Versus
- Safeway Insurance TPA Pvt. Ltd., 815, Vishwa Sadan, District Centre, Janakpuri, New Delhi-110058.
- National Insurance Co. Ltd., H.O. 3, Middleton Street, Prafulla Chandra Sen Sareni, Kolkata-700071 (W. Bengal) with Regi9ona Office at 4th Floor, Grand Walk, Ferozepur Road, Ludhiana. …..Opposite parties
Complaint under Section 35 of Consumer Protection Act.
QUORUM:
SH. SANJEEV BATRA, PRESIDENT
SH. JASWINDER SINGH, MEMBER
MS. MONIKA BHAGAT, MEMBER
COUNSEL FOR THE PARTIES:
For complainant : Sh. Surinder Singh Kalra in person.
For OP1 : Exparte.
For OP2 : Sh. R.K. Chand, Advocate.
ORDER
PER SANJEEV BATRA, PRESIDENT
1. Briefly stated, the facts of the case are that the complainant was retired as Chief Manager from Punjab & Sind Bank on 31.01.2012 and from the year 2016-2017, IBA framed the policy of Health Insurance wherein a Group Insurance Policy is purchased after collecting premium from all retired employees for coverage of employee & his/her spouse and Third Party Administrator (TPA) is involved for settlement of cases for each bank on year to year basis. The complainant has been opting for coverage since inception of the scheme by paying premium which is increased every year as Rs.20,010/- in 2016-17, Rs.40,804/- in 2017-18, Rs.33,841/- in 2018-19, Rs.39,327/- in 2019-2020, Rs.38,818/- in 2020-21 and with enormous increase of Rs.54,850/- for 2021-22. The complainant submitted that he and his wife have never availed any hospitalization expenses since inception of scheme except the present one. The complainant renewed the insurance policy for 2021-2022 with a premium of Rs.54,850/- for covering himself and his wife Prabhjeet Kaur Kalra and National Insurance Co. Ltd. was chosen by the bank with a change in TPA as Safeway Insurance Co. Pvt. Ltd. The details of hospitalization and day care treatment were never shared with the insurer and the insurance cards are issued vide policy Nio.251100/50/21/10000255 and ID number of the complainant and his wife are PSBR/S06234/NI1800339725 and PSBR/S06234/1800343835 respectively. The complainant has further stated that his wife suffered from Macular Eye Edema on 11.08.2018 and it was recommended by Dhami Eye Care Hospital, 81-82-B, Kitchlu Nagar, Ludhiana that there is need for certain injections/insertions/implantation from time to time to cover the risk of going blind. Before the present claim, there were 14 such insertions from the year 2017-18 to 2020-21 and all such treatments were fully authorized by respective TPA’s and all pre & post treatment expenses were fully paid by insurance companies without any hesitation. Further there are 41 TPA’s attached with the hospital and as per comments on refusal letter, all TPA’s are authorizing the same disease and some authorizations are attached. As there was considerable recovery and on his visit to the hospital on 11.02.2022, it was recommended for need of implantation OZURDEX on 15.02.2022 for which pre-authorization was sent to opposite party No.1 TPA by the hospital which was rejected on the ground that it is not coverable. The complainant had to delay the treatment and borrowed the amount for treatment of both eyes and got it done on 03.03.2022 (right eye) and 08.03.2022 (left eye) and sent all the original documents vide registered speed post on 09.03.2022 to TPA for reimbursement which has been rejected and referred to opposite party No.2 but no response was received from insurance company. The complainant further stated that his claim has been rejected arbitrarily, illegally and against the principles of natural justice when 14 such claims for same disease and from same hospital have been approved which amounts to deficiency in service and unfair trade practice on the part of the opposite parties which caused harassment to the complainant. In the end, the complainant has made a prayer for directing opposite parties to pay Rs.57,600/- along with compensation of Rs.15,000/- and litigation expenses of Rs.10,000/-.
2. Notice was sent to opposite party No.1 through registered post on 30.04.2022 but none turned up for opposite party No.1 despite service of notice and as such, opposite party No.1 was proceeded against exparte vide order dated 27.07.2022.
3. Upon notice, opposite party No.2 appeared and filed written statement. In the preliminary objections, opposite party No.2 assailed the complaint on the ground of maintainability, lack of jurisdiction and deficiency in service etc. Opposite party No.2 alleged that immediately on receipt of the claim, it was duly entertained, registered and referred to M/s. Safeway Insurance TPA Pvt. Ltd. and the complainant/insured was called upon to submit the documents in support of his claim and said TPA duly processed the claim file in terms of the insurance policy and after adopting the procedure laid down for settlement of claim. The said TPA after completion of formalities and after obtaining documents found that the claim of the complainant is not payable and accordingly they returned the file to opposite party No.2 with the recommendations reproduced as under:-
On scrutiny of claim documents it has been observed that patient Prabhjeet Kaur Kalra 62Y/F submitted documents for reimbursement of expenses incurred during hospitalization Dhami Eye Care Hospital, Ludhiana. As a case of Right eye recurrent Diabetic Macular Oedema. However, injection Ozudrex is not listed in the list of day care procedure nor requires hospitalization. In the light of above claim is recommended to insurance company for repudiation as per policy cause 3.3 list of day care procedure.
