M/s Medi Assist India TPA Pvt. Ltd., and others(hereinafter referred to as the OP/s)
2. Briefly the case of the complainant is that he purchased mediclaim insurance policy bearing No.233500/48/2015/720  commencing from 25.6.2014 to mid night 24.6.2015 from OP No.5 and paid Rs.6830/-as premium for the assured amount of Rs.5,00,000/-with regard to which card was issued to the complainant. Insurance policy was issued by OPs No.3&4 covering the complainant, his wife Manpreet Kaur and his son Pawandeep Singh.Thereafter the complainant got renewed the policy from 25.6.2015 to mid night 24.6.2016 and paid Rs.6930/-as premium after that for the period from 25.6.2016 to 24.6.2017 and paid the premium of Rs.6990/-covering the risk of himself, his wife and his son.
3. It is averred that in the month of Marcy,2017 the wife of the complainant diagnosed with the problem of heart and she was got admitted in Max Health Care Centre on 3.3.2017 where she was operated upon on 6.3.2017 and bye pass surgery was done and she was discharged on 11.3.2017 for which the OPs were duly intimated by the complainant as well as the hospital authorites. It is averred that total expenditure came to Rs.2,85,950/- which was paid by the complainant from his own pocket. After getting discharge his wife from the hospital, complainant submitted the claim for reimbursement of medical expenses before OPs No.1&2 along with relevant documents on 17.3.2017 but they reimbursed only Rs.1,60,000/-on 12.7.2017 and was directed deposited in account maintained with OP No.5 through NEFT. Thereafter complainant moved application to the head office of OPs No.1&2 on 27.6.2017. He also moved application dated 25.7.2017 under RTI Act to get know about the deduction of Rs.1,25,000/-from the total amount and OPs No.3&4 provided the information alongwith prospects and GIPSA rate list which was not provided while issuing the insurance policy to the complainant. It is further averred that non payment of the remaining amount by the OPs not only amounts to deficiency in service on the part of the OPs but they also committed unfair trade practice. Hence this complaint with the prayer to accept the same by giving direction to the OPs to pay/reimburse the remaining medical expenses of Rs.1,25,000/- alongwith Rs.30,000/-as compensation and cost of litigation for causing mental agony, tension and harassment to the complainant.
4. Notice of the complaint was issued to the OPs.OPs No.3,4 and 5 appeared through their counsel and contested the complaint by filing written reply while OPs No.1&2 did not come present to contest the complaint and were accordingly proceeded against exparte vide order dated 8.12.2017.

