Partha Kumar Basu, Member
This is a complaint case in a dispute in the Insurance sector with a prayer from complainant for a direction on the OP Insurance company to allow health insurance claims alongwith a compensation and cost for the negligent act and deficiency in services by the OPs. The complaint is valued at Rs 1,77,270/- which is filed at the instance of the complainant no. 1 and 2 for a health insurance claim wherein the OP 1 to OP 3 are the Insurance company and their office bearers, OP 4 to OP 6 the Third Party Administrators and their representatives (TPA), the OP 7 and OP 8 are the Hospital authorities, OP 9 the Insurance Desk at Hospital and OP 10 & OP 11 being treating doctors of the hospital being Proforma Opposite parties.
The case of the complainant as averred is that the Petitioner no. 1 is a senior citizen holding a Mediclaim policy no 101900502110002161 at the National Insurance Company Ltd along with his wife who is petitioner no 2 herein and they are the health insurance policy holders that is being renewed perpetually till current period.
It is the case of the complainants that during her stay in the network hospital of the insurer from 22.02.2022 with provisional diagnosis of acute cholecystitis, the complainant no 2 undergone a surgery of gall bladder on 24.02.2022 including removal of stones. While the surgery was ongoing, the attending surgeon intimated the complainant no 1 that the proposed Laparoscpy Adhesiolysis Cholecystectomy (Lap Coli) was required to be converted to Open Adhesiolysis Cholecystectomy which was intimated to the Insurance Agent onwards by the complainant due to the change in plan of treatment and as a part of the cashless claim. However during settlement of the claim, a sum of only Rs. 54,000/- was allowed by the Insurer citing reason for such deduction as ‘Reasonable & Customary charges for Open Cholecystectomy’. Further the TPA in their letter dated 16.02.2023 to the Insured stated inter-alia that as per new PPN rate of the hospital, the highest PPN rate for Open Cholecystectomy would be Rs 62,400/- (as per room eligibility - Private Bed) whereas the Hospital has charged Rs 1,55,099/- for the procedure. Hence the TPA stood by their ground of settlement of claim limited to the original amount. It is also mentioned in the said letter of TPA that for the claims other than PPN packages there would be a 5% discount on OT charges. It is the contention of the complainants that from the conjoint reading of the exhibits and as per narration above, it becomes evident that the Open Cholecystectomy surgery is on package basis as per the PPN rate chart and after applying a maximum discount @ 20% on the total billed amount of Rs.1,55,099/- the approved amount should have been Rs. 1,24,079.20/- instead of Rs.54,000/- being the type of surgery as Open Cholecystectomy, which is a clam under ‘other than PPN packages’. The complainants claimed that the discharge certificate dated 01.03.2022 also supports this contention with the nature & type of treatment given as ‘Laparoscopy Adhesiolysis -Converted Open Adhsiolysis Cholecystectomy’. The complainant claims that the surgeon also pointed out the same in a note (annexure F) that the surgery undergone was not ‘Lap coli’ type but an ‘Open Cholecystectomy’ one.
The OP 1 to OP 3 Insurance company opposed the move of the complainants by filing W/V in which it is contended that the complaint petition has been suffering from infirmities in as much as denying that the Insurer a service provider having any relationship whatsoever that is existing between the complainant and the insurance company. The OP also contested all the allegations denying as incorrect, false and baseless. It is also denied by OP Insurer about having any relationship as a service provider under the Consumer Protection Act 2019 as claimed by the complainants.
The OP 7 & OP 8 being Hospital authorities denied having any role in settlement of the bills between the Insurer and the Insured. Their main contention is that the they have not billed Rs 62,400/- as per PPN package as there was no such rate persisting between the Hospital & the Insurance company for an Open Coli type surgery prevailing at respective point of time of surgery on 24.02.2022. Therefore the patient was charged as the the rate schedule of the Hospital during 2018 till 2022.
The OP 4, OP 5 and OP 6 being the TPA operating under an arrangement with Insurance company and Insurance regulatory authority authorities also denied in the same line as above about having any role in settlement of the bills between the Insurer and the Insured.
The OP9, OP 10 & OP 11 also took the similar stand.
The Ld. Advocates of both sides were present during final hearing who exchanged BNAs and advanced their arguments which were heard in full on 10.09.2024 in presence of contesting parties. The delivery of Judgment is scheduled today on 24.09.2024.
Upon perusal of all records and documents and after hearing submissions of both sides, it appears that there is no quarrel between the contesting parties regarding the factual part of this dispute. However it appears that the moot question is centering around only one issue about the applicable rate of Surgery charges as per extant arrangements between the contesting parties.
