PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding deficiency in service on the part of Opposite Party as it rejected the mediclaim of the Complainant
2) The facts of this complaint as stated by the Complainants are that the Complainants were having a Mediclaim Policy bearing No.250400/48/098500003645/261200 valid from 10/03/09 to 09/03/2010. The sum insured being Rs.2,25,000/- + Rs.75,000/- aggregating to Rs.3 Lacs for each Complainant.
3) The Complainants further stated that the Complainant No.2 was admitted in Apex Hospital, Borivali (W) on 30/11/2010 for operation of bilateral oteocr of both knee TKR. She was discharged on 08/12/2010. After discharge from the hospital the Complainants lodged the claim of Rs.3,74,180.37 with Opposite Party being hospitalization charges alongwith necessary papers in support of the claim. However, the Complainants received a letter dtd.14/04/2011 from M/s. Heritage Health TPA Pvt. Ltd., stating that the Opposite Party has settled the claim for Rs.1,84,2756/- only on the basis of 50% of claim amount without any explanation and without mentioning any terms of policy. Accordingly, Opposite Party sent cheque of the said amount towards full & final settlement.
4) The Complainants immediately on 18/04/2011 lodged a protest and asked for the balance amount from the Opposite Party. Thereafter the Complainants vide their letter dtd.11/07/2011 called upon the Opposite Party to settle for the balance claim of Rs.1,89,905/-, but in vain. Therefore, the Complainants seek to receive the amount of Rs.1,89,905/- being the remaining mediclaim insurance amount from the Opposite Party, Rs.50,000/- compensation for mental agony, etc alongwith interest being aggregate amount of Rs.2,76,635/-.
5) The Complainants have attached the xerox copies of the following documents in support of their complaint –
a) Insurance Policy.
b) Claim Form.
c) Letter dtd.14/04/2011 (from Opposite Party).
d) Letter dtd.18/04/2011 (from Complainant).
e) Discharge Certificate from Apex Hospital.
f) Letter dtd.11/7/2011 (from Complainant).
g) Notice dtd.05/12/2011.
6) The complaint was admitted and notice was served on the Opposite Party. the Opposite Party filed its written statement wherein it denied the allegations of deficiency in service on the part of Opposite Party& further stated that it has settled the claim as per the terms and conditions of the policy. The Opposite Party has admitted that the Complainants have obtained a mediclaim policy from the Opposite Party and the insured amount was Rs.3 Lacs as mentioned in paragraph no.3 of the complaint. Complainant No.2 was admitted in Apex Hospital. The Complainants filed their claim with Opposite Party and the same was forwarded to the Heritage Health TPA Pvt. Ltd. However, the Complainant has failed to annex the 1st page of discharge card, medical bills, with the complaint.
7) The Opposite Party has submitted that the sum insured aggregating to Rs.3 Lacs. The terms and conditions of the said mediclaim policy read as under –
“In the even of any claims becoming admissible under this scheme, the Company will pay to the insured person the amount of such expenses as would be under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate mentioned in the schedule hereto.”
(b) Surgeon, Anesthetist, Medical Practitioner, Consultants Specialists Maximum limit per illness 25% of the sum insured.
(c) Anesthesia, blood Oxygen, OT charges, Surgical appliances, Medicines, Drugs, Diagnostic Material & X-Ray, Dialysis, Chemotherapy implant, Maximum limit per illness 50% of the sum insured.
8) Thus, the schedule of the policy clearly states the limits of the claims. The Opposite Party has further stated in its letter dtd.14/04/2011 that the Opposite Party has mentioned the details of deductions against each bill. The medical bills submitted by the Complainants were in excess. Hence, the amount was mentioned as to how much deducted, the exact calculation of deduction and why it was deducted.
