7Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-71/2020
Ms. Mamta Gupta w/o Sh. Manoj Kumar Gupta
r/o 1/6826, East Rohtash Nagar, Shahdara, New Delhi-110032 …Complainant
Versus
The National Insurance Co. through its Director/ Manager
Office at: East West Assist TPA, Plot No. 172, JP House, Lane 2,
Westend Marg,Saidulajab, Next to Saket Metro Station, N. Delhi-110030
Also at: The National Insurance Co. through its Director/ Manager
Office at: New Delhi, Division XII 3rd Floor, 6/90, Padam Singh
Road, Karol Bagh, New Delhi-110005 ...Opposite Party
Date of filing: 06.10.2020
Date of Order: 07.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Inder Jeet Singh, President
ORDER
1.1. (Introduction to case of parties) – The complaint was filed with allegations of deficiency of services and unfair trade practice, since the complainant, being insured, had undergone medical treatment and spent Rs. 2,36,243/- during hospitalization and Rs. 19,419/- after her discharge but the OP/ insured disbursed Rs.1,66,318/- and Rs. 9,554/- respectively, the balance amount of Rs.80290/- was deducted without any explanation.
1.2. The complaint was opposed by OP, while denying the allegations that claim was settled for Rs. 1,75,372/- out of total bill of Rs. 2,55,662/- and it was after deducting Rs.80,290/-. This claim was settled in full and final settlement. The deductions were made as complainant failed to justify over and above GIPSA billing and extra stunt placement charges. There is no deficiency of services and unfair trade practices.
2.1. (Case of complainant) – The complainant purchased medical policy from OP through its agent Sh. Mohan Kumar. The complainant has been buying the policy for the last about 5 years under best health scheme and she has been paying huge yearly premium. Insurance policy no. 351200501910000059, with effect from 15.04.2019 to 14.04.2020, was issued against paying yearly premium of Rs. 41,734/- (covering all diseases) (Annexure-A to complaint).
The complainant got ill and he was admitted in Sir Ganga Ram Hospital on 25.06.2019, the OP was informed and cashless facility was not processed due to certain issue with TPA. The complainant paid hospitalisation expenses/bill of Rs.2,36,243/- and she was discharged on 27.06.2019, she was also issued discharge summary (Annexure-B to the complaint). She also paid post discharge medical bills of Rs. 19,419/-.
2.2. On 01.07.2019 the complainant submitted all bills and other documents of discharge summary, medical prescription (Annexure-C) in the office of OP but OP issued qurery letter dated 10.07.2019 (Annexure-D) of her claim no. 657218, however, the hospital resolve the query by letter dated 24.07.2019. OP issued another letter dated 02.08.2019 (Annexure-E) and the same was also resolved by the complainant. It was assured by OP that there will be reimbursement of bills within 2-3 days. But OP rejected the claim arbitrarily, without proper investigation and it was told that the bill made by the hospital is inflated on advice of complainant. The claim of post discharge bills of medicine of Rs. 19,419/- was submitted on 28.08.2019 (Annexure-G).
2.3. The OP failed to clear the claim till December 2019 despite visiting the OP as well as office of TPA. After waiting for long period for 6 months, the complainant received claim of Rs. 9,054/- on 09.12.2019. After further efforts and visits to the office of OP, she further received claim of Rs. 1,66,318/- on 23.01.2020, but whole claim was not cleared. The OP made deductions and behaved like unprofessional as it was not apprised and communicated explanation or reasons for those deductions. Out of total claim of Rs. 2,55,262/- (i.e. Rs. 2,36,243/- + Rs 19,419/-), the OP cleared amount of Rs. 1,75,372/- (i.e. Rs. 1,66,318/- + Rs. 9,054/-), thus balance amount of Rs. 80,290/- was deducted.
2.4. The complainant keep on cooperating the OP and it was falsely assured by the OP and TPA, they were also sent so many mails but no result that is why the complainant was feeling frustrated and she sent legal notice dated 19.02.2020 by post (Annexure-H & I) and despite service of legal notice (track report is Annexure-J) no reply or compliance was done. The complainant sustained mental torture, agony, disturbance in the family and harassment. That is why, the complaint for balance amount of Rs. 80,290/- with interest at the rate of 24% pa, compensation of Rs. 1,00,000/-, cost of Rs. 50,000/- and for other appropriate relief.
