Haryana

Panchkula

CC/384/2021

MRS.GOVERDHAN BALA MARYA. - Complainant(s)

Versus

NATIONAL INSURANCE COMPANY LTD. - Opp.Party(s)

IN PERSON

18 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

 

                                                       

Consumer Complaint No	:	384 of 2021
Date of Institution	:	14.09.2021
Date of Decision	:	18.04.2024

 

 

1.     Mrs.Goverdhan Bala Marya, aged 71 years wife of Shri     Gianeshwar Singh Marya.

 

2.     Sh.Gianeshwar Singh Marya, Aged 71 years son of Late Shri      Arjan Singh Marya.

 

        Both  resident of House No.262, Sector-15, Panchkula, Haryana.

 

 

                                                                ….Complainants

 

Versus

1.     National Insurance Company Ltd. Regd. Office-3, Middleton       Street, Post Box No.9229, Kolkata-700071(through its authorized       representative)

2.     National Insurance Company Ltd., Though its Branch Manager, First Floor, SCF-131, Sector-17, Panchkula, Haryana.

3.     National Insurance Company, Safeway Insurance Pvt. Ltd, SCO         No.1, First or Second Floor, Ranjan Plaza, Palam Enclave,    Zirakpur, District Mohali, Punjab.

                                                                                      ….Opposite Parties

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019

 

 

Before:              Sh. Satpal, President.

Dr. Sushma Garg, Member.

Dr. Barhm Parkash Yadav, Member

 

 

For the Parties:   Sh.Anil Kaliraman, Advocate along with the complainant   No.2. 

                        Sh.Sudhir Gupta, Advocate for OPs No.1 to 3.

                         

ORDER

(Satpal, President)

1.             The brief facts, as alleged, in the present complaint are, that a medical claim policy bearing no420200/48/09/850000365, having assured sum of Rs.5,00,000/-, was purchased by the complainants from Ops for one year w.e.f. 11.02.2010 to 10.02.2011 and the said policy was being renewed from the last 10 years without any lapse. It is stated that the complainant got the said policy renewed vide policy no.420205501910000144, valid from 11.02.2020 to 10.02.2021, from the OP No.2, by paying a premium of Rs.39,960/-. It is stated that no claim was lodged by the complainants prior to the renewal of the said policy. The sum assured was Rs.5,00,000/-, wherein premium payable was Rs.39,960/-. It is averred that the complainants were got admitted in Max Super Specialty, Mohali on 24.11.2020 for the treatment of Covid-19. The complainant no.2 was discharged from the hospital on 09.12.2020, wherein he paid an amount of Rs.1,57,329/- for his treatment. The complainant no.1 was discharged from the hospital on 15.12.2020 and she had paid an amount of Rs.3,90,596/- towards the hospital bill. As such, the complainants paid a total amount of Rs.5,47,925/-(Rs.1,57,329+ Rs. 3,90,596) to the hospital. The complainants lodged the claim along with bills seeking the reimbursement of the expenses incurred on their treatment in the hospital. It is averred that the Ops had allowed only an amount of Rs.3,85,435/- against the total claimed amount of Rs.5,47,925/- and wrongly disallowed the payment of Rs.1,62,490/- on totally erroneous grounds. It is averred that a sum of Rs.1111809 under the head of “medicines” as disallowed qua the claim no.NI-6-2041 pertaining to Mrs.Goverdhan Bala Marya(complainant no.1)  was totally invalid and incorrect. Further, the expenses incurred qua the “PPE charges” amounting to Rs.45,000/- pertaining to claim no.NI-6-242 relating to the claim of complainant no.2(Sh. Gianeshwar Singh Marya) were not allowed whereas “PPE charges” amounting to Rs.63,000/- was allowed in the claim no.NI-6-241 relating to Mrs. Goverdhan Bala Marya (complainant no.1). Further, a sum of Rs.2,430/- was disallowed by OPs as excess consultation, which was not justified. It is stated that the consultation given by the Doctors were need based and not at the choice of the complainants. It is averred that the OPs malafidely and arbitrarily had not allowed the payment of full amount as claimed by the complainants and feeling aggrieved, email was sent by them to the TPA on 28.01.2021 and 29.01.2021, seeking the reasons for partial rejection of the claim. Thereafter, the complainant sent the complaint to IRDAI on 20.06.2021, 30.07.2021 and 16.08.2021, who advised the OPs to resolve the issue but grievance of the complainants were not redressed by them(the OPs). Due to the act and conduct of the OPs, the complainant has suffered financial loss and mental agony, physical harassment; hence the present complaint.

