Before the District Consumer Dispute Redressal Commission, Central District,                                       .ISBT Building,  5th Floor,  Kashmere Gate, Delhi.

Complaint Case  No. 142/2017

                                                            Versus

OP1   National Insurance Company

            8390 First Floor, Roshanara Road,

            New Delhi-110005

OP2     MD India Health Care Services Pvt. Ltd

            S. No.-46/1, E-Space, A-2 Wing, 3^rd floor,

            Pune Nagar Road, Vadgaon Sheri,

            Pune-411014                                     

            Also at - 18/13, WEA Ground Floor,

            Ganga Plaza, Pusa Lane, Karol Bagh,

            New Delhi-110005                                                       ...Opposite Party

Quorum: Shri Inder Jeet Singh, President

              Shri Vyas Muni Rai, Member

              Ms. Shahina, Member (Female)

Inder Jeet Singh, President

ORDER-

1.  (Introduction ) - The complaint is of allegation of deficiency in service. It was filed u/s 12 of the Consumer Protection Act 1986.   Shri Prem Kumar Chugh (hereinafter referred as  the complainant) seeks direction to the Opposite parties (hereinafter referred as  the complainant OPs) to pay balance amount of medical bills of Rs. 13,670/- along with interest @ of 12%  p.a. with effect from 01.09.2016 till date of payment, apart from compensation of Rs. 50,000/- on account of mental agony and harassment suffered by him; complainant also seeks directions for cost of Rs. 5000/- against the OPs. Whereas National Insurance Company (hereinafter referred as  the complainant OP1) opposed the claim on the ground of contractual terms and conditions of medical claim policy by explaining that amount of Rs. 13,670/- was deducted on exclusion clauses in the policy.  And whereas, other opposite party MD India Health Care Services Private Limited (hereinafter referred as  the complainant OP2 or TPA) failed to appear and contest the complaint, it was proceeded ex-parte on 26.09.2017.

2.1 (Complainant’s case)- Succinctly, complainant took medi-claim policy no. 360701/50/16/10001549 for period 09.03.2016 to 08.03.2017 from National Insurance Company (policy is now Annexure-A to the complaint), who hired the services of the MD India Health Care Services Private Limited/TPA. On 18.08.2016 at about 01:00 pm the complainant had to rushed to the hospital with severe problem of chest pain, he was checked vide registration no. 192197 Episode No. EM00448671, where Triage Cardio Profiler Panel, Complete Blood Count and Xray chest PA (CXR) was carried against bill no. 2016-2017/Ca/E/0012561 for Rs. 2,370/- (bill is now Annexure-C) and ECG (bill is now Annexure-D). Moreover, complainant was admitted on the hospital at 07:38pm on 18.08.2016 and there was estimate of treatment, which was communicated to OP2 through TPA desk, OP2 had approved a sum of Rs. 34,700/-. It was 20.08.2016 when complainant was discharged, the bill was for Rs. 38,204/- which was also sent to OP2 for payment. There was no payment of bill despite repeated request and reminders on telephone to OP2 and there was also no response from OP2 which compelled and forced the complainant to overstay in the hospital. Further, even on 21.08.2016 there was no response by OP2,  which result into consequential inability of the complainant to clear the bill and he was forced to overstay in the hospital in the absence of receipt of pre-approved payment from OP2. The complainant reported to the local police, then officers of OP2 apologized on telephone. The complainant was also told, since there was delay on the part of the company, the further charges would be borne by the OP2, even complainant was made a commitment that settlement of paying would be forthwith in  an hour.  Since, the OP2 had acknowledged their fault, no action was initiated by the police.

2.2   However, OP2 approved belatedly only Rs. 37,516/- against bill sent on 20.08.2016, they had not sent further charges claimed by the hospital against bill dated 21.08.2016. the complainant made repeated calls to OP2 and every time it was told that the bill is in process and it would take half an hour but all in vain. Later, the officers of OP2 stopped taking the telephone calls of the complainant. Finding no other way, the complainant arranged cash to pay balance bill to the hospital by using his Debit Card no. 9844 and got him discharged from hospital (bill dated 21.08.2016 is now Annexure-E and receipt dated 21.08.2016 is Annexure-F).