9) The Opposite Party has admitted in para 11 of the written statement that the Complainant had submitted medical bills for an amount of Rs.3,74,180.37 but as per terms & conditions, their agent, health TPA has sanctioned only Rs.1,84,275/-. Item No.2,5,6,7,8,9,10,11, 16 to 22 were deducted under clause C-50%. Item No.3,4,11 to 13 were deducted as per clause B i.e. 25%. Item No.1,15 were not covered under the policy.
10) Thereafter, the Opposite Party also filed its affidavit and filed the copy of the medical officer review.
Medical Officer’s Review
Policy No.250400/48/09/8500003645
Sr.No. | Expenditure Head | Net Amount | Deduction | Payable | Reason for deduction |
1 | Investigation ECG | 300 | -- | 300 | |
2 | Consultant | 400 | | 400 |
3 | Investigation Laboratory | 2,980 | 250 | 2,730 | 50% SI for other charges exhausted |
| | 3,680 | 250 | 3,430 | |
4 | Anesthesis | 6,000 | 6,000 | | 25% of Doctor charges exhausted Limit of Doctor charges exhausted |
5 | Room Service | 2,000 | | 2,000 | |
6 | Room Rent | 18,000 | | 18,000 | |
7 | OT Blood O2 | 2,500 | 1,000 2,500 | Exhaust ---“--- | 50% other charges exhausted ----“---- |
8 | OT Blood O2 Infusion Pump |
9 | OT Blood O2 Monitoring | 1,600 | ----“--- | --- | ----“---- |
10 | Room service Nursing | 350 3,150 | | 350 3,150 | |
11 | OT Blood OT Charges | 14,700 | | 14,700 | 50% other charges exhausted |
12 | Surgeon | 42,000 | | 42,000 | |
13 | Medicine (consumable) | 7,000 | 7,000 | ---- | Exhausted |
14 | Medicine Implant | 1,84,000 | 95,630 | 88,370 | Exhausted |
15 | OT Blood O2 consumable | 5,000 | 5,000 | ---- | Exhausted |
16 | Others Registration | 150 | 150 | ---- | Outside policy coverage |
17 | OT Blood O2 | 1,600 | 1,600 | ---- | 50% Exhausted |
18 | OT Blood O2 | 2,400 | 2,400 | ---- | 50% Exhausted |
19 | Physiotherapist | 1,500 | ---“--- | ---- | 25% Exhausted |
20 | Consultant | 1,750 | | 1,750 | |
21 | OT Blood O2 | 600 | | 600 | |
22 | Laboratory | 350 | | 350 | |
23 | Asst. Surgeon | 7,000 | 5,700 | 1,300 | 25% Professional charges exhausted |
24 | Asst. Surgeon | 14,000 | 14,000 | ---- | 25% Professional charges exhausted |
25 | Consultant | 9,000 | 1,875 | 7,125 | 25% Professional charges exhausted |
26 | Medicine In fluids | 1,350 | | 1,350 | |
27 | Doctor Duty Dr. | 3,150 | 3,150 | ---- | Outside policy coverage |
28 | Blood | 3,500 | 3,500 | ---- | 50% other charges exhausted |
29 | Medicine from shop | 36,050 | 36,050 | ---- | Exhausted 50% |
| | 3,67,950 | 1,88,655 | 1,79,295 | |
30 | OT Blood O2 procedure | 200 | | 200 | |
31 | Other Dressing | 150 | | 150 | |
32 | Consultant | 300 | | 300 | |
33 | ----“---- | 900 | | 900 | |
34 | Other Dressing | 150 | | 150 | 50% other charges exhausted |
35 | OT Blood O2 procedure | 200 | | 200 | 50% other charges exhausted |
36 | Investigation Echo Print | 1,250 | ---“--- | ---- | 50% other charges exhausted |
37 | Laboratory | 50 | 50 | ---- | 50% other charges exhausted |
38 | | 3,200 | 1,650 | 1,500 | |
Grant Total | 3,74,830 | 1,90,555 | 1,84,275 | |
11) In this affidavit also the Opposite Party has reiterated that the claim of the Complainant has been settled as per the terms and conditions of the policy and hence, there is no deficiency in its part and hence, the complaint be dismissed with cost.
