PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief consumer dispute is as under –
The Complainant is a housewife, Opposite Party No.2 is a TPA of Opposite Party No.1 Insurance Company. The Complainant had been taking out a Mediclaim Policy known as Hospitalization and Domiciliary Hospitalization Benefit Policy for last 5 years from Opposite Party No.1. The aforesaid policy was renewed from time to time on the same terms and conditions. Policy under scrutiny is for the period from 13/05/06 to 12/05/07. The Complainant has produced xerox copy of the policy alongwith complaint at Exh.‘A’ colly. In the policy for the period 13/05/06 to 12/05/07 sum assured given to the Complainant is Rs.5,00,000/-. Cumulative bonus of Rs.25,000/- is also recorded against the name of the Complainant. In the Exclusion Clause column any of the disease is not excluded. For aforesaid policy the Complainant and her husband together have paid total premium of Rs.17,344/- to the Opposite Party No.1.
2) On 25/09/06, the Complainant had undergone a surgery of lumbo-sacral spine, at the Bombay Hospital. The Complainant telephonically informed Opposite Party No.1 about the pending surgery giving the full and complete details for availing the cashless services. On 07/11/06, the Complainant sent a letter to Opposite Party No.1 giving copy of the insurance policy and the original bills amounting to Rs.2,00,756.51 paise for the pre and post hospitalization expenses. The bills after availing cashless facility amounted to Rs.1,50,000/- out of the total sanctioned limit of Rs.2,50,000/-. The Complainant has produced copy of the claim form alongwith complaint at Exh.‘B’.
3) On 28/09/06, Opposite Party No.2 sent a letter to Bombay Hospital confirming pre-authorization of Rs.2,50,000/-. However, thereafter Opposite Party No.2 settled the claim of the Complainant for sum of Rs.32,257/- alongwith the cheque for the said amount.
4) The Complainant had several telephonic conversations with Opposite Party No.1 & 2 but to no avail. Therefore, the Complainant addressed a letter dtd.10/01/07 to the Opposite Party. Copy of the said letter is annexed to the complaint at Exh.‘E’. On 10/01/07, the Complainant wrote another letter to Dy. General Manager, National Insurance Co. Ltd., Kolkata, stating that the Complainant did not accept the settlement of the claim and returned the reimbursement cheque of Rs.32,257/-.
5) It is submitted that Opposite Party No.1 & 2 have disallowed following charges
i) Provisional services paid in main bill amounting to Rs.1,50,000/-.
ii) Pre hospitalization expenses for the sum of Rs.14,982/-.
iii) Chemist bill on which the name was not written for the sum of Rs.673.76 paise.
6) It is submitted by the Complainant at the time of surgery performed on 03/06/04 was the same as the surgery performed on 26/09/06. The total amount at that time which was claimed was Rs.4,98,015/- and what had been reimbursed was Rs.4,93,464.91 paise.
7) The cashless hospitalization had not been asked for as Opposite Party No.2 was not registered with the Bombay Hospital. The second claim has been disallowed on the ground that the Surgeon’s charges of Rs.1,50,000/- had been disallowed on the ground that the same had already paid in the main bill. According to the Complainant, in the month of June, 2004, the same surgeon had charged fees of Rs.3,00,000/-, in addition to the fee charged by Bombay Hospital under the head of Surgeon’s fee amounting to Rs.45,000/- which was sanctioned by Opposite Party No.2. The Complainant also placed on record the pre-hospitalization expenses consisting of tests and x-rays was an inherent part of the process by which it would be established whether the second surgery was necessary or not. Similarly, the expenses of pelvic traction- kit, bed-pan and private nursing charges etc. amounting to Rs.2,845/- were also disallowed.
8) It is submitted that Opposite Party No.2 sent a letter in reply dtd.12/01/07 interalia stating that there was no mention made of the fact that the cashless claim had been allowed. With a view to explain the same, the Complainant wrote another letter dtd.17/01/07 to Opposite Party No.2 giving the factual position of the two claims.
9) Since there was no reply either from Opposite Party No.2 or Opposite Party No.1, the Complainant sent another letter to the Dy. General Manager, National Insurance Co. Ltd., Kolkata, asking him to use his good offices and intervene in the matter. Opposite Party No.2 replied to the letter dtd.07/01/07 by repeating and reiterating the same stand and once again enclosed the cheque of Rs.32,257/- inspite of sum of Rs.2,00,757/-.
10) The Complainant then took up the matter with Mr. Naveen Jindal, Member of Parliament through Mr. Vivek Mittal, but the same has not been taken seriously. By letter dtd.21/03/07, the Complainant explained by Opposite Party No.1 that doctor’s fee of Dr. K.E. Turel does not form part of pre & post hospitalization expenses and therefore, the same is not admissible. On 01/06/07 Opposite Party No.1 finally repudiated claim of the Complainant and therefore, complaint has filed this complaint. The Complainant has requested to direct Opposite Party to pay sum of Rs.2,00,756.51 paise together with interest @ 18 % p.a. from 07/11/06 till realization of entire amount to the Complainant. The Complainant has claimed sum of Rs.1,00,000/- towards legal expenses and for cost of this complaint.
