| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM FATEHGARH SAHIB Consumer Complaint No. : 65 of 06.10.2017 Date of Decision : 29.04.2019 Tejinder Singh Kang aged about 52 years son of Sh.Tarlochan Singh Kang, Resident of House No.B/771, Ward No.5, Khamanon, Tehsil Khamanon, DistrictFatehgarh Sahib. ..........Complainant Versus - National Insurance Company Limited, having its Branch Office G.T. Road, Sirhind, Tehsil District Fatehgarh Sahib through its Branch Manager.
- National Insurance Company Limited, Divisional Office No.1, SCO No.133-135, Sector 17-C, Chandigarh – 160017 through its Authorized Persons.
- Safe-way Insurance, TPA Private Limited, having its Branch Office SCO No.6-7, Cabin No.32 & 33, Rajan Plaza, Palam Enclave, AmbalaZirakpur Highway, Zirakpur – 140603.
- Safe-Way Insurance TPA having its Head Office 815, VishwaSadan, District Center, Janakpuri, New Delhi – 110058.
… Opposite Parties Complaint Under Sections 12 & 14 of the Consumer Protection Act 1986. Quorum Sh. Kuljit Singh, President Sh. Inderjit, Member Present: Sh.H.S. Pandher, Adv. counsel for the complainant. Sh.Amit Gupta, Adv. counsel for OPs No.1 &2. Opposite Parties No.3&4 ex-parte ORDER By Kuljit Singh, President - Complainant has filed this present complaint against the Opposite parties Under Section 12 to 14 of the Consumer Protection Act 1986. The brief facts of the complaint are that he purchased National Medi-claim policy bearing No.422200/48/16/8500000339 from OP and paid Rs.35,092/- for medi-claim insurance of his family. The said insurance was from 28.11.2016 to 27.11.2017. The said insurance was cashless policy and OPs had given assurance that in case of any problem regarding the health occurs in life of complainant and his family leading to admission in hospital, then OPs without any hesitation will deliver the payment of expenses/rent of room/dietitian and any other expenses of Hospital will also be borne by OPs i.e. National Insurance Company. Complainant is consumer of OPs since 2003. Complainant and his family members never took any claim before the incident. As per clause 3.5 of said policy, the OPs are duty bound to provide cashless facility to complainant but they have not paid the service of cashless policy. Complainant’s wife JasdeepKaur admitted in Max Health Care Hospital, Mohali on 13.06.2017 due to headache (ICD R51) and discharged on 13.06.2017 at about 9:57 PM and paid Rs.10,464/- to said hospital. She again felt unwell and was again admitted in the hospital due to same problem on 14.06.2017. She remained under treatment of hospital upto 17.06.2017. On 14.06.2017 TPA department ofsaid hospital has sent the information through email to OPs and OPs put many queries to Max Care Health Services and which were replied within time to OPs and send all original record to the OPs but inspite of that OPs did not send the payment/approval of payment to said hospital till discharge of patient on 17.06.2017. Complainant paid the amount through credit card of HDFC Bank, Khamanon for Rs.71,500/- on 17.06.2017. After that, Ops, to cover up deficiency of cashless payment to the Max Health Care, Mohali again and again put the queries to the claimant of thisclaim No.NI-6-55. The original bills were submitted by the Max Care Health Center to OPs but they again demanded the bill of treatment. Complainant got computerized bill second time. The said bill issued by hospital has been shown as duplicatebill but theO.P.’s objected to filing of these duplicate bills. The complainant has submitted claim to OPs for Rs.92,363.77. The OPs illegally deducted the amount of Rs.38,226/- from the claim of complainant and sent payment of Rs.54087/- on 12.09.2017 in account of complainant. The Ops has deducted Rs.4200/- for dietitian, CM, RMO, Excessconsultation, Rs.400/- deducted from ECG Graph, Rs.615/- was deducted soft swap etc, Rs.2580/- deducted CSF expenses etc, Rs.440/- deducted from no prescription dated 20.06.2017, Rs.170/-, Rs.826/- Rs.226 for needle, syringe, dressing gage swap and Rs.1500/- deducted by medical history, Rs.1350/- deducted for diet charges, Rs.20,110/- of test of no report and film, Rs.4250/- from room charges and Rs.1600/- from triage. The said amount deducted illegally from the claim of complainant. The said amount is payable by OPs as per clause No.5.5.5 “in case of delay in payment, the OP shall pay interest @2% above bank rate prevalent at the beginning of financial year in which the claim is review.” It has been prayed that OPs be directed to pay Rs.38,336/- i.e. balance claim amount to complainant; interest @ 24% per annum on the amount of Rs.92363/- with effect from 17.06.2017 i.e. date of discharge from hospital till actual and final realization. Rs.1,00,000/- claimed as compensation for harassment.