2.             Upon notice, the OPs No. 1 to 3 appeared through counsel and filed written statement, wherein the preliminary objections were taken the maintainability of the complaint on the ground that the complainants have not approached the Commission with clean hands as they have concealed  the material facts; that the dispute involved is of intricate and complex nature, which requires elaborate evidence in the shape of examination and cross examination of the witnesses, which is not permissible under the Consumer Protection Act and that the complaint is bad for mis-joinder and non-joinder of the parties as the Max Super Specialty, Mohali, who is a necessary party for the proper and adjudication of the case, was not impleaded; no cause of action has accrued in favour of the complainants and against the OPs. On merits, it is submitted that the OPs have allowed the claim amounting to Rs.3,85,435/- and disallowed the payment of Rs.1,62,490/-, on the basis of terms and conditions of the insurance policy as well as GI Council’s guidelines. It is submitted that whatever, was not found payable was disallowed on the basis of terms and conditions of the insurance policy as well as the guidelines issued by the GI Council. It is submitted that the claim of the complainants were processed in the right earnest and paid thereof as per the expert medical opinion and the guidelines of IRDAI as well as the terms and conditions of Contract of Insurance. It is submitted the under the Contract of Insurance of Mediclaim Policies, particularly in Covid-19 period, the General Insurance Council of Insurers(A Council of Government of India Companies of Insurance) had decided to settle such claims under the guidelines issued  by IRDAI(Insurance  Regulator  of India) and advised the hospitals accordingly, it is submitted that an amount of Rs.1,06,642/- was approved  qua the claim no.NI-6-242, pertaining to Sh.Gianeshwar Singh Marya(complainant no.2) & a sum of Rs.50,687/- was disallowed in view of the fact that he was diagnosed with Covid Pneumonia and his RTPCR test was negative. Similarly, in the claim no. NO-6-2041 pertaining to the treatment of Mrs. Goverdhan Bala Marya(complainant no.1) as against Rs.3,90,596/- claimed, an amount of Rs.2,78,793/- was paid whereas amount of Rs.1,11,803/- was deducted as GI Council Covid Package without prejudice. It is submitted that, whatever, was payable to the complainants qua the expenses incurred during their hospitalization, as per GI Council guidelines, the same was paid and non payable amount, which was as per said guidelines, was disallowed and thus, there was no deficiency in service on the part of the OPs No.1 to 3 and the complaint of the complainant is liable to be dismissed.       

3.             To prove the case, the complainant no.1 has tendered affidavit(Annexure C-A) along with documents Annexure C-1 to C-7 in evidence and closed the evidence by making a separate statement. On the other hand, the learned counsel for the OPs No.1 to 3 has tendered affidavits as Annexure R-A, R-B & R-C along with documents as Annexure R-1 to R-4 and closed the evidence.

                During the course of arguments, the learned counsel for the complainant has placed on record the letter dated 19.12.2020 vide which some additional information was sought from complainant no.2, which is assigned Mark ‘A’.

4.             We have heard the learned counsels for the complainants as well as OPs No.1 to 3 and gone through the record available on file including the written arguments/Synopsis/Additional arguments filed by the complainant and written arguments filed by the OPs No.1 to 3, minutely and carefully.

