Chandigarh

DF-I

CC/185/2020

Gopal Lal Sharma - Complainant(s)

Versus

SBI General Insurance - Opp.Party(s)

Mayank Mathur & Gulshan Kumar Moudgil

25 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.

:

CC/185/2020

Date of Institution

:

26.6.2020

Date of Decision   

:

25.1.2023

 

Gopal Lal Sharma s/o Sh. Durga Ram Sharma R/o House No.545/2, Sector 38A, Near Santokh Nursing Home, Chandigarh.

.

… Complainant

V E R S U S

  1.    SBI General Insurance 1st and 2nd floor, SCO 335-336, Sector 35-B through its authorized representative & also at State Bank of India Branch, Punjab and Haryana High Court, Chandigarh.
  2.    Land mark Hospital, Site No.1&2, Sector 33-C, Chandigarh.
  3.    Paramount Health Service & Insurance TPA Pvt. Ltd, Plot No. A-442, Road 28-A, M.I.D.C., Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukmani Mandir, Thane, Mumbai.

 .  … Opposite Party

CORAM :

PAWANJIT SINGH

PRESIDENT

 

SURJEET KAUR

SURESH KUMAR SARDANA         

MEMBER

MEMBER

 

                        

ARGUED BY

 

Sh.Mayank Mathur, Advocate for the complainant.

 

 

Sh. Sh. J.P. Nahar, Advocate  for OPs No.1&3.

 

 

None for Opposite Party No.2

 

 

 

Per surjeet kaur, Member

  1. Briefly stated, the complainant purchased a health insurance policy i.e. Family Floater from Opposite Parties  valid for the period from 19.5.2019 to 18.5.2020 covering the complainant and his wife by paying premium amount of Rs.4300/-.  Unfortunately, the complainant was diagnosed with kidney stone and was admitted in the Opposite Party No.2 hospital on 21.3.2020 and underwent surgery for removal of the stone at the Opposite Party No.2 hospital and discharged on 22.3.2020. A bill of Rs.22000/- was raised by the Opposite Party No.2 hospital for the surgery and treatment. It is alleged that out of the total bill amount  the Opposite Party No.1 only paid Rs.7,334/- and the rest of the bill amount was paid by the complainant from his own pocket. The complainant approached the Opposite Party No.1 for refund of remaining bill amount but  it denied to pay the same.  Ultimately the complainant sent a legal notice to Opposite Party No.1 but to no avail. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed
  2. The Opposite Parties NO.1&3 in their joint reply stated that the payment of claim is always as per terms and conditions. It is averred that the complainant had taken insurance policy of Rs.1.00 lakh only.  The claim was to be paid subject to deductions of any deductible as reflected in the policy schedule in respect of such insured person as specified in the schedule. Room, Board and nursing charge as provided by the hospital upto 1% of sum insured max. Rs.1500/- for normal room per day. If admitted into intensive care upto 2% of sum insured per day max. 2,500/-. In case the insured opts for a higher room category than his eligibility, the same can be covered up on specific acceptance by the insurer or Administrator. In such a case all incremental expenses pertaining to room rent, medical practitioners/specialists fees and other incidental expenses to be borne by the insured. Thus as per terms and conditions the complainant was eligible  to opt for room for Rs.1000/- but he opted for the room which was of higher category i.e. Rs.3,000/-. However,  all the incremental expenses pertaining to room rent medical practitioners/specialists fees and other incremental expenses to be borne by the insured proportionately.  The package of Rs.22,000/- has thus to be paid in proportion to the eligible category of room i.e. Rs.1000/- and other charges proportionately  also being incremental charges. All other allegations made in the complaint has been denied being wrong.
  3. The Opposite Party No.2 while admitting the factual matrix of the case stated that the answering Opposite Party has no concern with the grievance of the complainant as the payable amount is to be settled by the insurance company.  Thus, denying all other allegations made in the complaint against the  answering Opposite Party a prayer for dismissal of the complaint has been made.
  4. Rejoinder was filed and averments made in the consumer complaint were reiterated
  5. Contesting parties led evidence by way of affidavits and documents.
  6. We have heard the learned proxy counsel for the complainant and Opposite Parties No.1&3 and gone through the record of the case.
  7. The sole grouse of the complainant through the present complaint is that as per bill raised by the hospital he was entitled for the full bill amount of Rs.22000/- for the surgery and treatment taken in the OP No.2 hospital alongwith other expenditure of Rs.3500/- spent after the surgery but the OP No.1 (insurance company) did not pay full bill amount but made deductions therefrom.  
  8. The stand taken by the OP insurance company that it is the complainant choice to stay in a special room category worth Rs.3000/- in the hospital. Thus, reasonable deductions were made as per terms and conditions of the policy and accordingly a sum of Rs.7,334/- were paid to the complainant towards his claim.
  9. After going through the evidence on record it is abundantly clear that the complainant paid Rs.22,000/- for the surgery and treatment taken by him as is evidence from Annexure C-3 (colly).  A perusal of the policy in question Annexure C-1 shows that the complainant paid the required premium and had cover of Rs.1.00 lakh for himself and his wife. The grouse of the complainant is that the OP insurance company only paid Rs.7,334/- out of his total claim of Rs.22,000/- after making  illegal deductions.
  10.    As per terms and conditions at page 26 of the paper book under the heading of SCOPE of Cover, the complainant was entitled for expenses relevant portion whereof is as under:-

