Complainant Parveen Kumar has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to pay full claim of Rs.3,70,000/- alongwith interest @ 18% per annum from date of discharge i.e. 31.03.2016 till its realization. Opposite parties be further directed to pay the medicine expenses of Rs.74,213/- incurred by him from the date of discharge. Opposite parties be next directed to pay Rs.20,000/- as litigation expenses alongwith Rs.20,000/- for damages on account of physical and mental harassment and any other relief which this Hon’ble Forum deem fit, in the interest of justice.
2. The case of the complainant in brief is that he got an insurance policy for his family titled as “Parivar Mediclaim” having its policy no.401502/48/14/8500000105 commencing from 30.6.2014 to 29.06.2015 from opposite party no.1 after paying the total premium of Rs.16,442/-. Before the expiry of the policy, he got it renewed from the opposite party no.1 on 25.06.2015 after paying the premium of Rs.14,828/-, which was again renewed on 21.6.2016 after paying the premium of Rs.15,895/-. The opposite parties also issued the health card bearing no.M5814963167 to him and his family members and the policy is cashless and as per the policy he has to show the health card in case of any medical problem. He has further pleaded that on 24.03.2016 when he returned to home after closing his shop he became unconscious, so ultimately he was taken to Dr.Ram Murthi Hospital at Gurdaspur for the checkup and he told his family members that he suffered with a stroke in his heart and required to be treated immediately from a hospital having the facility and doctor gave the first aid on the spot and as there is no treatment available in Gurdaspur city for the heart problem, he was admitted to the EMC Super Specialty Hospital at Green Avenue Amritsar on the same night, where he was admitted in the ICU. His son gave his health card and identity proof to the hospital authorities for the cashless benefits of the insurance policy and as per the procedure the hospital authority submitted his claim to the opposite party no.2 and the doctors in hospital started his treatment and angiography test was conducted by the doctor and he told that the two arteries of the heart are blocked out of which one is required to be opened immediately by the inserting stunt, so immediately angioplasty was done by the doctor and blockage was removed from one artery by inserting stunt. The second stunt was inserted on 29.03.016 for removing another blockage. The opposite party no.2 did not respond qua his claim and kept on delaying the genuine claim. The previous insurance policies as demanded by the opposite party no.2 were also provided but the opposite party no.2 denied the cashless facility. And under the compelling circumstances he has to pay the total expenses of the treatment which comes to Rs.3,70,000/- and after the payment he was discharged from the hospital on 31.03.2016. Thereafter, he went to the office of opposite party no.1 and met the manager of the opposite party no.1 who suggested to send his claim for reimbursement to opposite party no.2 and as such he again sent his claim alongwih all relevant documents but the opposite party no.2 never replied regarding his claim. He visited the office of opposite party no.1 many times who replied that his claim has not been decided yet and ultimately he came to know about his claim from the opposite party no.1 that the opposite party no.2 has closed his file because he has not provided the copy of previous policies to the opposite party no.2 but he had already supplied the previous policy during claim reimbursement. This act of the opposite parties tantamount to deficiency in service and unfair trade practice. Hence this complaint.
3. Notice of the complaint was issued to the opposite parties. Opposite party no.1 appeared through its counsel and filed their written reply taking the preliminary objections that the complaint filed by the complainant is not maintainable. The complainant suffered from CHRONIC DISEASE CALLED AWMI, HYPERTENSION WITH DIABITIES MILLITUS. On receiving the information regarding the hospitalization of the complainant, the treating hospital was informed by TPA RAKSHA that since the disease was chronic in nature, cashless facility cannot be accorded. It was specifically told by the TPA that denial of cashless facility was not denial of treatment. As the very name suggests these types of diseases do not develop in a short period. Since these are chronic in nature they develop with continued and frequent illness; the complaint is also not maintainable because the insured/complainant was requested to submit certain certificate from the doctor who had treated him vide letter dated 27.05.2016, 19.09.2016, 26.9.2016 and finally on 17.12.2016, but he neither produced the required certificate nor he respond to the letters. Hence his claim was repudiated as per terms and conditions/contract of insurance and the complaint is vague and silence about the type of disease the complainant suffered and was treated for. Hence the same is liable to be dismissed. On merits, it was submitted that as per record available in office of OP-1, Raksha TPA had demanded following documents from the complainant:-
(a) Treating doctor’s certificate mentioned the history of HTN with DM.
(b) Original Pre-numbered, pre-printed and stamped final bill of Hospital.
(c) Original Pre-numbered, pre-printed duly signed and stamped receipt EMC hospital for EMC super specialty for Rs.3,70,000/-.
(d) Original detailed discharge summary duly signed and stamped by hospital.
(e) Photo Identity proof for proposer.
(f) Proof of residence of proposer. All documents in original. Therefore the allegations made in this complaint is totally false and uncalled for.
All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Notice issued to the opposite party no.2 had not been received back. Case called several times but none had come present on its behalf. It is therefore, proceeded against exparte vide order dated 10.7.2017.
5. Counsel for the complainant tendered into evidence affidavit of complainant Ex.CW1/A, alongwith other documents Ex.C1 to Ex.C26 and closed the evidence.
