Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 82/2016
Sh. Rajnish Virmani son of Sh. D.V. Virmani
Resident of D-233, Sector-47, Noida District
Gautam Budh Nagar, U.P. …Complainant
Versus
The New India Assurance Company Limited
Office: 2/2A, 3rd Floor, Laxmi Insurance Building
Asaf Ali Road, N. Dehli-110002, (through its P.O./CMD)
And also through its Branch Manager, (Branch Code: 311503)
Having its office at : S-1, Manish Link Road, Plaza-1, Plot No.9,
Sector-5, Dwarka, New Delhi-110075 ...Opposite Party
Date of filing: 26.02.2016
Date of Order: 04.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Inder Jeet Singh, President
ORDER
1.1. (Introduction to the consumer dispute of parties) – During the validity of medi-claim insurance policy, the complainant had under-gone medical treatment for heart ailments and total hospitalisation medical expenses were Rs. 5,45,980/- but his entire bill was not reimbursed by OP, the complainant was constraint to pay bill of Rs. 1,61,700/- to hospital. When complainant made representation/claim of Rs.1,67,753, however, an amount of Rs. 1,60,000/- was declined on the ground that OPs panel hospital had made extra charges. Whereas, the sum insured was Rs. 5,00,000/-but claim was declined on extraneous reasons. There is deficiency of services. That is why the complaint for release of balance bill amount of cost of implant of Rs. 1,60,000/-, with interest; compensation of Rs. 1,00,000/- on account of mental harassment and agony etc.
1.2. Whereas, the OP opposed the complaint that the admissible amount under policy was paid to complainant. A per GIPSA norms for rates of Implants settled between the OP and treating hospital, however, the hospital had overcharged, the claim was for Rs. 1,98,000/- for each implant, there is a difference of Rs. 80,000/- per implant (i.e. Rs. 1,60,000/- for two implants), it is to be borne by the complainant. There is no deficiency of services.
2.1. (Case of complainant) – The complainant purchased medi-claim policy vide customer ID No. IH2781384, Medi-claim Policy-2012 and the validity period was w.e.f. 31.03.2015 to 30.03.2016 for sum assured of Rs. 5,00,000/- against payment of premium of Rs. 22,703/-. The complainant suffered heart ailment, he was diagnosed for ACS/CAD and he has undergone surgical management including surgery at Fortis Escorts, New Delhi, who raised bill of Rs. 5,45,980/- out of which a sum of Rs. 1,61,700/- was not reimbursed by OP1 and complainant had to pay the same to the hospital.
2.2. The complainant requested OP for reimbursement of all medical bills, and raised bill of Rs.1,67,753/-, however, an amount of Rs. 1,60,000/- being cost of stunt/Implants was not paid without any reason and deductions of Rs. 1,60,000/- were also not explained. The complainant also made correspondence inclusive of written request and email of 7.11.2015 and 16.11.2015 but no result. The deduction is, inhuman, highly objectionable, illegible and arbitrary. It is also against the norms of medi-claim policy and business of insurance. There is breach of terms and conditions of policy. The complainant has been a valuable loyal customer for the OP for the last twenty five years.
2.3. Since, the OP failed to respond despite sufficient time passed, therefore, the complainant issued legal notice dated 23.12.2015 to the OP but no result. That is why, the present complaint. [It is relevant to mention that throughout in the complaint, the complainant has been referring non-reimbursement of balance amount but at two places he has mentioned 'repudiation of the claim' being used as synonymous to non-refund of the amount, otherwise there is no repudiation of claim by OP].
2.4 The complaint is accompanying with copy of medi-claim policy (three sheets and a separate receipt), discharge summary (five sheets) reports, email, correspondence, final bills (also showing share of complainant of Rs. 1,61,700/-), copy of legal notice with copy of postal receipts.
3.1 (Case of OP)- The OP opposed the complaint vehemently. There is policy along-with GIPSA norms for rates of Implants settled between the OP and treating hospital, however, the hospital had overcharged from the complainant as Rs. 1,98,000/- for each implant, there is a difference of cost of Rs. 80,000/- per implant (i.e. Rs. 1,60,000/- for two implants, which was over charged), it is to be borne by the complainant.
