Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor, Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 280 dated 01.10.2015
Raju Sagar , R/o 153, Gujranwala Town,
Part-II, Delhi-110009 …Complainant
Versus
OP1- M/s Oriental Insurance Company Limited,
CBO-Kashmere Gate, 1576, Church Road, Kashmere Gate,
Delhi-110006
Also at: Oriental House, A-25/27, Asaf Ali Road,
New Delhi-110002
(through its Managing Director/Directors)
OP2- M/s Vipul Medcorp TPA Private Limited, (through its
Managing Director /Directors), 515, Udyog Vihar, Phase-5,
Gurgaon, Haryana-122016.
OP3. Sir Ganga Ram Hospital, (through its Chairman/
Managing Director/Administrator) Rajinder Nagar,
New Delhi-110060 ...Opposite Parties
Date of filing: 23.09.2015
Date of Order: 03.10.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER
Inder Jeet Singh , President
1.1. (Status of the parties)- The complainant is insured, OP1 Oriental Insurance Co. Ltd. is Insurer, OP2 M/s Vipul Medcorp TPA Pvt. Ltd. is Third Party Administrator of OP1. OP3 Sir Ganga Ram Hospital is the treating hospital of spouse of complainant.
1.2. (Introduction to consumer dispute of parties) – The complainant has grievances of deficiency of services against OPs that he took Happy Family Floater Policy (briefly policy) from OP1 by paying huge amount of premium. Complainant’s wife have episode to take treatment from OP3, the total medical expenses were to be met by the complainant from his own pocket as cashless facility was declined by OPs. When total bill claim of Rs. 2,54,514/- was raised, he was paid arbitrarily part claim of Rs. 90,838/-. His claim of balance amount of Rs. 1,63,676/- was declined. The OP1 & OP2 are liable to pay the balance amount with interest @ 18% pa recoverable from the OPs.
OR, in alternative if OP3 has overcharged the bills (under some PPN arrangement as stated) then OP3 has to refund that excess amount of Rs. 1,50,036/- & remaining unpaid amount of Rs. 13,640/- by OP1 & OP2 with interest @ 18% pa recoverable from the OPs. The complainant also claims compensation of Rs. 2,00,000/- for harassment & agony, besides appropriate costs and other relief.
1.3. OPs opposed the claim that the claim was settled as per terms of policy and OP3 also asserts that there was no overcharges but as per agreed charges schedule for the treatment, all the patients are being charged equally, there is no question of any overcharges or its refund or other relief.
2.1. (Case of complainant) - The complainant took Happy Family Floater policy no. 271601/48/2015/178 from OP1 for insured/beneficiaries - himself, his spouse Heena Sagar, their son Mradul Sagar and second son Krishan Sagar for period from 13.04.2014 to 12.04.2015 for insurance cover of Rs. 10 lakhs against payment of premium of Rs. 33,110/-.
2.2. Complainant’s wife was diagnosed with Fibroid Uterus by OP3/Hospital, she was admitted for treatment as indoor patient on 06.06.2014 and discharged on 10.06.2014. She was advised by the doctors for Robotically Assisted Total Laparoscopic Hysterectomy [THL] with BIL Salphingo-Ophorectomy [SO] , the said procedure was performed by the doctors of OP3. The OP3 hospital applied for cashless facility for the complainant but it was not approved by OP1 & OP2, the complainant had to make the entire payment of Rs. 2,54,514/- from his own pocket (which comprises hospitalization expenses of Rs. 2,40,874/- and Rs. 13,640/- of other medical bills spent).
2.3. The complainant lodged claim no. 15RD01OIA0638, however, on 14.11.2014 bill of Rs. 90,838/- was passed against claim of bills of Rs. 2,54,514/- and the remaining claim of Rs. 1,63,676/- was deducted arbitrarily and without any justification.