11) Alongwith complaint, the Complainant has filed affidavit in support of complaint and produced documents as per list of document.
12) Opposite Party No.1 has filed written statement and thereby resisted claim of the Complainant contending interalia that allegations made in the complaint are false and the complaint deserves to be dismissed with cost. According to the Opposite Party No.1, there is no deficiency in service on the part of Opposite Party. Initially the hospital requested for cashless authorization for Rs.4.5 Lacs and the servicing TPA sanctioned Rs.2.5 Lacs as cashless on 28/09/2006. Subsequently, the hospital submitted final bill of Rs.1,59,901/- which included Doctor’s fee of Rs.16,667/- and Surgeon’s fee of Rs.5,000/- for Microdisectomy done. The TPA paid Rs.1,56,881/- directly to the hospital against their bill of Rs.1,56,901/-. The Surgeon’s fee for conducting operation had been paid by the TPA to the hospital directly. As such, the claim is already settled. The Complainant has not stated aforesaid fact in the complaint. The Complainant has not come with clean hands and deliberately trying to mislead this Forum.
13) Thereafter, pre and post hospitalization claim, the Complainant claimed Rs.2,00,757/- in which Dr. Keki Turel charge Rs.1,50,000/- as operation charges separately. Since the surgeon’s fees of Rs.50,000/- had already been paid to the hospital against their cashless bill. Therefore, further payment of any amount to the same surgeon under the head of ‘Surgeon’s Fee’ did not arise. As such, the actual bill of hospitalization against their cashless bill of hospital was settled and directly paid to the hospital. Therefore, alleged bill of Rs.1,50,000/- for the same operation charged by the surgeon cannot be called as official bill, since the same was already included in the hospital bill. If the bill had been an official bill then the same would have been routed through/included in the hospital bill itself under the head of “Surgeon’s Fee”. The Surgeon cannot charge twice for the same operation.
14) According to the Opposite Party, additional sum of Rs.32,357/- towards pre and post hospitalization was sanctioned and sent to the Complainant which was returned by the Complainant. The Opposite Party has already settled the claim of the Complainant. There is no deficiency in service on the part of Opposite Party and therefore, complaint is liable to be dismissed.
15) The Opposite Party No.1 has denied the allegations made in the complaint and submitted that the Complainant’s claim is settled as full and final as per terms and conditions of the policy. Therefore, Opposite Party is not liable to pay the amount claimed by the Complainant. Hence, complaint may be dismissed with cost.
16) It appears form the Roznama dtd.06/05/08 that Opposite Party No.2 was duly served with the notice of the complaint. However, inspite of service with notice, Opposite Party No.2 has not appeared before this Forum. The Complainant has filed rejoinder and thereby denied allegations made in the written statement of Opposite Party No.1. The Complainant has filed written argument. Opposite Party No.1 has also filed written argument. Opposite Party No.1 has passed pursis contending that their written argument may be treated as oral submission. Heard oral submission of Ld.Advocate Mrs. Geeta Handa Khanuja for the Complainant and the complaint was closed for order.
17) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Parties ?
Findings : Yes.
Point No.2 : Whether the Complainant is entitled to recover total Rs.2,00,756.51 paise with compensation for mental
agony and cost of this proceeding from Opposite Party as prayed for ?
Findings : As per final order.
