District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/118/2019
(Date of Filing:-19.08.2019)
- Smt. Suchitra Das
228/4, RBC Road, P.O. & P.S. Naihati
Dist. 24-parganas (N), Pin:-743165…..Complainant
- National Insurance Company Ltd.
Represented by its Manager, Chandannagore Divisional Office
147/128, G.T.Road, Baghbazar, (East)
P.O. & P.S. Chandannagore,
District:- Hooghly, Pin:-712136.…..Opposite Party
Before:-
Mr. Debasish Bandyopadhyay, President
Mr. Debasis Bhattacharya, Member
-
Final Order/Judgment
DEBASIS BHATTACHARYA:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with the service extended by National Insurance Company Ltd. (hereinafter referred to as OP) of the address as mentioned pre-page, in the matter of lodging of a claim for reimbursement of medical expenses related to the medical treatment and surgery of the Complainant herself, against a medical insurance policy maintained by her with the OP Insurance Company and disbursement of an amount against the said claim by the OP insurance Company after truncating a substantial portion from the amount originally claimed by the Complainant insured, the instant case has been filed u/s 12 of the Consumer Protection Act 1986.
The fact of the case is as follows.
The complainant, was a holder of the ‘National Medical Policy’ bearing No. 153600501710002174 which was valid for the material period i.e. 01.03.18 to 28.02.2019 with a coverage of Rs.1,30,000/-
However the Complainant with a complaint in her left eye was diagnosed to be a patient of cataract with ‘Primary Angle Closure Glaucoma’ in the left eye and on 04.09.2018 she had to take admission in L.V. Prasad Eye Institute Hyderabad for required medical management. Accordingly she underwent a ‘Small Incision Cataract Surgery with foldable posterior chamber Intraocular Lens implantation’ in the said eye institute and was discharged on the same date. Expenses incurred for the said medical treatment amounted to Rs.63,000/-
The Complainant claims to have lodged a claim with the OP Insurance Company on 26.09.2018 for Rs.64,359/- accompanied by the all relevant documents. However the OP Insurance Company after considering the claim, disbursed an amount of Rs.36,000/- through the concerned TPA in favour of the Complainant.
The Complainant referring to the terms and conditions of the policy agitates over the issue related to curtailment of the claim to the extent of Rs.28,359/-
The complainant claims to have suffered immense mental agony, anxiety and harassment for this monetary loss.
Considering the stance taken by the OP, as deficiency of service, willful negligence and unlawful activities, the complainant submits a prayer before this Commission to impose direction upon the OP to reimburse the balance claim to the extent of Rs.28,359/- with interest @18% with effect from 26.09.18, to pay Rs.1,00,000/- as compensation for causing sufferings and mental agony and Rs.5,000/- towards litigation cost and to pass any other order or orders as the Commission may deem fit and proper to meet the ends of justice.
The complainant, to establish her point, has filed copies of the premium collection receipt, Policy document for the period 01.03.2018 to 28.02.2019, premium certificate, corresponding tax invoice, Certificates of the respective medical institution dtd.27.11 2018 and 05.09.2018, clinical pathology report, bills issued by the medical institution, discharge summary, final bill and the claim form related to medical insurance.
Evidence on affidavit and the brief notes of argument are almost replicas of the complaint petition.
In view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(1)(d)(ii) of the Consumer Protection Act 1986 are concerned.
The opposite party is having their office address within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.20,00,000/-Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, are taken together for convenient disposal.
The OP has contested the case by filing written version, which on prayer is considered as evidence on affidavit.
Brief notes of argument are filed by both the sides.
Defence case:- The Op insurance Company points out in their representations filed through the written version and brief notes of argument that claim lodged by the Complainant was investigated and it was found that the institute where the medical treatment was received by the Complainant was within the list of the Preferred Provider Network (PPN) as per the terms and conditions of the insurance policy contract.
The OP Insurance Company referring to clause 3.23 of the policy terms and conditions mentions as follows
“Preferred Provider Network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. 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.”
The OP insurance Company draws attention to the fact that as because the said L. V. Prasad Eye Institute at Hyderabad is within the list of the PPN, any procedures undergone at the said hospital shall be subject to the package rates applicable for the said procedures.
Decision with reasons
Materials on records are perused. Before taking any decision in the instant case the relevant aspects of PPN rates require brief discussion.
PPN rates are specialized rates listed by PPNs for customers of public sector health insurance companies with which the insurance companies have tie up.PPN rates are specified for a list of specified illness only.
Health claims are settled in two ways viz. cashless settlement and reimbursement.
PPN in health insurance stands for preferred provider network. It is a network of hospitals which are tied up with the health insurance companies to provide cashless health claim settlements to policyholders.
PPN rates would be applicable only if 1) the health plan is bought from a Government health insurance company 2) the illness is a listed illness as prescribed by the insurance companies 3) medical treatments are taken at the networked hospitals of the insurance companies (PPN).
Every hospital which has a tie up with an insurance company maintains three different rates for the same treatment. Those are
- PPN rates applicable for claim settlements under plans offered by public sector health insurers.
- Cash rates applicable if there is no health insurance claim and the treatment costs are payable by the patient in cash.
- Non-PPN rates applicable for claim settlements under plans offered by private health insurance companies which are tied up with the hospital.
Now the petitioner admits that the expenses incurred for the treatment was to the extent of Rs.63,000/- and the break-up of expenses as certified by the medical institute also shows the same figure. However the claim was lodged for Rs.64,359/- and finally the OP insurance Company disbursed an amount of Rs.36,000/- as reimbursement of medical expense against the claim lodged by the Complainant. The petitioner’s grievance is centered around the curtailment to the extent of Rs.28,359/-
The Complainant referring to the Clauses 2.1, 2.2, and 2.3 of the terms and conditions of the policy mentions the extent to which the OP insurance Company was supposed to reimburse the expenses.
It is further mentioned that as the said Eye Institute is ‘not’ under PPN of the OP Insurance Company, the coverage mentioned in the terms and conditions of the said policy is applicable in the case of the Complainant.
The Complainant also agitates over the fact that she was deprived of the information regarding her claim.
However, on examination of the respective website of the OP Insurance Company it is found that the medical Institute where treatment and surgery of the Complainant were undertaken, was under PPN network of the OP Insurance Company.
Thus, so far as the terms and conditions of the policy are concerned, sub-limit (as mentioned in clause 2.1, 2.2 and 2.3) will not apply in case of hospitalization in a preferred provider network (PPN).
On meticulous scrutiny of all the aspects of the case, this Commission does not find any reason to pass any directive to the OP Insurance Company to deviate from their stand in the matter of reimbursement of the expenses incurred by the Complainant towards her medical treatment.
Hence it is
ORDERED
that the complainant case no.118/19 be and the same is dismissed on contest.
However the OP has stated in the written version that the details of the deductions from the claim are always available in the website of the TPA and one can always have an access to that by entering the relevant details.
Now the Complainant may check the website accordingly. In case of non-availability of the required information, the Complainant will be at liberty to approach to the OP for the required information and the OP Insurance Company will be bound to supply the exhaustive details with regard to the deductions accordingly within seven days for the sake of transparency.
There is no order as to costs.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in.
