Delhi

Central Delhi

CC/59/2024

YOGESH BANSAL - Complainant(s)

Versus

ORIENTAL INSURANCE CO. LTD. - Opp.Party(s)

05 Dec 2024

ORDER

Heading1
Heading2
 
Complaint Case No. CC/59/2024
( Date of Filing : 20 Mar 2024 )
 
1. YOGESH BANSAL
1-75, ASHOK VIHAR PHASE-1, NEW DELHI-110052.
...........Complainant(s)
Versus
1. ORIENTAL INSURANCE CO. LTD.
30/26, FIRST FLOOR, NAGIA PARK, SHAKTI NAGAR, DELHI-110007.
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MR. INDER JEET SINGH PRESIDENT
 HON'BLE MS. RASHMI BANSAL MEMBER
 
PRESENT:
 
Dated : 05 Dec 2024
Final Order / Judgement

Before the District Consumer Dispute Redressal Commission [Central District] - VIII,        5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi

                                 Complaint Case No. (RBT)  59/23.03.2024

 

Yogesh Bansal son of  Late Shamlal Gupta,

r/o  I-75, Ashok Vihar, Phase-I,  New Delhi-110052                                       …Complainant     

                                                            

                                                              Versus

 

OP1:  The Oriental Insurance Company Ltd.

30/26, First Floor, Nagia Park, Shakti Nagar

Delhi-110007

 

OP2:   Park Mediclaim TPA Pvt. Ltd.

702, Vikrant Tower, Rajendra Place

New Delhi-110008                                                                            ...Opposite Party

 

                                                                        Date of filing (RBT):   23.03.2024             

                                                                        Date of filing (N/W):   27.07.2017

Coram:                                                             Date of Order:             05.12.2024

Shri Inder Jeet Singh, President

Ms Rashmi Bansal, Member -Female

 

                                                FINAL ORDER

Inder Jeet Singh, President

 

It is scheduled today for order (item no.3)

 

1.1. (Introduction to case of parties) – The complainant has grievances of deficiency of services and unfair trade practice against OPs that a latest health insurance no.271400/48/2017/194 valid from 11.04.2016 to 10.04.2017 [hereinafter referred as insurance policy] was taken for himself, his wife Smt Sunita Bansal and their daughter Megha Bansal from OP1/Insurer. However, the complainant suffered difficulty in walking, he was admitted in Sir Ganga Ram Hospital on 26.12.2016 and discharged on 02.01.2017. There were medical expenses/bills of Rs.1,36,749/- incurred by the complainant but the same were partly reimbursed and an amount of Rs.96,713/- was not reimbursed by OP1. That is why the present complaint for reimbursement of this balance amount with interest @ 18%pa, compensation of Rs. 50,000/- in lieu of harassment, litigation costs of Rs.11,000/- and other relief.

1.2. The Insurer/OP1 opposed the complaint by filing detailed written statement that there is no deficiency of services or unfair trade practice on the part of OP1 nor it liable to pay any amount since the hospital has charged excess amount but admissible amount was reimbursed, the remaining amount is not within the purview of terms and conditions of policy.  The complaint is liable to be dismissed.

1.3.   The OP2/TPA was also served with the notice on complaint, however, it failed to appear and to file the written statement as per record received.

1.4  This complaint case was transferred from DCDRC North West District, Delhi to the present DCDRC Central District, pursuant to order dated 05.03.2024 in TA-16/2024 by the Hon’ble State Commission, Delhi.

 

2.1. (Case of complainant) – The complainant is Insured. The OP1 is Insurer. The OP2 is TPA of OP1. The complainant took health insurance policy from insurer/OP1 to cover the risk for himself, his wife and their daughter.

          On 26.12.2016, the complainant suffered difficulty in walking, he was swaying during walking, therefore, he came to Sri Ganga Ram Hospital on the same day, he was admitted there and discharge on 02.1.2017 in stable condition while issuing discharge summary. The complainant was asked by the hospital to deposit Rs, 50,000/- as advance and later the total amount demanded was Rs.1,25,282.27p/- as per statement dated 02.01.2017. The complainant was entitled for cashless treatment to be allowed by the OPs as per agreement.