The OP2 had sent by post discharge voucher-cum-consent letter dated 14.11.2014 for an amount of Rs. 90,838/- as full and final settlement against claimed amount of Rs. 2,54,514/- and amount was stated to be deducted on account of GIPSA package applicable for hysterectomy, but it was never disclosed by the OP1 to the complainant at the time of issue of policy of such GIPSA package, otherwise complainant has no knowledge about the so called GIPSA package; complainant is not a party to the same. The complainant did not accord his consent for amount of Rs.90,838/-. Otherwise, without prejudice, OP3 has over-charged the complainant beyond the PPN rates and consequently the bill has been inflated by Rs.1,50,036/-.
2.4. The complainant has been subscribing policy regularly for the last so many years and he has been paying the considerable amount towards premium. Since, the OP1 & the OP2 failed to reimburse bona-fide claim of complainant and he was constraints to spent amount of Rs. 2,54,514/- but OPs failed to reimburse the same. The complainant also sent legal notice dated 31.03.2015 by e-mail to the OPs to settle the claim, then on 01.04.2015 after receipt of legal notice, the OP2 forwarded an amount of Rs. 90,838/- by way of NEFT into the bank account of complainant without his knowledge. It was partly deposited claimed amount, which is wrong as the entire amount was required to be deposited. It has caused harassment to the complainant on the part of OP1, OP2 & OP3. That is why the complaint.
2.5. The complaint is accompanied with many documents, briefly, PAN cards, aadhar cards, insurance policy issued (3 pages), medical papers and discharge summary, bills, legal notice, etc.
3.1 (Case of OP1 & OP2)- At the outset, the title of reply is as written statement of no.1 and no. 2, it is also accompanied with the vakalatnama, which also mentions being executed by OP1 & OP2. However, the vakalatnama bears single signature and seal of Oriental Insurance Company/OP1 as it is in the written statement, besides exclusive name of Oriental Insurance Company Ltd. is specifically typed/written. Moreover, the name of author of the written statement is not mentioned either in the vakalatnama or in the written statement.
However, at the stage of evidence of affidavit of Sh. Satish Kumar Sharma, Sr. Divisional Manager, Oriental Insurance Co. Ltd. was filed, the signatures appearing thereon is identical with the signatures appearing in vakalatnama and written statement; meaning thereby the written statement is authored by Sh. Satish Kumar Sharma, Sr. Divisional Manager of OP1. Nowhere, in the written statement it is mentioned that Satish Kumar Sharma, Sr. Divisional Manager, was authorized by OP2 to file written statement on behalf of OP2 nor there is any fact that Sh. Satish Kumar Sharma was competent to file written statement of his own for OP2 nor he holds any position in OP2/TPA. It is also not out of context to mention that affidavit was also filed under the title evidence for OP1 & OP2 by Sh. Satish Kumar Sharma, Sr. Divisional Manager but when he is signing affidavit and leading evidence for OP1/Oriental Insurance Company, then how he could write evidence for OP2?. He cannot write so. Therefore, the written statement will be considered for OP1 exclusively. It will not be read for OP2.
3.2. The OP1 does not deny issue of Happy Family Floater Policy to the complainant as well as admission of complainant’s wife in hospital of OP3 and her treatment there, apart from settlement and payment of claim of Rs.90,838/-. But OP1 denies the other allegations.
3.3. The complainant is not entitled for any further medical bill amount or other relief claimed, since it was settled for, and paid, amount of Rs. 90,838/- (being hospitalization expenses as per GIPSA package & pre-hospitalization expenses of Rs.6,838/-) under reasonably and necessarily incurred provision of the policy. The OP1 had given package for lap hysterectomy procedure for Rs. 84,000/- as per policy terms and accordingly her medical claim was settled, therefore, there was no unwarranted deductions of Rs. 1,63,676/- nor it can be construed deficiency in services. The complaint is liable to be dismissed. The reply is not accompanied with any document.
