Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case 184/13.05.2016
Shri Krishan Mohan S/o Late Mani Ram Aggarwal,
D-12, Pushpanjali, Biwasan, Delhi-110061 …Complainant
Versus
OP1. Senior Divisional Manager,
National Insurance Company Limited
Divnl. Office: V, 7 floor, Hemkunt House,
Rajendra place, New Delhi - 110008 …Opposite Party no.1
OP2. Park Mediclaim TPA Pvt. Ltd.
702, Vikrant Tower, Rajendra place,
New Delhi-110008 …Opposite Party no.2
Senior Citizen Case
Order Reserved on: 10.01.2023
Date of Order: 28.04.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. (Introduction to the consumer dispute of parties) : The complainant has taken medi-claim policy for himself and for his wife from OP1. Complainant's wife Ms Usha Mohan was operated of cataract surgery of left eye in May 2015. Then need felt for cataract surgery of right eye in October 2015; it was also operated. The complainant paid the medical bills from his own pocket, however, his claim was not properly assessed and settled by OP2/TPA; the valid claim was not honored completely. There is deficiency of services and unfair trade practice on the part of OPs for want of reimbursement of bills actually paid, besides OP1 introduced by OP2/TPA, who is an alien to contract between the complainant & the Insurer/OP1.
1.2: The OP1 opposed the complaint that complainant has already received the entitled amount of claims. The complainant's wife was admitted twice for Femto cataract surgery with PC IOL. He submitted claims with the OP2/ TPA of OP1 and the OP2 duly processed both the claims of the complainant and found eligible amounts payable as per the PPN package rate as per the definition clause No. 3.23 of the terms and conditions of the policy, which were allowed and remaining were disallowed being inadmissible under the terms and conditions of the policy. The complainant was also informed of the same. There is no deficiency of services nor unfair trade practice.
1.3. The complainant also narrates in detail his antecedents as well as about full fledge settlement of once claim raised fairly about 8 years back, despite he has been subscriber to policy since 1982 and also another episode of 2011. However, the present order just confines to present consumer dispute, accordingly, relevant facts will be narrated, as the previous episodes are not facts in issue.
1.4 There is no appearance and reply by OP2.
2.1 (Case of complainant) - The complainant seeks directions in his favour and against OPs to direct (a) OPs to reimburse/pay the balance amount of Rs. 67,000/- towards the cataract surgery performed in left eye in May 2015 and the amount of Rs. 90,000/- towards the cataract surgery performed in other eye on 16.10.2015 being covered under the Medi-Claim Policy No. 360200/48/14/8500004717 with interest @ 24% per annum from the date of payment by the complainant till its realization (b) compensation/damages of Rs.10,00,000/- for inconvenience, harassment and mental agony and pain suffered by the complainant because of the unwarranted, arbitrary and whimsical act and conduct of the OPs apart from interest on the compensation @ 24% per annum till realization of the compensation and (c) the costs.
2.2. The complainant is a insured/consumer under clause (ii) of sub section (1) of section 2 of the Consumer Protection Act, 1986. OP1 is Insurer/Insurance Company established by an Act of Parliament and primarily transacts in non-life insurance The complainant for himself as also for his wife, subscribed to a Medi-claim Policy with the OP1 around the 1982, which was roughly the year when the policy was introduced/launched by the Government of India. Ever since then, the complainant has remained subscribed to the policy, without any interruption. Needless to the say, the policy got renewed year to year and the requisite premium has always been paid by, the complainant and the policy is subsisting till date. Under the same the complainant as also his wife were/are insured for a basic sum of Rs. 3,00,000/- individually. As per the records of the OP1 the policy is bearing no. 360200/48/14/8500004717. Both, the complainant aged about 83 years of and his wife about 75 years of age, are senior citizens.
