Complaint under Section 35 of the Consumer Protection Act, 2019.

Before:       SH. PADAM SINGH THAKUR……. PRESIDENT

                   MRS.SUKHDEEP KAUR……………MEMBER.

                   SH. OM PARKASH TUTEJA ……… MEMBER              

Present:       Sh. Manbir Singh,  Advocate for the complainant.

                   Sh. Ravinder Goyal, Advocate for opposite parties no.1 and 2.                           

                Sh. Abhishek Pal Singh, Advocate for opposite party no.3.

ORDER

                   The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as OPs).

2. In brief, the case of the complainant is that he is consumer of ops as policy bearing no. P/211121/01/2021/001078 from 21.05.2020 to 20.05.2021 for covering the risk of medical insurance for all the family members to the extent of sum insured with further additions of the benefits of enhancement of sum insured and other features were purchased and this policy has been further renewed from 21.05.2021 to 20.05.2022. That complainant was affected with COVID when he was at his in-laws family at Ludhiana and he was treated by COVID management. That hospital authorities got deposited Rs.50,000/- in advance from complainant and file was prepared and approval for treatment charges was sought by hospital, but same with only meager amount was given by ops no.1 and 2. It is further averred that during the first year of the policy, complainant after being affected with the fever etc. was hospitalized at D.M.C. Ludhiana, where he was diagnosed with COVID and treated accordingly and he remained admitted there from 10.01.2021 to 14.1.2021. That on discharge from hospital on 14.01.2021, he was asked to deposit Rs.19,840/- as ops no.1 and 2 did not pay this amount incurred on treatment, medicine prescribed by expert doctors of op no.3 during the hospitalization. The complainant was given bill of Rs.78,694/- and Rs.48,854/- were only paid by ops no.1 and 2 and he was forced to pay Rs.19,840/- from his own pocket due to non disbursement of entire treatment expenses to op no.3. It is further averred that complainant made representation to the ops no.1 and 2 for payment of entire amount but the ops adopted unfair trade practice and acted deficiently and his request was rejected by them vide mail dated 14.05.2021 and he was asked to approach Corporate Grievance Department, whose officials were also of company and they also instead of watching the interest of policy holder without passing a speaking order communicating the reasons for each and individual item for which the deduction from the hospital bill payment was made by the ops and by non speaking cyclostyle order as passed by the claim Head/ Authorities, the same was done by redressal team of the company. Similarly, medical treatment and expenses bills of his wife Smt. Ajinderpreet Kaur were also denied. That decision of repudiation of claim by ops no.1 and 2 is wrong, against law and facts, policy terms and conditions and is the result of unfair trade practice. It is further averred that complainant was intimated that amount has been deducted due to Gloves, mask, cannula, fix, electrodes, tray, disposable charges etc. but without explaining the reason for non payment of individually deducted item, the legitimate claim of expenses has been paid partially to op no.3. That representation to the Redressal Authority was submitted specifically by complainant with the contention that amount has been spent by hospital administration on his treatment as per need and not as per his choice, hence amount of Rs.19,840/- ought not to have been deducted and should have been paid to the complainant. The deduction regarding medicine is not permissible in the repudiation. It is further averred that op no.3 is being impleaded as party in order to avoid any plea to be taken by ops no.1 and 2 about no requirement/ need of medicines/ treatment, amount/ claim of which has not been paid to the complainant as entire record is either with ops no.1 and 2 or with op no.3 and complainant has apprehension that ops no.1 and 2 may not submit entire record of treatment, hence op no.3 is to be directed to submit entire record of treatment bills, claim, approval forwarded by them to ops no.1 and 2 and if any false bills are prepared or medicines not required for treatment has been given, in the eventuality, op no.3 is to be held liable for acting deficiently. It is further averred that in case treatment, which was not required for the treatment of COVID of complainant, in that eventuality, complainant is also entitled for the cash amount charged from complainant by op no.3. Hence, this complaint.

3. On notice, opposite parties appeared. Ops no.1 and 2 filed written statement taking certain preliminary objections regarding maintainability, no locus standi, no cause of action etc. It is submitted that claim of complainant has been fully and finally settled and paid by answering ops to the complainant, therefore, present complaint does not lie. That at the time of availing the policy, the terms and conditions of the policy were duly explained to the complainant and the same was served to the complainant alongwith the policy schedule. It was clearly stated in the policy schedule that “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc.” The insured requested for a pre authorization for treatment of COVID at Dayanand Medical College and Hospital, Ludhiana on 10.01.2021. The complainant lodged his claim with the answering ops, which was duly processed and scrutinized. In the claim, the complainant claimed a sum of Rs.78,694/-. During the course of scrutiny and processing the claim of complainant, it was observed by answering ops that maximum eligible amount payable to complainant is Rs.58,853/-, as some of the amounts claimed by the complainant under different heads were not payable under the above policy, detail of which is as under:-

** As per other excluded expenses of the policy towards mask,       disposable kit deducted ray, bed-sheet are not payable, hence Rs.17,592/-        deducted

**  As per other excluded expenses of the policy, the charges towards   other for admission and Misc. hence Rs.2248/- are deducted.