To answer the above queries, this commission has gone through the exhibits, complaint petition, W/V, evidences and questionnaire /replies and arguments. All the points are taken up together for the sake of brevity and to avoid repetitions.
On perusal of evidences, questionnaire and replies and BNAs and exhibits, it appears that the complainants availed the services of the Insurance company for a coverage through a valid Health Heath Insurance policy and their network hospital and made payment of annual premiums in this respect from time to time. Hence the complainants are consumers u/s 2(7) (ii) of the Consumer Protection Act 2019. And this point is decided in favour of the complainants.
We have also carefully perused the policy documents and rate charts as exhibited and placed on record. The further perusal of documents reveals that the patient remained admitted at hospital for the period from 22.02.2022 till 01.03.2022 when diagnosed for Cholelithlasis and was given treatment including surgery on 24.02.2022 for ‘Laparoscopy – Adhesiolysis – converted Open Adhesiolysis – Cholecystectomy’. As per contention of OP Insurer supported by TPA vide their letter dated 16.02.2023, the new PPN rate approved for this Hospital for Open Coli was Rs 62,400/- against actual bill of Rs. 1,55,099/- (Annexure D ; page 46). But it also appears that the date of effect of the new PPN rate of the OP hospital is 04.08.2022 as per MOU/agreement executed between Insurance companies and Hospital which depicts that the package cost for OT procedure of LAP Coli (Sl 28) is Rs.62,400/- and for Open Coli (Sl 29) is also Rs.62,400/-. The Insurer claims having settled the bills as per New PPN rate of the hospital for Open Coli for Rs.52,000/- and the Hospital also submitted the document in support of giving intimation to Insurance Company to that effect. But the disputes lies around the point that the PPN rates were not effective on the dates of treatment though the complaints had to make the payment upfront on this account. The OP insurer had only contended to settle an amount of Rs.4,402/- on post-hospitalisation reimbursement claims as 5% discount on new rates. Therefore it gets unfolded that the PPN Discount as per the MOU between hospital and the Insurer can not be governed by the New PPN rates which became effective from 04.08.2022 wherein the date of surgery that took place was as back as on 24.02.2022. As the said procedure of Open Coli was not included in the rate chart / MOU that persisted between the Insurance Company & the Hospital since 01.11.2018 to July 2022, therefore the new PPN rates can not be given effect with prospective rate & given effect for an old case.
The terms and conditions of an insurance policy are sacrosanct and it governs the rights and obligations of the parties to the contract of insurance. The claims and expenses are to be duly settled and reimbursed to the Insured which were covered under the Policy. So there is no scope in reading into and interpreting terms and conditions of the Health Insurance policy, especially when the terms were clear and no ambiguity existed to warrant any different interpretation in favour or against allowing the claim. The Hon'ble Apex Court in Deokar Exports (P) Ltd. v. New India Assurance Co. Ltd. (2008) 14 SCC 598 has categorically observed that no exception or relaxation can be made on the ground of equity in an insurance policy. In the present case, the Operation procedure is found squarely excluded from the coverage of any listed price settled between the Insurance Company and Hospital authorities at respective point of time. Hence the arrangement existed between the Hospital& the Insurance company during hospitalisation period needs to be factored in. In view of the foregoing, the contentions of parties were examined on merits in the light of documents placed on record. After a careful consideration of entire facts and circumstances of the case, we are of the considered view that and are in agreement with the contentions of the Complainants as well as OP 7 & OP 8 Hospital authorities as summarized in the preceding paras and hold that the claim is covered under the policy. In the result, the complaint case succeeds. Fees paid is correct. Hence, it is, ORDERED That the complaint case be and the same is allowed on contest against the OP 1, OP 2 and, OP 3 all being from the Insurance Company or their representatives alongwith a cost of Rs.10,000/- (Rupees Ten Thousand) only and dismissed on contest against OP 4, OP 5, OP 6, OP 7, OP 8 , OP 9 , OP 10 and OP 11. That the OP 1, OP 2 and OP 3 jointly and/or severally are directed to refund the amount of Rs.1,01,099/- (Rs. One Lakh One Thousand and Ninety Nine) only being the excess amount paid to the settle the Hospital bills along with simple interest @ 9 % per a annum w.e.f. date of discharge on 01.03.2022 within 45 days from the date of this order. That the OPs 1, 2 and 3 jointly and/or severally are directed to pay compensation to the tune of Rs.50,000/- (Rupees Fifty Thousand) to the complainant within 45 days from the date of this order. That the complainant is at liberty to put the order into execution if the orders are not complied with within 45 days from the date of this order. Let a copy of this order be supplied to the parties concerned free of cost. That the final order will be available in the following websitewww.confonet.nic.in. Dictated & corrected by me. Partha Kumar Basu Member |
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