Order dictated by:

Sh.Anoop Sharma,Presiding Member

1.       Sh.Anil Arora has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that he has been obtaining the medi claim policy from the Opposite Party for the last more than 18 years and previously  the complainant insured himself  and his wife vide policy No. 401209/48/15/8500000 355 dated 23.6.2015 by paying premium of Rs.23259/- under which complainant was insured for Rs. 3 lacs and his wife Parveen Arora  was insured for Rs. 2 lacs for the period from 26.6.2015 to 25.6.2015. The complainant has regularly insured himself and his wife from the opposite party No.1 and since last more than 4 years the complainant has not received any claim  and accordingly the bonus on sum insured was given to complainant i.e. Rs. 60000/- for four years and accordingly total sum insured in the year 2015 is Rs. 3,60,000/-. Unfortunately the complainant became ill on 8.9.2015 and has received cardiac problem. Accordingly , complainant admitted with opposite party No.3 for getting treatment and at that time opposite party No.3   assured the complainant and his relatives that they are under the penal of opposite party No.1 and will provide cashless treatment to the complainant. The complainant as well as his family members were told by opposite party No.3 that complainant has to undergo from PTCA and also told about PTCA package and also assured that the treatment will be cashless. As such complainant and his family members became ready to get treatment from opposite party No.3. The complainant was given treatment by opposite party No.3  but at the time of discharge from the hospital, the complainant and his family members were directed to deposit Rs. 2,71,579/- with opposite party No.3. The complainant then approached opposite party No.1, who directed the complainant to deposit the amount with opposite party No.3 and assured the complainant that the amount paid by the complainant shall be reimbursed to the complainant. As such the complainant made the payment to opposite party No.3  of entire medical expenditure i.e. Rs. 2,71,579/- to the opposite party No.3.   Thereafter complainant approached opposite party No.1 and told that his claim has not been reimbursed  and further sent e-mail in this regard. Opposite party No.1 had given reply to said email that opposite party No.3 is still in their penal and claim shall be settled as per (preview package network) and further directed the complainant to make a representation before TPA i.e. opposite party No.2. The complainant made representation to opposite party No.2. The complainant was surprised to know that opposite party No.1 has issued RIGS in the account of the complainant  which was to the tune of Rs. 1,71,579/- i.e. 1 lac short from the amount incurred by  the complainant on his treatment.  The complainant again made representation in this regard before opposite party No.1, but to no avail. Vide instant complaint, complainant has sought for the following reliefs:-

(a)     Opposite party No.1 be directed to make the payment of the remaining claim amount of Rs. 1,02,000/- alongwith interest @ 18% p.a. ;

(b)     Opposite party No.1 may also be directed to pay Rs. 50000/- for harassment and opposite party No.2  be directed to pay Rs. 50000/- for not providing proper claim to the claimant whereas opposite party No.3 be directed to pay compensation of Rs. 1,00,000/- for not apprising the complainant about true fact at the time of admission ;

(c )     Opposite parties be directed to pay compensation of Rs. 2,00,000/- for harassing and humiliating the complainant ;

(d)     Opposite parties be also directed to pay litigation expenses to the tune of Rs. 15000/-.

Hence, this complaint.

2.       Upon notice, opposite party No.1 appeared and filed written version in which it was submitted that contract of insurance is always subject to its terms and conditions of the policy. Admission of the complainant in the hospital concerned is a matter of record. It is worthy to mention over here that infact there is no procedure for any oral sanction of cashless treatment to any policy holder. It is a process which has to be followed by the patient concerned and the hospital concerned  and thereafter the said facility has approved in a particulars case subject to terms and conditions of the policy. It is pertinent to mention over here that the opposite party No.3 i.e. Care well hospital had been under the purview of PPN Hospitals (preferred provider Network hospital) as the hospital has authorization for the same from GIPSA i.e. an Autonomous body of General Insurance Companies, who give authorization to hospitals to come under the purview of PPN and no PPN hospital can over charge from the policy holder for the medical treatment taken by him from the rates already settled between the hospital  and GIPSA under any circumstances and if it is proved on record then the hospital concerned is solely responsible for the same . The replying opposite party has already settled down the claim of the complainant as per terms and conditions of the policy. While denying and controverting other allegations, dismissal of complaint was prayed.