There was no such entity of OP2 at the time of the launch of the policy or the issuance of the Medi-Claim Policy, in fact, the so called TPA/ OP2 is unilaterally involved by the OP1, the complainant had never agreed for the involvement of the OP2. There is no privity between the complainant and the OP2. However, the OPs in general and OP 2 in particular (after its unilateral introduction by the OP 1) have been utmost negligent and callous in their dealings with the complainant. OP 2 has always acted in most arbitrary and high handed manner. The unwanted acts and conduct of the OPs, have not only caused monetary losses to the complainant but also caused grave mental pain and agony to the complainant and his family.
2.3.1. Sometime in the month of May 2015, complainant's wife was operated for cataract in one eye, by Dr. Kamal Kapur and the complainant paid Rs. 92,000/- towards surgery charges. The complainant lodged claim for Rs. 92,000/- with the OP1, since she is also covered under the policy. However, OP1 of its own, entrusted the same to OP2/TPA, who in most arbitrary, illogically and unreasonably and in whimsical manner, sanctioned a paltry sum of Rs. 25,000/- which was without any basis san calculations. The complainant lodged his written objections by letter dated 05.08.2015 and refused to accept amount of Rs.25,000/- and the complainant till date has not accepted the offer of that amount and the issue of balance amount of Rs. 67,000/- is still unresolved.
2.3.2 Thence, complainant's wife developed serious problem in her second eye also. She was advised immediate surgery of second eye. She had undergone cataract surgery for the second eye in mid-October 2015 and the complainant had spent Rs. 90,000/- towards the said surgery. The complainant again lodged claim for the reimbursement of Rs. 90,000/- with the OP1. However, to his utter shock and surprise, the OP2 by its letter dated 05/11/2015, Ref No. NICDR2/128356, disallowed a substantial sum of Rs 66,000/- without any basis and in most arbitrary and whimsical manner. It is material to note that OP2 alleges in that letter that MICS is a widely acceptable procedure for cataract surgery and the cost of it in the best hospital would be Rs. 34,000/- only, but still it offered a sum of Rs. 24,000/-only. However, the complainant would not accept any lesser amount than Rs. 90,000/-. Simultaneously, it does not stand to any reason that if the cost of the procedure (as per own admission of OP2) is Rs. 34,000/- then on what basis the complainant would become entitled for just Rs. 24,000/-. The figure is simply baseless and imaginative, It clearly demonstrate the callousness, arbitrary and high handed approach of OP2.
The complainant has subscribed to the Medi-claim policy, for his immediate financial cushion in times of emergency, instead the complainant has been put to utmost discomfort and agony by acts and conduct of the OPs. The complainant is entitled to avail medical facility/ treatment as per his stature in life. Money loses its relevance when health and life is involved. Eye is most important organ in human body and no human would like to risk his/her eyes, for sake of money. If the complainant and/or his wife can afford the best treatment, no one and nothing could force him other way. The cataract surgery conducted by Dr. Kamal Kapur, was carried out with the assistance of the latest machine available. The procedure is untouched by hand and takes just one minute three seconds and has no side effects or any chance of error. The complainant can avail the best treatment and OPs in no way can force the complainant for any particular procedure, arbitrarily and unilaterally.
2.4. Since, OP failed to pay/reimburse the entire amount of Rs. 90,000/- incurred for the cataract surgery of the second eye too, performed in mid-October 2015 and rather the OP 2 had offered a grossly inadequate sum, without any basis and logic, the complainant got issued a notice dated 20.11.2015 to both OPs, Chairman, IRDA (Insurance Regulatory and Development Authority of India), Chairman of OPI and also to the Joint Director (Office Head of IRDA, Delhi), which were duly received by them and by OP1 & OP2 on 23.11.2015.
After receipt of the notice dated 20.11.2015, the OP2 out of mala-fide and for ulterior reasons sent letter dated 05.11.2015, Ref No. NICDR2/128356 that as against the claim of Rs. 90,000/- for the surgery performed on 16.10.2015, the OP 2 conveyed an amount of Rs
58,000/- has been disallowed. It was also alleged in the letter that MICS is a widely accepted procedure for cataract surgery and the cost of the procedure in Sharp Sight Centre is Rs. 32.000/- only and accordingly amount of Rs. 32,000/- was approved. OP2's letter dated 25.11.2015 is totally false and baseless as well as contradictory to its own letter dated 05.11.2015, written with oblique motives. There remains no doubt that the alleged approval/sanction of the amount is without any basis and erroneous but as per whim and fancies of the OPs. The OPs cannot wriggle out of their legal liability of reimbursing the lawful claim of the complainant by making false and baseless allegations.