Moreover, there is no cause of action for the complaint as the claim has already been settled in terms of clause 2.4 of the policy. The complainant was issued policy no. 31150334142500001555. The medi-claim policy is under the head 'new Medi-claim 2012 Policy'. In terms of the policy, cashless facility cannot mean unlimited cover but limited only to extend of pre-approved rates, which is binding on the complainant.
3.2. The claim settlement voucher dated 09.10.2015 clearly mentions (which is at page no. 20 of complainant’s paper book) that the deductions have been made on account of implant in accordance with the norms of rates. There is no unfair trade practice or negligence or deficiency in services. The OP denies other allegations of complaint. The complainant alleges repudiation of claim, however, there is no such repudiation as complainant’s claim was settled as per terms of policy. The complaint is liable to be dismissed.
3.3. The complaint is accompanying with claim settlement voucher dated 06.07.2015 (one sheet, showing approved amount of Rs. 6,053/- against claim of Rs. 1,67,753/-; an amount of Rs. 1,61,700/- was deducted); cash settlement voucher dated 09.11.2015 (one sheet, showing approved amount of Rs. 3,42,540/- against total claim of 5,54,980/-; an amount of Rs. 1,65,380/- was deducted) and medi-claim 2012 policy document (one sheet only).
4.1 (Replication of complainant) -The complainant filed detailed replication and opposed the allegations in the written statement, by explaining that complainant was entitled for cashless facility. There is no privity of contract between the complainant and the hospital. It was an inter-se agreement between the complainant and hospital, in case the hospital has violated GIPSA PPN agreed settled rate with OP, the complainant should not suffer thereto and complainant should not have been denied his valid claim.
4.2. It is appropriate to mention, that the OP had taken the objection in the written statement that complaint is bad for non-joinder of treating hospital and this plea was opposed by the complainant in the rejoinder that it is not a necessary party, since this complainant is not a party in the agreement/arrangement between the OP and the Hospital. Then, the OP had filed an application for impleading the (treating) Hospital as OP to the complaint, however the application was dismissed by order dated 14.07.2017.
5.1. (Evidence)- The complainant led his evidence by filing his detailed affidavit along with the documents filed in support of complaint.
5.2. The OP led evidence by filing affidavit of Sh. Laxman Singh, Divisional Manager and it is also supplemented with the documents filed with the reply, by mentioning that GIPSA PPN rate are filed with the written statement, whereas no such GIPSA PPN rate filed with the written statement.
6.1 (Final hearing)- At this stage of the case, the complainant and the OP filed their respective written arguments, they are narration of their cases based on pleading and evidence.
6.2. The parties were given opportunity to make oral submissions, Sh. V. K. Sharma, Advocate for the complainant use this opportunity, however, no oral submissions were made on behalf of OP.
7.1 (Findings)- The contentions advanced are considered, keeping in view the case of both sides, especially the documentary record. It is apparent that issue of policy, its tenure, treatment of complainant as indoor patient in the hospital and payment of bills are not disputed except the amount in dispute in the present complaint.
7.2. According to OP1, the deductions of Rs. 1,60,000/- was because of over-charge of amount for two implants (Rs. 80,000/- each) as cost of each implant was pre-approved for Rs. 1,18,000/- but the hospital had over-charged at Rs. 1,98,000/- per implant, the hospital could not overcharge beyond the GIPSA norms of rates entered with that hospital.
7.3. However, the OP has not proved any document or any contract, in which the complainant and the OP had agreed that GIPSA norms of rate are to be accepted by the complainant nor the OP had proved any terms and conditions in the policy that complainant had consented so. To say, the complainant is stranger to the arrangement agreed, if any, between the OP and the hospital for GIPSA norms of rate.
7.4. The OP has filed medi-claim 2012 policy document (annexure C, page-11 of paper book of OP) and no other record was filed to show about the inter-se arrangement between the OP and the hospital, if any, to be binding on the complainant. To say, the OP could not establish its oral plea by documentary record.
