BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.265 of 2015

Date of Instt. 16.06.2015

Date of Decision :23.09.2015

D.K.Wig (Dalip Kumar Wig) son of Late Sh.Bhin Sain Wig R/o 85, New Radio Colony, BMC Chowk, Jalandhar.

..........Complainant Versus

National Insurance Company, B.O. III, BMC Chowk, Above PNB, Jalandhar.

.........Opposite party.

Complaint Under the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Complainant in person.

Sh.Raman Sharma Adv., counsel for opposite party.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under the Consumer Protection Act, against the opposite party on the averments that he is policy holder of the mediclaim policy with the opposite party since 27.10.2008 and he has continued the same till date without any break. He had undergone treatment for the left eye cataract operation on 2.4.2015 and the claim form alongwith bills and other required documents were submitted on 3.4.2015 and also the cash memo amounting to Rs.35800/- as required by M/s Raksha TPA. He has been put to harassment and his claim was delayed without any valid reason however after 1.5 month i.e on 16.5.2015 his claim was settled for Rs.22,000/-, making the deduction of Rs.13,800/- and the reason mentioned in the letter is that "13,800/- Non Payable as per Hospital Gipsa PPN Package Rates". When he enquired from the TPA office telephonically about the meaning of the reason mentioned which he could not understand, and he was surprised to know that the said deduction has been made as per the agreement between the Hospital & TPA without taking into confidence the insured who has been penalized for his no fault, however the insured is bound only by the policy terms and conditions where there is no mention of the above clause under which the deduction has been made. On such like averments, the complainant has prayed for directing the opposite party insurance company to pay him the deducted amount. He has also claimed litigation expenses.

3. Upon notice, opposite party appeared and filed a written reply, inter-alia, pleading that the complainant can not take advantage of his own wrongs. The complainant was fully aware that he has to undergo left eye cataract surgery as advised by the treating doctor Thind and the complainant had intimated of his intention of undergoing such surgery vide letter dated 27.3.2014 to the opposite party and asking for the claim form to be submitted by the complainant, but the complainant did not disclose about the mediclaim insurance policy to the Thind Eye Hospital. Had the complainant disclosed about the mediclaim insurance policy to the Thind Eye Hospital, one of the hospitals under preferred provider network (PPN) which have agreed to a cashless packaged pricing for certain procedures for the insured person, the hospital would had procured pre-authorization from the Raksha TPA Pvt Ltd under cashless treatment. As per policy, in case of reimbursement of expenses claimed which were incurred for treatment in PPN Hospital (Preferred Provider Network Hospital) for the procedure as listed under PPN package shall be subject to the rates applicable to PPN package pricing as in the present case. The claim of the complainant has already been approved and paid by Raksha TPA Pvt Ltd amounting to Rs.22,000/- payable under the PPN package rates, as the treatment of the complainant is from PPN Hospital. The amount of Rs.13,800/- was not payable as per clause 3.23 of the insurance policy terms and conditions, as the treatment of the complainant was from PPN Hospital. The complaint is bad for non-joinder of necessary party. M/s Raksha TPA Pvt ltd, which processed and paid the claim and Thind Eye Hospital which treated the complainant have not been impleaded as the necessary party, as such the complaint is liable to be dismissed. Out of the claimed amount of Rs.35,800/-, Rs.13,800/- was not payable as per Hospital GIPSA PPN Package Rates. It denied other material averments of the complainant.

4. In support of his complaint, complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C8 and closed evidence.

5. On the other hand, learned counsel for the opposite party has tendered affidavit Ex.OA alongwith copies of documents Ex.O1 and Ex.O4 and closed evidence.

6. We have carefully gone through the record and also heard the complainant in person and learned counsel for the opposite party.

7. It is not disputed that the complainant has obtained mediclaim insurance policy from the opposite party insurance company. It is also not disputed that he underwent cataract operation for the left eye on 2.4.2015 and after discharge, he lodged the claim with the opposite party insurance company for Rs.35,800/- but opposite party insurance company paid him Rs.22,000/- after making deduction of Rs.13,800/- on the ground that the said amount was non payable as per hospital Gipsa PPN Package Rate. The complainant contended that the insured is bound only by the policy terms and conditions where there is no mention of any Gipsa PPN Package Rates and as such the complainant is not bound by the same. He further contended that if the hospital has charged amount beyond Gipsa PPN Package Rates then it is a matter between the opposite party insurance company and the hospital. We have carefully considered the above contentions. The opposite party insurance company has produced terms and conditions of the policy Ex.O2. Clause 3.23 provides as under:-

"Preferred provider network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN Package) shall be subject to the rates applicable to PPN package pricing".

8. It is not disputed that the complainant has undergone cataract operation in PPN (Network) Hospital. So as per clause 3.23 of the terms and conditions of the policy, reimbursement of expenses incurred in PPN Hospital for the procedures as listed under PPN Package shall be subject to the rates applicable to PPN package pricing. Ex.O3 is list of PPN Hospitals and Thind Eye Hospital is mentioned at serial No.79. So as per above clause, the insured was only entitled to rates applicable to PPN package pricing i.e Rs.22,000/- which has already been paid to complainant.

9. In view of above discussion, we hold that there is no merit in the present complaint and same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

23.09.2015 Member Member President