Date of Filing : 23 February, 2021.
Date of Final Order : 29 March, 2023.
Mr. Dhiraj Kumar Dey, Hon’ble Member.
The instant case arises when Smt. Sulata Datta, the Complainant, filed a complaint U/S 35 of the Consumer Protection Act, 2019, hereinafter called the said Act, against (1) National Insurance Co. Ltd., said to be the Opposite Party or O. P., and 2) Implant’s Better Sight Centre Pvt. Ltd., described as the Proforma Defendant alleging deficiency in service on the part of the O. P.
The fact of the case, in hand, in short, is that the complainant has a continuous Mediclaim Policy under the O. P. company for about 25 years having Policy No. 1000901501710005347 for the period 11/02/2018 to 10/02/2019. She underwent PHACO surgery in her right eye on 25/01/2019 in the Proforma defedant’s hospital under Claim Reimbursement Option for which a bill of Rs.53,995/- was raised by the hospital and when this bill was placed before the O. P. for reimbursement the TPA, on behalf of the O. P. paid only Rs.28,765/- and the complainant had to pay Rs.25,230/- from her own pocket. On 09/02/2019 when she underwent PHACO surgery in her left eye in the same hospital under Cashless Option she had to pay Rs.23,000/- from her own pocket and the O. P. paid Rs.26,000/-. Thus the complainant had to pay total Rs.48,230/- for herself despite she had the Mediclaim Policy. When she claimed before the O. P. for reimbursement this amount the O. P. refused to pay further stating that they had paid as per their PPN policy and they could not pay further as per norms. She then complained before the IRDAI who dropped her complaint without any explanation. Then she filed a complaint before the Insurance Ombudsman who awarded her by saying: “ …. the decision of Insurance Co. in respect of settlement of claim is correct and justified. Hence, the complaint is dismissed without any relief to the complainant.” Then the complainant filed this instant complainant praying to direct the O. P. to reimburse Rs.48,230/- with 9% interest from the dates of refusals, to pay Rs.10,000/- for costs and damages, Rs.10,000/- for unfair trade practice, etc.
The complainant attached copies of (i) Policy Schedule & Premium Certificate for the period 11/2/18 to 10/2/19, (ii) Claim Settlement Advice issued by the TPA on 26/02/2019 for the Bill of Rs.53,995/-, (iii) Credit Bill and Bill Cum Receipt for the 2nd operation, (iv) mail correspondences with O. P., (iv) Award letter issued by the Hon’ble Insurance Ombudsman, etc. as annexure to the complaint.
This Commission, after admitting the complaint, sent notice to the O. P. and Proforma Defendant to contest the case by filing their written versions. The Proforma Defendant did not appear for contest and the case proceeded ex parte against them. The O. P. appeared and filed their written version with annexure therein. Complainant then filed her Evidence on Affidavit. O. P. did not file any questionnaire and prayed to treat their written version as their Evidence. Complainant did not file any questionnaire and ultimately argument was heard. Brief Notes of Argument was filed by both the parties.
The statement of the complaint and annexure therein, written version of the O. P. and its annexure, Evidence of Affidavit of the complainant, BNAs, the day-to-day proceedings and the other documents are taken into consideration for finalising the order.
We are now in the juncture to consider the following questions:
1. Whether the Opposite Party is deficient in delivering the desired service?
And, 2. Whether the Complainant is entitled to get relief as prayed for?
Let us take these points one by one to come to a decision. Be it mentioned here that if the Proforma Defendant had participated in the case then it would be helpful for better judgement in this case.
Decision with reasons
1. The complainant submitted copy of Policy Schedule and Premium Certificate for the period 11/2/2018 to 10/2/2019 having Policy number 1000901501710005347 issued by the O. P. company as annexure to her complaint petition which clearly states that the Complainant is a Consumer as defined under Section 2(7)(ii) of the C. P. Act, 2019 hiring service of the O. P. under their Mediclaim Policy.
On careful scrutiny of the documents annexed with the complaint we find that the above stated policy is named as ‘National Mediclaim Policy’ issued in the name of Smt. Sulata Datta and her daughter, Ms. Ajeya Datta. No documents have been filed by the complainant wherefrom we can find the terms and conditions of this type of policy. Complainant stated in her complaint that in the year 2011 her husband namely Sri Satyabrata Datta underwent same type of PHACO surgery in his both eyes and the total bill of Rs. 65,642/- was fully disbursed by the same O. P. company. She has annexed a copy of the policy document issued by the same O. P. for the period 12/2/2010 to 11/2/2011 issued in her husband’s name. In this copy we see that this policy bears the terms ‘Hospitalisation Benefit Policy’ and ‘Individual Mediclaim’. The policy schedule for the period from 11/02/2013 to 10/02/2014 bears the same term ‘Imdividual Mediclaim’ issued in the name of the complainant whereas for the period from 11/02/2014 to 10/02/2015 bears the name ‘National Mediclaim Policy’. So the O. P. has changed the policy between 11/02/2013 to 11/02/2014 which supports the claim of the O. P. as stated in their written version. These clearly state that the previous policy was different from the present policy. When the complainant claimed the amount paid by herself, the O. P., refusing this claim, stated that they have already reimbursed the amounts as per their PPN rate under National Mediclaim Policy and no further claim could be disbursed. Complainant stated that she, for the first time, came across the PPN terminology in this refusal. The O. P. stated in their written version that the Individual Mediclaim Policy had been replaced by the National Mediclaim Policy in the year 2013 and they annexed the detailed policy document under the head ‘National Mediclaim Policy’. The O. P. stated in their brief notes of argument that: “As per norms, while obtaining policy, the Premium Certificate along with the Policy, Policy Schedule and its terms and conditions are issued to the Policy holder. Moreover, ‘….. the clauses, endorsements and policy wordings as available in the website of the National Insurance Company shall be read together as one contract……’ has been specifically written in the Policy Schedule issued to the Policy holder.” Complainant stated that she never knew the term PPN since 2013 until the O. P. inform her through mail during refusal of her claim. A question now arises, whether she knew that her policy had been changed from Individual Mediclaim Policy to National Mediclaim Policy? Since the Policy documents bear the name of the policy so this change must have been noticed by the complainant and such change should bring the curiosity in her mind to look through the changes in the policy. Since she is familiar in using mail so this curiosity might be quenched by going through the website of the O. P. company, even if we consider that the O. P. company failed to supply the details of policy with the policy documents sent to her during yearly renewal.
