Complainant Smt.Pinki Saini 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 make payment of reimbursement amount of treatment alongwith interest for which she is legally entitled being insured under the Health Insurance Policy. Opposite parties be further directed to pay Rs.10,000/- as litigation expenses and Rs.15,000/- on account of mental harassment and torture, in the interest of justice.

2.       The case of the complainant in brief is that she got a Medical Insurance Policy bearing No.401501/48/17/8500000008 which was valid from 04.04.2017 to 03.04.2018.  She has further pleaded that unfortunately she fell ill and was got admitted in Navchetan Multi Specialty Hospital, Pathankot  on 27.09.2017 for treatment of Acute Viral Syndrome with Critical Thrombocytopenia and she was discharged on 29.9.2017. At the time of discharging she paid total bills amounting to Rs.19,669/- to the Hospital, but the opposite party only paid Rs.6149/- which was deposited in her Bank but uptil today the opposite party has failed to make the payment of reimbursement remaining amount of Rs.13,520/- to which she is legally entitled as such there is clear cut deficiency in services on the part of the opposite party. She has already submitted all the required documents to the opposite parties for her claim. Hence this complaint.

 3.          Notice of the complaint was issued to the opposite parties. Opposite party no.1 appeared through their counsel and filed their written reply submitted therein that Mrs.Pinki Saini is covered under National Medi-claim Policy with sum insured of Rs.50,000/- + Rs.10,000/- Cumulative Bonus since 04.04.2016 only. The complainant had not submitted the hospitalization bill and had supported his claim with IPD services receipt only and the submitted IPD services receipt had several unusual heads like Emergency charges, Emergency Doctor charges, Room Rent for one day although the complainant was hospitalized for 2.5 days and an investigator was appointed who visited the hospital and collected a copy of the complainant record, the detailed IPD bill and the tariff of the hospital. On perusal of the submitted copy of the tariff of the hospital, it has been observed that the hospital's tariff does not bear the Admission Charges, the Emergency charges, the Emergency doctor charges and the Generator charges. The complainant was hospitalized for 2.5 days from 27.9.2017 at 09.58 AM and discharged on 29.09.2017 at 08.33 PM but has been billed room rent for one day only. The complainant has been billed for the Emergency charges @ Rs.3500/- and Emergency Doctor charges @ Rs.2000/- which do not correspond with the tariff of the hospital. On perusal of the IPD records of the complainant it has been observed that on admission, the complainant had the history of Fever for 1 week and at the time of admission her BP was 130/70mmHg, Pulse 82 per minute, SPO2 98% with temperature 98.6F. During  subsequent period of hospitalization, all the mentioned parameters remained well within normal limits without much fluctuation. The submitted records clearly show that there was no Emergency. Still the complainant has been billed for Emergency charges and the Emergency Doctor charges. It was next submitted that the claim was rightly processed and settled as per the terms and condition of National Mediclaim Policyas per the details given here under:-

                           Claimed Amount   -   Rs.19,449/-

                            Disallowed Amount -   Rs.13,300/-

Reason for Disallowed Amount =Rs.3800/- amount in excess of the Room Rent including Nursing/RMO charges 1% of sum insured + Cumulative Bonus limit per day (Room charges Limit : 1% of sum insured per day subject to maximum of Rs.5,000/-), since the claimant had the per day limit of Rs.600/- per day only.

Rs.2000/- + Rs.3500/- disallowed towards the Emergency charges + Emergency  Doctor charges since the same were not indicated as explained above + Rs.2000/- excess cost of consultant visit fees disallowed under the definition 3.18 "Medical Expenses means those expenses that an Insured person has necessarily and actually incurred for medical treatment on account of disease/injury on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment and "3.29 Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similarly services, taking into account the nature of the illness injury involved"

Rs.1000/- Admission Charges + Rs.1000/- Generator charges (non payable items deducted as per the terms and conditions of the policy.) Granted amount of  Rs.6149/-. Thus, there is no deficiency in service on the part of the opposite parties. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       R.C. of opposite party no.2 has not been received back. Period of 30 days had already been elapsed. Presumption could be drawn that opposite parties had been served but was intentionally evading the service of the notice. Case called several times, but none had appeared on behalf of opposite party no.2. Hence, opposite party was ordered to be proceeded against exparte vide order 24.9.2019.   

5.       Alongwith the complaint, complainant has filed her own affidavit Ex.C-1 alongwith other documents Ex.C-2 to Ex.C-15.

6.      Alongwith the written statement ld.counsel for the opposite parties filed affidavit of Sh.Janak Raj, Branch Manager Ex.OP-1/A alongwith document Ex.OP-1/1.

7.      Written arguments have been filed by the opposite party no.1.

8.    We have carefully gone through the pleadings of counsel for the complainant; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the parties for the purposes of adjudication of the present complaint.

9.     Complainant alleged in the present complaint that opposite party has deducted an amount of Rs.13,520/- illegally from the medical claim of Rs.19,669/- under Policy No.401501/48/17/8500000008 (Ex.C-3)  and reimbursed only Rs.6149/- and denied the reimbursement of balance amount. Complainant also placed on record the medical bills at Ex.C-5 to Ex.C-15 alongwith IPD services receipts at Ex.C-5. As per Ex.C-5 IPD list it include Admission Charges, Emergency charges, Emergency doctor charges, rooms rent, doctors visit and generator charges etc. Hospital added emergency doctor charges but no evidence is put on record in proof of the visit of emergency doctor.

10.     Opposite party no.1 in their written reply has given the detailed clarification for disallowed amount of claim under definition 3.18, Medical expenses and 3.29, reasonable and customary charges. Opposite party further mentioned that as this case is not an emergency admission and advise of emergency doctor is not available on record, hence following charges claimed in IPD service receipts placed at Ex.C-5 are not admissible as per policy.

           Admission charges Rs.1000/-, Emergency charges Rs.3500/-,         Emergency doctor charges Rs.2000/-, Doctor visit Rs.1500/- and     generator charges Rs.1000/-. Besides this room rent is admissible only @ Rs.600/- per day.

Opposite party no.1 also submitted the investigation report also in proof of their justification of deductions.

11.    From the above details it can be construed that the complainant remained admitted for two days as per discharge summary (Ex.C-6) and IR at Ex.OP-1. Hence Rs.1200/- room rent is admissible.

12.    As per page 33 of IR patient  was admitted at 9.58 AM with normal parameter and there is not advise/consulted note of emergency doctor on record, so emergency admission charges and emergency doctor charges does not seem to be in order.

13.    In view of the above, we are of the opinion that the present complaint can be best disposed of with the directions to opposite party to pay the rest of the claim amount except   Rs.7300/- charges for Emergency charges, Emergency Doctor Charges, Room Rent and Generator Charges, within 30 days from issue of orders. Besides this, opposite party is further directed to pay lumpsum amount of Rs.5000/- to the complainant for litigation and harassment. Hence, present complaint is disposed off accordingly.

 14.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

15.    Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.                                                                                                                                                         

            (Naveen Puri)

                                                                            President   

Announced:                                                   (B.S.Matharu)

July 20, 2022                                                       Member

*MK*