Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.49/2016
Shri Ashok Kumar Jain son of Late M.L.Jain
R/o. 134-B, Ground Floor, Veer Nagar,
Jain Colony, Delhi-110007 ...Complainant
Versus
OP1. Park Mediclaim TPA Private Limited,
702, Vikrant Tower, Rajendra Place,
New Delhi-110008
OP2. National Insurance Co. Ltd. having its Registered
Office at 17-18, Inderprastha Bhavan, 2nd floor,
New Subzi Mandi, Azadpur, Delhi-110033. ...Opposite Party
Date of filing: 12.02.2016
Order Reserved on: 15.12.2022
Date of Order: 20.12.2022
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. (Introduction to case of parties) : This complaint, under consideration, was filed u/s 12 of the Consumer Protection Act 1986, for allegations of deficiency in services and unfair trade practice against OPs, since complete legitimate and valid medi-claim of ailment of his wife Smt. Sunita Jain, covered under the policy, was denied by the OPs, which caused immense suffering by the complainant, from the time of discharge of his wife from hospital and onwards. The cover was of Rs.5 lakhs. Whereas the OP2 had opposed the complaint that the patient Smt. Sunita Jain had history of hypertension 3-4 years, and insurance sum insured was considered as Rs.2,00,000/- and in terms of cover, the admissible claim was processed, allowed and paid by TPA/OP1. No further claim is made out.
2.1 (case of complainant ) : Succinctly, the complainant Shri Ashok Kumar Jain alongwith his family has been residing at the address given in array of parties. He is a consumer/insured, the OP1- Park Medi-claim TPA Private Limited is an agent/TPA of OP2/Insurer- National Insurance Company Limited. OP2 is in the business of insurance, it formulated various policies cover to cater the needs of various customers against the payment of premium. The complainant has been holding medi-claim policy since 2003 from OP2. OP2 had also extended the cover to complainant's entire family consisting the complainant Shri Ashok Kumar Jain, his wife Smt Sunita Jain and their daughter Ms Vasudha Jain, they all are covered in the policy for a sum of Rs.5,00,000/- each, which was also extended to current year period (2015-2016) with effect from 09.07.2015 to 08.07.016 (copy of policy is annexed to complaint at pages 13-14), on payment of premium to OP2 against receipt (which annexed to complaint at page 15), however, policy issued was without terms and conditions and after payment of premium.
2.2: On 21.9.2015, complainant's wife Smt Sunita Jain suffered from headache & dizziness. After necessary examination and tests, she was admitted in Fortis Hospital, Shalimar Bagh, New Delhi and she was also operated for her ailment. She remained indoor patient and discharged on 28.9.205 (discharge summary is annexed at page 16). The complainant was entitled for cashless facility for treatment of his wife but OPs have not provided entire cashless facility within limits of coverage of sum insured for her treatment. The total amount of bill of hospital was Rs.4,36,411/- and complaint was revealed that only Rs.1,68,000/- was processed by the OP1 and complainant was asked to pay balance amount of Rs.2,68,411/- being his share. The complainant was compelled to arrange and pay such charges at the time of discharge of his wife from hospital. The hospital has charged the amount as OP1 has not processed the legitimate claim of his wife, the complainant suffered immensely.
2.3: Then complainant submitted claim form with documents and discharge slip and inquired of non-compliance of entire cashless facility, no reasons were told to him. Later, a sum of Rs.32,508/- were directly deposited by OP2 into the account of complainant (as per letter at page 20), which was without consent for settlement of claim by complainant, however, after adjustment of this amount, balance of Rs.2,35,903/- is still not paid. The complainant was forced to sign settlement of claim as processed by OP1, which complainant denies as the claim was not offered as per actual expenses. The complainant visited to OPs number of times to settle his claim but it was rejected and when complainant requested for re-examine the case, on the basis of insurance policy issued but of no avail. Whereas at the time of taking of policy, the complainant was assured by OP2 about quality, standard or grade services & various facilities including cashless facility and cover of entire family by such insurance cover as well as OP1/TPA will always remain available to facilitate and solve all problems, if so arises, which proved false.
