Hon’ble Mr. Nityasunda Trivedi, Member

The Appeal case was filed at this Hon’ble State Commission for alleged denial of justice at the District Level through Judgment dated 17.11.2023 which gave clean chit to the two Opposite Parties i) National Insurance Co. Ltd., Division IX, Kolkata ii) Implant’s Better Sight Centre Pvt. Ltd. (Proforma Defendant).  The findings of the Hon’ble District Level Commission (Kolkata, Unit-III) was:

“….. we find no reason to say that the Opposite Party is deficient in rendering proper service to the Complainant and they have such unfair trade practice.  We find no reason to uphold the allegation of the Complainant which is devoid of any merit and is liable to be dismissed”.

The complaint case being No.CC/101/2021 was filed U/s.35 of the Consumer Protection Act, 2019 at the District Level.

The fact of this case is like that there was a Medical Policy issued by the Opposite Party No.1 (Respondent No.1 in this Appeal case) for the period 11.02.2018 to 10.02.2019.  The Appellant underwent PHACO Surgery in her right eye on 25.01.2019 in the Hospital of the Opposite Party No.2/Proforma Defendant’s (Respondent No.2) for which a bill of 53995/- was claimed by the Hospital.  When this amount was claimed by the Appellant/Complainant from the National Insurance Company/O.P No.1/Respondent) they paid Rs.28765/-.  Residual Rs.25230/- had to be paid by the Appellant/Complainant from her own resources.

Subsequently, when PHACO Surgery was done for the second time (left eye) she got reimbursement of Rs.26000/- out of Hospital’s billed amount Rs.49000/- which meant Rs.23000/- was to be paid by her from her own resources.  Thus in aggregate Rs.48230/- was to be borne by herself despite being under cover of Mediclaim under the National Insurance Company. 

Thus in two counts she was, in her words, deprived of Rs.48230/- (Rupees Forty eight thousand two hundred & thirty) only for alleged corrupt practice of the National Insurance Company who claimed they did not do any wrong.  They simply followed their PPN Policy.  Taking up the matter with IRDAI and thereafter moving the Ombudsman by the Appellant/Complainant was also of no avail.  The IRDAI and the Ombudsman echoed in the same voice as the National Insurance Company.

Then the present Appellant/Complainant moved the District Commission with prayer for Order of payment of Rs.48230/- plus Rs.10000/- as cost of damages and Rs.10000/- for unfair trade etc. and such other belief as legally entitled.

Related papers show the proforma defendant (Opposite Party No.2) did not contest this case at the District Level.  Opposite Party No.1 (the National Insurance Company) was the sole O.P accordingly.

The O.P No.1 (Respondent No.1) did not come this Commission when summoned to contest this Appeal not for single day, for which this case was heard ex-parte.

The main argument of the Appellant is the following:-

The complaint was dismissed at the District Level since the trial court mainly relied on following PPN Criteria by the main O.P (O.P No.1, the National Insurance Company) who claimed they had no discriminatory mentality against the Complainant in rejecting her claim, they being a Govt. of India Undertaking.

PPN stands for “Preferred Provider Network”.  In its Judgment the Hon’ble District Commission emphasized why the Complainant/Appellant never raised any question for extra charge to the Proforma Defendant where her surgeries was done.

It is neither a strong nor a fair logic that the person who took insurance policy will bargain with the Hospital as to why Hospitals are charging more.  The relationship of the policy holder is with the Insurance Company to which a policy holder makes premium payment each year and not with the Hospital.  Quite natural, the Hospital will either not entertain any such query of the policy holder or will advise the policy holder to approach the Insurance Company for having the desired reply or will ask the policy holder to come to them through the Insurance company.

Hon’ble District Commission also observed the following:-

“……..on the other hand why such extra charge has been made by a Hospital which is under PPN is beyond our expectation especially when they have some contract with the insurer for fixed charges under specific procedures………….”.

We are also of the opinion that the Insurance Company is standing in between the policy holder and the Hospital.  So, if the Hospital charges more rate than the PPN mentioned rate, honoured by the Insurance Company, which is being used as a shield to pay lesser amount in times of making payment, the Insurance Company cannot shirk off its responsibility of not allowing the PPN scale to be varied without keeping the insurer duly informed.  They are to make necessary liaison with the Hospitals to get the PPN scale fixed till there is no change of policy premium paid by an individual policy holder for an annum which is the unit of fixation of a premium amount.  When this has not been ensured by the Insurance Company and when the Hospital chosen by the Insurance Company varies the scale of PPN without keeping the insured person who is the main stake holder in this regard, this can at best be said to be an irresponsible work on the part of the Insurance Company.  This certainly entails negligence on the part of the Insurance Company.

This being so, we hold and firmly hold that the sudden change (rise) of PPN Scale in the treatment of insured person, should be borne by the insurance company as they have tacit consent and indulgence in whimsical charge of cost of PHACO Surgery/Arbitrary amount of reimbursement payment under the plea of honouring the PPN scale.  

On such logic the Order of the Hon’ble District Commission dated 29.03.2023 in complaint case No.CC/101/2021 is set aside.   The Insurance Company is directed to pay the claimed amount of Rs.48230/- along with compensation of Rs.10,000/-(Rupees Ten thousand) only for mental agony etc. and litigation cost of Rs.5000/- (Rupees Five thousand) only within a period of forty five (45) days failing which O.P.1 will be liable to pay interest @9% on this amount from the date of passing of this Order till its realisation. 

The Appellant will have the liberty to put this Order into execution in case it is not complied as per Order.

Let a copy of this Order be sent to the parties free of cost.

Inform the Hon’ble District Commission accordingly.

The Appeal being No.A/156/2023 succeeds.

Note accordingly.