7.5. The complainant has also grievances that deductions were not explained by the OP but on the other side OP contends that the complainant was explained deductions of Rs. 1,60,000/-. The OP had not filed any document showing deductions, except discharge voucher from its record filed with reply, the same were not provided to complainant earlier. But on the other side the complainant had filed letter dated 09.10.2015 (at page-20) written by OP that as per standard norm the claim payment was made of Rs. 2,36,000/- (means Rs. 1,18,000/- for one implant) and then the complainant sent email dated 07.11.2015 (at page-19) about deduction Rs. 1,60,000/-. The situation is speaking itself.
7.6. The conclusion drawn in paragraph 7.2 to 7.5 above, it is apparent that the OP had made deductions of Rs. 1,60,000/- from the medical bills of complainant but detail was in the discharge voucher, however, the OP could not establish to justify the deductions on the plea of overcharging by the hospital beyond the GIPSA norm rate. The OP is taken stand as if there is agreement between the hospital and OP but it has not been proved. The complainant is not party to that arrangement, then how the complainant can be deprived of his rights.
7.7. Moreover, in case there is arrangement between OP and Hospital, its violation, if any, may be breach of terms and conditions between them, the complainant cannot be put to suffer for such breach. The insured-patient remains in a very delicate situation during treatment, physically and emotionally, to cope with treatment & recovery as well as administrative aspect personally or through others. The patient remains with no option to pay bills, when the same remains unpaid through cashless facilities.
7.8. The circumstances stand established are leaning in favour of complainant, thus complainant is entitled for reimbursement of balance medical bills, but it is subject to within the limit the sum insured of Rs. 5,00,000/-.
7.9.1. Now two sets of things are appearing. In final medical hospitalisation bill, the total amount is Rs, 5,45,980/- out of which Rs. 3,84,280/- was pre-authorized by TPA and remaining amount of Rs. 1,61,700/- was stated as complainant’s share to be paid by him. The complainant further raised bill of Rs. 1,67,953/- after his discharge (which includes denial amount of Rs.1,61,700/-), out of which Rs. 1,60,000/- was denied, meaning thereby an amount of Rs. 7,953/- was deemed to have been approved for payment. Consequently, the total amount authorized was Rs. 3,84,280/- +7,953/- = Rs. 3,92,233/- .
7.9.2. The another set of fact is as per documentary record of discharge voucher that out of bill of Rs. 5,45,980/-, an amount of Rs. 1,65,380/- was not approved and remaining amount of Rs. 3,42,540/- was approved. Further, as per second discharge voucher, out of claim of amount of Rs. 1,67,73/- and amount of Rs. 1,61,700 was declined and an amount of Rs. 6,053/- was approved. The total approved amount is Rs. 3,42,540/-+6,053/-= Rs. 3,48,573/-. To say the complainant’s bills were approved of Rs. 3,48,573/-.
8.1. Since the sum insured is Rs. 5,00,000/- out of which the complainant finally approved of Rs. 3,48,593/- and balance amount left is Rs. 1,51,407/-. The complainant is held entitled for this balance amount of Rs. 1,51,407/- [which is out of deducted/declined amount of Rs.1,60,000/-] .
8.2. The complainant claims interest of 18 % pa but no interest as such is mentioned in any document, therefore, interest at the rate of 6% pa from the date of complaint till realization of amount will meet both ends.
8.3. The complainant seeks compensation of Rs. 1,00,000/- on account of mental harassment and agony and cost of Rs. 15,000/-. The complainant has not established his financial status, income or sources of income for the purposes of evaluating the compensation amount. However, the circumstances of ailment, claim for balance medical expenses and efforts made are speaking that he had faced difficulty, inconvenience and other harassment, particularly he has been taking policy from long time from OP, he was approaching the OP as well as writing to the OP to pay legitimate balance medical bill amount, therefore, compensation of Rs. 20,000/- is allowed in his favour and against the OP. Cost is also quantified as Rs. 10,000/-.
9. Thus, the complaint is allowed in favour of complainant and against the OP to refund/ reimburse balance amount of Rs.1,51,407/- along-with simple interest @ 6%pa from the date of complaint till realization of amount; apart from to pay compensation of Rs.20,000/- & costs of Rs.10,000/- to complainant.
OP is also directed to return/pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 8% per annum on amount of Rs. 1,51,407/-.
10. Announced on this 4th July, 2023 [आषाढ़ 13, 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [Shahina] [Inder Jeet Singh]
Member Member (Female) President
