DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/238/2022

Date of Institution : 18.11.2022

Date of Decision : 29.09.2023

Rakesh Kumar Singla son of Devi Dayal resident of Kothi No. 62, Aasthaa Enlave, Dhanaula Road, Barnala, District Barnala, Punjab-148101.   

                  …Complainant

Versus

1. M/s United India Insurance Co. Ltd., Khati Bazar, Branch Office, Rampura Phul-151103, District Bathinda through its Branch Manager. 

2. M/s Raksha TPA Pvt. Ltd., 15/5 Mathura Road, Faridabad-121003 through its Branch Manager.  

              …Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Present: Sh. Jashan Modi Adv counsel for complainant.

Sh. N.K. Singla Adv counsel for opposite parties.

Quorum.-

1. Sh. Jot Naranjan Singh Gill : President

2. Smt. Urmila Kumari : Member

3. Sh. Navdeep Kumar Garg : Member

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

    The complainant Rakesh Kumar Singla filed the present complaint under Section 35 of the Consumer Protection Act 2019 against M/s United India Insurance Co. Ltd., and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant purchased Individual Health Insurance Policy (Cashless Policy) from the opposite party No. 1 vide policy No. 2004042820P105854829 for the period from 9.9.2020 to 8.9.2021 and the opposite party No. 2 is the TPA of opposite party No. 1. It is further alleged that the complainant was suffering from Hernia and was admitted in Dayanand Medical College & Hospital, Ludhiana on 22.1.2021 and deposited Rs. 2,200/- as advance at the time of admission for Surgical Management and was discharged on 25.1.2021. The said hospital raised a bill of Rs. 93,756/- for treatment but the opposite parties paid only Rs. 66,300/- to the hospital and the hospital refused to discharge the complainant till the receipt of remaining bill amount. It is alleged that forced by these compelled circumstances the complainant deposited Rs. 24,338/- with the hospital and got himself discharged from the said hospital. Thereafter, the complainant served a number of emails to the opposite parties for the payment of remaining amount and supplied all the documents to the opposite parties as desired by them from time to time. But the opposite parties did not pay the remaining amount of Rs. 24,338/- + Rs. 2,200 = Rs. 26,538/-. It is further alleged that thereafter the complainant suffered with Covid 19 fever cough and admitted on 10.5.2021 in Satguru Partap Singh Hospital at Ludhiana for medical management and deposited Rs. 50,000/- as advance and was discharged on 18.5.2021. The said hospital raised a bill of Rs. 1,51,779/- for the treatment but the opposite parties paid only 1,12,282/- from the actual bill. The SPSH after deducting Rs. 39,497/- from the advance of Rs. 50,000/- refunded an amount of Rs. 10,503/- to the complainant. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1)The opposite parties may kindly be directed to pay Rs. 26,538/- for the treatment at DMC&H for the period 22.1.2021 to 25.1.2021 alongwith interest @ 18% per annum from the date of deposit i.e. 26.1.2021 till realization. 

2)To pay Rs. 39,497/- for the treatment at SPSH for the period 10.5.2021 to 18.5.2021 alongwith interest @ 18% per annum from the date of deposit i.e. 10.5.2021 till realization. 

3)To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment and Rs. 11,000/- as litigation expenses.