2.5. The complaint is accompanying with the documentary record, already referred, being Annexure to the complaint.
3.1 (Case of OP)- The OP filed detailed reply and opposed the complaint vehemently to dismiss the same. The complainant admits in para 8 of the complaint of settled amount of Rs. 1,66,318/- and Rs. 9,054/- after deducting Rs. 80,290/- from total amount of Rs. 1,75,372/-, the cheque amount issued was in full and final settlement (it is relevant to mention here that there is no such averment in the complaint that the complainant admitted of receipt of amount as full and final settlement). Since the amount has been settled and paid, the complaint does not survive. It is legally not maintainable. The OP failed to mention as to how there is deficiency of services. It is a false complaint and no amount is payable by the OP.
3.2. The TPA discovered and found that treating hospital has been charging arbitrarily for package being provided by them for treatment of CAD by procedure of angiography, PTCA + stent. The OP had served query letter dated 10.07.2019 (Annexure-A) and asked the complainant to verify about justification for extra GIPSA billing and stent charges. Complainant could not satisfactorily resolve the query.
The hospital has charged separately for coronary angiography and coronary angioplasty for an amount of Rs. 14,800/- and Rs. 1,32,000/- (i.e. total Rs. 1,46,800/-) but as per standard procedure being adopted, then both procedures of coronary angiography and coronary angioplasty are done in one sitting, then only the charges for coronary angioplasty are to be charged. But both the procedures for the complainant were done simultaneously within 2 days of her admission in the hospital. Moreover, the standard package rates for both procedures simultaneously are Rs.1,07,100/- as per GIPSA and an amount of Rs. 39,700/- was deducted (as per reasonable and customary clause no. 3.29 in the terms and conditions of policy, which is Annexure-B).
Further Rs.3,470/- were deducted against laboratory investigations bills of Rs. 7,600/- since one lab test was done on 17.05.2019, which was one month prior to pre-hospitalisation, such charges are not payable as per clause 3.1. One original lab test receipt dated 01.07.2019 was not furnished. The net amount (under lab investigation) is Rs. 4,130/-.
The pharmacy charges of Rs.21,515/- were deducted from billing amount of Rs. 71,093/- being non-payable and pharmacy amount of Rs. 49,578/- were allowed as per policy. The amount of Rs. 840/- were deducted from miscellaneous charges as diet charges are not payable as per clause 4.17.
3.3. In respect of post hospitalistion medical bills, a query letter was raised on 05.09.2019 to provide relevant record (of original lab report, prescription, advising x-ray, echo and original prescription dated 20.06.2019, 23.07.2019 and prescription advising admission of 16.07.2019, 12.08.2019, 29.07.2019 and 21.06.2019). The complainant failed to resolve the issue, therefore, an amount of Rs. 9,054/- was settled against claimed amount of Rs. 19,419/-. Para 6 of reply gives details of deducted amount of Rs. 19,365/-.
3.4. The OP also denies other allegations in the complaint while justifying the deduction of Rs. 80,290/-, but complainant failed to justify over and above GIPSA norms of rates. The complaint deserves dismissal as there is no mental agony or harassment was caused but the OP and TPA had acted in diligence.
4. (Replication of complainant) – The complainant filed detailed replication and opposed the allegations of the written statement. The OP has wrongly pleaded of full and final settlement by voucher. In Oriental Insurance Co. Ltd. vs Govt. Tool Room and Training in FA no. 383/05, CPJ 2008 (1) 267 NC it was held that discharge voucher signed under compulsion is wrong practice being followed by insurance company in not paying single pie without having discharge voucher, however, mere execution of discharge voucher and acceptance of insurance claim not stop insured from making further claim. Further, in New India Assurance Co. Ltd. vs Shiv Khanna in FA 153/2001 it was held that if full and final settlement is protested within a reasonable period then it can be reopened.
OP has also not considered post hospitalization bill, whereas there is 60 days period post discharge for reimbursement of medical bills; the complainant had deposited all documents with OP on 28.08.2019 under acknowledgment, (Annexure-G is already with the complaint). The para 6 of the replication explains that OP has wrongly deducted the amount, it is without any justification since all the prescriptions and reports were already furnished to the OP. Moreover, the doctors have also given justification regarding requirement of treatment or requirement of procedure, thus GIPSA billing rates are not applicable and treating doctors had already clarified in his certificate that two stents were required to the patient. The OP cannot deduct the amount under the garb of GIPSA billings. The replication further states that amount of Rs. 39,700/- was wrongly deducted by invoking clause no. 3.19. The complaint is correct.
5.1. (Evidence)- Complainant Mamta Gupta led her evidence by filing her detailed affidavit support of documentary record filed with the complaint. She is an exclusive witness.