2.4: The rejection of complainant's valid claim on baseless grounds is covered by deficiency of services and unfair trade practices on the part of OPs. The complainant suffered mental agony and harassment at the hands of officers of OPs and it has also caused loss of precious time of the complainant. That is why complaint is filed for refund of Rs.2,35,903/-being balance amount of treatment, interest @ 18%pa from the date of discharge till realization, compensation of Rs.2,00,000/- on account of mental paid and agony for non-payment/refund of amount of treatment and litigation costs of Rs.55,000/-.
3.1 (case of OPs) : OP1/TPA had caused appearance, memo of appearance was also entered through counsel but no reply was filed. Whereas the other OP2 filed detailed reply dated 12.5.2016 under the signature of counsel for OP2 (and without the signature of OP2 or its officer) and it had opposed the claim. Briefly, neither there is any deficiency of services nor unfair trade practice. TPA (i.e. OP1) has already paid the admissible claim of the complainant and no further amount is payable. OP2 filed terms and conditions of policy (annexure-A is copies of policy for the year 2013-2014; 2014-2015 and 2015-2016) and report of TPA (annexure-C).
3.2: In this complainant's case, the sum insured was considered as Rs.2 lakhs since patient Smt Sunita had history of hypertension for 3-4 years. The terms and conditions of policy (now annexure-B) were duly supplied to the complainant but complaint pleads contrary to it. The amount of Rs.32,508/- was deposited with the consent of complainant and it was full and final amount as mentioned in the letter (annexure-C) that in case no confirmation would be received, it would be presumed that complainant has consented to the settlement. The other allegations were denied by OPs with prayer to dismiss the complaint.
4. (Replication of complainant) : The complaint filed replication, the allegations of OP2's reply were denied and complainant reaffirms his complaint as correct.
5. (Evidence of parties) : Complainant/Ashok Kumar Jain filed his affidavit of evidence on the lines of complaint and it is also tendered all the documents, which were annexed with the complaint. Similarly, on the other side, an affidavit of one Mr. Surinder Rai, National Insurance Company, was filed for evidence of OP2, which is replica of a few paragraphs extracted from the written statement of OP2. The deponent of affidavit relies upon two documents (which were annexure-A and Annexure-B to the reply). However, Mr. Surinder Rai in his affidavit says that he being Senior Official of the company is competent and authorized to depose on behalf of OP2 Company but he has not disclosed his designation/position in his own affidavit nor any documentary record filed of his authority to depose on behalf of OP2.
6. (Submission of Parties) : The written submissions have been filed on behalf of parties, which are extracts of pleading and evidence. Shri Sachin Bhadra, Advocate for complainant also made oral submission also but other-sides/OP2 confines on written submission to be considered as complete submissions.
7.1 (Findings) : The case of both the sides is viewed, assessed and considered. On face of it, the relationship of the complainant as Insured and of OP2 as Insurer and of OP1 TPA is not disputed. The complainant had insurance policy from OP2 for the period 09.07.2015 to 08.07.2016 is also not disputed, complainant also filed copy of policy. The complainant claims he has been having policy since 2003, which is not disputed by OP2 in its reply. On the other side, OP2 filed on record polices of other periods of 09.07.2013 to 08.07.2014 and from 09.07.2014 to 08.07.2015 of complainant. In all such policies, the complainant, his wife and their daughter are covered for sum insured of Rs.5,00,000/- for each.
7.2: It is also not disputed that complainant's wife was admitted in the hospital on 21.9.2015, she was diagnosed of 'spontaneous intracerebellar hematoma left' operated and discharged on 28.9.2015, hospital had raised the bill. However, the complainant's wife case was considered of hypertension of 3-4 years and then sum insured limit was constraint to Rs.2,00,000/- against Rs.5,00.000/- by OP2. On that basis, out of total bill of Rs.4,36,411/- , the complainant's claim was considered for Rs.1,68,000/- (directly paid by TPA/OP1 to hospital) and then further amount of Rs.32,508/- was paid finally. There are dispute on these points and the same are to determined.