2.2. The complainant was billed for Rs. 1,36,749/- towards full and final settlement of the treatment, out of which an amount of Rs. 51,000/- was paid by OP1 under the guidance of OP2, therefore, complainant was constraint to pay the remaining balance amount from his own pocket. The complainant wrote and requested the OPs to pay further balance amount of Rs. 1,06,713/- by letter dated 18.04.2017, however, he was allowed a sum of Rs. 9,665/- and remaining amount of Rs. 96,713/- was not reimbursed and the request was rejected by OP2. The OP1 has been issuing and renewing the old policy time and again but the complainant was never handed over the terms and conditions, the refusal of balance amount surprised the complainant. It is unfair trade practice and deficiency of services since at the time of buying the policy, the complainant was assured of best health cover. It caused mental loss, agony and financial hardship by repudiating the valid claim of complainant that too without reason. That is why the complaint.

2.3 The complaint is accompanied with photocopies - insurance policy and previous policies, receipts of advance/deposits to hospital, pre-authorization letter dated 02.01.2017 claim form, expenses detail, discharge summary, final bills with detail, letter dated 18.04.2017 while confirming claim of Rs.9,665/- out of balanced claimed of Rs.1,06,713/ and disallowing amount of Rs.96,713/-.

 

3.1 (Case of OP1)- The complaint is opposed by OP1 that there is no cause of action against OP1, besides no deficiency of services or unfair trade practice on the part of OP1.

 

The complaint is not maintainable for claimed amount or of interest component or compensation of Rs. 50,000/- or costs of Rs.11,000/- or other relief.  The complaint is un-conceived and the complainant approached the Consumer Fora without clean hands. In fact on perusal of the record and documents,  it manifest that the OP was always prompt in redressing the grievance of the complainant but the complaint was filed to make unlawful gains.

3.2.  The complainant obtained happy family floater policy from OP1. The complainant aged about 55 years was hospitalized and he was primarily diagnosed diabetes mellitus, hypertension, right cerebella infarct, vitamin-B12 deficiency, as per discharge summary issued by the hospital. During scrutiny of inpatient record, the OP found that the treating hospital has charged excessively. The patient was considered for cashless and reimbursement, which was allowed for total amount of Rs. 60,888/- (i.e Rs. 51,223 + Rs. 9,665/-) in full and final settlement of his claim after deduction of non-payable items out of the total claimed amount. The amount allowed was credited into the account of the complainant. The balance being claimed by the complainant was held inadmissible/non-payable by the OP2 vide letter dated 18.07.2017. The acts of OPs were bona-fide and in discharge of their duties, it cannot be termed as negligent or deficiency. The complainant is seeking sympathy of this Fora on flimsy reasons. Therefore, complainant’s claim is based on unfounded reasons. The complaint is liable to be dismissed.

3.3 The reply of OP1 is not supplemented with any document.

3.4 (Case of OP2)- There is no appearance and pleading by OP2/TPA.

 

4 (Replication)- The complainant filed detailed replication and he denies all the allegations of written statement, while reaffirming the complaint as well as by explaining that terms and conditions of policy were not supplied and filed by the OP1, it is not clear under which terms and conditions the balance of claim was withheld and not released. The complainant is entitled for balance medical bills amount under contractual obligation of OPs and not out of sympathy.

 

5. (Evidence)- The complainant filed  his detailed affidavit of evidence, which is on the  trend of complaint with the support of documents.  The OP1 also led its evidence by affidavit of Shri Chhotu Ram, Sr. Divisional Manager, Divisional Office-11 and affidavit is in compact from based on written statement of OP1.   However, there was no appearance or written statement of OP2/TPA, consequently no evidence of OP2.

6.1. (Final hearing)- The complainant and the OP1 filed their respective written arguments. The parties were also given opportunities for making oral submissions, then Sh. Nikhil, Advocate (associate of Shri Sameer Nandwani, Advocate) for complainant and Shri Bhupesh Chandna, Advocate for OP1 made their respective submissions.