5.2. OP led evidence by filing affidavit of Karishma R. Negi, Administrative Officer of OP, it is supplemented with letter dated 10.07.2019, schedule of insurance policy and terms and conditions of policy.
6.1 (Final hearing)- The complainant filed written arguments, which are reiteration of pleading and evidence. The complainant further supplements and fortifies her contentions while relying upon the following additional cases:
(i) Punita Gupta w/o Ravinder Kumar Gupta vs M/s National Insurance Co. Ltd.& Ors. “Para 10. But opposite party no. 1 has not placed on record of this Forum any cogent evidence to prove that the complainant was informed at the time of renewal of the policy in question that General Insurance Public Sector Association (GIPSA) rates would be paid for treatment in those hospitals which had arrangement with opposite party no. 1 and that opposite parties had supplied the list of such hospitals to the complainant.
Para 11. From the aforesaid facts it is ample clear that opposite parties were not entitled to disallow amount of Rs. 1,91,153/- on account of excess amount than GIPSA package rate from the claim amount of the complainant. Thus, opposite parties have rendered deficient services to the complainant. Resultantly, the complaint is allowed”.
(ii) R.G. Mundhra vs United India Insurance Co. Ltd., Complaint no. BNG-G-051-1617-0760 in which it has been held that it is the sole responsibility of the TPA/ respondent insurer to ensure the implementation of pre-agreed rates/ packages and the deviation, if any, would be at their risk. Therefore, it was an issue to be settled between the respondent insurer and its network hospital. The insured cannot be penalized for the breach made by the hospital of the agreement with the insurer, as its TPA had not advised the insured about the pre-agreed package rate and had not warned them against any additional payment. Therefore, the respondent insurer was advised to release the balance amount to the complainant.
6.2. The OP also filed detailed written argument, it is replica of written statement while highlighting that the amount was settled in terms of policy conditions and GIPSA billing, the discharge voucher were also for full and final settlement.
6.3. Sh. Ronak Gupta, Advocate for complainant and Sh. Pushpender, Advocate for OP made oral submissions, they have highlighted the case of each party on the basis of material on record.
7.1 (Findings)- The contentions of both the sides are considered keeping in view the material on record. It is apparent that the issue of policy, the period of treatment during the subsistence of insurance policy, furnishing of bills with claim are not disputed, acknowledgments of receipt of record from complainant are not disputed facts. The dispute is with regard to entitlement and extent of reimbursement of the claim. Accordingly, this core issue will be discussed and determined apart from other rival stand of the parties.
7.2. Before analyzing the case of parties it is material to mention that the OP has referred insurance clauses no. 3.29 (reasonable and customary charges) and 4.17 (vitamins and tonics). The clause no. 3.29 is an arrangement in the policy with regard to standard charges for specific provider and consistent with the prevailing charges in the geographical area for identical or similar service, taking into account the nature of illness, injury involved. The OP has not established those norms for deductions or its rates, which were deducted in the present case. Since specific amount has been deducted, which are above 27% and 30%, it would have been on some methods. Those norms or methods have not been proved by OP. Another clause no. 4.17 is under the exclusions that vitamins and tonics are not allowable, unless the same were certified by the attending medical practitioner to be part of treatment.
7.3. There is also dispute raised by the OP of want of receipt of certain record or prescription, whereas, the complainant had proved acknowledgement (Annexure-C/ page no. 27) that record of pre-discharge from hospital was furnished and she has also proved claim form (Annexure-C/ Page no. 35) of furnishing the record, both were acknowledged by the OP. To say, the complainant had furnished the record and the same were received and acknowledged by the OP.
7.4. The OP has made deduction on the basis of GIPSA bill but complainant opposes it. The OP has filed process sheet (Annexure-C and Annexure-D, of its TPA) and the same are internal record of OP, which has been filed in support of written statement. In both the process sheets there is detail of item being considered and one row pertains to GIPSA package, however, corresponding that, it is shown 0 (Zero) of GIPSA package. However, preceding this row there is another row of package, the complainant’s case was considered in that package in Annexure-C. Moreover, there is no clause shown in the insurance policy of GIPSA billings clause but other clauses number were specifically mentioned in written statement of OP. To say, as per process sheets, it is not case of GIPSA package.
7.5. In the aforementioned initial conclusions, the other aspects of case of parties are being considered. It would be appreciable to take the item wise, since the pleadings are also referring them - .