4. It is further submitted that amount of Rs.58,853/- has already been paid to the complainant, which has been duly accepted by the complainant without any protest. That complainant has not furnished the bills of payment of amounts to the hospital. Subsequently, the insured submitted claim documents for reimbursement of medical expenses. On scrutiny of the claim documents, it is observed that the claim was processed as per the bills and documents submitted by the insured. An amount of Rs.56,395/- was settled vide NEFT transaction dated 30.01.2021. Hence, the sum is the maximum payable as per terms and conditions of the policy. Hence, the claim was repudiated and communicated to the insured vide letter dated 02.08.2021. It is further submitted that complainant while filing the present complaint has concealed and suppressed the true and material facts and has not come with clean hands. On merits, while reiterating the pleas of preliminary objections, it is again submitted that complainant did not furnish the bills of payment of Rs.19,840/- to the answering ops as alleged. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.      
5. Op no.3 also filed written statement taking preliminary objections that presently complainant has no cause of action against answering op which is impleaded by complainant merely on the apprehension and as such present complaint is liable to be dismissed qua answering op. The answering op cannot be impleaded as party merely for production of record, which can be otherwise obtained by complainant directly from answering op. That complainant has not claimed any relief against answering op and has dragged answering op in the present false and frivolous litigation by misusing the process of law and thus complaint is liable to be dismissed on this ground as well. It is further submitted that there is no privity of contract between the complainant and answering op for reimbursement of the treatment cost to the complainant. The complainant is insured with ops no.1 and 2, therefore, they are liable to provide the cashless facility/ reimbursement of treatment cost to the complainant. The answering op has every right to claim the treatment cost, which may be paid either by complainant or by the insurance company. It is internal arrangement between the patient and the insurance company. The answering op has no role to decide the eligibility of any beneficiary of an insurance policy and it is the prerogative of the concerned insurance company to decide the eligibility of any patient to receive the benefit under the insurance policy according to its terms and conditions agreed upon between the concerned beneficiary and the insurance company. It is further submitted that there is no specific allegation of negligence or deficiency in rendering the treatment to the complainant against answering op. The complainant was treated according to the standard medical norms and there is no negligence of deficiency on the part of any of the treating doctors.
6. It is further submitted that complainant was admitted with answering op on 10.01.2021 with the chief complaint of fever and cough since four days with pain in abdomen since one day, shortness of breath few hours prior to admission and oxygen saturation was 86%. The complainant got conducted his RTPCR Test on 06.01.2021, which was found to be positive and accordingly he was sent for home isolation according to the Government Guidelines. But at home when the complainant had a complaint of shortness of breath, he approached the answering op where he was treated according to the Government Guidelines as per standard medical norms and he was discharged on 14.01.2021 in a stable condition. It is further submitted that on admission of complainant on 10.01.2021, he informed the Corporate Department of answering op that he is insured with ops no.1 and 2 and accordingly a request for cashless hospitalization was sent to ops no.1 and 2 on 10.01.2021 to provide the cashless facility to the complainant. That in pursuance to the request sent by answering op, ops no.1 and 2 accorded its sanction vide letter dated 10.01.2021 and provided authorization for cashless facility up to Rs.12,000/- only. On discharge of complainant, a request to sanction the final treatment bill of Rs.78,693/- was sent to ops no.1 and 2 alongwith all relevant documents i.e. final treatment bill and the medical record of the complainant through the online portal available at the website of ops no.1 and 2 and ops no.1 and 2 sanctioned an amount of Rs.58,853/- after deducting an amount of Rs.19,840/- being not admissible according to the terms and conditions of the policy obtained by complainant. It is further submitted that at the time of admission, the complainant deposited Rs.1,00,000/- on 10.01.2021. Out of this amount an amount of Rs.80,160/- was refunded to the complainant at the time of his discharge after deducting an amount of Rs.19,840/- which was not sanctioned by ops no.1 and 2. With these averments, dismissal of complaint qua op no.3 prayed for.
7. The parties then led their respective evidence.
8. Complainant has tendered his affidavit Ex.C1 and copies of documents Ex.C2 to Ex. C15.
9. On the other  hand, ops no. 1 and 2 have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.RW1/A and copies of documents Ex.R1 to Ex.R10. Op no.3 has tendered affidavit of Dr. Sandeep Sharma, Medical Superintendent Ex. RW3/A and re-exhibited documents Ex. OP3/1 to OP3/5 tendered by complainant.
10. We have heard learned counsel for the parties and have gone through the case file carefully.
11. The main grievance of the complainant is that ops no.1 and 2 have wrongly deducted the amount of Rs.19,840/- from the bill of Rs.78,694/- issued by op no.3 hospital. Admittedly complainant purchased insurance policy named Family Health Optima Insurance Plan from opposite parties no.1 and 2 for himself, his wife Smt. Ajinderpreet Kaur and children Ikjot Singh and Amarjot Singh for the period 21.05.2020 to 20.05.2021 and the sum insured under the policy was of Rs.20,00,000/- and the policy in question was further got renewed by complainant from ops no.1 and 2 for the period 21.05.2021 to 20.05.2022. On 10.01.2021 i.e. during the first year of the policy in question complainant was admitted in the hospital of op no.3 as he was affected with fever etc. and at the hospital, he was diagnosed with COVID and was treated accordingly. He remained admitted in the hospital of op no.3 from 10.01.2021 to 14.01.2021 and the hospital authority prepared bill of Rs.78,694/- for the treatment of the complainant. It is also not in dispute that out of the above said amount of Rs.78,694/- of the treatment of the complainant, an amount of Rs.58,854/- was paid by ops no.1 and 2 to the hospital i.e. op no.3 and remaining amount of Rs.19,840/- was to be paid by the complainant to op no.3 as ops no.1 and 2 did not pay the said amount to the op no.3. The representation submitted by complainant to the ops no.1 and 2 alongwith relevant documents i.e. bills etc. to reimburse the remaining amount of Rs.19,840/- to the complainant has been declined by ops no.1 and 2 on the ground that as per other excluded expenses of the policy towards tet, mask, disposable kit deductedray, bedsheet, Misc., admission are not payable, hence amounts of Rs.17,592/- and Rs.2248/- deducted.