Reasons :-
Point No.1 :- The Complainant is a housewife. Opposite Party No.2 is a TPA of Opposite Party No.1 Insurance Company. According to the Complainant, she had obtained Mediclaim Policy known as Hospitalization and Domiciliary Hospitalization Benefit Policy for last 5 years from Opposite Party No.1. The Complainant has produced policy in question which is for period 13/05/06 to 12/05/07 alongwith complaint at Exh.‘A’ colly. In the aforesaid policy for the period 13/05/06 to 12/05/07. It appears that the Complainant and her husband had obtained the said policy in which sum assured given to the Complainant is Rs.5,00,000/-. Cumulative bonus of Rs.25,000/- is recorded against the name of Complainant. None of the disease of Complainant or her husband is excluded from the policy. For aforesaid policy the Complainant and her husband together have paid total premium of Rs.17,344/- to the Opposite Party No.1. The aforesaid policy was renewed from time to time on the same terms and conditions. The aforesaid policy is admitted by the Opposite Party. Opposite Party has also admitted the fact that the cashless facility under the said policy was given to the Complainant. It is not in dispute that the Complainant was admitted in the Bombay Hospital on 25/09/06 where she undergone a surgery of lumbo-sacral spine. The Complainant has produced bills of the Bombay Hospital. It is undisputed fact that by letter dtd.28/09/06 addressed to the Bombay Hospital by Opposite Party No.2 sanctioned cashless facility of Rs.2,50,000/-. The Opposite Party in their written statement have stated that thereafter hospital submitted final bill of Rs.1,56,901/- which included doctor’s fee of Rs.16,667/- and surgeon’s fee of Rs.50,000/- for Microdisectomy done. Opposite Party No.2 is a TPA of Opposite Party No.1 paid Rs.1,56,881/- directly to the hospital. The aforesaid facts stated in the written statement are not disputed by the Complainant in the rejoinder. In the complaint, the Complainant has not stated about payment of final bill of Rs.1,56,881/- paid by the Opposite Party No.2 directly to the Bombay Hospital. In this complaint the Complainant has produced claim form at Exh. ‘B’ in which the Complainant has stated about cashless facility sanctioned by the Opposite Party of Rs.2.5 Lacs and payment of hospital bill of Rs.1,56,901/- by the Opposite Party. The Complainant has claimed balance bills containing surgeon’s fees, chemist bills, laboratory charges, physiotherapy, etc. Total bill is Rs.2,00,756.51 paise. It appears from the evidence that Opposite Party No.2 is the TPA of Opposite Party No.1 after scrutiny of the aforesaid bill sanctioned only Rs.32,257/- out of total claim. Rs.2,00,756.51 paise claimed by the Complainant. Opposite Party disallowed the Complainant’s claim regarding professional service paid in main bill amounting to Rs.1,50,000/-. Pre hospitalization expenses for sum of Rs.14,982/-, Chemist bill on which the name of patient is not written for sum of Rs.673.76 paise.
Ld.Advocate for the Complainant has submitted that earlier on 03/06/04 same surgery was performed on the Complainant and that time Opposite Party under the same policy reimbursed Rs.4,93,464.91 paise. That time Opposite Party had paid the Surgeon’s fee mentioned in the hospital bill as well as the Surgeon’s fee which were charges of Rs.1,50,000/- on the ground that the Surgeon’s charges in the hospital bill are already paid in the main bill. The Opposite Party has submitted that in the final bill submitted by the hospital included doctor’s fees of Rs.16,667/- and the surgeon’s fees of Rs.50,000/-. According to the Opposite Party bill of Rs.1,50,000/- towards the Surgeon’s charges claimed by the Complainant is not a official bill. If the bill had been official bill then same must have included in the hospital bill itself under the head of ‘Surgeon’s Fee’. The Opposite Party is not liable to pay the Surgeon’s fee twice for the same operation. It is not disputed by the Complainant that hospital bill & the Surgeon’s bill of Rs.50,000/- was paid in the main hospital bill. Insurance Company is not supposed to pay the Surgeon’s fee twice for the same operation. Further when patient name is not mentioned on the medicine bill, the Complainant is not entitled to claim aforesaid amount form the Opposite Party. It appears that after scrutiny of the bill for Rs.2,00,756.51 paise the Opposite Party has sanctioned an amount of Rs.32,257/- and cheque for the said amount was sent to the Complainant. Considering documentary evidence produced on record, decision taken by the Opposite Party sanctioning claim of Rs.32,257/- cannot be treated as unjustified. Therefore we hold that the Complainant has failed to prove deficiency in service on the part of Opposite Party. As discussed above, Opposite Party sanctioned cashless facility of Rs.2.5 Lacs to the Complainant on 28/09/06 and thereafter directly paid final bills of Rs.1,56,881/- to the concerned hospital. Thereafter, the Complainant has preferred this claim for additional Surgeon’s fee, medicine, etc. After scrutiny of the claim the Opposite Party sanctioned Rs.32,257/- and cheque of the said amount was sent to the Complainant, but the Complainant refused to accept the same. Considering aforesaid facts, we think it just to direct Opposite Parties to pay to the Complainant an amount of Rs.32,257/-.
For the reasons discussed above, we partly allow the complaint and passed following order -
O R D E R
i. Complaint No.14/2008 is partly allowed.
ii. Opposite Party No.1 & 2 shall jointly and/or severally pay an amount of Rs.32,257/- (Rs. Thirty Two Thousand Two Hundred Fifty Seven Only) to the Complainant within period of one month from the date of receipt of this order.
iii. In case of delay in payment of Rs.32,257/- to the Complainant within stipulated period, the Opposite Party No.1 & 2 shall jointly and/or severally liable to pay interest on Rs.32,257/- to the Complainant @ 9 % p.a. from the date of this order till realization of entire amount to the Complainant.
iv. No order as to costs.
v. Certified copies of this order be furnished to the parties.
