Chandigarh

DF-I

CC/165/2023

RENU GUPTA - Complainant(s)

Versus

NEW INDIA ASSURANCE Co. Ltd. - Opp.Party(s)

SAHIL SINGLA

03 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/165/2023
Date of Institution	:	25/03/2023
Date of Decision	:	03/06/2024

 

Renu Gupta w/o Sh. Aditya Kumar Gupta, resident of House No.1767, Sector 59, Phase V, SAS Nagar, Mohali, Punjab.

… Complainant

V E R S U S

1. The New India Assurance Co. Ltd., LIC Building, Second Floor, Sector 17-B, Chandigarh through its Manager.
2. Vipul Medcorp Insurance, TPA Pvt. Ltd., S.C. I. No.98, First Floor, Industrial Area, Phase-2, Chandigarh through its Manager.
3. Ivy Hospital, Sector-71, Mohali, Tehsil & District SAS Nagar, Mohali, through its Superintendent/Incharge.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh.Sahil Singla, Advocate for complainant (through VC)
	:	Sh.Nikunj Dhawan, Advocate for OP-1 (through VC)
	:	OP-2 ex-parte.
	:	Sh.Pradeep Sharma, Advocate  for OP-3 (OP-3 ex-parte)

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Smt.Renu Gupta, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant had purchased a mediclaim policy from OP-1/insurer namely “New India Mediclaim Policy” (hereinafter referred to as “subject policy”) covering herself and her husband, Aditya Kumar Gupta, valid w.e.f. 30.3.2021 to 29.3.2022 (Annexure C-1) on payment of requisite premium, which included extra cover of ₹5.00 lacs and the additional top up policy is Annexure C-2. Unfortunately, husband of the complainant (hereinafter referred to as “insured patient”) had some health issue and on 13.4.2021 he approached the clinic of Dr. Pankaj Arora as he was suffering from fever and influenza.  Since there were symptoms of COVID, he was advised test for RT-PCR and was also prescribed certain medicines vide prescription slip (Annexure C-3).  The insured patient was found Sars-CO-2 RNA Positive vide report (Annexure C-6).  Thereafter, his HRCT test was also done for which the complainant had paid an amount of ₹4,500/- vide invoice (Annexure C-7).  On 19.4.2021, insured patient purchased medicines worth ₹4,896/- vide invoice (Annexure C-8).  On the same day certain other tests were also got conducted from Helix Pathlabs, Mohali and an amount of ₹5,560/- was paid vide receipt (Annexure C-9). Medicines were also purchased from Ivy Pharmacy for an amount of ₹1,980/- vide receipt (Annexure C-10).  As the health of the insured patient continuously deteriorated, he was admitted in OP-3/Ivy Hospital, Sector 71, Mohali on 20.4.2021 (hereinafter referred to as “Treating Hospital”) who had issued package for his treatment as per instructions of Govt. of Punjab (Annexure C-11).  Unfortunately, the insured patient died on 29.4.2021 and the treating hospital had raised bill of ₹3,38,883/- by giving discount of ₹49,600/- and reserved ward charges of ₹9,000/- as the actual bill was of ₹3,97,483/-, which was paid by the complainant vide payment slip (Annexure C-13).  The death summary of insured patient is Annexure C-14, details of hospital bill is Annexure C-15 and the death certificate is Annexure C-16.  Thereafter on 26.5.2021 complainant lodged claim (Annexure C-17) with OP-1 by submitting all the requisite documents for reimbursement of total amount of ₹3,56,879/-, which included ₹3,38,883/- as hospital bill and ₹17,996/- incurred as pre-hospitalisation charges.  OP-2 had issued letter of query to the complainant with respect to the tests regarding which she had submitted the documents.  However, vide letter dated 17.7.2021 (Annexure C-19), OP-1 through OP-2 has wrongly and arbitrarily settled the claim of the complainant to the tune of ₹1,56,206/- only against the total claim of ₹3,56,879/- and thereby made deduction of ₹2,00,673/-.  In this manner, the aforesaid act of the OPs amount to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OP-1 resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, locus standi and suppression of facts.  However, it is admitted that the subject policy was obtained by the complainant from the answering OP and the copy of the policy alongwith terms & conditions is Annexure R-1/1. It is further alleged that the admissible amount of claim of ₹1,56,206/- was remitted to the account of the complainant as per terms & conditions of the subject policy as well as the Govt. guidelines issued at the time of COVID-19.  It is further alleged that there was nothing to be surprised about as the TPA had approved the reasonable expenses as agreed upon by the Network Hospitals which are in the panel of the TPA and copy of the guidelines is Annexure R-1/2.  It is further alleged that an amount of ₹2,00,673/- has been deducted as per the treatment charges for COVID-19 issued by the Govt. and the answering OP is not liable to pay the same.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OPs 2 & 3 did not turn up before this Commission, despite proper service, hence they were proceeded against ex-parte vide order dated 30.5.2023.