After receipt of file from M/s. Safeway Insurance TPA Pvt. Ltd. and after going through the documents available in the claim fie and after scrutinizing the file by the officials of opposite party No.2 the claim of the complainant was repudiated on the grounds mentioned above. As per clause 3.3 of the terms and conditions of the policy, the claim of the complainant is not payable. It is well settled law laid down by the Appellate Authorities that where the officials or any authorities of the company after applying the minds in terms of the insurance policy and after adopting the procedure laid down for the settlement of the claim repudiate the claim, then there is no deficiency in service. Opposite party No.2 further alleged that the insurance policy is contract between the insured and the insurer and all the terms and conditions of the policy are binding between the parties. The contract is based on utmost good faith and as per cause 2.15 of the Medical Policy the claim of the complainant is not payable.
On merits, opposite party No.2 reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service and prayed for dismissal of the complaint.
4. In support of his claim, the complainant tendered affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of health insurance claim dated 08.03.2022, Ex. C2 is the copy of postal receipt, Ex. C3 is the copy of insurance policy, Ex. C4 is the acknowledgement slip, Ex. C5 is the copy of ID cards of complainant and Prabhjeet Kaur Kalra, Ex. C6 is the copy of details of bills approved by TPA, Ex. C7 is the copy of claim denial, Ex. C8 is the copy of email dated 14.02.2022, Ex. C9 is the copy of pre-authorization approval letter dated 12.01.2022, Ex. C10 is the copy of pre-authorization approval letter dated 11.12.2020, Ex. C11 is the copy of pre-authorization approval letter dated 22.12.2020, Ex. C12 is the copy of cashless authorization letter, Ex. c13 is the copy of cashless authorization letter dated 29.06.2022, Ex. C14 is the copy of news item, Ex. C15 is the copy of passbook joint account of complainant and his wife and closed the evidence.
5. On the other hand, counsel for opposite party No.2 tendered affidavit Ex. RA of Sh. Gurcharan Singh, Deputy Manager of opposite party No.2 along with documents Ex. R1 is the copy of insurance policy w.e.f. 01.11.2021 to 31.10.2022, Ex. R2 is the copy of Part-II mentioning clauses, Ex. R3 is the copy of recommendation to insurer dated 17.06.2022, Ex. R4 is the copy of health insurance claim dated 08.03.2022 and closed the evidence.
6. We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.
7. Perusal of documents shows that the claim for treatment of wife of the complainant for “Non Proliferative Diabetic Retinopathy” was being paid by the opposite parties in the past by way of preauthorization. The details of which has been fully mentioned in Ex. C1. But in the present case, the pre-authorization as well as reimbursement of the claim was declined on the ground that Injection OZURDEX is not listed in the list of Day Care Procedure and invoked clause 3.3 of the policy.
8. During the course of arguments, it was fairly submitted by the complainant that he had received the claim amount of Rs.57,600/- on 28.06.2022. The counsel for opposite party No.2 after taking the instructions from the office of opposite party No.2 has also confirmed the factum of payment to the complainant. Apparently, the opposite parties themselves took u-turn from earlier stand and found the claims to be admissible. In view of the aforesaid circumstances, certainly there was deficiency in service on the part of the opposite parties so the complainant is entitled to interest on the amount of Rs.57,600/- @6% per annum from 15.02.2022 to 28.06.2022 along with composite cost of Rs.4,000/-.
9. As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to pay the interest on the amount of Rs.57,600/- @6% per annum from 15.02.2022 to 28.06.2022 to the complainant within 30 days from the date of receipt of copy of order. The opposite parties shall further pay Rs.4,000/- (Rupees Four Thousand only) to the complainants compositely assessed as compensation and litigation expenses. Liability of the opposite parties shall be joint and several. Compliance of this order be made within 30 days from the date of receipt of copy of the orders. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.
10. Due to huge pendency of cases, the complaint could not be decided within statutory period.
Monika Bhagat) (Jaswinder Singh) (Sanjeev Batra) Member Member President
Announced in Open Commission.
Dated:24.01.2023.
Gobind Ram.
Surinder Singh Kalra Vs Safeway Insurance TPA Pvt. Ltd. CC/22/165
Present: Complainant Sh. Surinder Singh Kalra in person.
OP1 exparte.
Sh. R.K. Chand, Advocate for OP2.
Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to pay the interest on the amount of Rs.57,600/- @6% per annum from 15.02.2022 to 28.06.2022 to the complainant within 30 days from the date of receipt of copy of order. The opposite parties shall further pay Rs.4,000/- (Rupees Four Thousand only) to the complainants compositely assessed as compensation and litigation expenses. Liability of the opposite parties shall be joint and several. Compliance of this order be made within 30 days from the date of receipt of copy of the orders. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.
Monika Bhagat) (Jaswinder Singh) (Sanjeev Batra) Member Member President
Announced in Open Commission.
Dated:24.01.2023.
Gobind Ram.
