New Complaint No.253 of 2023.
Date of Institution:27.10.2023.
Old Complaint No:353 of 2018.
Date of Institution: 28.08.2018.
Date of order:19.01.2024.
Balwinder Kumar Son of Ramesh Kumar, resident of Village Daburi, P.O Magar Mudian, Tehsil and District Gurdaspur.
…..........Complainant.
VERSUS
1. Raksha Health Insurance TPA Pvt. Ltd., 14/3, First Floor, Main Mathura Road, Faridabad, Haryana. Phone: 0129-4289999, 18001801444, through its Manager.
2. Abrol Medical Centre Multispecialty Hospital, Kailash Enclave, Batala Road, Gurdaspur.
3. United India Insurance Co. Ltd., Regional Office: Feroze Gandhi Market, Ludhiana, through its Manager / Authorized Officer.
….Opposite parties.
Complaint U/s 12 of Consumer Protection Act.
Present: For the Complainant: Sh.Kewal Singh Saini, Advocate.
For the Opposite Party No.2: Sh.Pardeep Kumar and Sh.Vikram Kapil, Advocate.
For the Opposite Party No.3: Sh.Sandeep Ohri, Advocate.
Opposite Party No.1 exparte.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Balwinder Kumar, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act (here-in-after referred to as 'Act') against Raksha Health Ins. TPA Pvt. Ltd. Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the complainant is serving in Punjab National Bank and presently posted at PNB Branch Village Chak Hakim, Phagwara District Kapurthala. It is pleaded that the complainant alongwith his father Ramesh Kumar and his mother Anita are insured with the opposite party No.3 under Health Insurance Corporate Plan vide policy No. 5001002817P110672408 valid from 01.10.2017 to 30.09.2018 and their ID No. is UIC 545319986 PNBA. Smt. Anita wife of Ramesh Kumar i.e. mother of the complainant being member of the insurance policy vide member ID No. UIC 545319986 PNBA and is insured for medical treatment expenses upto Rs.3,00,000/- per year. It is further pleaded that the opposite party No. 1 registered under the Companies Act, 1956 is a licensed TPA under IRDA Act, 2001 to act as facilitator for the proceeding of the claim of the opposite party No. 3 and the opposite party No. 3 is responsible for the act of the opposite party No. 1 being principle insurer and the opposite party No. 1 is responsible being processing agency. Therefore, the complainant is entitled to claim the medical expenses from the opposite parties No. 1 and 3. It is further pleaded that the complainant is paying the premium on behalf of the complainant, his father Ramesh Kumar and mother Anita Rani through his employer bank i.e. PNB Branch, Chak Hakim, Phagwara and as such the complainant as well as his mother is consumer of the opposite parties and is entitled to claim medical expenses incurred on his mother Anita Rani who is member of insurance medi claim policy. It is further pleaded that on 01.05.2018, the mother of the complainant namely Anita felt severe pain in back radiating and difficulty in walking etc. so she was brought to the opposite party No. 2 / AMC Hospital, Gurdaspur which is one of the empanelled hospital of the opposite party No. 3. The mother of the complainant Anita was admitted in the said Hospital on 01.05.2018 and was discharged on 08.05.2018 and an amount of Rs.35,932/- was spent on her treatment as well as on the medicine. It is further pleaded that timely intimation was given to the opposite party No. 1 regarding admission of Anita i.e. mother of the complainant under the policy for cashless treatment and opposite party No. 1 also replied On-line to the hospital for admitting the above said Anita Rani in the AMC Hospital Gurdaspur vide opposite party's On-line letter dated 01.05.2018, addressed to the AMC Hospital, Gurdaspur. It is further pleaded that on 02.05.2018 the opposite party No. 1 denied the cashless treatment facility On-line. However, on the same day the opposite party also informed the AMC Hospital Gurdaspur that this denial is not the denial of treatment but is denial of the credit facility. The claim for reimbursement can be sent to them. Then, the complainant made the payment of Rs.35,932/- from his own pocket to the opposite party No. 2 on account of treatment expenses of his mother. It is further pleaded that when the opposite parties refused to allow the cashless treatment, the complainant could not treat his mother well due to financial difficulties and as such could not get full treatment and has to take their mother back to home without being fully recovered and this as such it is deficiency in services on the part of the opposite party No. 1. It is further pleaded that thereafter the complainant sent the claim dated 30.05.2018 regarding the payment of expenses incurred on the treatment of his mother to the opposite party No. 1 in their prescribed format alongwith bills etc. but the opposite party No. 1 refused to reimbursement the amount of claim vide On-line intimation dated 06.06.2018 and rejected the claim as 'Non-Payable'. It is further pleaded that