2.5 The OP1, has remained a speechless spectator all throughout in the matter of settlement of the claims of the complainant and its aftermath. Although the agreement/contract of the policy in question is between the complainant and the OP1 only and the premium is being collected/realized by the OP1 only and though there is absolutely no privity between the complainant and the OP 2, still, the approval/sanction of the claims, has been dealt with by the OP2 only, which has assumed the de-facto authority, which is totally illegal and perverse. The OP2 has been given unbridled power, by the OP1, for the purposes of scrutiny, approval and sanction of claims(s), which is totally illegally and without any authority. The OP1 in the name of TPA has unilaterally roped in the OP2 whose sole and prime aim is to create hurdles and to search for frivolous reasons to disallow the genuine claims of the policy holders and the complainant has become a victim of such planning and connivance by the OPs.
Thus, immediately after the receipt of letter dated 25.11.2015, the complainant had got issued and served notice dated 14.12.2015 to the OPs and others by way of protest and to streamline the things. The complainant had already sent notice dated
20.11.2015 inter-alia to the OPs no. 1 & 2, it was received by them on 23.11.2015, however, no reply was received from the OP1 at all and a false and frivolous letter dated 05.11.2015 was sent by OP2. Moreover, the IRDA had acknowledged the receipt of notice dated 20.11.2015 and had communicated a token number for the grievance/complaint.
In view of the such approach of the OPs and particularly letter dated 05.11.2015 of the OP2, the complainant thought it fit to obtain a separate and categorical proof of payment made for the cataract surgeries to Sharp Sight Centre and in furtherance thereof, he sent a request letter dated 22.01.2016 to Sharp Sight Centre, which issued letter/certificate dated 23.01.2016 in acknowledgement of the two cataract surgeries performed upon the eyes of Smt. Usha Mohan wife of the complainant.
2.6 Though the complainant has lodged his claim(s) with the OP1 since the agreement/contract for the policy is between the complainant and the OP1 only, but it was dealt solely by the OP2; OP1 has been a mere spectator in the matter of settlement of claim(s) et al. Moreover, after the receipt of the notice dated 14.12.2015, a totally false and frivolous reply was sent by OP1, without even a whisper of the receipt of the notice dated 20.11.2015. It is apparent that the OP1 & OP2 have been acting in connivance and collusion with each other, with sole motive of defeating disallowing the genuine and legal claim of the complainant by creating unwarranted hurdles in the way of settlement of his claims. The OPs have been acting in tandem in dealing with the complainant as per their own sweet will so as to disallow the genuine and legal claim of the complaint.
The complainant has privity with OP1 only and exclusively, which has unilaterally roped in OP2, allegedly to act as a facilitator and for expediting the processing and disbursement of the claims of the policy holders. On the contrary, the OP2 has been acting as per its whim and fancies.
The OP2 has acted in most arbitrary and whimsical manner in processing the claim(s) of the complainant. In fact, the OP2 with a tacit consent of OP1, has always put unwarranted and unfounded obstacles in the smooth processing and disbursement of claim(s) of the complainant and other policy holders. The complainant has no privity with the OP2, which indeed has been brought into the arena by OPI without the consent of the complainant.
In fact, OP2 has no locus to deal with the claims of the complainant and other policy holders. When the complainant had subscribed to the policy, the OP2 or the concept of TPA did not even exist and hence any privity between the complainant and OP 2 is out of question.
Notwithstanding its illegal existence, OP2 have been acting as a de facto insurer and holding the policy holders to ransom. OP 2 acts as a trouble creator and create unnecessary and unwarranted impediment in the smooth discharge of obligation under the policy for and on behalf of the OP1. In simple words OP 2 has nothing but pure and simpliciter nuisance value.