3.4. (Case of OP3)- The OP3 gives self-introduction about its medical services, specialization and goodwill in the medical field across the country and also overseas. But complaint is opposed that it is fancy litigation, complaint was filed to harass OP and extract money. Patient Ms. Heena Sagar was admitted in OP3 hospital in nursing home category from 06.06.2014 to 10.06.2014 in unit of Obstt. & Gyane. for removal of Uterus level-II hysterectomy. She was given treatment estimate of Rs. 2,65,000/- for Robotically Assisted THL with BIL SO. The patient has opted to make payment in cash.
The bill was raised as per prevailing schedule of charges and no extra charges were taken from the patient. OP3's charges is Rs. 1 lakh for Nursing Home Category patient under GIPSA package for hysterectomy (Laparoscopic Surgery) under cashless facility of insurance company and for cash patient, the charge is Rs. 2,40,874/- for robotic surgery. Moreover, OP3 charges uniformly for all patients and bill does not differ from patient to patient. Robotic surgery charges are not paid by TPA as per GIPSA terms, the guidelines are filed with the reply that insurance company will take only for conventional for laparoscopic surgery and not for robotic surgery. The complaint is liable to be dismissed.
4.1 (Replication of complainant) – In rejoinder the reply of OP1 & OP2, the complainant took legal objection as well as objection to the reply on merits. The written statement is not verified as per law, the written statement bears signature of OP1 only and written statement cannot be considered of OP1 from any quarter. There is no authority letter in support of written statement that its author was authorized to sign the reply filed.
The rejoinder denies other allegations of the reply para-wise and complainant reaffirms that the treatment advised was by the treating doctor vis-à-vis the complainant was never apprised of arrangement of GIPSA-PPN nor of such rates bring projected by the OPs, the para-8 of the complaint has not been denied by the OPs specifically about arbitrary deduction of Rs.1,63,676/-, it is admitted by them. The complaint is correct.
4.2. The complainant also filed separate rejoinder to the reply of OP3, he also denies allegations of fancy litigation or to extract money from the OP3 or other allegations, by emphasizing that OP1 & OP2 were requested for cashless facility through OP3 but same was declined despite insurance cover. The complainant was never disclosed about GIPSA package at any point of time. The complainant was constraint to make the entire payment.
5.1. (Evidence)- Complainant Raju Sagar filed his detailed affidavit of evidence, it is on the pattern of complaint with the support of documents filed with the complaint.
5.2. OP1 led evidence by filing detailed affidavit of Sh. Satish Kumar Sharma, Senior Divisional Manager, it is compact affidavit (para-9 of affidavit narrates that documents are already on record, whereas documents were not filed with the reply nor it were part of record of OP and documents were filed with the affidavit, without leave of the Commission).
5.3. In sub-paragraph 3.1 above, it is already determined that there is no written statement by OP2. There is no evidence led by and on behalf of OP2.
5.4. There is also no evidence by and on behalf of OP3.
6.1 (Final hearing)-At this stage, the complainant, the OP1 and OP3 filed their respective written arguments. At that stage, the OPs were given opportunity to place on record guidelines pertaining to GIPSA-PPN and matter also remained adjourned from time to time to place on record guidelines but OPs failed to file the same.
6.2. The parties were given opportunity to make oral submissions, and ultimately Sh. Sandeep Vishnu, Advocate for complainant make the oral submissions but no oral submissions were presented on behalf of OPs.
6.3. However, the case of parties will be appreciated on the basis of material on record besides written arguments filed.
7.1 (Findings)-The contentions of both the sides are considered, keeping in view the narrations given by the parties in their pleading as well as certain admitted facts, documentary evidence and the analysis presented by the parties in the form of written argument and oral submissions on behalf of complainant.
7.2. By taking into account, stock of all such material, the following are undisputed facts are culled out:-
(a) The complainant is insured and OP1 is insurer, the beneficiaries in the policy are the complainant, his spouse and their two sons. The sum insured is of Rs. 10 lakh.