Reply/written statement

5. In the reply file by OPs No.3&4 preliminary objections have been raised to the effect that the complaint is not maintainable as claim has already been settled for an amount of Rs.1,60,000/- as per rates agreed with the hospital; that the complaint is bad for non joinder of necessary parties as the Max Smart Super Specialty Hospital, Saket, New Delhi has not been impleaded as party and that the complainant has got no cause of action and locus standi to file the present complaint.
6. On merits, the issuance of the policy for the period from 25.6.2016 to 24.6.2017 covering the risk of complainant, his wife and son  for a sum of Rs.5lac is admitted. It is further stated that OPs No.3&4 have issued the policy but OPs No.1&2 are the Third Party Administrator of the policy as per IRDA guidelines. It is further stated that complainant requested for pre authorization which was not conceded by OPs No.1&2. It is further stated that on receipt of treatment documents on 23.3.2017 for reimbursement of Rs.2,85,950/-the claim was processed by the panel of experts as per policy terms and conditions and settled the claim of Rs.1,60,000/- as per rates agreed with the hospital for ailment for which treatment was taken and the insured was informed accordingly. Rs.1,22,000/- was deducted as these were in excess, Rs.3000/- were deducted on account of extra charges for ICU and Rs.950/- was deducted on account of extra nursing charges. Thus there is no deficiency in service or unfair trade practice on the part of OPs No.3&4. After denying all other averments, these OPs prayed for the dismissal of the complaint.
7. In the written reply filed by OP No.5, it is submitted that it is a bank working under the name and style of Oriental Bank of Commerce .It is admitted that complainant has an account with it. It is submitted that the insurance policy was issued by OP No.4 and the claim etc. if permissible have also be settled by them and it did nothing and has prayed that the complaint qua it may kindly be dismissed.
8.  
8. In support of the complaint, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C18 and closed the evidence.
9. On the other hand, the ld. counsel for OP No.5 tendered in evidence Ex.OPA affidavit of Sh.Bharat Bhushan and closed the evidence.
10. The Ld. counsel for OPs No.3&4 has tendered in evidence Ex.OPB affidavit of Sh.Mukesh Malhotra, Divisional Manager, Ex.OPC affidavit of Dr.Sidharth Parthasharthi alongwith documents Exs.OP1 to OP4 and closed the evidence.
11. The complainant filed the written arguments. We have gone through the same, heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
12.  
12. The ld. counsel for the complainant has argued that the complainant was maintaining his account with OP No.5 and in the month of 2014 on the advise of OP No.5 got the medical insurance policy from 25.6.2014 to 24.6.2015 and Rs.6830/-was paid as premium vide which he and his family were insured for Rs.5lac. In the year 2015 the complainant had renewed the same policy from the same insurance company for the period from 25.6.2015 to 25.6.2016 premium of Rs.6930/-was paid and after that the same was renewed from 25.6.2016 to 24.6.2017 and Rs.6990/-was paid as premium. In the month of March/2017, the wife of the complainant was diagnosed with heart problem , as such she was got admitted in the Max Health Care Centre on 3.3.2017 and was operated on 6.3.2017.Total bill of Rs.2,985,950/- was made by hospital authorities. The ld. counsel argued that this bill was paid by the complainant from his own pocket. The OPs have reimbursed only Rs.1,60,000/- and they have not reimbursed the remaining amount, so the complaint be allowed.
13. On the other hand, the ld. counsel for the OPs 3&4  has argued that there was agreement between the insurance company and the Max Hospital that as per the rates agreed for CABG only Rs.1,60,000/- will be reimbursed. The ld. counsel further argued that this fact is clearly mentioned by them in their written statement. The ld. counsel further argued that whole amount was paid and nothing is due to be paid. Hence the complaint be dismissed.
14. To prove this case Sh.Bhupinder Singh has tendered his affidavit Ex.CA and he has deposed as per the complaint. Ex.C1 is the insurance policy card,Ex.C2 is insurance policy card, Ex.C3 is cover note of insurance company, Ex.C4 is also cover note of insurance company issued on 30.3.2015,Ex.C5 is also cover note issued on 21.6.2016,Ex.C6 is receipt of Max hospital for advance deposit of Rs.44,000/-, Ex.C7 is receipt of Max Hospital for deposit of Rs.2lac,Ex.C9 is total bill of Rs.2,85,950/-,Ex.C10 is letter written by Bhupinder Singh,Ex.C11 is receipt of courier, Ex.C12 is also letter written by Bhupinder Singh,Ex.C13 is courier receipt,Ex.C14 is bank pass book in which Rs.1,60,000/- was deposited by the insurance company in the account of the complainant,Ex.C16 is information sought under RTI Act by the complainant to know the reason for deducting Rs.1,25,000/-,Ex.C17 is reply of Insurance company that insurance company was only liable to pay Rs.1,60,000/-Ex.C18 is prospectus of Oriental Insurance Co.
15. On the other hand on behalf of OP No.5 Bharat Bhushan has tendered his affidavit, Ex.OPA. On behalf of OPs No.3&4 Sh.Mukesh Malhotra ,Divisional Manager has tendered his affidavit, Ex.OPB and has deposed as per the written statement, Ex.OPC is the affidavit of  Dr. Sidharth Parthasharthi of Medi Assist,Ex.OP1 is insurance policy, Ex.OP2 reply to RTI, Ex.OP3 is rate list,Ex.OP4 prospectus.
16. The ld. counsel of insurance company has argued that there was agreement between Max Hospital and the insurance company that in case of bye pass i.e. CABG Rs.1,60,000/- will be paid. This rate list is Ex.OP3 but the stand of the insurance company is totally false as  the agreement was with the Max Hospital from where wife of the complainant was operated upon .So the OPs have tried to mis lead this commission on this account and this is not good for the insurance company which is Govt. aided company. The complainant has cited the judgment of Hon’ble National Commission, New Delhi passed in K.Vasudeva Rao Vs. United India Insurance Co. Ltd. 2012(2)C.P.J.119 and the facts of the same are identical to the facts of the complaint in hand. In that the company deducted the money but the Hon’ble National Commission ordered to reimburse the full medical expenditure. In this case, there is no dispute that final bill,Ex.C9 of Max Hospital of Rs.2,85,950/- was not submitted and the contents of the bill has not been challenged by the insurance company in their written statement. Only it is submitted that there is an agreement vide which they are entitled to pay Rs.1,60,000/- and as already stated above this stand is totally false. Out of Rs.2,85,950/- only Rs.160,000/- was paid. There was no where a clause in the insurance company that in case of hospital treatment only Rs.1,60,000/- will be paid. As per bill,Ex.C9 the total amount of CABG is Rs.2,20,000/-, medical consumable Rs.35,000/-, medical supervision fee Rs.950/-, other procedure Rs.30,000/- and total is Rs.2,85,950/- It is not clear that for what purpose Rs.950/- is given, so out of Rs.2,85,950/- Rs.950/- will not be paid.
17. By taking into consideration the law laid down by the Hon’ble National Commission, the complaint is allowed and the complainant is held entitled to Rs.2,85,000/- out of which Rs.1,60,000/- have been already paid. Accordingly the OPs No.1to4 are directed to pay balance amount of Rs.1,25,000/- to the complainant alongwith interest @6% per annum from 12.7.2017,the date when Rs.1,60,000/-was credited into the account of the complainant. The OPs No.1to4 are also directed to pay Rs.25,000/-as compensation and Rs.11000/-as litigation expenses.Compliance of the order be made by the  OPs within a period of 45 days from the date of the receipt of the certified copy of this order.

Since the complaint has been pending since 2017 but it could not be decided due to heavy pendency of cases.

ANNOUNCED

DATED:4.3.2021         

                                   Y.S.Matta   Vinod Kumar Gulati     Jasjit Singh Bhinder

                                      Member              Member                   President