The OPs have acted in most negligent and unfair manner and has wrongly and illegally pruned/repudiated legitimate claim(s) of the complainant without any basis and without assigning any valid reason in most arbitrary and whimsical manner which is not only against the terms of the policy but also against public policy. The OPs are guilty of adopting unfair means to cause wrongful losses to the complainant and wrongful gains to themselves. The complainant has been put to grave mental agony and harassment by such unwarranted acts of the OPs.
The complainant after spending huge sums of Rs.92,000/- and another sum of Rs. 90,000/- have been made to run from pillar to for reimbursement of the same. The entire purpose of having the Medi-claim policy has been defeated by such unwarranted acts of the opposite party. If the entire money spent/incurred by the complainant is not received the very purpose of the policy is negated. The apathy, negligence and high handed approach of the OPs in the matter of the reimbursement for the two surgeries has not only caused extreme financial hardship to the complainant but has also caused acute mental tension and agony to him and his wife. The complainant has undergone immense mental pain and agony not only for the financial issues but also because of unprofessional, whimsical, arbitrary and unjust act on the part of the OPs and is entitled to the reliefs in the form of not only the reimbursement of the entire cost of the two cataract surgeries with interest but also for the compensation for the mental agony and harassment undergone by him.
3.1 (Case of OP1) : The OP1 filed its written statement on 06.09.2016. OP1 opposed the complaint and its allegations that complainant has not come with clean hands, he has concealed and suppressed the true and material fact. The complainant has already received the claim, hence, the complaint is nothing but an abuse of process of law and the same is liable to be dismissed. The complainant is not a consumer within the definition of 'consumer'.
3.2.1. The true facts are that complainant's wife was admitted at Sharp Sight Centre for surgery against Femto cataract surgery with PC IOL and submitted the claim for a sum of Rs.91,260/- with the OP2/TPA of OP1. OP2 processed the claim of the complainant and found it payable for a sum of Rs.32,000/- as per the PPN Package Rate as per the definition clause No. 3.23 of the terms and conditions of the policy and disallowed the rest amount being not admissible under the terms and conditions of the policy, which was also informed to the complainant.
The claim of the complainant was duly processed and as per the instructions of the complainant, the OP2/TPA transferred a sum of Rs.25.260/- in the account of the complainant through NEFT on 19.08.2015 and also informed the complainant by letter dated 19.08.2015 (which is Annexure-R-1). Further, when OP2 informed OP1 of release/transfer of claim payment of Rs.25,260/- to the complainant, then OP1 further instructed its TPA/OP2 to release payment as per the terms and conditions of the policy (i.e., the amount as per PPN Package rate) as the cost of the procedure for cataract surgery in Sharp Sight Centre is Rs.32,000/- and accordingly, the OP2/TPA released & transferred balance amount of Rs.8,000/- through NEFT on 11.01.2016 and also informed the complainant by letter dated 11.01.2016 (which is Annexure-R-2).
3.2.2. The second claim submitted with OP2 was for complainant's wife surgery against Femto cataract surgery with PC IOL for a sum of Rs.90,000/-. The OP2 duly processed the claim of the complainant and found a sum of Rs.32,000/- was payable as per the PPN Package Rate as per the definition clause No.3.23 of the terms and conditions of the policy and disallowed remaining inadmissible amount under the terms and conditions of the policy and also intimated the complainant. As per the instructions of the complainant, OP2 transferred a sum of Rs.32,000/- in the account of the complainant through NEFT on 01.03.2016 and also intimated the complainant by letter dated 01.03.2016 (which is Annexure R-3).
3.2.3. Since, the claim of the complainant has already been settled and the claim amount has already been paid to the complainant as per the Preferred Provider Network (PP) package, therefore, the complaint is nothing but an abuse of process of law in as much as the complainant has no cause of action to file the complaint, it is not maintainable and it is liable to be dismissed with costs.