3. Upon notice of this complaint, opposite parties filed written reply taking legal objections that complaint is bad for non-joinder and mis-joinder of necessary parties, concealment of material facts, complainant has not come with clean hands, no cause of action, complaint is false and frivolous etc. On merits, it admitted that the complainant admitted in Dayanand Medical College & Hospital, Ludhiana on 22.1.2021 and deposited Rs. 2,200/- as advance at the time of admission and was discharged on 25.1.2021 and the said hospital raised a bill of Rs. 93,756/- for treatment and the complainant deposited Rs. 24,338/- with the hospital. It is denied that the opposite parties paid only Rs. 66,300/- to the hospital and it is also denied that the hospital refused to discharge the complainant till the receipt of the remaining bill amount. It is further denied that the complainant was forced by any alleged compelled circumstances to deposit Rs. 24,338/- with the hospital. It is submitted that out of the bill amount of Rs. 93,756/- an amount of Rs. 26,538/- was not payable by the opposite parties on the basis of policy terms and conditions purchased by the complainant as is clear from the reasons of deductions mentioned in the claim settlement voucher. Rs. 553/- was given as discount by the hospital in the said bill and approved amount of Rs. 66,664/- was paid by the opposite parties to the hospital and remaining amount of Rs. 26,538/- was to be paid by the complainant. It is further submitted that any disagreement about the settlement was to be intimated to the opposite party No. 1 within 10 days otherwise the same shall be deemed as acceptance as full and final settlement of the said claim and no intimation was given by the complainant to the opposite party within time. So, the complainant is not entitled to the refund of Rs. 26,538/- as alleged. 

4. It is admitted fact that the complainant was admitted on 10.5.2021 in Satguru Partap Singh Hospital at Ludhiana for medical management and deposited Rs. 50,000/- as advance and was discharged on 18.5.2021 and the said hospital raised a bill of Rs. 1,51,779/- for the treatment and the opposite parties paid only 1,12,282/- from the said bill. It is denied that Rs. 39,497/- was deducted from the advance amount of Rs. 50,000/- deposited by the complainant at the time of admission and Rs. 10,503/- was refunded to the complainant. It is further submitted that out of the bill amount of Rs. 1,51,779/-, Rs. 12,144/- was given as discount by the hospital and the complainant was to paid only Rs. 27,353/- which was deducted from the bill amount to which the complainant was not eligible as mentioned in cashless authorization letter subject to terms and conditions of the policy and Rs. 22,647/- was refunded to the complainant out of the advance amount of Rs. 50,000/- deposited by him. Other allegations of the complainant are denied and it is also denied that there is deficiency in service and unfair trade practice on their part and lastly prayed for the dismissal of complaint. 

5. In support of his complaint, the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2 (containing 5 pages), copy of cashless authorization letter Ex.C-3 copies of bills Ex.C-4 & Ex.C-5, copy of cashless authorization letter Ex.C-6 (containing 4  pages), copies of emails Ex.C-7 (containing 23 pages), copy of claim settlement voucher Ex.C-8, copy of claim form Ex.C-9 (containing 2 pages) and closed the evidence. On 7.2.2023 the complainant has suffered the statement that I do not want to file any rejoinder.  

6. To rebut the case of the complainant the opposite parties tendered in evidence copy of insurance policy alongwith terms and conditions Ex.O.Ps-1 (containing 28 pages), copy of claim settlement voucher Ex.O.Ps-2, copy of cashless authorization letter Ex.O.Ps-3 (containing 4 pages), affidavit of Baldev Singh Ex.O.Ps-4 and closed the evidence.  

7. We have heard learned counsel for the parties and have gone through the record on file. Written arguments filed by the complainant and opposite parties. 

8. It is admitted case of the complainant that the complainant purchased Individual Health Insurance Policy (Cashless Policy) from the opposite party No. 1 vide policy No. 2004042820P105854829 which was valid for the period from 9.9.2020 to 8.9.2021 (Ex.C-2 & Ex.O.Ps-1). It is also admitted case of the complainant that the complainant was suffering from Hernia and was admitted in Dayanand Medical College & Hospital, Ludhiana on 22.1.2021 and was discharged on 25.1.2021 and on his treatment the complainant has spent an amount of Rs. 93,756/-. It is further admitted case of the complainant that the complainant suffered with Covid 19 fever cough and was admitted on 10.5.2021 in Satguru Partap Singh Hospital at Ludhiana for medical management and was discharged on 18.5.2021 and the complainant spent an amount of Rs. 1,51,779/- in the said hospital. 

