Date of Filing : 23.12.2020
Date of Disposal: 28.04.2023
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law) .…. PRESIDENT
THIRU. P.VINODH KUMAR., B.Sc. B.L., ......MEMBER-I
THIRU.P.MURUGAN,.MCom., ICWA(Inter)., B.L., ....MEMBER-II
CC. No.02/2021
THIS FRIDAY, THE 28th DAY OF APRIL 2023
Sri.Ragavendra Hospital,
Rep. by Dr.Jyoti Subramanian,
Having its hospital at No.87/52-A,
North Park Street,
Venkatapuram, Ambattur,
Chennai 600 083. .........Complainant.
//Vs//
M/s.Religare Health Insurance Company Limited,
D-3, District Centre,
Saket, New Delhi 110 017. ...Opposite party.
Counsel for the complainants : M/s.Logaraj, Advocate.
Counsel for the opposite party : Mr.T.V.Suresh, Advocate.
This complaint is coming before us on various dates and finally on 17.04.2023 in the presence of M/s.Logaraj counsel for complainant and Mr.T.V.Suresh counsel for the opposite party and upon perusing the documents and evidences of both sides, this Commission delivered the following:
ORDER
PRONOUNCED BY THIRU.P.VINODH KUMAR, MEMBER - I
This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service in non-reimburse the claim along with a prayer to direct the opposite party to reimburse the claim of Rs.49,000/- together with interest @ 18% per annum from the date of discharge from hospital on 20.06.2019 till the date of the paryment, to pay a sum of Rs.50,000/- towards compensation for the mental agony and hardship caused to the complainant and to pay a sum of Rs.5,000/- towards cost of the proceedings.
Summary of facts culminating into complaint:-
That the complainant had entered into a service agreement dated 12.12.2016 with the opposite party and empanelled the complainant as one of the opposite party network providers for providing health services for the persons who have insured with the opposite party. On 13.06.2019, a patient Mrs.Karthika admitted in the complainant’s hospital for delivery and requested the complainant to get approval and sanction of medical expenses from the opposite party. The opposite party on receipt of communication from complainant and accorded approval vide authorization letter dated 13.06.2019 bearing A.L.No.80285848-00 authorizing the payment upto Rs.50,000/- for the above referred patient. The new born child developed Neonatal Jaundice and therefore the patient was inpatient for 7 days in hospital. Hence the total bill of the patient comes around Rs.83,627/- and the opposite party denied the additional sanction of Rs.33,627/-. The complainant had collected the additional charges of Rs.33,627/- directly from the patient. The complainant submitted their claim of Rs.50,000/- with supporting documents to the opposite party. The opposite party informed the complainant vide email dated 29.07.2019 that the complainant’s claim was covered under “RHICL medical packages”. The terms agreed between the complainant and the opposite party under service agreement is “Open Rate Basis”. The opposite party received a letter dated 07.08.2019 stating that the current approval amount is Rs.1000/-. The opposite party had made payment of Rs.1000/- to the complainant without assigning any reason is totally unfair and unjust. The act of the opposite party amounts to deficiency in service and unfair trade practice. Hence the complaint.
Crux of the defence put forth by the opposite party:-
That a corporate health insurance policy was issued to M/s. Gavs Technologies Private Limited vide policy No.14056994 under plan namely “Group Care” for the employees of the said company. The maximum limit for maternity claims for Rs.50,000/- for normal and LSCS. Upon receipt of cashless request from complainant, the opposite party perused the medical documents and gave an initial sanction of Rs.50,000/- vide authorization letter dated 13.06.2019 that the said approval has been made as per agreed tariff under maternity limit with maternity sub-limit exhausted. Subsequently additional sanction claim was denied by the opposite party vide letter dated 20.06.2019 on the grounds that the sub-limit for maternity benefit under the policy had been exhausted. The opposite party came to know that the insured member had paid certain amount of money to the complainant’s hospital. A query was raised by the opposite party and the complainant submitted the payment receipt which shows that the patient had paid an amount of Rs.33,500/-at the time of discharge. That as per the agreed tariff/package list between the complainant and the opposite party, the maximum charges for caesarean section procedure is limited to an amount of Rs.34,500/- with maximum duration of stay for 7 days. In view of the above facts the opposite party had paid the balance amount of Rs.1000/- after the deducting the amount paid by the patient. There is no deficiency in service on the part of the opposite party and hence the opposite party prays to dismiss the complaint.