(b) The episode of treatment for complainant’s spouse had occurred during the life of insurance policy, she remained indoor patient in the hospital/OP3 and total expenses incurred were Rs. 2,54,514/-, out of amount of Rs. 90,838/- was reimbursed through OP2.
(c) The discharge summary dated 10.06.2014 is not disputed and the doctors of OP3 has advised that patient requires Level-II hysterectomy, to be performed Robotically assisted THL (page no.123 and 141-142 of the paper book) under GA, and accordingly the same was performed.
(d) The discharge voucher cum consent letter dated 12.11.2014 was framed and advised by OP2 by email to the complainant to consent it for reimbursement of the amount, it is a unilateral document by OP2.
7.3. In view of the admissions mentioned in paragraph-7.2. above and other facts & features of the case, the following conclusions are drawn:-
(i) The complainant has proved insurance policy cover (it is in 3 pages), the complainant alleges that he was not provided with the terms & condition of the policy nor OPs have informed him of GIPSA-PPN. The OPs have not proved the terms & conditions of policy nor they produced guidelines despite adjourning the matter for couple of dates.
(ii) It was duty of OP1 to provide all terms and conditions of policy and not to keep the insured in dark. In Manmohan Nanda Vs United- India Assurance Co. [Civil Appeal no. 8386/2013) decided on 6.12.2021 by Hon'ble Supreme Court of India has also dealt the regulations 'the IRDA (Protection of Policyholder' Interests) Regulations 2002' and it was held (in paragraph 34 thereof) "that just as insured has a duty to disclose all material facts, the insurer must also inform the insured about the terms and conditions of policy that is going to be issued to him and must strictly confirm to the statement in the proposal form or prospectus or those made through its agents. Thus, principle of utmost good faith imposes meaningful reciprocal duties owned by the insured to the insurer and vice-versa".
(iii) The terms & conditions could be complied with only when the same are known to the insured, however, the OP1 failed to inform the terms & conditions of policy to the complainant, then how it could be expected that those terms & conditions are within the knowledge of complainant/insured to complied with. In Bharat Watch Company (through its partners) vs National Insurance Co. Ltd., Civil Appeal no. 3912/2019 in SLP(C) no. 25468/2016, it was held that in the absence of appellant being made aware of terms of exclusions, it is not open to the insurer to rely upon exclusionary clauses.
(iv) Regulation no. 9(b) and regulation no. 10 (a) (i) of IDRA (Health Insurance) Regulation 2013 talks about PPN agreement by and between health service provider, TPA and Insurer but the same ought to have been in the insurance policy so that insured may have knowledge thereof. However, the OPs have not proved those tripartite agreement between them nor the insurance policy showing that there is existence of such tripartite agreement. It makes out an adverse inference against them.
(v) The OP3 asserts in the reply that the complainant was given estimate for treatment of patient and she had opted to make payment in cash. However, the facts are contrary to it and vexatious - firstly, the OP3 made request to OP1 & OP2 for cashless facility (page no. 22 of complainant’s paper book); secondly, the OP3 is giving detail in written statement as to what extent amount was admissible for conventional surgery and not for robotic assisted THL. But the OP3 had not furnished such clear detail to complainant nor filed any record that when estimates were advised to complainant, he was informed of charges under conventional surgery or of other surgery under agreement with OP1 to enable the complaint to make choice out of two or OP3 performs both types of surgery.
(vi) Since the unilateral discharge voucher cum consent letter dated 12.11.2014 was framed and delivered by the OP2/TPA, but it would not exonerate OP1 from its obligation , when valid claim is made out. In Oriental Insurance Co. Ltd. vs Govt. Tool Room and Training in FA no. 383/05, CPJ 2008 (1) 267 NC it was held that mere execution of discharge voucher and acceptance of insurance claim would not stop insured from making further claim.