4. In rejoinder to the written version of OP-1, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the contesting parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy from OP-1, which was valid w.e.f. 30.3.2021 to 29.3.2022 covering the complainant and her deceased husband namely Sh.Aditya Kumar Gupta, i.e. the insured patient with sum insured of ₹5.00 lacs and the insured patient was being treated for COVID-19, on being diagnosed as Sars-CO-2 RNA Positive, and the complainant had spent an amount of ₹3,38,883/- towards his hospitalisation and ₹17,996/- towards his pre-hospitalisation, totaling ₹3,56,879/-, out of which OPs had only remitted an amount of ₹1,56,206/- in the account of the complainant by making deduction of ₹2,00,673/-, the case is reduced to a narrow compass as it is to be determined if OPs 1 & 2 are unjustified in deducting an amount of ₹2,00,673/- from the actual amount spent by the complainant for the treatment of her husband and complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if OPs 1 & 2 are justified in settling the claim of the complainant to the tune of ₹1,56,206/- and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of OPs 1 & 2.
   2. In the backdrop of foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms & conditions of the subject policy (Annexure R-1/1) and the TPA brief (Annexure R-1/3) as well as Govt. guidelines (Annexure R-1/2) and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of terms and conditions of the subject policy (Annexure R-1/1) clearly indicates that the medical expenses spent by the complainant for the treatment of her husband/insured patient has not been excluded under any exclusion clause.
   4. The defence of OPs 1 & 2 solely is that they have made deduction of ₹2,00,673/- as the hospital had charged excessive amount against the Punjab Govt. guidelines as specific rates were prescribed in the order dated 16.7.2020 (Annexure R-1/2) for the treatment of COVID-19 by the Punjab Govt. and in pursuance to the same, amount was approved by the TPA/OP-2 vide TPA brief (Annexure R-1/3). However, when it is an admitted case of the parties that the insured patient had taken treatment from the Network Hospital/OP-3, which was on the panel of OP-2/TPA, it is for the insurer/OP-1 to get the said excessive amount, if any, recovered from the said panel hospital and for that act of any panel hospital, the insured is not to suffer. 
   5. Moreover, when it stands proved on record that the complainant had spent an amount of ₹3,56,879/- i.e. ₹17,996/- as pre-hospitalisation expenses, as is also evident from Annexure C-4 to C-10 and ₹3,38,883/- during hospitalisation, as is also evident from the payment receipt (Annexure C-13) issued by OP-3, out of which OP-1 has only remitted an amount of ₹1,56,206/- to the complainant by deducting an amount of ₹2,00,673/-, it is safe to hold that OPs 1 & 2 have illegally, wrongly and arbitrarily made deduction in violation of the terms and conditions of the subject policy, which otherwise do not permit any such deduction by the insurer.  Not only this, vide circular/letter dated 13.1.2021 the Insurance Regulatory and Development Authority of India (IRDA) had communicated to all the General and Health insurers on settlement of health insurance claims against General Insurance Council’s instructions dated 20^th June, 2020 on “Reference Rates for COVID-19” and the relevant portion of the same is reproduced below for ready reference :-

“3.  All the insurers are directed to ensure that the “Reimbursement claims” under a health insurance policy shall be settled as per the terms and conditions of the respective policy contract.  Hence, the insurers shall honor all the health insurance claims as per the terms and conditions of the policy contract.”

6. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the deficiency in service and unfair trade practice on the part of OPs as well as cause of action set up in the consumer complaint and the same deserves to succeed.  OPs 1 & 2 are liable to pay the deducted amount of ₹2,00,673/- to the complainant alongwith interest & compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1 & 2 are directed as under :-

1. to pay ₹2,00,673/- to the complainant alongwith interest @ 9% per annum from the date of partial claim settlement i.e. 17.7.2021 onwards.
2. to pay ₹30,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OPs 1 & 2 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been proved against OP-3, the consumer complaint against it stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

03/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member