5.             Admittedly, the complainants were hospitalized in Max Super Specialty, Mohali, on 24.11.2020, qua their treatment during Covid-19 situation. The complainant no.1, Mrs. Goverdhan Bala Marya, remained hospitalized till 24.11.2020, whereas her husband Sh. Gianeshwar Singh Marya(complainant No.2) remained hospitalized till 09.12.2020. The complainant No.1 lodged the claim no.NI-6-241 seeking the reimbursement of the expenses amounting to Rs. 3,90,596/- incurred by her during her hospitalization & her husband (complainant no.2) lodged the claim no.NI-6-2042 seeking the reimbursement of amount of Rs.1,57,329/-. The payment of sum amounting to Rs.2,78,793/- was allowed out of the claimed amount of Rs.3,90,596/- in the claim no.NI-6-2041 of Mrs.Goverdhan Bala Marya(complainant no.1) and thus, payment of sum Rs.1,1,1803/- was disallowed. In the claim no.NI-6-2042 pertaining to Sh. Gianeshwar Singh Marya(complainant no.2), the payment of a sum of Rs. 1,06,642/- was allowed against the claimed amount of Rs.2,78,793/- and thus, the claim was disallowed to the extent of Rs.50,687/-.

6.             As per version of the complainants, the OPs have wrongly disallowed the claim partially on invalid and erroneous grounds, whereas the OPs have claimed that the deductions were rightly made as per the guidelines issued by the GI Council. During arguments, the complainant reiterated the averments as made in the complaint as also in Affidavit(Annexure C-A) and contended that deductions were wrongly made by OPs, out of the claimed amount, on erroneous and invalid grounds and thus, the complaint is liable to be accepted by granting the relief as claimed for in the complaint.

7.             On the other hand, the learned counsel for the OPs has reiterated  the averments as made in the written statement as also in affidavits(Annexure R-A, R-B & R-C) and contended that, whatever was payable to the complainants, has already been paid as per the guidelines issued by GI Council and thus, no illegality and infirmities can be pointed out in the deductions made by the OPs, while settling the claim no.NI-6-2041 and claim no.NI-6-2042 of the complainants and thus, the complaint is liable to be dismissed being frivolous, baseless and meritless. 

8.             After hearing the learned counsel for the parties and perusing the record available on the file, we take up the claim no.NI-6-2041 and the claim no.NI-6-2042 as filed by the complainant no.1 & complainant no.2, for discussion, the necessary details whereof, as per Annexure C-4 & C-5 qua disallowed payment and allowed payment have been reduced into tabular form vide Table “A” & Table “B” as under:-

Table ‘A’(wherein payment was disallowed)

Sr. No.	Detail of heads wherein  payment was disallowed	Claim of Mrs. Goverdhan Bala Marya(claim no. NI-6-2041)	Claim of Mr. Gianeshwar Singh Marya(claim no. NI-6-2042)	Remarks
a)	Medical consumable	Rs.         01	Rs.    01
b)	Medicine	Rs.1,11,802	-	As per GIC
c)	Gloves Mask etc.	-	Rs.   167
d)	PPE Charges	-	Rs.45000
e)	Ambulance	-	Rs.  1035
f)	Consultation	-	Rs.  2430
g)	Laboratory	-	Rs.    550
	Total	Rs.1,11,803	Rs.50,687

 

Table ‘B’(wherein payment was allowed)

Sr. No.	Detail of heads wherein  payment was allowed	Claim of Mrs. Goverdhan Bala Marya(claim no. NI-6-2041)	Claim of Mr. Gianeshwar Singh Marya(claim no. NI-6-2042)
a)	Medical consumable	Rs. 24999	Rs. 15590
b)	Medicine	Rs. 81932	Rs. 35950+ Rs. 2338(fromshop)
c)	Gloves Mask etc.	Rs.      58
d)	PPE Charges	Rs. 63000
e)	Ambulance	-	Rs.1000
f)	Consultation	Rs. 16200	Rs.8640
g)	Laboratory	Rs. 46684	Rs.9724
i)	Procedure	Rs.   3920	Rs.3400
	Room Rent	Rs. 42000	Rs.30000
	Total	Rs.278793	Rs.106642

 