7.3: The material dispute is in respect of hyper-tension of Smt. Sunita Jain. The OP2 says that she had history of hyper-tension for the 3-4 years but OP2 had not filed any document for showing, she had such history of 3-4 years. On the other side, there is discharge summary dated 28.9.2015 (annexure to complaint at page 16), which reflect 'past history - hypertension since 6 months', which means six months prior to 21/28.9.2015, which comes to month of March 2015. The OP2's such plea is without any base. Therefore, the very basis of OP2's opinion to treat the sum insured to the limit of Rs.2,00,000/- instead of Rs.5,00,000/- is without substance and record. Moreover, it was not the first policy of period from 09.07.2015 to 08.07.2016 as the complainant has been taking cover from previous years too. Therefore, the cover of insurance is for Rs.5,00,000/- for Smt. Sunita Jain and OPs could not be considered reduced cover/sum insured as R.2,00,000/-.
7.4: The other controversy raised is regarding disallowed amount, which OP2 refers to its email dated 8.3.2016/Annexure-C, it consists two parts, viz. in first part when Smt Sunita was in hospital and an amount Rs.1,30,092/- was paid/allowed and in the second part another sum of Rs.32,508/- was allowed; its total is Rs.1,62,600/-. Simultaneously, medical bill (annexure to complaint on page 19) shows that when hospital raised the bill of Rs.4,36,411/- out of which an amount of Rs.1,68,000/-was share of TPA/OP1 and other amount was shown as share of patient. Later, an amount of Rs.32,508/- was credited to the account of complainant. The total amount allowed for treatment was Rs.2,00,508/- [i.e. Rs.1,68,000/-+ Rs.32,508/-], which OP2 claims that the sum insured was treated as Rs.2,00,000/-. As per proceedings of this Commission, the OP was inquired to furnish information on what basis there was disallowed amount to arrive at figure of Rs.32,508/- but no such information was supplied. The amount is shown in first part of email/annexure-C of OP2 is contradictory to amount paid by TPA to hospital, as per detail shown in bill. Moreover, no terms and conditions of insurance policy has been produced and prove to support the deductions mentioned by the OPs, whereas the OPs were required to establish those terms and conditions that those deductions were under contractual covenant. Although, the OP2 opposed complaint's plea of not furnishing terms and conditions with policy but OP2 itself has not produced/proved those terms and conditions to establish its own case.
7.5: Therefore, the documents and circumstances on record proves the case of complainant that his family member/patient Smt Sunita was covered by said insurance policy for sum insured to the extent of Rs.5,00.000/-. On the other side, the OP2's written statement was not signed and verified by any of its Officer, the affidavit of evidence also did not disclose designation of its author/deponent, the email/annexture-C is contradictory to other records. The case of OPs is too weak to dilute the case of complainant. The Complainant is entitled for medical expenses to be under maximum limit of Rs.5,00,000/-.
7.6: Since complaint has been paid total bill of Rs.2,00,508/- out of total bill of Rs.4,36,411/-, the remaining bill of Rs.2,35,903/- is to be refunded by OPs jointly and severally, which he has succeeded to establish.
7.7: The complainant has also proved that he started facing trauma and stress when the entire medical bill was not shared by OPs and when claim was lodged, it was not considered and then complainant lodged the complaint to seek his valid claim, which stands allowed. Thus, he deserves damages of Rs.10,000/- for suffering harassment and mental agony to him and his family.
7.8: The complainant has claimed interest @ 18%pa, however, there is no supporting evidence of such rate of interest claimed. However, it is manifest that the complainant paid the balance bill amount out of his own pocket to get discharged his wife from hospital, he was deprived of use of his money, thus interest @ 07% pa appears reasonable, which is allowed from the date of complaint till realization to meet both ends of justice.
7.9: The cost to complainant is also allowed, it is quantified as Rs,5,000/- in his favour against the OPs.
7.10: Accordingly, the complaint is allowed in favour of complainant against the OPs, while directing the OPs jointly and severally to pay Rs.2,45,903 [i.e. the balance medical bills of Rs.2,35,903/- plus damages of Rs.10,000/-] along-with interest @ 07% pa from the date of filing of complaint till realization, apart from cost of Rs.5,000/-. The OPs shall pay the amount to complainant within 30 days.
8: Announced on this 20th day of December, 2022. Copy of this Order be sent/provided to the parties free of copy as per Regulations.