       Thence, on 21.08.2016 complainant lodged claim on prescribed form with letter to OP2 for Rs. 22,628/- (now Annexure-G colly.) in respect of forcible overstay in the hospital because of non-settlement of claim and non-payment of the bill/dues of the hospital. The complainant did not receive any intimation or forwarding letter but OP2 directly remitted an amount of Rs. 8,958/- in the account of complainant (copy of bank pass book entry is now Annexure-H), consequently it could not be ascertained why balance amount of Rs. 13,670/- against bill of Rs. 22,628/- was not remitted by OP2, despite the claim was supported by bills issued by Sir Ganga Ram Hospital. Then complainant sent registered letter dated 31.01.2017 to OPs for payment of remaining amount of Rs. 13,670/- (copy of register letter along with copies of postal receipts are now Annexure-I to L). Neither that letter was replied nor the amount has been paid. There is deficiency in the services which has attributed agony and suffering of overstay in CCU of the hospital apart from stay of an attendant in the hospital, which also cause immense stress to the complainant. They are liable to pay damages for harassment, mental agony and financial losses on the part of OPs.

3.   (Case of OP2)-OP2 was served with notice of complaint, however, it remained absent despite opportunity by adjourning the matter,  but ultimately it was ex-parte on 26.09.2017 because of non-appearance.

4.1   (Case of OP1)-  OP1 had filed its reply to put its plea, which is not a paragraph-wise reply to the complaint. In nut-shell, OP1 opposed the claim of complainant by referring certain conditions of insurance policy as well as exclusion clauses 4.1, 4.2 and 4.3 of the policy,  while narrating the policy and its duration from period 09.03.2012 to 08.03.2013 and onwards policies upto the period 09.03.2016 to 08.03.2017.  OP1 also explains as to why deduction of Rs. 9,700/-, other deduction of Rs. 1,000/- and one more deduction of Rs. 2,970/- and it was because of these terms and conditions of policy.

4.2 (Rejoinder of complainant)- The complainant filed rejoinder to the reply of OP1, the reply was opposed while reaffirming his case. Not only OP1 concealed the material information and  facts that complainant has been insured since 2002 and not just from the year 2012, the copies of the policy for the period 09.03.2002 to 08.03.2003 and onwards till 08.03.2012 were filed (now Annexure-N). Moreover, the complainant was never mentioned of such clauses of policy or supplied national medical claim policy by OP1, although policy was got renewed from time to time;   the complainant never agreed for those terms and conditions. Otherwise, the reply of OP1 is not applicable in the case of complainant.

5. (Evidence of the parties)- The complainant filed his affidavit of evidence, while referring and relying upon the documents annexed with the complaint and rejoinder (i.e. Annexure A to Annexure M). Whereas, OP1 stopped appearing after filing the reply, although reasonable opportunities were given to lead evidence but OP1 failed to use such opportunities, consequently, right to lead evidence by OP1 was closed. The OP2 has been ex-parte.

6.   (Submissions/arguments of the Parties)-  The complainant filed the written arguments. Whereas OP1 was given opportunities for filing written arguments and argument but again OP1 failed to utilize this opportunity also. The complainant also made oral submissions.

7.1     (Findings)- We have  considered the pleas of the parties as well as their contention, in the light of material on record being testimony of complainant as well as documents  on record.  On analysis, the following undisputed facts are culled out"-

(i) the complainant was insured under National Medical Policy no. 360701/50/16/10001549 for period 09.03.2016 to 08.03.2017 issued by OP1,

(ii)  OP2 is Third Party Administrator(TPA) for OP1,

(iii)  the complainant was medically examined on 18.08.2016 and then he was admitted in Sir Ganga Ram Hospital,  where he remained indoor patient  till his discharge on 21.08.2016 and

(iv) the complainant had lodged his claim of medical bills  to the OP2, it was initially approved for Rs. 34,700/- and the bill was Rs. 38,204/- when he was discharged on 20.08.2016. The complainant’s claim of Rs. 13,670/- was not paid by the OP.

