The instant case was started on the basis of a petition under Section 12 of the Consumer protection act, 1986 which was registered as Consumer Case No. 40/17 in this Forum.
The fact of the case as revealed from the petition of complaint is that the complainant/petitioner purchased a Medi Claim policy on 09.06.2010 and renewing the policy every year and his current policy No. 313501/48/2017/755.
During the continuance of the said policy the complainant taken to Emergency of Peerless Hospitex Hospital and Research Centre Limited for heart palpitation on 18th December 2016. He was treated by Dr.Kushal Vikram and shifted to ICCU of Peerless Hospital on the same date. The family members of the petitioner submitted documents at Peerless Hospital for cashless facility from MD India Health Insurance TPA Pvt. Ltd. (TPA). The TPA acknowledged the request for cashless facility on 19th December, 2016 and demanded all previous year policy copies. But the family members were not in a position to submit all previous year policy copy except current year policy copy, MID ID Card and valid photo-id proof, applied for cancellation of cashless benefit. Finding no other alternative the family members of the petitioner somehow collect the amount of Rs.42,202/- for the treatment of the petitioner and paid the bill of hospital and the petitioner released on 20.12.16 from the hospital.
After discharging from the Nursing Home the complainant submitted all the documents relating to treatment before the OP/Insurance Co. on 30.12.16 claiming Rs.42,202/- (Rs.40,456/- hospitalization cost & Rs.1,746/- post hospitalization checkup and medicine) towards medical reimbursement. But the O.P/Insurance Co. settled the claim amounting to Rs.15,606/-.
As such the complainant was compelled to file the petition before this Forum for reimbursement of Rs.42,202/- (rupees forty two thousand two hundred and two only) for medical treatment with a prayer for compensation of Rs. 50000/- for harassment and mental pain and agony and Rs.10,000/- as litigation cost.
The petition has been contested by the OP by filling the written version denying all the material allegations as leveled against the OP contending inter alia that the case is not maintainable, the case is bad for non joinder of necessary parties as MD India Healthcare Service (TPA) PVT. Ltd who is the TPA in this case. The claim is barred by Law of Limitation. There is no cause of action to file this case.
The definite defence case is that the O.P settled the claim amount as per terms and conditions of the policy through TPA as the TPA is the Authority to settle the claim.
There is no deficiency or negligence on the part of the OP Insurance Company. Considering such facts and circumstances the case is liable to be dismissed with cost.
During trial the complainant was himself examined as P.W.1. On the other hand the O.P/Ins. Co did not adduce any evidence. Both parties file document to prove their respective case.
Now the point for determination whether the complainant/petitioner is entitled to get any relief as prayed for.
DECISION WITH REASONS:
At the time of argument the Learned Lawyer for the complainant argued that the complainant expend Rs.42,202/- for his treatment at Peerless Hospital. But the Insurance Co. paid only Rs.15,606/- against the claim of Rs.42,202/- which is in gross violation of the policy and the amount has been withheld with intention to deprive the complainant for his legitimate claim.
On the other hand the Ld.lawyer for the Insurance Co. argued that the claim was decided by the TPA namely M.D India Health Care Services Pvt. Ltd. after proper scrutiny. The Ld. Lawyer for the O.P further argued that in the W.V it has been clearly stated that as per policy condition No.3.41 and I.C guideline the surgical PPN package is applicable for noncash less as well as cashless claim. According to the calculation the amount comes to Rs.15,606/- and that amount has been credited to the account of the complainant. Besides that the company is not liable to pay any amount of money.
Now let us consider the policy condition. On perusal of the policy it is found that the company will pay as per policy for hospitalization expenses, for medical/surgical treatment taken as an inpatient in any nursing home/hospital in India as defined in the policy. Moreover, according to terms and condition as laid down in clause 3.41 means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved. According to clause 3.41 reasonable and customary charges means the charges of services or supplies charge the standard charges or the specific provider and consistent with the prevailing charges in the geographical area for the identical or similar services, taking into account the nature of the illness/injury involved.
On perusal of the document it is found that the complainant was treated as indoor patient of Peerless Hospital, angiography was done and necessary medicines were prescribed for which the bill has been submitted. On perusal of the bill it is found that the complainant expend Rs.42,202/-. So, the insurance Co. is liable to pay the same amount. But the Insurance Co. has paid Rs.15,606/-. So, the Insurance Co. is liable to pay the rest amount of Rs.26,596/-. In a treatment as indoor patient taking medicines is a vital factor unless and until medicines is taken by the patient, the condition of the patient may be deteriorated and for the purpose of purchase the medicines the complainant is entitled to get the amount. Mere getting the angiography cost is not sufficient. So, considering such facts and circumstances the complainant is entitled to get money for treatment of Rs.42,202/-. As the Insurance Co. has paid Rs.15,606/- the rest amount Rs.26,596/- is likely to be paid by the Insurance Co.
Fees paid are correct,
Hence, it is
ORDERED
That the complaint case being no. CC-40/17 be and the same is allowed on contest against the OP..
The complainant gets compensation of Rs. 42,202/- for medical expenses. As the Insurance Co. has paid Rs.15,606/- the rest amount of Rs.26,596/- is likely to be paid by the Insurance Co. Besides that the complainant is entitled to get Rs.10,000/- for mental pain and agony and harassment and Rs.5000/-as litigation cost.
The OP is directed to pay the amount within one month from the date of order failing which it will carry interest at the rate of 5% per annum from the date of default of payment till recovery. In case of failure of payment the complainant is at liberty to proceed as per law.
Let a copy of this order be given to the parties free of cost.
