Delhi

North

CC/182/2021

SANTOSH K. SETHI - Complainant(s)

Versus

ORIENTAL INSURANCE COMPANY AND OTHERS - Opp.Party(s)

09 Jan 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

CC NO-182/2021

In the matter of

1. Sh.Santosh K.Sethi

Supreme Towers

Sector-99, T-5/1301

Noida-201304                                                                                  …Complainant

1.         M/s Oriental Insurance Co.Ltd

Head Office

A-25/27, Oriental House

Asaf Ali Road, New Delhi-110002

Through: CMD...Opposite party

2. M/s Oriental Insurance Co.Ltd.

CBO-12, Shakarpur

Scope Minar, Core-2, First floor

Delhi-110092

Through-Branch Manager...Opposite party

3.         M/s.Health Insurance TPA of India Limited

Majestic Omnia Building, 2^nd floor

A-110, Block A, Sector-4

Noida-201301

ORDER

09/01/2024

Ms.Harpreet Kaur Charya, Member

The present complaint has been filed by Sh. Santosh Kumar Sethi, the complainant against, M/s Oriental Insurance Co. Ltd. Head Office as OP-1; M/s Oriental Insurance Co. Ltd., Shakarpur as OP-2 and M/s.Health Insurance TPA of India Ltd. as OP-3, with the prayer for directions to OPs to pay Rs.25,214.50; compensation of Rs.25,000/- for deficiency in services and causing mental pain and harassment  and cost of litigation expenses.

1. Briefly stated the facts of the present complaint are that, Ms.Kusum Lata Sethi, a super senior citizen and mother of the complainant has been taking medical Insurance Policy from OP-1 for more than 20 years. The Medi-claim policy no.271701/48/2020/424 with policy period 28/05/2019 to 27/05/2020 was issued by OP. The mother of the complainant was admitted at J.P.Hospital, Noida, UP on 24/11/2019 in emergency at about 12.00 p.m. with the complaint of fever, loose motion and chills at the advice of the doctor.  The mother of the complainant was admitted for carrying out further investigations as she was diagnosed of acute “FIBRILE ILLNESS”.
2. OP-3 was immediately informed and all the relevant information and documents were submitted for approval.  The complainant has alleged that in order to avoid making claim cashless and paying hospital directly OPs did not respond till the mother of the complainant was discharged on the next day which caused unnecessary harassment and undue stress to the complainant and his family.
3. Complainant had to opt for single room with exorbitant charges of Rs.10,800/- per night, as room in the category for which the insured was entitled to was not available, which was conveyed by the hospital to the OP at the time of admission. The complainant has alleged that neither OP nor hospital informed the complainant about the charges and its admissibility at any point of time.  As there was no response from OP-2 and OP-3, the complainant had to pay Rs.34,763/- to the hospital at the time of discharge.
4. The complainant had to spend Rs.640/-+Rs.1235.60+Rs.1240.90 post hospitalization as well, thus Rs.37,885.50 were the total expenses towards hospitalization and post hospitalization.  The claim for reimbursement was filed on 20/01/2020.  The complainant was asked to submit original receipts for payment which was already submitted with the claim form.  OP-3 was informed about the same vide letter dated 08/02/2020. Despite several personal visits and telephonic communications there was delay in the settlement of claim.  Finally, on 28/02/2020, the TPA (OP-3) deposited Rs.12,671/- directly in the account of the complainant without intimation to the complainant.  A sum of Rs.25,214.50 was deducted from total claim without any valid reason and the claim settlement letter  as well as claim processing sheet were sent to the complainant after repeated requests.
5. The complainant has also disputed claim processing sheet where professional fees of the doctors amounting to Rs.3400/- has been disallowed and only a sum of Rs.630/- has been allowed.  Similarly, instead of Rs.12,980/- only Rs.2,950/- have been allowed for routine investigations.
6. Despite letters/emails sent to OP-3 on various dates i.e. 06/03/2020, 08/03/2020 & 19/09/2020 the grievance of the complainant was not redressed.  The complainant has further alleged that instead of easing the settlement process, OP-3 invariably complicated the manner, delayed the settlement and made the complainant run from pillar to post for their genuine claim settlement.  He has also alleged that the OP-1 claims for providing cashless facility, however, no such facility has been offered and in majority of cases the insured is left at the mercy of the hospital and Insurance Company. Thus, it is unethical conduct and unfair trade practice, thereby defeating the purpose of taking medi-claim insurance policy.
7. Copy of email dated 31/12/2019 to OP-3 as Annexure-C-1, letter dated 20/01/2020 to OP-3 for reimbursement of hospitalization and post hospitalization expenses as Annexure-C-2, letter dated 08/02/2020 as Annexure-C-3, discharge voucher cum claim settlement letter dated 28/02/2020 as Annexure-C-4 (Colly), email dated 06/03/2020 as Annexure C-5 (colly) have been annexed with the complaint.
8. Notice of the present complaint was issued to the OP-1, OP-2 and OP-3.
9. Thereafter, Written statement was filed on behalf of the OPs where they have taken several preliminary objections such as there was no cause of action in favor of the complainant because OP-3 had already processed the insurance claim of bills of hospitalization as per terms of policy and had paid claim of Rs.12,671/- to the complainant as full and final payment and the complainant has also issued the discharge voucher.  The complainant was insured for a sum of Rs.2,00,000/- and as per clause (a) of medi-claim policy, the room rent was only 1% of the insurance value and accordingly, other charges such as doctor consultation, investigations and nursing charges were paid in same proportion were also deducted as per room rent except medicine.  They have reproduced the clause as hereunder :

1. Room, boarding and Nursing expenses as provided by Hospital/Nursing Home not exceeding 1% of the sum insured or Rs.5000/- per day whichever is less. 

