Chandigarh

StateCommission

A/5/2023

RAJINDER PAUL PATHELA - Complainant(s)

Versus

MUKAT HOSPITAL HEART INSTITUTE - Opp.Party(s)

ROHIT GOSWAMI

02 Jun 2023

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	05 of 2023
Date of Institution	:	13.01.2023
Date of Decision	:	02.06.2023

 

Rajinder Paul Pathela, resident of House NO.3201, 2^nd Floor, Sector 27-D, Chandigarh

……Appellant/Complainant

 

V e r s u s

 

1. Mukat Hospital Heart Institute, (A Unit of City Clinic Pvt. Ltd.), SCO No.47-49, Sector 34-A, Chandigarh through its Director
2. Care Health Insurance Company Limited, Unit No.604-607, 6^th Floor Tower C, Unitech Cyber Park, Sector 39, Gurgaon 122001 Haryana through its M.D.
3. Care Health Insurance Company Limited, SCO No.56-57-58, 2^nd Floor, Sector 9-D, Chandigarh through its Branch Manager.
4. Punjab National Bank through its Chief Branch Manager, SCO 48, Sector 26-D, Chandigarh.

…..Respondents/opposite parties

 

BEFORE:    JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                   MR.RAJESH K. ARYA, MEMBER

                                                         

Present:-     Sh.Rohit Goswami, Advocate for the appellant.

                   Sh.Gaurav Dhiman, Advocate proxy for Sh. Anant Pal Singh,                    Advocate for respondent no.1.

                   Sh.Savinder Singh Gill, Advocate proxy for Sh.Ramandeep Partap            Singh, Advocate for respondents No.2 & 3.

                   Ms.Anchal Jain, Advocate proxy for Sh.Ajay Sapehia, Advocate                 for respondent no.4 (on VC).

 

PER JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                   The complainant has come up with this appeal for enhancement of the reliefs awarded by the District Consumer Disputes Redressal Commission-II, U.T., Chandigarh (in short the District Commission), vide order dated 25.11.2022, whereby the consumer complaint bearing no.206 of 2021 filed by him was allowed and opposite parties no.1 to 3/respondents no.1 to 3 were directed as under:-

“……9]     Taking into consideration the above discussion and findings, we are of the opinion that the OPs No.1, 2 & 3 remained deficient in their service.  Therefore, the present complaint is allowed against OPs No.1 to 3 with directions as under:-

a)  OP No.1 shall refund an amount of Rs.38,882/- to the complainant, along with interest @9% p.a., from the date of discharge i.e. 6.11.2020 till its realization.

 b)  OPs No.2 & 3 shall reimburse an amount of Rs.45,997/- along with interest @9% p.a. from 6.11.2020 & Rs,90,500/- along with interest @9% p.a. from 23.11.2020, till its realization.

 c)  The OP No.1 & OPs NO.2 & 3 are also directed to pay to the complainant compository amount of Rs.20,000/- i.e. Rs.10,000/- each towards compensation for the harassment suffered by the complainant as well as litigation cost.

 This order shall be complied with by the OP No.1 to 3 within a period of 45 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional cost of Rs.10000/- each, apart from above relief.

                  10]    The complaint qua OP NO.4 stands dismissed….…”

2.           Succinctly stated that despite the fact that the complainant was duly insured under Health Insurance Policy of opposite parties no.2 and 3, valid from 30.1.2020 to 29.1.2021 (Annexure C-1), yet, when he took treatment in the opposite party no.1-hospital for COVID-19, his claim was not settled by opposite parties no.2 and 3, as a result of which, he was forced to pay an Rs.2,32,546/- on 06.11.2020 to opposite party no.1. It was further stated that  thereafter due to ill health , the complainant was again admitted in Max Hospital and raised claim in respect of the same, out of which, an amount of Rs.90,500/-, was also deducted by opposite parties no.2 and 3. Hence, consumer complaint was filed before the District Commission. 
3.           In the reply filed, opposite party no.1 Mukat Hospital stated that the condition of the complainant was improved with the treatment given by it. It was further stated that an amount of Rs.50,000/- was approved by the Insurance Company towards the treatment of the complainant, yet, an amount of Rs.2,32,546/- was incurred for the same. However, the complainant paid Rs.2,32,546/- with a condition that as soon as Insurance Company would release the payment to the Hospital, he would collect back his money from opposite party no.1 and would make the adjustment of the payment accordingly.  An amount of Rs.35,907/- was given back to the complainant on 4.1.2021 and another amount of Rs.38,882/- is still lying with opposite party no.1, which complainant despite being intimated refused to collect.         
4.           Opposite parties no.2 and 3- Insurance Company in their reply stated that  out of the total cashless claim amount of Rs.2,32,546/-, they approved the claim for Rs.1,86,549/- as per policy terms & conditions. The complainant was again hospitalized on 6.11.2020 at Max Hospital, Mohali and discharged on 23.11.2020 and out of the cashless claim raised for Rs.6,88,175/-, they approved the claim for Rs.4,84,688/- as per policy terms & conditions (Ann.R-5 & R-6).        
5.           Opposite party no.4 (Punjab National Bank) in its reply stated that it had no role either in issuance of insurance policy as well as to release the medical claim to the complainant or the treatment taken by the complainant in the said hospitals. 
6.           The contesting parties led evidence by way of affidavits and numerous documents before the District Commission.
7.           The District Commission after hearing the contesting parties and on going through the material available on record, allowed the consumer complaint, as stated above. However, this appeal has been filed by the appellant/complainant for enhancement of the relief awarded by the District Commission.
8.           We have heard the contesting parties and carefully gone through the material available on the record, including the written arguments filed by the parties concerned.
9.           During arguments, counsel for the appellant-Rajinder Paul Pathela vehemently contended that the award  given by the District Commission needs modification and enhancement on  following grounds:-
   1. Firstly, though the District Commission has directed opposite parties no.2 and 3 to pay part amount of Rs.45,997/- alongwith interest @9% p.a., yet, if fell into an error by not ordering to refund the  entire amount of Rs.2,32,546/- (less Rs.35,907/- already received on 04.01.2021) which was paid by him from his pocket to opposite party no.1-Hospital for his treatment.
   2. Secondly, even the interest @9% p.a. on the awarded is on the lower side.
10.           First coming to the contention raised by counsel for the appellant to the effect that the District Commission fell into an error by not ordering to refund the  entire amount of Rs.2,32,546/- (less Rs.35,907/- already received on 04.01.2021) which was paid by him from his pocket to opposite party no.1-Hospital for his treatment. Before coming to any conclusion on this contention raised, it is significant to mention here that the order impugned has not been challenged by the opposite parties no.1 to 3/respondents no.1 to 3 and has been challenged by the complainant only. Thus, after going through the case file and also the  contents of order impugned, we are of the considered opinion that the appellant was entitled to get total amount of Rs.3,23,046/- from the insurance company as indicated below:-