3.3. The OP1 issued the Medi-claim Insurance policy no. 360200/48/10/ 8500004717 valid from 27.11.2014 to 26.11.2015 for a sum of Rs. 3,00,000/- with its terms and conditions to complainant (it is enclosed as Annexure-R-4 (Colly). But the complainant has very cleverly not filed the complete policy with its terms and conditions as issued to him. Since claim of the complainant has already been paid in full and final, therefore, the complaint is false, frivolous and is devoid of merit and the same is liable to be dismissed. In case the complainant had paid to the hospital any amount over and above
the amount of PPN package rate i.e., Rs. 32,000/- for Femto cataract
surgery with PC IOL surgery rate, the OP1 is not liable to pay the amount exceeding Rs.32,000/-, therefore, the complaint is not maintainable and the same is liable to be dismissed.
3.4. OP2/TPA is service provider having a team of professional and technical persons to process the claim of policy holders expeditiously on merits and as per terms and conditions of policy of insurance. TPA has been appointed under the guidelines and rules framed by the IRDA, which has been created by the Act of the Parliament. The TPA, being a professional expert, process the claim of policy holders as per terms and conditions of policy of insurance. However, the privity of contract of insurance is between the complainant and the OP1, the TPA/OP2 has nothing to do with such contract. Since TPA has been appointed under the rules & guidelines of the IRDA, then consent of complainant for appointment of TPA does not arise. Moreover, TPA/OP2 was instructed by OP1 to release the amounts to the complainant and then only amount was released.
3.5 There is no cause of action ever arose in favour of the complainant to file
the complaint nor there is deficiency of service on the part of OP1, thus no complaint can lie under the provisions of the Consumer
Protection Act. The complaint deserves dismissal.
4. (Replication of complainant) : The complaint filed detailed replication to the written statement of OP1, it is reaffirmation of complaint as well as denial of allegations & explanation of written statement. The transfer of amount by NEFT was without the consent of complainant, appropriate objections were raised in writing letters.
5.1 (Evidence of parties) : Complainant Shri Krishan Mohan filed his detailed affidavit, it is on the lines of the complaint coupled with documents as per index, the same is as follows-
1. copy of summary of bill dated 16.10.2015. & copy of receipt dated 16.10.2015
2. copy of letter dated 05/08/2015 by the complainant to OP
3. copy of letter/intimation dated 05/11/2015 by the OP to the complainant.
4. Notice dated 20/11/2015 on behalf of the complainant.
5. Postal receipts notices (sol no.4 above).
6. delivery/tracking reports of the above notices.
7. copy of reply of IRDA dated 09/12/2015
8. copy of letter/intimation dated 25/11/2015 of the OP2
9, copy of notice dated 14/12/2015 on behalf of the complainant
10. Postal receipts of the above notices
11. copy of reply dated 18/12/2015 of OP1
12. copy of letter dated 22/01/2016 of complainant
13. copy of letter/certificate dated 23.01.2016 issued by Sharp sight Centre.
5.2. OP1 filed detailed affidavit of Shri Ajay Sethi, Sr. Divisional Manager, it is also on lines of written statement and documents filed thereto, the documents are as follows:-
(i) Exh. R-1 -copy of letter dated 19.08.2015
(ii) Exh. R-2 -copy of letter dated 11.01.2016;
(iii) Exh. R-3 -copy of letter dated 01.03.2016;
(iv) Exh. R-4 -copy of Medi-claim Policy
6.1 (Final hearing): At the stage of final hearing, both the parties filed their respective written arguments and then Shri V K Singh Advocate for complainant and Shri Sanjay Kumar, Advocate made oral submissions. The submission are on the pattern of the case of parties, which have already been detailed in the matrix of case of parties, which do not require to reproduce them.
