DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.666/2010
Shri Sheel
S/o Shri B.Lal,
116-A,Krishna Nagar,
Street-8 Safdarjung Enclave
New Delhi-110029. ….Complainant
Versus
- R.G.Stone Urological Research Institute
F-12, East of Kailash
New Delhi-110065
- United India Insurance Ltd.
46, Vasant Lok,
2nd Floor Vasant Vihar,
New Delhi. ….Opposite Parties
Date of Institution : 03.11.10 Date of Order : 13.12.18
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
Ms. Kiran Kaushal, Member
Kiran Kaushal, Member
ORDER
Briefly stated facts of the complainant are that:-
1.1 The complainant, Shri Sheel, had taken individual medi-claim policy from United India Insurance Company Ltd. hereinafter referred to as OP-2 for the period 18.11.2007 to 17.11.2008 covering the complainant himself and his wife Ms. Neelam. On 15.03.2008, wife of the complainant was diagnosed with stone in Gallbladder by R.G. Stone Research Urological Institute (OP-1). She underwent a surgery by OP-1 and thereafter OP-1 sent a cashless request form for reimbursement of expenses worth Rs.40,371/- incurred during the surgery to OP-2.
1.2 On 15.03.2008, the TPA of OP-2 issued a preapproval certificate in which the total sum of Rs.31,200/- were approved against the expenses incurred in the surgery of the patient. The complainant states that the patient was discharged at 11.30AM and the complainant along with patient waited till 06.00 PM due to non clearance of bills as the remaining amount of Rs. 9,171/- was not disbursed by OP-2. After waiting for long time the complainant paid the balance amount of Rs.9,171/- to the hospital with temporary receipt and released the patient from the hospital.
1.3 It is next alleged that the complainant approached OP-2 for the balance amount but received unsatisfactory response and later on 05.11.2009 complainant received a letter from OP-2 stating that out of total balance amount of Rs.9,171/- they had already paid Rs.3,280/- to R.G. Stone Hospital and balance Rs.5,891/- was not payable under the head of ‘Pharmacy’. It is next averred that the complainant approached R.G. Stone Hospital to ask for refund of the money deposited with them. OP-1 by way of reply to the notice of complainant stated that OP-1 has done nothing against law. Therefore, there was no question of refund of Rs.9,171/-.
1.4 Under said circumstances, the complainant approached the Forum with the prayer to refund the basic amount of Rs.9,171/- with interest @ 2.5% per month and lumpsum payment of Rs.50,000/- for damages, harassment by way of compensation and Rs.18,000/- for legal expenses.
2. OP-1 and OP-2 resisted the complaint by filing their written statements respectively.
2.1 OP-1 submitted in its written statement that the complainant has no grievance on account of treatment with OP-1. OP-1 after the treatment raised a final bill of Rs.40,371/- and took up the matter with the TPA of the complainant wherein it was informed that OP-2 had sanctioned the authorized limit of Rs.31,200/-. TPA of OP-2 company while issuing preapproval certificate had made it clear that “if no additional authorization is available then the hospital must collect the access amount directly from the beneficiary at the time of admission /prior to discharge from the hospital”. Under these circumstances OP-1 requested the complainant to make rest of the payment and get the patient discharged. OP-1 submits that it was mainly concerned with the payment which was to be made either by the insurance company or complainant hence the dispute is between the complainant and the insurance company. There is no negligence on part of OP-1 and the complainant has not suffered any loss due to OP-1. It is prayed that the complainant has no grievance qua OP-1 therefore complaint merits dismissal.
2.3 OP-2 resisted the complaint by filing its written statement inter-alia on the ground that the complainant had taken individual medi-claim policy and after the treatment of the insured the hospital where the patient is treated had sent a cashless request form for reimbursement of the expenses worth Rs.40,371/- on 15.03.2008 TPA of OP-2 company issued a preapproval certificate in which the TPA approved a total sum of Rs.31,200/- against the expenses incurred in the surgery of the patient. OP-2 further states that in the claim sheet it was specifically mentioned the amount of Rs.5,891/- is not payable under the head ‘Pharmacy’ and reasons for deduction given as cover, stapler, leukoplaster, clip, Tegaderm charge not payable. Further under the head miscellaneous it is shown that the amount of Rs. 3,280/-was deducted as per issued of PAC. The TPA after considering the deduction on said two heads amounting to Rs.9,171 had approved the claim of the complainant to the tune of Rs. 31,200/- and OP-2 already paid the amount approved by TPA therefore no further amount was payable by OP-2 as wrongly alleged by the complainant.