She got her first surgery under Claim Reimbursement Option while her second surgery was done under Cashless Option. Now we look at the policy details under National Mediclaim Policy attached with the written version of the O. P. In Clause 3.23, page 6, we See :
“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 persons. The list is available with the company/TPA 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 rules applicable to PPN package pricing.”
So, we can presume that the complainant was aware of the Cashless package facility, whether under PPN or not. She had her surgeries in a hospital which was under PPN. It is very confusing that the hospital, which is under PPN policy of the O. P. company charged Rs.14,000/- extra as Surgeon Fees and this is well above the PPN rate! The O. P. refused to pay this amount as this is beyond the PPN rate. The complainant never raised a question for such extra charge to the Proforma Defendant where her surgeries were done. 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. The complainant failed to file details of bills of the two surgeries from which we can find which payments have not been reimbursed by the O. P. and what was the reason for refusal to pay the amount paid by the complainant herself. Only in case of the first surgery on 25/01/2019, the TPA issued a Claim Settlement Advice dated 26/02/2019 against the claim amount of Rs.53,995/- we see in Details of deductions that:
Rs.14,000/- on Bill No. 3404 dated 25/1/2019 (Surgeon Fees) – Beyond PPN Rate.
Rs.30/- on Bill No 5 dated 13/1/2019 (Pathology) – collection charges.
Rs.1,200/- on Bill No 4 dated 12/2/2019 (Others) – Charges for infected eye only.
Rs.10,000/- on Bill No 3404 dated 25/1/2019 (Consumable – IOL) – Beyond PPN Rate.
So, an amount of Rs.25,230/- was refused to pay by the O. P. and this amount was paid by the complainant from her own pocket. Relevant to this claim a Bill Break-up having Bill No. 003404, dated 25/01/2019 is found where the Hospital charges Surgeon Fees for Rs.21,500/- and the O. P. refused to pay Rs.14,000/- out of the charged amount. We failed to correlate this Bill Break-up with the Claim settlement advice and hence we found no reason to interfere in the inference of the O. P. through their TPA for reimbursement in this case. In the second case the O. P. directly paid Rs.26,000/- to the said hospital and an amount of Rs.23,000/- was paid by the complainant. In this case also we failed to take any decision on whether the reimbursement is justified or not, especially when the O. P. pointed out in the above noted Clause 3.23 that the hospitals under PPN have agreed to a cashless packaged pricing for certain procedures. The Insurance Ombudsman has observed in their above award stated herein above that: “ …. if the hospital charges beyond the agreed rate, the Insurance Company does not have any liability to the additional charges beyond the PPN rate.”
The O. P. referred in their BNA two judgements of the Hon’ble National Commission in (1) New India Assurance Co. Ltd. –Vs – Dr. Girish M Wagher [2017(1) CPR 526 (NC), Fisrt Appeal No. 135 of 2011], and (2) National Insurance Co Ltd -Vs- Premjibhai Laxmanbhai Motka [2011 (1) CPR 8 (NC), RP/2090/2007], which have no relevance with this case. But it is a settled principle that we cannot go beyond the terms of the contract made between the parties. We cannot grant any relief beyond the terms of the insurance policy in the instant case, especially when the complainant could not justify her claim.
2. These above discussions make it clear that the O. P. has followed their planned schedule under the specific policy and the complainant failed to comprehend about her changed Mediclaim Policy. In their written version the O. P. stated that they have acted in accordance with law and settled the claim of the complainant as per policy conditions and the guidelines framed under the policy. They also said that their company is a Government of India Undertaking, so “there is no grudge upon the complainant”. When we go through the complaint we see that there is only one contention of the complainant that she has not been informed about the PPN system by the O. P. prior to the surgery where we seen that the operation was done in a hospital which is under PPN and that too had charged extra amount beyond prescribed rate(s). The complainant has no complaint against the hospital which charged extra amount and this extra amount was not reimbursed by the O. P. Besides, the complainant failed to establish her claim with reasonable explanation at what extent the O. P. failed to comply.
Thus, we find no reason to say that the O. P. is deficient in rendering proper service to the complainant and that they have used 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.
Hence,
it is
ORDERED
That the Complaint Case being No. CC/101/2021 is dismissed on contest with no cost.