9.             As per above table ‘A’,  pertaining to claim no.NI-6-241 lodged by Mrs.Goverdhan Bala Marya(complainant no.1), the payment of a sum of Rs. 1,11,802/- was disallowed under the head of “medicines” against the billed amount of Rs.1,93,734/- and in the column of remarks, it has been shown that the deductions of Rs.1,11,802/- against the billed amount of Rs.1,93,734/- was made as per guidelines of GI Council. In this regard, it is pertinent to mention here that no such guidelines, on the basis of which, the alleged deduction was made, has been placed on record by the OPs. Moreover, the details of medicines qua which the payment was disallowed by the Ops have not placed on record. Needless to mention here that the medical notes and treatment file of a patient is kept by the hospitals for record and thus, the OPs were at liberty to seek the details of medicines as prescribed in the treatment file of the complainant no.1, which could have made clear as to which medicines were given to the complainant no.1 during her hospitalization. There is not even a whisper of averments made in the entire written statement filed by the OPs that any communications seeking the clarification from the Max Super Specialty, Mohali qua the prescription of “medicines” was ever made by them. Thus, we find no valid and justified ground on the part of Ops, while making deductions of Rs.1,11,802/- out of the billed amount of Rs.1,93,734/-.

10.            Now, we advert to the claim no.NI-6-2042, which was lodged by Sh. Gianeshwar Singh Marya(complainant no.2) and find that  the payment of a sum of Rs.50,687/- was disallowed under the various heads, the details whereof is given in said table “A’ above.                                  Pertinently, a sum of Rs.45,000/- was disallowed under the head of “PPE charges” whereas a sum of Rs.63,000/- was allowed in the case of his wife, namely, Mrs. Governdhan Bala Marya(complainant no.1). In this regard, the OPs have taken the shelter that Sh. Gianeshwar Singh Marya(complainant no.2) was found not Covid infected.

                The said plea is not acceptable because Sh.Gianeshwar Singh Marya(complainant no.2) was diagnosed with Covid-19 Pneumonia vide discharge summary(Annexure C-2). Further, as per the discharge summary(Annexure C-3) pertaining to Mrs. Goverdhan Bala Marya(complainant no.1), who was found Covid-19 infected, shows that she had the history of contact with Covid-19 positive patient i.e. her husband, namely, Sh.Gianeshwar Singh Marya(complainant no.2). Thus, the decision of the OPs making disallowance of payment of the Rs.45,000/- under the head of “PPE charges” was not based on valid and justified ground.

11.            Resultantly, the OPs No.1 to 3 are held deficient, while rendering services to the complainants, for which, they are liable, jointly and severally, to compensate them.

12.            In relief, the complainants have claimed the reimbursement of Rs.1,14,565/- along with interest. Further, the complainants have also claim Rs.3,00,000/- and Rs.55,000/- on account of mental agony, harassment and litigation charges respectively. 

                The complainants have received an amount of Rs. 3,85,435/- against the insured sum of Rs.5,00,000/- and thus, they are entitled  to the reimbursement of sum of Rs.1,14,565/-.

13.            As a sequel to the above discussion, we partly allow the present complaint with the following directions:-

1. The Ops No.1 to 3 are directed to make the payment of sum of Rs.1,14,565/-to the complainants, along with interest @ 9% per annum(simple interest) w.e.f. 17.12.2020 i.e. the date of lodging of the claim till its realization.
2. The Ops No.1 to 3 are also directed to pay an amount of Rs.15,000/- to complainants on account of mental agony and  harassment.  
3. The OPs No.1 to 3 are further directed to pay an amount of Rs.7,500/- to complainants as litigations charges.

14.            The OPs No.1 to 3 shall comply with the order within a period of 45 days from the date of communication of copy of this order failing which the complainants shall be at liberty to approach this Commission for initiation of proceedings under Section 71/72 of CP Act, against the OPs No.1 to 3. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance.  

Announced on:18.04.2024

 

Dr.Barhm Parkash Yadav      Dr.Sushma Garg             Satpal               

                Member                       Member                   President

 

Note: Each and every page of this order has been duly signed by me.

 

                                         Satpal                               

                                        President