9. The case of the complainant is that on his first treatment the complainant has spent an amount of Rs. 93,756/- (for the period from 22.1.2021 to 25.1.2021) in the DMC&H Ludhiana, but the opposite parties paid only Rs. 66,300/- to the hospital and the remaining amount of Rs. 24,338/- the complainant under compelled circumstances had to pay to the hospital and got himself discharged from the hospital. 

Further, the case of the complainant is that on his second treatment the complainant has spent an amount of Rs. 1,51,779/- (for the period from 10.5.2021 to 18.5.2021) in the Satguru Partap Singh Hospital at Ludhiana, but the opposite parties paid only Rs. 1,12,282/- from the actual bill and deducted an amount of Rs. 39,497/- from the advance of Rs. 50,000/- and refunded an amount of Rs. 10,503/- to the complainant. 

10. On the other hand, the stand of the opposite parties is that out of the bill amount of Rs. 93,756/- an amount of Rs. 26,538/- was not payable by the opposite parties on the basis of the policy terms and conditions purchased by the complainant, as is clear from the reasons of deductions mentioned in the claim settlement voucher and Rs. 553/- was given as discount by the hospital in the said bill and approved amount of Rs. 66,664/- was paid by the opposite parties to the hospital. Further, the second treatment bill raised by the Satguru Partap Singh Hospital of Rs. 1,51,779/- and out of this the opposite parties paid Rs. 1,12,282/- from the said bill and Rs. 12,144/- was given discount by the hospital and the complainant was to paid only Rs. 27,353/- which was deducted from the bill amount to which the complainant was not eligible. 

11. From the perusal of the records placed on the file by the parties it is made out that in DMC&H Ludhiana the total bill amount raised by the hospital was Rs. 93,756/- and out of this the opposite parties  paid Rs. 66,664/- and the remaining amount comes to the tune of Rs. 27,092/- minus Rs. 553/- the discount given by the hospital to the complainant in the said bill and the amount comes to the tune of Rs. 26,539/- for which the complainant is entitled. Further, in Satguru Partap Singh Hospital, Ludhiana the total bill amount raised by the hospital was Rs. 1,51,779/- and out of which the opposite parties paid Rs. 1,12,282/- and the remaining amount comes to the tune of Rs. 39,497/- minus Rs. 12,144/- discount given by the hospital to the complainant in the said bill and the amount comes to the tune of Rs. 27,353/-. Further, from the perusal of copy of Cashless Authorization Letter Ex.O.Ps-3 deduction details it shows that after deduction of room rent the amount comes to the tune of Rs. 16,793/- (Rs. 27,353/- minus Rs. 10,560/- i.e. from the Sr. No. 1 to 8 Rs. 1320/-x 8 = Rs. 10,560/-) and the same is not objected by the complainant because the complainant in the written arguments placed on record submitted that no doubt the complainant has room rent limit of Rs. 6,000/- only excess amount raised by the hospital can be deducted by the opposite parties. All the other deductions such as Medication Charges, Non- Medical Items, Raksha/PPN Package and TDS Deduction (as per Ex.O.Ps-2) and Consumable Charges, Doctor Fees, Hospital Services and Investigation Charges (as per Ex.O.Ps-3) are unreasonable and unjustified. Since it clearly reveals that all these expenses are the part of medical treatment of the complainant. Therefore, we are of the view that the amount deducted by the concerned opposite parties as per Ex.O.Ps-2 (Claim Settlement Voucher) and Ex.O.Ps-3 (Cashless Authorization Letter) is unreasonable and unjustified. 

12. Ld. Counsel for complainant placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.

13. In view of the above discussion, it is established that the remaining claim of the complainant was denied by the insurance company on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite party No. 1. Therefore, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay in total Rs. 43,332/- (i.e. Rs. 26,539/- + Rs. 16,793/-) alongwith interest @ 7% per annum to the complainant from the date of filing of the present complaint till realization. The opposite parties are further directed to pay Rs. 5,500/- on account of consolidated amount of compensation as well as litigation expenses to the complainant.

14. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

15. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

        29th Day of September, 2023

 

            (Jot Naranjan Singh Gill)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member