6. Counsel for the opposite party no.1 tendered into evidence affidavit of Parveen Chaddha, Branch Manager Ex.OP1, alongwith other documents Ex.OP2 to Ex.OP5 and closed the evidence.
7. We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for of some of the evidentiary documents that have been somehow ignored to be produced by the contesting litigants along with the scope of adverse inference that may be discretionarily/ judicially drawn on account of the intentional non-participation/ex-parte proceedings by one of the titled opposite parties despite the proven service of the summons; of course, in the very back-drop of arguments as put forth by the learned counsel(s) for the attending litigants.
8. We observe that the prime dispute (affidavit Ex.CW1/A) prompting the herein deposed complaint pertained to the alleged non-settlement closure/ repudiation (Ex.OP5) of the complainant’s medical-treatment insurance claim (Ex.C7) seeking reimbursement of hospital-expenses (Ex.C5) Rs. 3,70,000/- by the OP insurers allegedly on account of non-supply of History Certificate , Pre-printed Final Bills, Discharge Summary and the Pre-numbered Receipts for Rs.3,70,000/- from the treating Doctor/Hospital and the ID cum Residence Proof of the Proposer etc. It shall be pertinent here to mention that the OP2 TPA (Third Party Administrators) had earlier refused (Ex.C6) cashless credit facility to the patient on account of 2nd Year Chronicity of the policy for the contacted ailment whereas the complainant has successfully produced (Ex.C1 to Ex.C3) the present policy’s continuity since the year 2014 with no OP produced documentary evidence of its agreed-upon exclusion and/or dispatch to/receipt by the complainant of the policy’s terms/conditions pertaining to the related policy.
9. The OP insurers have simply produced its rebuttal affidavit (Ex.OP1) along with the copies (Ex.OP2 to Ex.OP4) of the query letters repeatedly requisitioning the same documents that were surely available with the treating hospital also on the list of its own network hospitals and readily procurable to both the opposite parties. The OP2 TPA had also once refused the pre-operative sanction to the treating hospital that otherwise has been eligibly available to network hospitals vide the terms of the applicable insurance scheme/policy. Further, we find that the medical-treatment rates as settled with the health insurers by network hospitals are quite moderate (and low) measured against its treatment-rates as charged to other individual patients. And, it is for this very reason/ logic that pre-sanction is anticipated by the network hospitals from the insurers so that they may claim reimbursement directly but @ network settled rates only. Also, the insured patients who prefer medical-treatment at the non-network hospitals are reimbursed @ network settled rates and the difference is borne by the insured patient.
10. Finally, we find here in the present case the complainant had received the medical-treatment at the insurers’ network hospital who had also applied for pre-treatment sanction (with the insurers) that was however refused for un-fairly explained reasons. And, the treating hospital thus charged Rs. 3,70,000/- @ higher individual-patient rates whereas the insurers reimburse complainant-claim @ network moderate rates could be for a less amount and presently any such difference in rates shall have to be necessarily borne by the OP insurers, themselves.
11. We get firm support to the above proposition/finding in the light of the judgment of the honorable State Consumer Commission, Punjab; in FA # 1100 of 2010 titled Fortis Hospital, Mohali vs. Medsave Healthcare (TPA) Ltd. & Ors; wherein, paragraph ‘22’ reads as: “After producing the ID Card, respondent no. 6 was to get cashless treatment but that was not provided for the reasons known to the appellant hospital or the insurance company (appellant in other appeal). The appellant Hospital has given the treatment and obtained the expenses for the treatment and the insurance company was liable to reimburse the same, but the District Forum held the appellant hospital liable to pay the expenses, compensation and costs jointly and severally and the said order is required to be modified”. However, in the light of the recent ruling by the honorable State Consumer Commission, Punjab in FA # 1105 of 2014 titled: Sukhdev Singh Nagpal vs. New Karian Pehalwal Co-op Ag Service Society & Ors., the insurers are liable to reimburse but only up to the standard-expenses fixed with the network hospitals for that particular medical treatment.
12. Further, we find that the impugned insurance claim has been duly filed by the complainant with the OP insurers (competent authority) who have somehow repudiated the same for arbitrarily inadvertent logic after having first refused pre-treatment sanction to treating hospital and have neither produced on record their expert opinion of the OP2 TPA (Third Party Administrator) who have somehow stayed away from the complaint proceedings nor the impugned claim-settlement has been supported by some other cogent evidence etc. We also find that the terms and conditions of the related policy are also not exhibited here and it does not stand proved on record that these ‘claim settlement terms’ stood communicated to the insured complainant and in the absence of the same these cannot be enforced upon him at the stage of settlement of reimbursement of claim(s).
13. In the light of the all above, we partly allow the present complaint and thus ORDER the titled opposite party (1 & 2) insurers to pay/refund the full hospital expenses/medical charges of Rs.3,70,000/- (incurred and settled) to the complainant besides to pay him a sum of Rs.10,000/- as cost and compensation (for having suffered undue harassment) within 30 days of the receipt of the copy of these orders otherwise the awarded amount shall attract interest @ 9% PA form date of orders till actual payment.
14. Copy of the order be communicated to the parties free of cost. After compliance, file be consigned to records.
(Naveen Puri)
President
ANNOUNCED: (Jagdeep Kaur)
June, 04 2018. Member
*MK*