the complainant then sent numerous On-line requests to the opposite party No. 1 to let him know the reason for rejecting the claim but no intimation/reason was given by the opposite party No. 1. The complainant then called on the Customer Care Centre of the opposite party No. 1 at Number 1800 180 1444 regarding the reason and then the complainant was asked by the officials to send the justification from the hospital where the patient was treated. Then, the complainant approached the AMC Hospital who issued justification letter certifying the circumstances under which the patient Anita Rani i.e. mother of complainant was admitted and regarding the treatment, date of admission and date of discharge vide certificate dated 24.06.2018 and the complainant sent the same to the opposite party No. 1, but the opposite party has not cared to reimbursement the treatment expenses of Anita Rani i.e. mother of complainant and has not made the payment of medical claim of Rs.35,932/- to the complainant. Due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. So, there is a clear cut deficiency in services on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and negligence in services and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite party No.1 to pay Rs.35,932/- alongwith interest @ 12% per annum from the date of discharge of Anita Rani i.e. mother of complainant from the hospital, till its realization and the opposite party No. 1 may also be burdened with compensatory costs to the tune of Rs.20,000/- as harassment, mentally and deficiency in services and litigation expenses, in the interest of justice.
3. Upon notice, the opposite party No.1 appeared through Sh.Charandeep Singh, Representative of opposite party No.1 and filing written reply. After that none had appeared on behalf of opposite party No.1 and opposite party No. 1 is ordered to be proceeded against exparte vide order date 28.05.2019. In the reply of opposite party No.1 stating therein that the complainant has filed the case against the answering OP No. 1 whereas the fact is that the Mediclaim Policy which the complainant had filed the claim, was issued by The Oriental Insurance Co. Ltd. The answering OP No. 1 registered under the Companies' Act 1956 is licensed TPA under IRDA Act 2001 to act as a facilitator for the processing of the claim. It is pleaded that the insurance contract is between the insured and the insurer i.e. The Oriental Insurance Co. Ltd. As per the privity of the contract, the insurance company by itself or its TPA (OP No. 1) is obliged to process the claim as per the terms and conditions of the policy. It is further pleaded that by the virtue of the Memorandum of the Understanding, signed with The Oriental Insurance Co. Ltd., OP No. 1 is nominated as Administrator for arranging to process the claims of the Insurance Company as the Third Party Administrator for arranging to process the claims of the Insurance Company as per the terms and conditions laid down by The Oriental Insurance Co. Ltd. It is further pleaded that the complainant was covered under the group Mediclaim Policy No. 5001002817P110672408 period of 01.10.2017 to 30.10.2018 issued by The Oriental Insurance Co. Ltd. The claim No. 54551819074759 is in respect of Mrs. Anita towards hospitalization in ABROL MEDICAL CENTRE GURDASPUR during 02.05.2018 to 08.05.2018. On perusal of discharge summary of the hospital it is noted that Mrs. Anita was treated case of ACUTE PIVD, and it is observed that no active treatment had been given to patient while she was in hospital & investigation only were done for the patient. Hence, the claim recommended as non-payable to insurer M/s. The Oriental Insurance Co. Ltd. as per clause 4.11 of the policy Terms & Conditions as laid down by the Insurer (The Oriental Insurance Co. Ltd.). It is further pleaded that the OP No. 1 is only the claim recommending authority, whereas the final decision for settlement of claim needs to be taken by The Oriental Insurance Co. Ltd., who had issued the policy cover. The complainant has not included the name of the insurance company, while lodging the consumer complaint for which he may be requested to include the name of insurer i.e. The Oriental Insurance Co. Ltd. as main opposite party for reply of the case. It is further pleaded that the present complaint filed on behalf of the claimant is not maintainable against the answering OP No. 1. The complainant has entered in to contract/Mediclaim policy with The Oriental Insurance Co. Ltd. and not with the answering OP No. 1. The answering OP No. 1 is just a third party administrator who act as a facilitator for the processing of the claims as per the policy terms and conditions laid down by The Oriental Insurance Co. Ltd,. It is further pleaded that name of the answering OP No. 1 is liable to be deleted as opposite party No. 1 is neither a proper nor necessary party to the present complaint.