(i) There was deduction of Rs. 39,700/- by the OP that as per GIPSA the procedure for coronary angiography and coronary angioplasty was to be done in one seating. As per certificate dated 24.07.2019 (page 29 of the complaint), the complainant was certified that two stents were required by her with other detail. The discharge summary dated 27.8.2019 specifies also procedure followed, the treatment given , clinical summary, advices besides other details. This establishes the medical requirement of complainant was considered by the treating doctors as per need and nature of ailment of complainant.
OP'sTPA has another view/opinion that both coronary angiography and coronary angioplasty could be done in one seating, would not demerit the case of complainant, since treating doctors formed the opinion as detailed in the discharge summary and certificate was also issued separately, because they had to manage patient and ailment.
Simultaneously, the process sheet (Annexure-C of OP) shows GIPSA package is '0' [zero] and claim was assessed in other package by making deduction of Rs. 39,700/-. Moreover, OP failed to establish the rates or amounts under clause no. 3.29. Therefore, deduction of Rs. 39,700/- is not justified by the OP nor proved to be within the policy terms and conditions. The circumstances are establishing that complainant is entitled for this amount of Rs. 39,700/.
(ii) The OP has deducted an amount of Rs. 21,515/- under the heading pharmacy by invoking reasonable and customary clause no. 3.19 (during hospitalization), whereas the rates or scales under clause 3.19 has not been proved by the OP. It is still a mystery in the present file. Therefore, the circumstances are establishing that complainant is entitled for this amount of Rs. 21,515/- (expenses of pharmacy during hospitalization), which were deducted by the OP.
(iii) The OP had deducted Rs. 3,470/- on account of laboratory investigation and one of lab tests was of 17.05.2019 which was prior to one month of pre-hospitalization. The complainant was hospitalized on 25.06.2019 and she was discharged on 27.06.2019. As per clause no. 3.24 of the policy, pre-hospitalization expenses are covered if they are within 30 days prior to the date of hospitalization. It is apparent that a lab test done on 17.05.2019 was one month prior to date of hospitalization on 26.06.2019. The amount of Rs. 3,470/- was properly deducted by the OP. The complainant is not entitled for this amount.
(iv) There is deduction of Rs. 840/- on account of miscellaneous charges and OP has invoked clause 4.17 of insurance policy and it could not have been deducted had there been certificate or prescription for such diet to be part of the treatment. There is no such prescription proved on behalf of the complainant. The OP has deducted Rs. 840/- properly by invoking clause 4.17 of insurance policy. The complainant is not entitled for this amount of Rs.840/-..
(v) The OP has deducted another amount of Rs. 10,365/- under the heading medicine (post discharge) by invoking reasonable and customary clause no. 3.19, whereas the rates or scales under clause 3.19 has not been proved by the OP. It is still a puzzle in the present file. Therefore, the circumstances are establishing that complainant is entitled for this amount of Rs. 10,365/- (post discharge medicine expenses). It is already held that the complainant had furnished the requisite record, which was acknowledged by the OP. The post discharge expenses of medicine are covered as per clause 3.24 of insurance policy and period prescribed is that it shall be of period within 60 days from the date of discharge.
(vi) The denial of reimbursement of valid claim amounts of deficiency of services.
(vii) The OP has also mentioned another clause 3.1 in written statement, however, it is in respect of accident, this is not fact in issue of this complaint.
7.6. Thus, the facts on record proves case of complainant that an amount of Rs. 71,580/- was not properly deducted by the OP in terms of insurance policy as well as for want of proof of appropriate record. The complainant is held entitled for reimbursement of Rs. 71,580/- on these accounts/ heads.
7.7.1. The complainant has sought interest @ 24% pa, however, considering facts & features of case as well as complainant was deprived of her claim, interest @ 8% pa would be justified for both ends (by considering the clause no. 5.5.5 of insurance policy, which mentions 2% the bank rate of interest), interest will be from the date of complaint till realization of amount against the OP.
7.7.2. The complainant has also sought damages of Rs.1,00,000/- towards harassment, tension and agony; considering totality of circumstances of case of both sides, damages are quantified as Rs 15,000/- apart from cost of litigation of Rs.10,000/-in her favour and against the OP.
7.7.3. Accordingly, the complaint is allowed in favour of complainant and against the OP to reimburse balance medical amount of Rs.71,580/- along-with simple interest @ 8%pa from the date of complaint till realization of amount; apart from, to pay damages of Rs.15,000/- & costs of Rs.10,000/- to complainant.
OP is also directed to pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 10% per annum on assured sum of Rs.71,580/-.
8: Announced on this 3rd July, 2023 [आषाढ़ 16, साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