12) The Complainants have also filed its affidavit of evidence and written argument wherein they have reiterated the facts and points mentioned in the complaint. The Opposite Party has also filed its written argument wherein it reiterated the facts and points mentioned in its written statement and affidavit of evidence.
13) The Ld.Advocates of both the parties have given the pursis that their written arguments be treated as oral arguments. We perused all the documents submitted by both the parties and our findings are as under –
14) The Complainants were having the valid Mediclaim Policy bearing No.250400/48/09/8500003645 valid from 10/03/2010 to 09/03/2011. The sum insured was aggregate of Rs.3 Lac alongwith bonus of Rs.86,250/-. During the validity of this policy the insured Smt. Kapiladevi Jani was hospitalized from 30/11/2010 to 08/12/2010. She incurred expenses of Rs.3,74,180.37 and submitted her claim of the same amount to the Opposite Party. Opposite Party settled the claim only for Rs.1,84,275/- and not allowed the remaining amount. In this respect the Heritage Health TPA letter dtd.14/04/2011 is relevant. According to this letter only the TPA partly settled the claim and partly disallowed. The Heritage Health TPA has communicated the Complainant in the following words –
“Amounts if any which are inadmissible under rule laid down by the insurance authorities have been deducted while processing your claim. Further, the TPA has attached the cheque of Rs.1,84,275/-. Thereafter, the TPA has given the details of deduction. The deductions are mentioned as per details give in para 10 above where no clause of policy was mentioned.”
15) The TPA has not mentioned as to how the amount of Rs.150/- towards the registration charges was outside the policy coverage. This amount is for the registration of the insured when she was hospitalized. The schedule of the policy has clearly mentioned that all the hospitalization chargers are reimbursable. Therefore, the TPA, the agent of the Opposite Party has adopted the unfair trade practice while deducting the hospitalization charges. Same is the case with all other charges which were deducted by the TPA. For e.g. Bill for Rs.1,600/- for O2 Gses. It is mentioned that “50% limit of other charges exhausted.” The TPA has not explained how 50% limit of other charges is exhausted.
16) In the written statement of the Opposite Party the Opposite Party has mentioned only clause 1 B & C. It has not mentioned clause A.
The Clause A specifically allows Room Boarding, Nursing expenses: 1 % of sum insured per day subject to maximum of Rs.5,000/-. Overall limit is 25% of sum insured. Therefore, the maximum admissible limit under this head is Rs.75,000/-. The Complainants have incurred only Rs.23,500/- during 9 days of her hospitalization.
17) As per clause B, Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist, fees, maximum limit is 25% of sum insured (The sum insured is Rs.3 Lacs). Thus, under this head, a maximum amount of Rs.75,000/- is admissible. The total expenses under this head are Rs.80,000/-. Therefore, the Complainant is entitled for Rs.75,000/- but the TPA has allowed only Rs.49,275/- under the name of 50% limit exhausted. Therefore, from this it is crystal clear that the TPA has not applied proper criteria and mind in settling this claim. They have not calculated the amounts as per the clause A, B & C of the policy. Similar is the case with laboratory expenses, echo print, Blood, OT O2 procedure, Dressing, Medicines, etc.