The complainant has filed proof affidavit and documents Ex.A1 to Ex.A14 were marked on their side. On the side of opposite party proof affidavit had filed and documents Ex.B1 to Ex.B9 were marked on their side.
Points for consideration:-
Whether the complainant is a consumer under Consumer Protection Act?
Whether the opposite party had committed deficiency in service as alleged by the complainant?
If so to what reliefs the complainant is entitled?
Points No.1& 2:-
That the complainant and opposite party have entered into a service agreement dated 12.12.2016 empanelling the complainant as network hospital providing health services to the persons who insured with the opposite party. Accordingly the opposite party has accorded approval on 13.06.2019 authorizing and guarantying payment up to Rs.50,000/- for the insured patient Mrs.Karthika. The said insured patient was admitted in the hospital for 7 days since the new born child developed Neonatal Jaundice. Hence the hospital bill come to Rs.83,267/-. The opposite party vide letter dated 20.06.2019 denied the additional sanction. The complainant had received the balance payment of Rs.33,500/- from the insured patient. The opposite party refused to pay the sectional amount of Rs.50,000/- to the complainant. Hence the complaint.
To prove the case, the complainant deposed proof affidavit with 14 documents which were marked as Ex.A1to Ex.A14. Ex.A1 is the Service Agreement, Ex.A2 is the request for cashless hospitalization for medical insurance policy and authorization letter, Ex.A3 is the credit bill issued by the complainant, Ex.A4 is the additional sanction denial letter issued by the opposite party, Ex.A5 is the email issued by the opposite party, Ex.A6 is the bill submitted by the complainant to the opposite party, Ex.A7 is the claim approval settlement letter issued by opposite party, Ex.A8 is the letter issued by the complainant to the opposite party to pay the sanctioned amount, Ex.A9 is the opposite party acknowledging the receipt of letter from the complainant, Ex.A10 is the legal notice issued by the complainant to the opposite party, Ex.A11 is copy of postal receipt, Ex.A12 is return cover, Ex.A13 is the copy of email and Ex.A14 is the copies of documents in respect of settlement.
Per contra, the opposite party interalia contended that there is no deficiency in service, and the opposite party acted as per the agreed terms entered between the complainant and opposite party vide service agreement dated 12.12.2016. As per the tariff/packages, the maximum limit of caesarean section procedure is Rs.34,500/- with maximum delivery of 7 days. The complainant received Rs.33,500/- directly from the insured member. Hence the opposite party had paid the balance amount of Rs.1000/-after deducting Rs.35,500/- already paid by the complainant from the maximum limit of Rs.34,500/-. The opposite party had not committed deficiency in service and therefore prays to dismiss the complaint.
On the side of opposite party the following documents were filed in proof of their defence. Ex.B1 is the Service Agreement, Ex.B2 is the group policy certificate, Ex.B3 is the cashless Pre-Authorization Form, Ex.B4 is the Authorization letter, Ex.B5 is an additional claim denial letter Ex.B6 is the deficiency letter and Reminder letter, Ex.B7 is the Payment Receipt by patient, Ex.B8 is the Tariff/package list and Ex.9 is Settlement letter.
The important point is to be decided by this commission whether the complainant is a consumer under the Consumer Protection Act 2019. Ex.A1 is the service agreement dated 12.12.2016 between the complainant and opposite party. As per the terms of service agreement, the complainant is a service provider to provide medical facilities and treatment to members covered under health insurance of the opposite party.
It is not disputed by the parties that one Mrs.Karthika, member of the opposite party’s insurance admitted in the complainant’s hospital for LSCS delivery. The opposite party also accorded approval for Rs.50,000/- towards cash less treatment. The new born baby suffered Neonatal Jaundice and hence there is an additional services provided to the patient which worked out to Rs.33,627/-. However, the opposite party denied the additional sanction requested by the complainant. As per Ex.B8 the agreed tariff/packages list between the complainant and opposite party, the maximum charged for caesarean section procedure is limited to Rs.34,500/- with maximum duration of 7 days. Accordingly the opposite party had paid Rs.1000/- to the complainant after deducting the amount of Rs.33,500/- collected from the patient by the complainant. Section 2(7) of Consumer Protection Act define the definition of Consumer and deficiency
2 (7) “Consumer” means any person who:-
buys any goods for a consideration which has been paid or promised or partly paid and partly promised, or under an system of deferred payment and includes any user of such goods other than the person who buys such goods for consideration paid or promised or partly paid or partly promised, or under any system or deferred payment, when such use is made with the approval of such person, but does not include a person who obtains such goods for resale or for any commercial purpose; or
hires or avails of any service for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any beneficiary of the services for consideration paid or who hires or avails of the services for consideration paid or promised, or partly paid and partly promised, or under any system of deferred payment, when such services are availed of with the approval of the first mention person, but does not include a person who avails of such service for any commercial purpose.