7.2   Now the controversy left to be decided is in respect of claim of bills of Rs. 13,670/-;  amount of  compensation and cost of litigation. On the one side, the complainant has pleaded his case in the form of complaint and he had also lead the evidence coupled with documents, which were filed with the complaint and the rejoinder. Whereas on the other side, the OP2 opted to remain absent from the proceeding, that is why it was proceeded ex-parte. Whereas, OP1 had filed the reply to complaint but it failed to lead any evidence despite opportunity. The plea of OP1 remained just pleading without taking the shape of evidence. Moreover, the complainant had opposed the pleading of OP1 while emphasizing that he was never informed of the terms and conditions of the policy or policy  or the exclusion clauses relied upon by OP1 vis-à-vis he never agreed on those terms and conditions. Therefore, the following conclusions are drawn from aforementioned discussions:-

(a) on 21.08.2016 the claim lodged by the complainant was of Rs. 22,628/- and he was paid Rs. 8,958/- by OP2 by direct remittance in the account of complainant; it left the balance amount of Rs. 13,670/-.  Neither OP1 nor OP2 through OP1 has established any letter of OP2 to the complainant by explaining the deduction of Rs. 13,670/-. However, the OP1 in its reply pleaded those deduction of Rs. 13,670/- but OP1 failed to lead any evidence about such deduction for want of bringing on record those policy, its terms and conditions  or exclusion clauses by way of evidence,

(b) had the complaint been paid the pre-approved bills in time, there was no scope or occasion for such dispute; the circumstances happened for want of payment of such bill in time and complaint was not discharged. These allegations proved by complainant remained un-rebutted,

(c) the OP1 has referred certain clauses stated to be part of insurance policy, however those policies along with exclusion clauses have not been proved on behalf of OP1, meaning thereby there is no proof of exclusion clause  by the OP1 and

(d) the OP1 was required to prove by evidence of the contention raised in the reply, the reply is not substitute of evidence.

       Hence, the complainant has succeeded to establish his case of deficiencies of service and of claim of Rs. 13,670/- against OP1 and OP2, that he had lodged the claim on the basis of medical bills and record, which was not paid;   OP1 and OP2 are liable jointly and severally to pay the same to the complainant.

7.3 The complainant has claimed interest @ 12% pa,  however, there is no supporting evidence or other circumstances to justify claim of interest @ 12% pa. Thus, keeping in view the prevailing circumstances in the period of 2017, it appears appropriate to us and in order  to  meet both ends of justice, to award interest @ 7% pa. from 30.05.2017 [being the date of filing of the complaint]  till the realization of the amount in favour of complainant and against OPs.

7.4  It is crystal clear from the material on record that when the complainant was indoor patient, the pre-approved bill amount was not tendered and he had to remain overstay in the hospital awaiting clearance for discharge and later when he lodged the claim, it was also  partly paid without informing the details or reasons of non-payment of entire bill amount. Thence, he had filed the complaint before the Commission.  He faced inconvenience, harassment, stress and other trauma during that those periods, thus he is held entitled for compensation. It is quantified as Rs. 17,000/- in favour of complainant and against the OPs payable by them jointly and severally.

7.5  So far cost component is concerned, the complainant is held entitled for costs of Rs. 2,000/- in his favour and against the OPs jointly and severally.

7.6  Accordingly,  complainant's complaint is disposed off while holding  and allowing his balance medical claim of Rs. 13,670/- alongwith interest @ 7%pa (from date of filing of complainant on 30.5.2017 till payment is made) against OP1 and OP2 jointly & severally, the complaint is also allowed in favour of complainant and against OP1 and OP2 to pay compensation of Rs.17,000/-  jointly and severally, apart from cost of Rs. 2,000/- in favour of complainant against the OPs jointly and severally.  

8. Copy of this order be sent to the parties as per rules.

File be consigned to record room after proper pagination and extra sets be returned to the parties as per rules.

Announced on this 06th  day of  December 2022.