1. Room Board and Nursing charges as provided by the hospital up to 1% of the sum insured max Rs.1500/- for normal room per say. If admitted into intensive care unit up to 2% of the sum insured per day  max Rs.2500/-. In case the insured opts for a higher room category than his eligibility the same can be covered upon specific acceptance by the insurer or Administrator. In such a case all incremental expenses  pertaining to room rent, medical practitioner/specialists fees and other incidental expenses to be borne by the insured.

2. Medical practitioner and specialists fees.

3. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines & drugs, diagnostic materials and X-ray, dialysis, chemotherapy, radiotherapy, cost of pacemaker, prosthesis/internal implants and any medical expenses incurred which is integral part of the operation.

4. x x x x x x

5. Post hospitalization expenses- Insurer shall pay for expenses as defined in the policy and incurred 60 days after the date of discharge from hospital.

 

  1.   The case of the  OP insurance company is that  the complainant had opted for higher category of room rent  of Rs.3000/- i.e. beyond his eligibility room rent of Rs.1000/- and as such incremental charges were to be borne by the complainant.  
  2. We do not concur with this plea of the OP insurance company as it is measurably failed to prove the same on record. A perusal of Annexure
    C-3 at page 52  the cashless authorization letter  prepared by the TPA OP No.3 shows that  in authorization remarks  it is mentioned that “al issued as per available agreed package as per tariff package charges for single room Rs.3000/- as per policy patient eligible Rs.1000/- per day hence incremental charges applicable.” Whereas at page 53 in the final bill issued by the hospital, it is nowhere shown the rate of room rent charged from the complainant. These are shown as package charges and no bifurcation has been given in the bill. Thus, we are failed to understand as to how the TPA has come to the conclusion that the bill of Rs.22000/- consists with room rent at the rate of Rs.3000/- per day. It is onus on the OP insurance company to prove their case by way of cogent and concrete documents, which they utterly failed to do so.
  3. Moreover Annexure OP1&3/2 placed on record by  the Ops No 1&3, at clause 3 it is mentioned that whether patient opted for eligible room category under policy it  was ticked as yes. Hence, it is proved on record that the OP insurance company has made deductions from the genuine claim of the complainant at its own whims and fancies. Even otherwise if it is believed that the complainant had opted for higher room rent of Rs.3000/- against entitled room rent of Rs.1000/- then they should have only deducted the excess room rent incurred by the complainant beyond his entitlement but they failed to show on record as to how they made other deductions and paid a claim of Rs.7,334/ only.  
  4. So far as the amount of Rs.3500/-  which has been paid by the complainant on 2.5.2020 (Annexure C-3 at page 54) after surgery towards radiology charges and procedure charges is concerned, the same is liable to paid by the OP insurance company to the complainant as per clause 5  of the terms and conditions of the policy as  reproduced above, though this relief has not been specifically sought in the prayer clause yet in our opinion we can grant the same as per clause 5 of the prayer made in the complaint.
  5.   It has become a common practice that the insurance companies while selling the policy shows rosy pictures to the consumer and do not explain the terms and conditions properly and at the time of reimbursement they deny the genuine claim of the insured on one pretext or the other. Hence, there is deficiency on the part of the Ops and they are liable to pay the entire bill amount to the complainant alongwith the post surgery charges incurred by the complainant.  
  6. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-
  1. to pay remaining bill amount of Rs.14666/- plus post-surgery expenditure of Rs.3500/- to the complainant alongwith interest @9% per annum from the date of bill till realization.  
  2. to pay Rs.10,000/- to the complainant as compensation for causing mental agony and harassment to him;
  3. to pay Rs.5000/- to the complainant as costs of litigation.
  1.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above
  2.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

 

 

 

Sd/-

 

 

 

[Pawanjit Singh]

 

 

 

President

 

 

 

Sd/-

 

 

 

 [Surjeet Kaur]

Member

 

Sd/-

 

 

 

[Suresh Kumar Sardana]

mp

 

 

Member

 

 

 

 

 

 

 

 

 

 

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