18) According to the schedule of the policy given by the Opposite Party only, the insured is entitled for all the charges incurred by the insured or any other person on its behalf for the hospitalization of the insured subject to the terms and conditions of the policy and upto the extent of sum insured with accumulated bonus if the sum insured is less than the expenses incurred by the insured. The amount of accumulated bonus i.e. Rs.86,250/- is not typed by the Opposite Party on the schedule of the policy document to attract the customers and to give satisfaction to the insured without any disbursement for the hospitalization. The insured was paying the premium when he/she were healthy and not subject to hospitalization. As they had not hospitalized they earned the bonus for their further arrangement if they are hospitalized and if the expenses exceed to the sum insured. Under such circumstances this amount of accumulated bonus is available to the insured for reimbursement of the expenses exceeding sum insured. In this case the sum insured is Rs.3 Lacs. The expenses were Rs.3,74,180.37. Therefore, under such circumstances, the Complainants were entitled for the bonus accumulated on their policy, the sum being Rs.86,250/-. The Opposite Party has not considered this bonus while settling the claim. Therefore, the Opposite Party is certainly guilty of deficiency in service and for unfair trade practice.
19) As per clause ‘C’ of the policy the maximum limit of expenses that can be reimbursed is 50% of the sum insured i.e. in this case, the sum insured being 3 Lacs, the maximum amount that can be reimbursed is Rs.1,50,000/- and the head of expenses under clause ‘C’ are Anesthesia, Blood, Oxygen, OT Charges, Surgical appliances, Medicines, drugs, Diagnostic material, X-ray, cost of pace-maker artificial limbs, cost implant, under this head, the expenses incurred by the Complainant are as under –
1) Investigation, Laboratory Echo print Rs. 4,930/-
2) Blood, OT O2, Procedure Rs. 36,050/-
3) -----“------- Dressing Rs. 450/-
4) Medicine Rs. 44,000/-
5) Implant Rs.1,84,000/-
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Total Rs.2,69,830/-
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i.e. the total expenses incurred by the Complainant are Rs.2,69,830/- under clause ‘C’. However, only Rs.1,50,000/- (maximum limit which can be reimbursed as per clause ‘C’ of the policy.
20) The accumulated bonus to the credit of the Complainant on the schedule of the policy is Rs.86,250/-. This amount is available to the Complainant for reimbursement of her expenses if the sum insured is exhausted. Therefore, according to the schedule of the policy and clause ‘C’ of the policy the Complainant is entitled for Rs.1,50,000/- + Rs.86,250/- = Rs.2,43,250/-.
21) Therefore, the Complainant is entitled for the following amounts as per the policy terms and conditions –
a) Expenses of Room, Nursing, etc. Rs. 23,500/- (1, A clause).
b) Expenses of Surgeon, etc. Rs. 75,000/- (1, B clause).
c) Expenses of Anesthesia implant, etc. Rs.1,50,000/- (1, C clause).
d) Accumulated Bonus Rs. 86,250/-
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Total Rs.3,34,250/-
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22) However, the Opposite Party has settled the claim for Rs.1,84,275/- disallowing the legitimate claim of Rs.1,49,975/- without applying mind and without quoting any reason. Therefore, the Complainant is entitled for the claim of Rs.1,49,975/-. Thus, the Opposite Party is not only deficient in its service but it has adopted unfair trade practice in settling the medical insurance claim of the Complainants. The Complainants must have gone through the mental agony and harassment due to the above deficiency and hence, they are entitled for compensation of Rs.25,000/-. They are also entitled for the cost of this complaint. In view of the above finding we pass the order as follows -
O R D E R
1. Complaint No.18/2012 is partly allowed.
2. Opposite Party is directed to reimburse a sum of Rs.1,49,975/- (Rs. One Lac Forty Nine Thousand Nine Hundred Seventy Five Only) to the Complainant alongwith interest @ 9% p.a. from 14/04/2011 till realization.
3. Opposite Party is also directed to pay a compensation of Rs.25,000/- (Rs. Twenty Five Thousand Only) to the Complainant towards the mental agony, inconvenience and harassment caused to the Complainant due to deficiency and unfair trade practice adopted by the Opposite Party.
4. Opposite Party is also directed to pay Rs.5,000/- (Rs. Five Thousand Only) to the Complainant towards the cost of this complaint.
5. Opposite Party is directed to comply with the above said order within 30 days of the receipt of this order.
6. Certified copies of this order be furnished to the parties.