2.4 It is next stated by OP-2 had informed the complainant vide letter dated 05.11.2009 that sum of Rs.3,280/- has already been paid by TPA of OP-2 company and adjusted further the sum of Rs.5,891/- was not payable on the head of centre ‘Pharmacy’ which is clearly shown in the final bill issued by OP-1. Therefore, the allegations of the complainant are baseless and without any substance and the relief claimed by the complainant are not payable. The complaint merits dismissal with exemplary costs.
3. Rejoinder and evidence by way of affidavit is filed by the complainant wherein facts of the complaint are reiterated. No evidence has been filed by OP-1. Evidence of Shri N.K Khana Assistant Manager United India Insurance Company Limited has been filed on behalf OP-2.
4. Written arguments have been filed by the parties.
5. Arguments are heard on behalf of complainant and OP-2. Despite affording opportunity to OP-1, none appeared on behalf of OPs to advance arguments.
6. We have gone through the material available on the record.
7. Admittedly, the complainant had taken the medical policy from OP-2 for the period from 18.11.2008 to 17.11.2008. As per the said individual mediclaim policy, the complainant and his wife were duly covered under various ailments with OP-2. On 15.03.2008, complainant’s wife was diagnosed with gallbladder stones and had to be admitted with OP-1 hospital for surgery. The said surgery was successfully performed in the hospital of OP-1. The complainant was informed that the mediclaim policy was a cashless policy. Therefore, a cashless form for reimbursement of the expenses worth Rs.40,371/- incurred in the surgery was sent to OP-1 for disbursal. On 15.03.2008, the TPA of OP-1 issued a preapproval certificate in which total sum of Rs.31,200/- against the expenses in the surgery of the patient was approved. TPA of OP-1 sanctioned the authorized limit of Rs.31,200/- with the instructions that if hospitalization expenses exceed the authorized limit then the additional letter needs to be sent for further authorization. If no additional authorization is available, then the hospital must collect the excess amount directly from the beneficiary at the time of admission/ prior to discharge from the hospital.
8. Dispute between the parties arose, when the balance amount of Rs.9,171/- was not approved by OP-1 and the complainant waited for long period of six hours in the hospital before he finally made the payment of Rs.9,171/- with temporary receipt and got the patient discharged from the hospital. On repeated requests the complainant received a letter dated 05.11.2009 stating that out of the total balance amount of Rs.9,171/- OP-2 had already paid Rs.3,280/- to OP-1 and balance amount of Rs.5,891/- was not payable under the head of ‘Pharmacy’. For the sake of identification we mark the said letter as Mark-A.
9. OP-2 has annexed the approval form by the TPA as Annexure-R3 wherein it is mentioned that the amount of Rs.5,891/- is not payable under the head ‘Pharmacy’ and the reasons for deduction given as – cover, stapler, lukoplaster, clip, Tegaderm charge not payable. Further under the head ‘miscellaneous’ it is shown that the amount of Rs.3,280/- is deducted for ‘as per issued of PAC’. OP-1 in its written statement has very categorically stated that the said letter dated 05.11.2009 “which was issued to the complainant does not specify when and to whom the amount of Rs.3,280/- has been paid and by what means. The OP hospital has checked accounts and finds that no such amount has been paid to the hospital”.
10. OP-2 has nowhere controverted or challenged the averment made by OP-1 therefore, this forum is of the opinion that though the amount of Rs.5,891/- was not payable under the head ‘Pharmacy’ but Rs.3,280/- remains unaccountable.
11. Hence, we allow the complaint and direct OP-2 to refund Rs.3,280/- to the complainant @ 9% per annum from the date of payment till realization. Additionally, OP-2 is to pay Rs.10,000/- towards harassment and legal expenses.
12. The order shall be complied within 30 days of receipt of copy of this order failing which OP-2 shall become liable to pay interest @ Rs. 12% per annum on the amount of Rs.3,280/- from the date of payment till its realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 13.12.18.