(vii) There is IDRA circular dated 24.09.2015 in respect of discharge voucher in settlement of the claim, its operating parts reads “accordingly insurers are hereby advised as under-where the liability and quantum of claim under a policy is established, the insurers shall not withhold claim amounts. However, it should be clearly understood that execution of such vouchers does not foreclose the rights of policy holder to seek higher compensation before any judicial for a or any other for a established by law. All insurers are directed to comply with the above instructions.” .
Moreover, in Worldfa Exports Pvt Ltd. Vs United India Insurance Company Ltd (2015) 225 DLT 722- it was held “in cases where such discharge voucher has been already been taken, the insurance companies shall not raise any objection to the maintainability of the claim on the basis of the discharge voucher. Therefore, the circular dated 24.09.2015 by IRDA and the ratio of case law Worldfa Exports Pvt Ltd. Vs United India Insurance Company Ltd (2015) applies to the situation in hand in favour of complainant and against OP1.
7.4. By reading the discussion and conclusions in sub-paragraph nos. 7.2 and 7.3 above, it stands establish by the complainant that he had furnished record of medical bills of treatment of his spouse in the hospital of OP3, the claim of Rs. 2,54,514/- and OP1 had reimbursed it for Rs. 90,838/- but OP1 could not prove that the amount deducted of Rs. 1,63,676/- was within the parameter, terms & conditions of the policy. Therefore, the complainant has proved his case of reimbursement of medical bills of Rs. 1,63,676/- of his wife against OP1.
It would not be out of context to mention, when there is some arrangement whether confidential or otherwise between the Insurer, TPA and health Service provider with regard to rates/charges, which are lesser than the amount ordinarily meant for the treatment or for alternate technology, then health service provider is supposed to provides that information with comparative table of conventional treatment charges or otherwise, then it would keep informed the patient at the initial stage to decide the option and consequently dispute, litigation, differences and would remain avoided.
7.5. The complainant claims compensation of Rs. 2 lakh in lieu of harassment, trauma and agony and considering the circumstances, compensation of Rs. 20,000/- is allowed in favour of complainant and against OP1. The complainant requests for cost without quantified it and cost of Rs. 5,000/- would serve the purposes.
7.6. The complainant claims interest @ 18% pa, however, considering that the complainant had paid the amount from his own pocket, he deserves interest on the amount subject matter of the complaint. The interest @ 7% pa from the date of complaint till realization of the amount will meet both ends.
7.7. Accordingly, the complaint is allowed in favour of the complainant and against the OP1 to pay an amount of Rs. 1,63,676/- along with interest @ 7% pa from the date of complaint till realization of the amount, apart from damages of Rs. 20,000/- and cost of Rs. 5,000/-.
The OP1 will pay the amount within 30 days from the receipt of this order, failing which the OP1 will be liable to pay interest @ 9% pa on the amount of Rs. 1,63,676/- from the date of complaint till realization of the amount.
7.8. Since the OP2 is TPA, it is facilitator in processing and settlement of the claim on behalf of OP1, therefore, no order against OP2 and complaint is dismissed against OP2.
7.9. OP3 is hospital. OP3 forwarded the cashless facility request for the patient to the TPA or insurer and at that moment of estimates, hospital knows very well about the charges admissible under the arrangement with OP1 or otherwise. The health service provider is expected to inform the patient then and there, it would save the patient from subsequent harassment and other trauma; to that extent, the OP3 with-held that information and failed to rendered this services towards the complainant. Thus directions are given that in all subsequent/future cases [involving similar elements of PPN etc.] to be received by the OP3, the OP3 will take care to inform the insured/patient about the extent admissibility of charges, like it is detailed in the written statement of this case (since this kind of detail is deserved by patient to form appropriate opinion at that material time/moment). It may be treated like standing direction, instructions and advises. Accordingly, complaint is also disposed off against OP3. No order as such of cost are passed against OP3, in view directions already passed against OP1.
8: Announced on this 3rd October, 2023 [अश्विन 11, साका 1945].
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances.
[Vyas Muni Rai] [Shahina] [Inder Jeet Singh]
Member Member (Female) President