6.2. It has been emphasized on behalf of complainant that in fact surgery of complainant's wife and charges paid are not disputed at all. There was payment of Rs. 91,250/- for cataract surgery for left eye and later payment of Rs.90,000/- for the second eye stands admitted by the opposite party. The complainant has also proved certificate dated 23.01.2016 issued by Sharp Sight Centre, that wife of the complainant had undergone the cataract surgery in both eyes at the Centre and had paid Rs. 90,000 (approx.) for each eye. This certificate is also not disputed by the OP1. However, the entire defence of the OP1 rests upon the reference of PPN package rate under clause 3.23 of the Mediclaim policy but PPN package rates are conspicuous by its absence. The entire defence of the OP1 is that the PPN package rate for cataract surgery at Sharp Sight Centre is Rs. 32,000/-, stands demolished not only by its contradictory averments but also in the face of non-filing and proof of the alleged PPN Package rates. The OP has failed to show and prove any alleged PPN package rate for cataract surgery. The complainant fortifies its plea while relying upon-
(1) The Manager, Arogyadaan vs. S. Sampath F.A. No. 997/2013 dod 20.10.2014 it was case of medical floater medical policy, the District Commission had declined the complaint, however, Hon’ble State Commission Hyderabad allowed the complaint as the Insurance Company was not able to show whether GIPSA as legal entity or GIPSA or TPA were registered under the Societies Act, Trust Act or Companies Act ;
(2) National Insurance Co. Ltd vs. Sarlaben Jayantibhai Patel Revision Petition/dod 10.04.2015 by Hon’ble National Commission Delhi, it was a case of knee replacement, two separate complainants were filed before the District Commission, the same were allowed by the District Consumer Commission, however it was assailed before the Higher Commissions, the Revision Petitions were dismissed as the claim was held the justified and repudiating the claim was deficiencies in service.
(3) Hari Om Agarwal vs. Oriental Insurance Co. Ltd AIR 2008 Delhi 29, the complainant relies upon para 23 that it was held “ the refusal by the insurer to process and reimburse the petitioner’s claim is arbitrary and unreasonable; as a State agency, it has to set standards of model behavior; its attitude here has displayed a contrary tendency. A direction is issued to the respondent to process the petitioner’s claim, and ensure that he is reimbursed for the procedure undergone by him according to the claim lodged with it, within six weeks;
(4) Surjeet Kumar vs. Union of India and others Civil Writ Petition No. 4916/2011 dod 10.07.2013 by Hon’ble Punjab and Haryana High Court, it was a writ petition under Article 226/227 of Constitution of India; the permanent Lok Adalat had passed an award dated 28.12.2010, it was set aside while directing the insurance company to reimburse the fixed amount as per medical claim and compensation of Rs. 50,000/-.
(5) Gaurang Dinesh Damani vs. Union of India and Ors.- PIL No. 12/2011 dod 13.08.2015 by Hon’ble Bombay High Court, certain directions were given by Hon’ble High court to IRDA, {the complainant of present case refers those directions mentioned in paragraph 16 and 17};
(6) Deep Saraf vs. United India Insurance Co. Ltd. Revision Petition dod 28.4.2015 by Hon’ble National Commission, the medical claim was repudiated on the ground of willful suppression of material fact, ultimately, the Revision Petition was allowed while allowing the complaint to reimburse the expenses incurred in replacement of hip joint as policy was for Rs. 5 laks.
It is concluded that the genuine and valid claims were lodged with the OPs, which were not considered and allowed. The complainant is entitled for reimbursement of total medical bills in respect of eyes surgery of wife of the complainant. Let the complaint be allowed.
6.3: The OP1 also maintain the same plea as detailed in the written statement and evidence that the claim was settled as per terms and conditions of the policy, the amount entitled has already been settled and paid. No more claim amount is allowed. OP1 fortifies its contentions with the followings :-
(1) In "Oriental Insurance Co. Ltd.
Vs. Sony Cherian" II (1999) CPJ 13 (SC), it was held that "the insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein.
OP1 supplements, in the light of the decision held by the Hon'ble Supreme Court of India the present complaint filed by the complainant is not maintainable as the claim has already been settled and payment of claim has already been made as per the policy of Insurance and therefore, the present complaint is not maintainable and the same is liable to be dismissed with heavy costs.