Thus, as per the policy clause out of the total bills of Rs.37,885.50, the OP has processed the claim of Rs.12,671/- was paid as full and final and Rs.25,214/- were deducted.The Claim Proceeding Sheet had already been supplied to the complainant and he has filed the discharge voucher cum claim letter and claim proceeding sheet alongwith complaint which suggest that at the time of accepting the claim amount, the complainant was satisfied.

10. They have further submitted that as per clause 2.3 and 2.3 (C) the present claim was not admissible because the expenses of hospitalization (pre-hospitalization and post hospitalization) are admissible only if the hospitalization is for minimum period of 24 hours and the disease/illness is of such a nature that patient is required to be hospitalized.  The complainant did not have any of the illness mentioned in the 2.3(A) clause.  And even as per clause 2.3(C) “other than these treatment mentioned under 2.3(A), the condition of minimum 24 hours hospitalization SHALL also not apply provided”

(i) the treatment is such that it necessities hospitalization and the procedure involves specialized infrastructural facilities available only in hospital.
OR
ii)  surgical procedure involves has to be done under general Anaesthesia
BUT
iii)  due to technological advances hospitalization in either of the case is required to less than 24 hours.

​

20. OPs have not placed anything on record to rebut the allegation of complainant as to non-supply of policy terms and conditions, thus, it has remained rebutted. Once, the policy terms and conditions have not been supplied to the insured, they are not binding on the insured. We would also like to refer to the guidelines issued by Insurance Regulatory and Development Authority of India (IRDAI). IRDAI had issued “Modified Guidelines on Product Filing in Health Insurance Business Norms on Proportionate Deductions” dated 11th June, 2020. In the said guidelines, it is provided:

“6. Insurers shall ensure that proportionate deductions are not applied in respect of the hospitals which do not follow differential billing or for those expenses in respect of which differential billing is not adopted based on the room category. This shall be clearly specified in the policy terms and conditions.”

21. Further, Hon’ble NCDRC  in New India Assurance Co. Ltd. v/s A.K.Kariappa Kaveri Niwas  Manu/CF/1559/2015 has held (para 8):-

8……. Instead of making proportionate deduction from the charges paid by the complainant to the hospital it ought to have inquired from the concerned hospital as to what exactly would be the charges payable in case the room rent was Rs.1,000/-per day.  It is quite possible that the said charges would remain same irrespective of whether the room rent is Rs.1,000/- or Rs.2,000/- or even Rs.5,000/-per day. Another possibility is that the charges would vary with the room rent charged by the hospital, but the variation may not be proportionate for the variation in the room rent, yet another possibility is that the charges would be directly proportionate to the room rent.  Therefore, it would be necessary for the Insurance Company to make an inquiry in this regard from the hospital and find out what would be the applicable charges for the room to which the insured is entitled under the terms of the policy.  However, since no such exercise was undertaken by the insurance company the deduction made by it except in respect of room rent was not justified.

                                                                        Claim Processing Sheet:

22. As per Ex.CW1/5 , the discharge voucher cum Claim Settlement Letter dated 28/02/2020, wherein the Room and Nursing charges have been approved as Rs.2,000/- as against Rs.10,800/-, EXCESS ROOM RENT, NURSING CHARGES AND RMO CHARGES. It is also seen from the table above that professional fee and investigation charges have been deducted proportionately with the remark “ROOM RENT LINKED DEDUCTION OF DOCTOR CHARGES AND ROOM RENT LINKED DEDCUTION OF INVESTIGATION CHARGES”.  Thus, in the light of the above discussion, we feel that in the absence of inquiry report from the treating hospital about the variation of hospital charges based on category of Room, the proportionate deduction by the OP-1 is not justified. The claim of the complainant has been settled by OPs in an arbitrary manner.  Therefore, we hold OP-1, liable for the deficiency of service and also for adoption of unfair trade practice.
23. Hence, in the facts and circumstance of the present case and in the interest of justice we direct OP-1 to :-

1. Reimburse the complainant Rs.24,550.50 (Rupees Twenty Four Thousand Five Hundred Fifty and fifty paisa only) [Rs.25,214.00 minus Rs. 664/-(deducted on account of consumables)]
2. Pay compensation of Rs.10,000/- to the complainant on account of deficiency in services and adoption of unfair trade practice, inclusive of litigation expenses.

The order be complied within 30 days of receipt of this order.  In case of non-compliance, OPs shall be liable to pay interest @7% p.a. on Rs.34,550.50(a+b) from the date of order till realization. Office is directed to supply the copy of this order to the parties as per rules.  Order be also uploaded on the website.  Thereafter, file be consigned to the record room.

(Harpreet Kaur Charya)                                                                              (Ashwani Kumar Mehta)

          Member                                                                                                           Member

                                                              (Divya Jyoti Jaipuriar)

                                                                          President