On merits, the opposite party No.1 denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
4. Upon notice, the opposite party No.2 appeared through counsel and contested the complaint and filing their written reply, stating therein that Anita i.e. mother of complainant aged about 42 years wife of Ramesh Kumar resident of village Daburi, P.O Magar Mudian, Tehsil and District Gurdaspur was admitted on 01.05.2018 in the hospital of the answering OP No. 2 with acute PIVD radiating to B/L lower limbs difficulty in walker daudication, numbness in B/L L/L in emergency condition. She was managed conservatively which includes epidural Injection and transformational nerve root block. She was discharged on 08.05.2018 under satisfactory condition. It is further pleaded that the answering opposite party No. 2 received payment of Rs.35,932/- from the complainant on account of treatment expenses of Smt. Anita. It is further pleaded that it is wrong that the answering opposite party No. 2 refused to allow the cashless treatment and the complainant could not treat his mother well one to financial difficulties and as such could not get full treatment and has to take their mother back to home without from being fully recovered. As a matter of fact, the patient was discharged under satisfactory conditions and was fully recovered. It is further pleaded that the answering opposite party No. 2 issued certificate regarding treatment, date of admission and discharge of Anita dated 24.06.2018.
On merits, the opposite party No.2 denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
5. Upon notice, the opposite party No.3 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complainant has no locus standi to file the present complaint and the complaint of the complainant is not maintainable in the present form. It is pleaded that the complainant has no jurisdiction to file the present complaint and the complainant has not come to the Ld. Commission with clean hands and as such not entitled for any relief and there is no deficiency in services on the part of the answering OP No. 3 / Insurance Co. It is further pleaded that the matter of fact is that the claim has been repudiated vide letter dated 18.03.2019. As per facts and document submitted the complainant is an acute PIVD and is admitted only for investigation. There is no active management and hence the claim not payable as per condition No. 4.7. The condition No. 4.7 clearly provides that charges incurred at hospital or Nursing Home primarily for diagnosis X-ray or Laboratory examination of diagnostic study not consistent with or incidental to the diagnostic and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at Hospital/Nursing Home, unless recommended by the attending Doctor. It is further pleaded that Further Condition No. 4.11 clearly provides that claim is not payable which states that attempted suicide, critical illness before the commencement of policy, war invasion, nuclear radiation are not covered. So, there is no deficiency in services on the part of the opposite parties and the claim has rightly been repudiated. It is further pleaded that even otherwise if this Ld. Commission comes to the conclusion that there is any liability of the Insurance Co. then in that case it is only as per the terms and conditions of the policy.
On merits, the opposite party No.3 has reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
6. Learned counsel for the complainant has tendered into evidence affidavits of Balwinder Kumar, (Complainant) as Ex.CW-1/A and Anita (W/o Ramesh Kumar R/o Village Daburi, Tehsil & District Gurdaspur) as Ex.CW-2/A alongwith other documents as Ex.C-1 to Ex.C-32.
7. Opposite party No.1 has filed affidavit of Vinay Batra, (General Manager of Raksha Health Ins. TPA Pvt. Ltd., Faridabad) alongwith reply.
8. After filing written reply to the main complaint none had appeared on behalf of opposite party No.1 and as such opposite party No.1 was proceeded against exparte vide order dated 28.05.2019.
9. Learned counsel for the opposite party No.2 has filed reply.
10. Learned counsel for the opposite party No.3 has tendered into evidence affidavit of Sh. Rakesh Gupta, (Branch Manager of United India Ins. Co. Ltd., Gurdaspur) as Ex.OP-3/A alongwith other documents as Ex.OP-3/1 to Ex.OP-3/6 alongwith reply.