(2) In Surajmal Ram Niwas Oil Mills Pvt. Ltd. Vs. United India Insurance Co. Ltd. reported as 2010 (10) SCC 567, has held (while reiterating the judgment of Sony Cherian) that since, the insurance between the insurer and the insured is a contract between the parties, the terms of agreement including applicability of the provisions and also to its exclusion had to be strictly construed to determine the extent of the liability of the insurer.
(3) Haryana State Cooperative Vs. Iffco Tokio Gen. Ins. Co. Ltd. vide R.P. No. 4713/2012 dod 05.04.2013- it was held by the Hon'ble National Commission that "the petitioner cannot be allowed to accept the offer of the OP only in part, which suited to its convenience and rejected the condition subject to which the offer was made"
It is concluded that complaint is not maintainable and the same merits to be dismissed.
7.1 (Findings) : The rival contentions of are considered, assessed and analyzed keeping in view the material on record, evidence, statutory provisions of law and case law presented.
7.2: The OP1 maintains that since the admissible claim was allowed to the complainant, there was no deficiency of service and consequently the claim does not lie under the Consumer Protection Act 1986. Whereas on the other side, complainant’s case is that the entire eligible amount was not paid, when valid claim was lodged then it was not honoured, it amounts to deficiency in service and complaint lies under the Act 1986.
Since, features of case of the parties, give rise to a consumer dispute, it is to be adjudicated, therefore, complaint is maintainable under the Act 1986.
7.3. The other strong issue raised by complainant is about the status of OP2/TPA, since it was introduced in the picture by the OP1, without the consent the complainant, thus OP2/TPA has no locus standi to process the claim of complainant.
It is an admitted case of parties that privity of contract exists between the complainant/insured on one side and OP1/insurer on the other side. So far status of TPA/OP2, its constitution, its functions are concerned, the same are subject matter of clause 3.32 of insurance policy and the provisions of IRDA (Third Party Administrators - Health Services) Regulations 2016. The said clause as well as relevant provisions of Regulations 2016, are being reproduced hereunder, it would also suffice to answer the objection raised on behalf of complainant:-
"Clause (3.3.2) - Third Party Administrator (TPA) means any entity, licensed under IRDA (Third Party Administrators - Health Services) Regulations 2001 by the Authority and is engaged, for a fee by the company for the purposes of providing health services".
IRDA (Third Party Administrators - Health Services) Regulations 2016 -
"Regulation 3. Health Services by TPA:
(1) A TPA may render the following services to an insurer under an agreement in connection with health insurance business:
a. servicing of claims under health insurance policies by way of pre-authorization of cashless treatment of settlement of claims other than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the guidelines issued by the insurers for settlement of claims.
b. servicing of claims for Hospitalization cover, if any, under Personal Accident Policy and domestic travel policy.
c. Facilitating carrying out of pre-insurance medical examinations in connection with underwriting of health insurance policies:
Provided that a TPA can extend this service for life insurance policies also.
d. Health services matters of foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalization outside India.
e. Servicing of health services matters of foreign travel policies issued by foreign insurers for policyholders who are travelling to India:
Provided that such services shall be restricted to the health services required to be attended to during the course of the visit or the stay of the policyholders in India.
f. Servicing of non-insurance healthcare schemes as mentioned in Regulation 22 (30 of these Regulations.
g. Any other services as may be mentioned by the Authority.
(2) While performing the services as indicated at Regulation 3 (1) of these regulations, a TPA shall not-
a. Directly make payment in respect of claims
b. Reject or repudiate any of the claims directly
c. Handle or service claims other than hospitalization cover under a personal accident policy
d. Procure or solicit insurance business directly or indirectly
e. Offer any service directly to the policyholder or insured or to any other persons unless such service is in accordance with the terms and conditions of the policy contract and the agreement entered into in terms of these regulations.
(3) A TPA can provide health services to more than one insurer. Similarly an insurer may engage more than one TPA for providing health services to its policyholders or claimants".
xxx
"Regulation - 21. General guidelines to TPA in respect of services in relation to Health Insurance Policies:
(1) The TPA shall have in place the necessary infrastructure to extend the health services as required to the policyholders at all times.