6.2 During the course of oral submission, the complainant also relies upon Kamaljeet Singh Vs. National Insurance Co. Ltd. VII 2019 SLT 310 that there was family medical claim policy and the patient was allowed 50% of insured be within the insurance limit of Rs. 5,00,000/ as per the terms and conditions of the policy. It is supplemented on behalf of complainant that the case of complainant is crystal clear on the basis of medical bills furnished to the OPs.

          Simultaneously, the OP has also filed record/ calculations showing intimation date 04.04.2017 of OP2 of payable amount out of claimed amount  and also deductions with reasons for deductions.

6.1 (Findings)- The rival contentions are considered keeping in view the case as set up by the parties, their evidence especially the documentary record and statutory provisions of law. The narrow issue within the compass of this dispute is ' whether or not there were excess charges by the hospital" or whether or not complainant the facilities beyond the entitlement under insurance policy"? Besides another allied issue raised on behalf of OP whether or not the present complaint can be dealt in summary proceedings, in fact this is to be dealt firstly as the further course of decision will depend in case the present DCDR Commission has jurisdiction to decide the same.

6.2.1.   According to OP1, there is complicated question of facts and law involved in the present complaint, it cannot be determined under summary procedure but the same are to be dealt by detailed examination, cross-examination and assessment documentary record by the Civil Court. However, the complainant has juxtaposition plea that the complaint is maintainable before the present Commission and the consumer dispute can be determined by this Commission.

6.2.2. Since the case of both the sides has been mentioned, the features are themselves speaking and it does not exhibit any question of fact or of law or of mixed question of fact and law to infers that matter needs trial by the general Civil Court. In addition it has also not been shown or pointed out during the oral submission as to which particular question of law or fact exists that it needs adjudication by other court than the present Commission. Therefore, it is held that this DCDR Commission is competent to decide the consumer dispute. With the disposal of this contention, now the other issues can be taken up.

7.1.  By considering all material, documents, features and circumstances [including the calculations carried by OP2/TPA to split the allowable or not allowable amounts] then following conclusions are  drawn :-

(i)  The case of OP1 is that  excess charges were made by the hospital but according to case of complainant, he had paid the medical bills and other expenses being charged by the hospital.

          In fact, it is nomenclature of excess charges by the hospital but as per calculation furnished by the OP1, it shows as if certain amounts paid by the complainant to the hospital were more than his entitlement, like the limit of room rent was 1% of sum insured, it was Rs. 3,000/-per day  but actually the room availed or provided was carrying rent of Rs. 8,800/- per day. It shows, prima facie, the hospital has charged the rent as mentioned in the bill issued but for the purposes of insured/complainant the room rent  allowable is of Rs. 8,800/ per day-, it was not the entitlement of the complainant since the rent limit was Rs. 3,000/- per day being 1% sum insured of Rs. 3,00,000/-. With this discussion, it stands cleared that hospital has charged excess amount is nomenclature by OP1 for the charges beyond entitlement of the complainant.

          Otherwise, onus was on the OP1 to establish that usually room rent is Rs.3000/- per day, for which amount charged was Rs.8,800/- per day; this has not been established by OP1.

 

(ii) The complainant has proved the final bill showing the items heading-wise  as well as the discharge summary besides letter dated 18.04.2017 showing the disallowed amount and reasons for disallowed amount. Moreover, at the stage of final hearing of the case, the OP1 had also filed intimation dated 04.04.2017 in respect of same subject of amount claimed, amount disallowed and reasons for disallowed amount.

 

(iii) By reading sub clause (i) and (ii) above, it dispels the clouds. Simply, the complainant is entitled for room rent at the rate of 1% of sum insured, which comes to Rs. 3,000/- per day, which is mentioned in the insurance policy scheduled proved by the complainant himself. But the room availed or provided in the hospital was carrying rent of Rs. 8,800/- per day but the entitlement of the complainant was to the extent of Rs. 3,000/- per day. The complainant is not entitled for amount beyond entitlement of room rent of Rs. 3,000/- per day under the policy. This proves that the deduction in respect of room rent were within the terms of the policy, reasons of policy condition is also mentioned in the said letter. Since policy schedule mentions so, therefore, complainant cannot say that he was not informed of this terms and conditions in the policy.