 

Sr.No.	Amount	Remarks
1.	232546.00 (A)	Admittedly paid by the appellant to Mukat Hospital on 06.11.2020
2.	90500.00(B)	Part amount which was denied by the insurance company, yet, awarded by the District Commission and has not been challenged by the insurance company by filing any appeal before this Commission.
Total (A+B)	323046.00  (C)

Out of the aforesaid amount of Rs.3,23,046/- which was to be paid with interest @9% p.a., only an amount of Rs.2,65,663.79 stood received by the appellant during pendency of this appeal/otherwise, as under:-

Sr.No.	Amount	Remarks
1.	35907.00	Received by the appellant from opposite party no.1 on 04.01.2021
2.	117861.12	Received by the appellant on 19.01.2023 from opposite parties no.2 and 3 vide cheque no.119399 dated 10.01.2023 drawn on HDFC Bank,
3.	55013.67	Received by the appellant on 19.01.2023 from opposite parties no.2 and 3 vide cheque no.119400 dated 10.01.2023 drawn on HDFC Bank
4.	10000.00	Received by the appellant, through his counsel, from opposite party no.1 vide cheque  no.942885 dated 23.01.2023 drawn on State Bank of India
5.	46882.00	Received by the appellant, through his counsel, from opposite party no.1 vide cheque  no.942886 dated 17.02.2023 drawn on State Bank of India
Total	265663.79 (D)
Balance payable to the appellant
(C-D)=	57382.21ps. [i.e. Rs. 323046 (-) Rs.265663.79]

 

                   Under above circumstances, the appellant/complainant is entitled to get remaining amount of Rs.57,382.21ps. and also the amount of interest @9% p.a. already awarded by the District Commission on the amount already paid and still payable by the respondents no.1 to 3/opposite parties no.1 to 3.

11.           The next question that falls for consideration is, as to whether, the appellant is entitled for enhancement of interest and also compensation for mental agony and harassment or not? We have considered this contention. In view of the rate of interest as on November 2020 of the nationalized banks, we are of the view that interest @9% p.a. awarded by the District Commission is appropriate to the circumstances of the case and there is no need of any enhancement of rate of interest. At the same time, it is also held that compensation awarded to the appellant in the sum of Rs.20,000/- over and above the interest on the amount to be refunded, in no way can be said to be on lower side. As such, no ground is made out to enhance the interest or compensation for mental agony and harassment, already awarded by the District Commission. 
12.           For the reasons recorded above, this appeal stands partly allowed. The order impugned is modified and the respondents no.1 to 3/opposite parties no.1 to 3 are directed as under:-

1. Opposite party no.1 shall pay interest @9% p.a. on the amount of Rs.35907/- to the complainant from the date of discharge i.e. 06.11.2020 till 04.01.2021-the date when the said amount was refunded to the complainant.
2. Opposite parties no.2 and 3 (Care Health Insurance Company) shall reimburse an amount of Rs.57,382.21ps. to the complainant alongwith interest @9% p.a. from 06.11.2020 till realization.
3. Opposite parties no.2 and 3 (Care Health Insurance Company) shall pay interest @9% p.a. to the complainant on the amount(s) (which have been paid during pendency of this case) i.e. on Rs.1,17,861.12ps. from 06.11.2020  to 19.01.2023; on Rs.55,013.67ps. from 06.11.2020  to  19.01.2023: on  Rs.10,000/- from 06.11.2020 to  23.01.2023 and on Rs.46,882/-  from 06.11.2020  to  17.02.2023, within a period of 30 days from the date of receipt of a certified copy of this order, failing which, thereafter they shall be liable to pay interest @12% p.a. on the said amounts, from the date of default till realization.
4. Opposite parties no.1 to 3 shall pay lumpsum compensation for mental agony and harassment to the tune of Rs.20,000/- i.e. Rs.10,000/- by opposite party no.1 (Mukat Hospital)  and Rs.10,000/- by opposite parties no.2 and 3 (Care Health Insurance Company) respectively (if not yet paid), within a period of  45 days from the date of receipt of a certified copy of this order failing which, they shall be liable to pay additional cost of Rs.10,000/- respectively, apart from above relief.

13.           Certified copies of this order be sent to the parties, free of charge.
14.           The concerned file be consigned to Record Room, after completion.

Pronounced

02.06.2023

 

 

Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

 

Sd/-

(RAJESH K. ARYA)

MEMBER

 

 

 

Rg