(2) The TPA and the insurer shall be responsible for the proper and prompt service to the policyholder at all times.
(3) Scrutiny and handling of claims:
a. TPA may admit claims, authorize cashless facility and recommend to the insurer for the payment of the claim which shall be in line with the detailed claims guidelines issued to TPA by the insurers for the particular product:
Provided that the detailed guidelines as given by the insurer to the TPA for claims assessments and admissions shall be within the terms and conditions of the policy contract, the capacity requirements envisaged and the internal control norms put in place.
b. TPAs shall endeavour to collect all documents pertaining to the claims reported in electronic mode for seamless processing and for recommending to the insurer for payment or rejection as the case may be.
c. A TPA shall adopt the following procedure with respect to settlement of the claims:
i. In case of admissible claim, full or partial: In the communication addressed to the policyholder or claimant, the TPA shall state clearly the following:
a) “Your claim bearing No<Claim No> against policy issued by <name of the insurer> has been settled for Rs <Amit Paid> against the Amount Claimed for Rs <Claimed Amount> towards Medical Expenses incurred for treatment of <name of the Ailment> at <Name and City of the Hospital> for the period from <Date of Admission> to <Date of Discharge>”:
b) The granular details of the payments made, amounts disallowed and the reasons there for.
c) The details of (i) Grievance Redressal Procedure in place with the insurer (ii) Contact details of concerned Grievance Redressal Office and officer (iii) Procedure to be followed for approaching Insurance Ombudsman in case the policyholder or claimant is not satisfied with the resolution provided by the insurer (iv) Contact details of office of Insurance Ombudsman:
Provided that the above details shall be mandatorily included in the communication to the policyholder or claimant in every case where the TPA has disallowed any part of the claim.
ii. In case of inadmissibility of the entire claim
a) The TPA on its own shall not reject or repudiate the claim;
b) The decision and the communication with respect to rejection or repudiation of claim shall be sent only by the concerned insurer directly to the Policy holder or the claimant as the case may be".
It is abundantly clear from these relevant Regulations about the status, locus functions of TPA as well as its role/services in processing the health insurance policies, apart from it has locus standi to process to the medical claim process under legal sanctions. It is also clear that consent of insured is not required for performing services in processing the health insurance policy by the health insurance company of insurer. The case of this complainant is not an exception to it. Accordingly, the contentions/objection raised on behalf of complainant stand disposed off.
7.4. Now the core issue left be decided is with regard to balance amount of medical bills. Since there is strong rival plea, whether or not claim is made out, it is necessary to reproduce relevant clauses 3.23 and 3.29 being under 'definition' part of clause-3 of the insurance policy contract (Ex.R-4), which reads as follows:-
Clause (3.23)- "Preferred provider network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing".
Clause (3.29) - "Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services. taking into account the nature of the illness /injury involved".
7.5: By taking stock of all the circumstances into account, evidence of the parties, the ratio of law laid down in various judgment aforementioned, and considering them, the complaint is dismissed for the following reasons:-
(i). It is settled law that insurance policy is a contract between the parties and both the parties are bound by the terms and conditions thereof.
(ii). Clause 3.23 of insurance policy also binds both the parties. The list of PPN is also available with the company/TPA and parties are bound by such arrangement being a contract between them.
(iii). Similarly, Clause 3.29 of insurance policy also binds both the parties. It has been customized by the parties with regard to standard charges. At the cost repetition parties are bound by such arrangement being a contract between them.
(iv). There is no other contrary evidence by the complainant to counter the clauses 3.23 and 3.29, referred above and to make out the case other than the claim settled by the OP1.
(v). Since the parties are bound by the terms and conditions of contract of insurance policy, therefore, any amount excess to the arrangements agreed upon, would not give rise claim for the complainant.
8. Accordingly, the complainant could not prove the complaint. The complaint fails. The complaint is dismissed. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
9: Announced on this 28th April, 2023 [वैशाख 8, साका 1945].
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