 

(iv)  On calculations in percentage, the rent of Rs. 8800/- per day is 193.33% more than the entitled amount of Rs. 3,000/- per day. The OP1 has applied this formula of excess 193.33% on other items of doctor professional fees, anesthesia and OT charges and investigation charges and correspondingly the total bill amount of Rs.85,525/- was disallowed as per intimation dated 4.4.2017.. The reason explained was that other items would have been correspondingly charged as per room rent of Rs. 8,800/- per day and they are reduced on pro-rata basis.

          Whereas, there is no evidence brought on record or any scale of charges/tariff of the hospital that hospital charges professional fees, investigation and OT charges as per the rate of room rent per day, therefore, the OP has wrongly assumed self determined percentage formula and applied the formula of excess 193.33% for disallowing the amount of aforementioned three items.  To say, the amount of Rs.13,538/- doctor professional fees, Rs.2029/- anesthesia OT charges and Rs.22,570/- of investigation charges (total Rs.38,137/-) were wrongly deducted but other deductible were as per policy.  The total deductable amount comes to Rs.47,388/-.  The other deductable are within those norms.

          Thus, out of claimed amount of Rs.1,36,749/- the deductible amount is Rs.47,388/- and balance amount payable comes to Rs.89,361/- out of which an amount of Rs.60,888/- was reimbursed to the amount on two occasions. The remaining unpaid/ balance amount of claim is Rs.28,473/-, for which complainant is entitled to be reimbursed by the OP1.

 

 

7.2. The conclusions in aforementioned paragraph prove the circumstances of complaint against OPs but  OP1 could do not establish its case and defence.  Therefore, the complainant has succeeded in establishing the case of reimbursement of medical bill amount of Rs.28,473/-, which remains within limit of sum insured of Rs. 3 lakhs.

7.3. Since the OP1 failed to reimburse the claimed amount of Rs.28,473/- and complainant had to spend the amount from his wallet,. The interest may not have been mentioned in the insurance policy contract but had his valid claim been settled, the complainant would not have been deprived of amount of Rs.28,473/-. It makes out case of complainant for interest on the amount spent by him. Thus, interest at the rate of 6%pa from the date 02.01.2017 of discharge summary till realization of the amount in favour of complainant and against OP1 will justify both sides.

7.4 The complainant seeks compensation of Rs.50,000/- in lieu of the inconvenience, harassment and agony suffered, besides cost of Rs. 11,000/- incurred by the complainant. The circumstances are speaking themselves that he had suffered inconvenience and harassment firstly for want of entire pre-authorization and then for want of settlement of eligible claim. Then complainant initiated the present complaint. Therefore, compensation of Rs.15,000/- and cost of Rs. 7,000/- are being considered appropriate to the situation of this case and accordingly they are determined in favour of complainant and against the OP1.

 

8.1     In view of the above, the OP1 is directed to reimburse to complainant  balance medical claim amount of Rs.28,473/-with interest at the rate of 6% pa from the date of discharge summary of 02.01.2017 till realization of the amount to the complainant, apart from compensation of Rs. 15,000/- and cost of Rs. 7,000/-. This amount will be payable by OP1 within 45 days from the date of this order, failing to pay the amount in that time, then rate of  interest will be 8% pa on amount of Rs.28,473/- (in place of interest of 6% pa). The OP1 may also deposit the amount by valid instrument in the Registry of this Commission in the name of complainant.

8.2     Since OP2 is TPA of OP1, it was a facilitator for the processing of claim for OP1. The relationship of insured and insurer is between the complainant and the OP1. Therefore, the complaint against OP2/TPA is dismissed

9.     Announced on this 5th day of December  2024 [अग्रहायण  14, साका 1946].   Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.

                                                                                                           [Rashmi Bansal]                                           

                                                                                                                    Member (Female) 

 

                                                                                                         [Inder Jeet Singh]

                                                                                                                      President

[ijs-150]

                                                   ***

 

 

 

 

 

 
 
[HON'BLE MR. INDER JEET SINGH]
PRESIDENT
 
 
[HON'BLE MS. RASHMI BANSAL]
MEMBER
 

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