Explanation.-For the purpose of this clause,-
The expression “commercial purpose” does not include use by a person of goods bought and used by him exclusively for the purpose of earning his livelihood, by means of self-employment.
The expression “buys and goods” and “hires or avails any services” includes offline or online transactions through electronic means or by teleshopping or direct selling or multi-level marketing;
2 (11) “Deficiency” means any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained by or under any law for the time being in force or has been undertaken to be performed by a person in pursuance of a contract or otherwise in relation to any service and includes-
any act of negligence or omission or commission by such person which causes loss or injury to the customer; and
deliberate withholding of relevant information by such person to the consumer;
In this case the complainant is a service provider to the opposite party. The complainant had not hired or availed any service from the opposite party. Moreover the complainant does not come under the provision of consumer Protection Act 2019.
The complainant can seek remedy against the opposite party before the appropriate Civil Forum in view of service agreement dated 12.12.2016 entered between them and the complainant knocked the doors of this commission which do not have jurisdiction to entertain this kind of dispute. We have perused all the records. Hence we are of the considered view that the complainant is not a consumer under Consumer Protection Act 2019 and the opposite party had not committed any deficiency in service to the complainant. These point are answered accordingly.
Point No.3:-
Since we have come to the conclusion that the complainant is not a consumer under Consumer Protection Act 2019, hence the complainant is not entitled to any of the reliefs prayed him and the complaint is liable to be dismissed. Accordingly the complaint is dismissed. This point is answered accordingly.
In the result the complaint is dismissed. No order to cost.
Dictated by the Member - I to the steno-typist, transcribed and computerized by him, corrected by the Member -I and pronounced by us in the open Commission on this the 28th day of April 2023
Sd/- Sd/- Sd/-
MEMBER-II MEMBER –I PRESIDENT
List of document filed by the complainant:-
Ex.A1 12.12.2016 Service Agreement. Photo copy
Ex.A2 13.06.2019 Request for cashless card to get approval and sanction and Authorization letter. Photo copy
Ex.A3 20.06.2019 Credit bill issued by the complainant. Photo copy
Ex.A4 20.06.2019 Additional sanction denial letter issued by the opposite party. Photo copy
Ex.A5 29.07.2019 Email sent by the opposite party to the complainant. Photo copy
Ex.A6 20.06.2019 Bill submitted by the complainant to the opposite party. Photo copy
Ex.A7 07.08.2019 Claim approval settlement letter issued by opposite party to the complainant. Photo copy
Ex.A8 08.08.2019 Letter given by the complainant to the opposite party to pay the sanctioned amount. Photo copy
Ex.A9 08.08.2019 Opposite party acknowledging the receipt of letter from the complainant Photo copy
Ex.A10 20.02.2020 Legal notice issued by the complainant to the opposite party. Photo copy
Ex.A11 .............. Copy of postal receipt. Photo copy
Ex.A12 ............... Return cover. Photo copy
Ex.A13 .............. Copy of email Photo copy
Ex.A14 ............... Copies of documents in respect of settlement. Photo copy
List of documents filed by the opposite party:-
Ex.B1 12.12.2016 Service Agreement. Photo copy
Ex.B2 16.05.2019 Group Policy Certificate. Photo copy
Ex.B3 13.06.2019 Cashless Pre-Authorization Form. Photo copy
Ex.B4 13.06.2019 Authorization Letter. Photo copy
Ex.B5 20.06.2019 Additional Claim Denial letter. Photo copy
Ex.B6 12.07.2019
&
22.7.2019 Deficiency letter and Reminder Letter. Photo copy
Ex.B7 20.06.2019 Payment Receipt by patient. Photo copy
Ex.B8 09.10.2015 Tariff/Package list. Photo copy
Ex.B9 07.08.2019 Settlement Letter. Photo copy
Sd/- Sd/- Sd/-
MEMBER-II MEMBER- I PRESIDENT