3.       Opposite party No.3 in their written version has submitted that family members of the complainant approached the replying opposite party on 8.9.2015 for the treatment of complainant and accordingly, complainant was admitted in the hospital of replying opposite party . It was denied that Sandeep Kapoor assured and told the complainant and his relatives that they are under the penal of opposite party No.1 and will provide cashless treatment to the complainant. It was submitted that the best medical treatment  of complainant which was required as per the diagnosis and medical guidelines were provided to the complainant. It was denied that any fraudulent assurance was given by the replying opposite party No.3. After giving the best medical treatment, complainant was discharged in satisfactory  condition. As far as deposit of amount is concerned, when the representatives of the complainant were asked to deposit the amount as per the bill, they raised unhealthy scene in the hospital of replying opposite party. It was admitted that replying opposite party showed its inability for the cashless treatment  and the same was immediately told to the representatives of the complainant on 9.9.2015. It was denied that any assurance for cashless treatment was given to the complainant . While denying and controverting other allegations, dismissal of complainant was prayed.

4.       Opposite party No.2 did not opt to put in appearance despite service, as such it was ordered to be proceeded against ex-parte.

5.       In his bid to prove the case complainant tendered into evidence his duly sworn affidavit Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-35 , affidavit of Sh.Nitil Arora S/o Anil Arora Ex.CW2/A and closed his evidence.

6.       To rebut the aforesaid evidence Sh.Subodh Salwan,Adv.counsel for opposite party No.1 tendered into evidence affidavit of Sh.Dhiraj Seth,Divisional Manager Ex.OP1/A  alongwith documents Ex.OP1/1 to Ex.OP1/9 .

7.       On the other hand Sh.Rajesh Bhandari,Adv.counsel for opposite party No.3 tendered into evidence affidavit of Sh.Sandeep Kapoor, Managing Director Ex.OP3/A and closed the evidence on behalf of opposite party No.3.

8.       We have heard the ld.counsel for the parties and have carefully gone through the record on the file.

9.       Ld.counsel for the complainant has  reiterated the facts narrated in the complaint and submitted that  the complainant has regularly insured himself and his wife from the opposite party No.1 and since last more than 4 years the complainant has not received any claim  and accordingly the bonus on sum insured was given to complainant i.e. Rs. 60000/- for four years and accordingly total sum insured in the year 2015 is Rs. 3,60,000/-. Unfortunately the complainant became ill on 8.9.2015 and has received cardiac problem. Accordingly , complainant admitted with opposite party No.3 for getting treatment , who assured the complainant and his relatives that they are under the penal of opposite party No.1 and will provide cashless treatment to the complainant. The complainant as well as his family members were told by opposite party No.3 that complainant has to undergo from PTCA and also told about PTCA package and also assured that the treatment will be cashless. As such complainant and his family members became ready to get treatment from opposite party No.3. The complainant was given treatment by opposite party No.3  but at the time of discharge from the hospital, the complainant and his family members were directed to deposit Rs. 2,71,579/- with opposite party No.3. The complainant then approached opposite party No.1, who directed the complainant to deposit the amount with opposite party No.3 and assured the complainant that the amount paid by the complainant shall be reimbursed to the complainant. As such the complainant made the payment to opposite party No.3  of entire medical expenditure i.e. Rs. 2,71,579/- to the opposite party No.3.   Thereafter complainant approached opposite party No.1 and told that his claim has not been reimbursed  and further sent e-mail in this regard. Opposite party No.1 had given reply to said email that opposite party No.3 is still in their penal and claim shall be settled as per (preview package network) and further directed the complainant to make a representation before TPA i.e. opposite party No.2. The complainant made representation to opposite party No.2. The complainant was surprised to know that opposite party No.1 has issued RIGS in the account of the complainant  which was to the tune of Rs. 1,71,579/- i.e. 1 lac short from the amount incurred by  the complainant on his treatment.  The complainant again made representation in this regard before opposite party No.1, but to no avail. Ld.counsel for the complainant submitted that all this amounts to deficiency in service on the part of the opposite parties.

10.     On the other hand opposite party No.1 has repelled the aforesaid contentions of the complainant on the ground that  opposite party No.3 i.e. Care well hospital had been under the purview of PPN Hospitals (preferred provider Network hospital) as the hospital has authorization for the same from GIPSA i.e. an Autonomous body of General Insurance Companies, who give authorization to hospitals to come under the purview of PPN and no PPN hospital can over charge from the policy holder for the medical treatment taken by him from the rates already settled between the hospital  and GIPSA under any circumstances and if it is proved on record then the hospital concerned is solely responsible for the same . It was submitted that opposite  party  No.1 has already settled down the claim of the complainant as per terms and conditions of the policy. Ld.counsel for opposite party No.1 has prayed for dismissal of the complaint.