12.  It is an admitted fact that complainant was treated for corona virus disease (COVID-19) in the hospital of op no.3. In this regard, op no.3 has asserted that complainant was treated according to the standard medical norms and medicines were prescribed according to the requirement of the diagnosis. However, the ops no.1 and 2 as per bill assessment sheet Ex.C3, out of the amount of Rs.29,529/- spent on medicines etc. have deducted the amount of Rs.17,592/- on the ground that medicines outside hospital and reason for disallowance has been mentioned that tet, mask, disposable kit, deductedray, bedsheet are not covered under the policy. However, the ops have wrongly and illegally deducted the said amount of Rs.17,592/- as ops have failed to prove on record that any medicines were purchased from outside hospital of op no.3. Further ops cannot deduct the amount spent on masks, disposable kits, and bed-sheets etc. because the same were used as per need and not as per choice of the patient. The masks, disposable kits are required for treating a COVID patient in order to avoid further infections in the Doctors, caring nursing staff and other patients and these items are necessary for treating a COVID patient as per standard protocol as per guidelines of ICMR and medical protocol. The ops no.1 and 2 have not placed on file any guidelines of ICMR and Government of India to prove the fact that above said items i.e. masks, disposable kits etc. are not covered for the treatment of COVID patient. Further more, the medicines and diet etc. were provided to the complainant as per standard protocol for treating a patient of COVID and all the medicines were provided in the hospital and were not purchased from outside as is evident from the bills issued by op no.3. So, the ops no.1 and 2 have wrongly and illegally deducted the above said amount of Rs.17,592/- out of the above said amount of Rs.29,529/-. The other exclusion clause relied upon by ops no.1 and 2 in order to deny the payment on account of Mask and Kit etc. in this case are not relevant and immaterial and not applicable in case of a treatment of a COVID patient. The ops no.1 and 2 have also deducted another amount of Rs.2248/- on the ground that Misc. admission not payable. But however, as per bill Ex.R9 of op no.3 an amount of Rs.1550/- was charged on account of admission fee and as such only an amount of Rs.1550/- was to be deducted by ops no.1 and 2 as per condition no.27 of clause 4 i.e. exclusions clause of terms and conditions of the policy in question. The ops no.1 and 2 have also wrongly asserted that complainant did not furnish the bills of payment of Rs.19,840/- to the answering ops whereas it is duly proved on record that complainant has already furnished total bill of the amount of Rs.78,694/- issued by op no.3 to ops no.1 and 2 at the time of making representation and said bill has also been produced on record. Therefore, it is proved on record that complainant is entitled to reimbursement of the above said amount of Rs.17,592/- as well as an amount of Rs.698/- (Rs.2248 minus Rs.1550) i.e. total amount of Rs.18,290/- from ops no.1 and 2 besides compensation for harassment and litigation expenses. However, there is nothing on file to prove the fact that op no.3 hospital did not provide treatment to the complainant as per standard medical norms and as such complainant is not entitled to refund of any amount from op no.3.

13. Thus, as a sequel to our above discussion, we allow the present complaint qua opposite parties no.1 and 2 and direct the ops no.1 and 2 to reimburse the amount of Rs.18,290/- to the complainant. We further direct the ops no.1 and 2 to further pay a sum of Rs.10,000/- as composite compensation and litigation expenses to the complainant. The ops no. 1 and 2 are liable to comply with this order within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive principal amount of Rs.18,290/- alongwith interest @6% per annum from the date of this order till actual payment. However, complaint qua op no.3 stands dismissed. A copy of this order be supplied to the parties as per rules. File be consigned to the record room after due compliance.

Announced.                    Member     Member                          President,

Dated: 11.01.2023.                                                        District Consumer Disputes

                                                                             Redressal Commission, Sirsa.

JK