- Upon notice, OPs No.1&2 appeared and filed joint reply by taking preliminary objections. It is stated that complainant has purchased National Medi claim Insurance policy w.e.f. 28.11.2016 to 27.11.2017 subject to terms and conditions of the policy. Complainant has applied for cashless treatment of his wife for secondary headache and migraine but the cashless treatment was denied by third party administrator i.e. TPA as the admission is primarily for investigation and evaluation which is not payable under the policy and the wife of complainant could be treated on OPD basis and admitted in hospital. The denial of cashless facility does not mean denial of treatment or denial of claim and complainant was apprised with the fact that the complainant could apply for reimbursement under the terms and conditions of the policy. Complainant has applied for reimbursement of Rs.92363/- incurred in the expenditure treatment of his wife at Max Hospital Mohali from 14.02.2017 to 17.06.2017. On receiving request of complainant, the TPA vide letter dated 15.07.2017 has requested the complainant to provide:
- Original final bill. Duplicate bill are not acceptable.
- All the original reports & Films, done during hospitalization.
- Original ECG Graph
- Original doctor’s prescription or investigation (electrolytes) done on 20.06.2017
O.P.’s submitted that amount of Rs.38276/- was deducted from total bill with justification. Claim of the complainant is not maintainable as answering OP has already decided the said claim and has paid the due amount under terms and conditions of the policy O.P.’s further stated that the policy was purchased from Divisional Office, Chandigarh and the treatment was also taken from Mohali and as such the claim of the complainant before this Forum is not maintainable. On merits, O.P.’s submitted that as per clause No.5.5.2 of terms and conditions it is mentioned that - The TPA reserves the right to deny pre-authorization in case of insured person is unable to provide the relevant medical details.
- In case of denial of cashless access, the insured person may obtain the treatment as per treating doctor’s advice and submit the claim documents to the TPA for reimbursement.
Other allegations of complaint are denied and prayer has been made for dismissal of complainant. - OP No.3&4 have failed to appeared despite notice and were proceeded against ex parte.
- In order to prove the complaint, complainant has tendered in evidence his affidavit Ex.C-1, alongwith photocopies of documents Ex.C-2 to Ex.C-71 and closed the evidence. In rebuttal, the counsel for OPs No.1&2 has tendered in evidence affidavit of Sh.SanjeevKhurana Ex.OP1/1, true copy of policy Ex.OP1/2, true copy of policy with terms and conditions Ex.OP1/3, copy of claim file and deductions bill detail Ex.OP1/4 and closed the evidence.
- We have heard learned counsel for the parties and have also examined written arguments of both the parties and the record of the case very carefully.
- The question for determination before the Forum is that whether this Forum has jurisdiction or not. From the record, it is transpired that Insurance Company hasits branch at District Fatehgarh Sahib for promoting their business. So this Forum has territorial jurisdiction to decide the dispute of present complaint.
- There is no dispute about the issuance of policy or purchase of medi-claim policy in question. It is an admitted fact that the policy in question is cashless policy. Some amount of reimbursement of medi-claim has already been made to complainant. The main controversy is that the OPs have deducted Rs.38,336/- from the claimed amount of Rs.92363/-. Ops have argued that as per section 2.1, 2.2 and 2.3 the amount was deducted. On the other hand, counsel for complainant has argued that the policy in question is cashless and the entire amount incurred under the said policy is liable to be refunded. The counsel has given more stress on insurance clause i.e. 5.5.5 (iv) i.e. In case of delay in the payment, the company shall pay interest at the rate which is 2% above the bank rate prevalent as the beginning of the financial years in which the claim is received. It is also considerable that if the policy in question is cashless then the policyholder is not liable to pay any is thing and entitled for all type of cashless treatments in the hospital. But in the case in hand, the Ops have deducted an amount of Rs.38336/- out the total reimbursable amount which is illegal and arbitrary. The Ops have also paid some amount to complainant with considerable delay. In this way, it is established that the Ops are deficient in providing consumer services to complainant and complainant is entitled for relief.
- In view of the above facts and circumstances, the present complaint is partly allowed and the Ops are directed to pay Rs.38336/- as deducted from the amount spent by the complainant on the treatment of his wife. However, record/X-ray Films/ and any other report if not submitted by complainant, the OP can take it from the file of wife of complainant through TPA from the MAX Hospital. Further, the Ops are directed to pay interest to complainant on the reimbursable amount as per their clause mentioned “supra” clause 5.5.5. of claim settlement Para IV of the policy and also to pay Rs.10,000/- as compensation for harassment.
- Compliance of above said order be made by the Ops within a period of 30 days from the date of receipt of copy of this order.
- Copy of this order be supplied to the parties as per permissible under rules.
Pronounced: 29.04.2019 (Kuljit Singh) President (Inderjit)\ Member | |