11. Rejoinder filed by the complainant.
12. Written arguments not filed by the parties.
13. Counsel for the complainant has argued that complainant had purchased health policy and his mother was also covered upto Rs.3,00,000/- and on 01.05.2018 mother of the complainant felt severe pain in back radiating and difficulty in walking etc. and was taken to opposite party No.2 hospital and she remained admitted from 01.05.2018 to 08.05.2018 and amount of Rs.33,500/- was spent. On claim being lodged the cashless treatment and reimbursement was declined by the opposite party No.3 without any justification which amounts to deficiency in service.
14. Opposite party No.1 did not appear at the time of final arguments as opposite party No.1 had already been proceeded against exparte vide order dated 28.05.2019. But in the written reply to the main complaint it is stated that opposite party No.1 is nothing to do with the settlement of the claim and is nominated as Third Party Administrator for arranging to process the claim of the Insurance Company as per the terms and conditions of the policy and claim was not payable as per clause No.4.11 of the terms and conditions of the policy.
15. Counsel for the opposite party No.2 has argued that opposite party No.2 has nothing to do with the insurance claim and as such complaint is liable to be dismissed against opposite party No.2.
16. Counsel for the opposite party No.3 has argued that as per documents submitted by the complainant it was a case of acute PIVD and is admitted only for investigation and as per policy terms and conditions No.4.7 the charges incurred at hospital or nursing home primarily for diagnosis X-ray or Laboratory examination of diagnostic study not consistent with or incidental to the diagnostic and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at hospital unless recommended by the attending doctor and as such claim was rightly repudiated by the insurance company.
17. We have heard the Ld. counsels for the parties and gone through the record.
18. It is admitted fact that complainant has purchased health policy from opposite party No.3 valid from 01.10.2017 to 30.09.2018. It is further admitted fact that mother of the complainant Smt.Anita was also covered under the policy for treatment upto Rs.3,00,000/- per year. It is further admitted fact that mother of the complainant remained admitted at AMC hospital of opposite party No.2 which empanelled hospital of opposite party No.3 w.e.f. 01.05.2018 to 08.05.2018 and amount of Rs.35,932/- was spent by the complainant. It is further admitted fact that cashless treatment and reimbursement of medical expenses was declined by opposite party No.3. The only issue for adjudication before this Commission is whether the reimbursement of medical expenditure on the party of opposite party No.3 is justified or not.
19. Perusal of file shows that opposite party No.2 hospital is empanelled hospital of opposite party No.3 and mother of the complainant remained admitted in the hospital from 01.05.2018 to 08.05.2018 on account of severe pain radiating to B/L lower limbs difficulty in walking which itself shows that mother of the complainant was taken to opposite party No.2 hospital in critical medical condition due to severe back pain and she remained admitted in the said hospital for seven days and had spent Rs.33,500/- on her treatment as per bill Ex.C12. Perusal of file further shows that the said hospital had charged the amount from the complainant vide bills Ex.C6 to Ex.C11 and the said bills had been issued day after day and thereafter final bill Ex.C12 has been issued wherein amounts under different heads have mentioned. The plea of the opposite party No.3 that as per terms and conditions No.4.7 the charges incurred at hospital primarily for diagnosis X-ray or Laboratory examination of diagnostic study not consistent with or incidental to the diagnostic and treatment of positive existence of any ailment, sickness or injury for which confinement is required, unless recommended by the attending doctor is further falsified from the facts that mother of the complainant was under severe back pain and required treatment and the admission in the hospital was recommended by the treating doctor who had issued certificate Ex.OP-3/6 which shows that the admission in the hospital was recommended by the attending doctor and the patient did not remained admitted in the hospital out of her sweet will only for diagnostic purpose rather she remained under continuous treatment. As such repudiation of the claim by the opposite parties by relying upon clause and frivolous excuses amounts to deficiency in service.
20. Accordingly, present complaint is partly allowed and opposite parties No.1 and 2 are directed to pay amount of Rs.35,932/- to the complainant alonwith interest @ 9% P.A. from the date of filing of the complaint till realization jointly and severally within 30 days from the date of receipt of copy of this order.
21. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
22. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
Jan. 19, 2024 Member.
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