11.     On the other hand ld.counsel for opposite party No.3 has vehemently contended that family members of the complainant approached the replying opposite party on 8.9.2015 for the treatment of complainant and accordingly, complainant was admitted in the hospital of replying opposite party . It was denied that Sandeep Kapoor assured and told the complainant and his relatives that they are under the penal of opposite party No.1 and will provide cashless treatment to the complainant. It was submitted that the best medical treatment  of complainant which was required as per the diagnosis and medical guidelines were provided to the complainant. After giving the best medical treatment, complainant was discharged in satisfactory  condition and  the family members of the complainant were asked to deposit the amount as per the bill but they raised unhealthy scene in the hospital of replying opposite party. It was admitted that replying opposite party showed its inability for the cashless treatment  and the same was immediately told to the representatives of the complainant on 9.9.2015. Ld.counsel for opposite party No.3 has prayed for dismissal of complaint.

12.     But, however, from the appreciation of the facts and circumstances of the case, it becomes evident that the complainant and his wife were insured vide policy No. 401209/48/15/8500000 355 dated 23.6.2015 by paying premium of Rs.23259/- under which complainant was insured for Rs. 3 lacs and his wife Parveen Arora  was insured for Rs. 2 lacs for the period from 26.6.2015 to 25.6.2015. It was the case of the complainant that he  became ill on 8.9.2015 as he has received cardiac problem and as such he was  admitted with opposite party No.3 for getting treatment , who assured the complainant and his relatives that they are under the penal of opposite party No.1 and will provide cashless treatment to the complainant. This fact that the hospital is enlisted on the panel of the opposite party is proved as the complainant has placed on record User Guide Book in which name of the opposite party No.3 hospital has been mentioned . But even then the cashless treatment of the complainant has been denied by opposite party No.3. As such the complainant has to pay the treatment expenditure to the tune of Rs. 2,71,579/- from his own pocket.  However, when the complainant lodged claim with opposite party No.1 , opposite party No.1 has issued RIGS in the account of the complainant  which was to the tune of Rs. 1,71,579/- i.e. 1 lac short from the amount incurred by  the complainant on his treatment.  In this regard complainant made representation to opposite party No.1, but no fruitful result has come forward. On the other hand , it was the case of opposite party No.1 that  opposite party No.3 i.e. Care well hospital had been under the purview of PPN Hospitals (preferred provider Network hospital) as the hospital has authorization for the same from GIPSA i.e. an Autonomous body of General Insurance Companies, who give authorization to hospitals to come under the purview of PPN and no PPN hospital can over charge from the policy holder for the medical treatment taken by him from the rates already settled between the hospital  and GIPSA under any circumstances and if it is proved on record then the hospital concerned is solely responsible for the same. So it stands proved on record that opposite party No.3 is on the panel of opposite party No.1 for cashless treatment to the policy holder and by not giving cashless treatment to the complainant being insured under policy No. 401209/48/15/8500000 355 dated 23.6.2015, opposite party No.3 itself caused harassment to the complainant and his family members and compelled the complainant to make payment of the treatment charges from his own pocket.  Secondly opposite party No.3 hospital had been under the purview of PPN Hospitals (preferred provider Network hospital) and no PPN hospital can over charge from the policy holder for the medical treatment taken by him from the rates already settled between the hospital  and GIPSA under any circumstances and if it is proved on record then the hospital concerned is solely responsible for the same. Opposite party No.1 has placed on record  calculation sheet Ex.OP1/8 vide which  the patient was billed for Rs. 2,44,090/- for the treatment given, however, the same procedure cost was Rs. 1,44,000/- as per PPN Package rates. However, the complainant was reimbursed the amount to the tune of Rs. 1,71579/- while the opposite party No.3 has charged Rs.2,71,579/- i.e. over charged Rs. 1 lac from the complainant. It is pertinent to mention over here that if the opposite party No.3 is enlisted on the panel of Insurance company, it has to follow the instruction given by opposite party No.1 i.e. it has to charge as per PPN rates . So by charging the amount more than the PPN rates, opposite party No.3 has violated the instruction given by opposite party No.1 and is responsible for the amount over charged from the complainant i.e. Rs. 1 lac more charged from the complainant. The aforesaid act of the opposite party No.3 first in not giving treatment on cashless basis and secondly not charging the amount as per PPN rates  amounts to deficiency in service, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant .

13.     Consequently , the instant complaint succeeds and opposite party No.3 is directed to reimburse the amount of Rs. 1 lacs over charged from the complainant as per PPN rates . Opposite party No.3 is also directed to pay compensation to the tune of Rs. 5000/- while litigation expenses are assessed at Rs. 3000/-. Compliance of this order be made within a period of 30 days from the date of receipt of copy of order ; failing which, the complainant shall be entitled to get the order executed through the indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Forum

Dated: 12.6.2017.