FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application u/s.12 of the C.P. Act, 1986.
The fact of the case in brief is that the complainant is a retired employee of State Bank of India holding the membership of a mediclaim policy issued by United India Insurance Company Ltd. w.e.f. 01.06.2016 and the same has been renewed from time to time under special scheme formulated by the State Bank of India for its retired employees. The membership under the policy has been issued in the joint name of the complainant himself with his wife Smt. Madhulekha Sarkar. In terms of the policy Plan “A” the Insurance Company was under obligation to reimburse cost of domiciliary treatment of specified diseases apart from the cost of hospitalization. It has been experienced by the complainant after submission of some claims under plan A the concerned TPA being the OP-1 would always endeavor to dismiss the claim on one or other pleas and also compelled the pensioner/complainant to run after them to different offices for payment of genuine claims. It is also very much painful to follow up the claims as the only channel for enquiring the fate of bills is the helpline of TPA from where incorrect information on the bills are given and no written communication are sent to the mail address of the pensioners advising the deficiencies or formalities to be completed. In a desperate situation, the pensioners are compelled to sort of begging for personal favors otherwise the bills are neither paid nor return in the normal course. Thus, in effect the pensioners are left at the mercy of TPA for reimbursement of claim of domiciliary treatment, however small it is. As per the policy A scheme (clause 5.7) no claim would be rejected unless the same is rejected by the committee comprising of the Bank, Insurance Company, TPA and the Insurance Broker but this clause has been violated time and again and the copy of rejection note of the committee as demanded by the complainant was never provided. A few bills submitted by the complainant have been rejected arbitrarily by the OP-1 details of which are furnished below.
1. Bill ID No. 1427800 for Rs. 1292/-; rejected with objection ” printed medicine bills required” (submitted copy is printed but the name of patient was hand written only, which was not legal in any way)” a lawyers notice dated 02.11.2017 was served upon the OPs but all went in vain.
2. Bill dated 05.12.2018 for Rs. 1510/-; rejected with objection “ previous period bill date” whereas his policy A coverage is under a continuous policy renewed every year and no specific clause in the policy stated that bill for previous period of policy will not be paid. On query TPA being the OP-1 advised the complainant by mail dated 15.03.2019 that Rs. 1452/- was deducted from ID No. 2074596 as this bills were before first June which fell under last year policy. This is totally wrong as the said amount was actual paid and not related to the bill dated 05.12.2018. As such non-payment of last bill for Rs. 1510/- is not tenable
3. Bill ID No. 2298928: deducted for Rs. 4,000/- being the amount of money receipt issued by the physiotherapist without advising the complainant. On further query the TPA advised vide
reply dated 15.03.2019.
(i) Money receipt issued the physiotherapist was not in proper format
(ii) Supporting document about money receipt required &
Reply dated 18.03.2019
(iii) Cannot process the remaining amount as per the terms and conditions of the policy. On receipt of aforesaid reply, the complainant clarify the definition of money receipt mentioned in section 2 (23) of the Indian stamp act, 1899. Thus, the rejection of the money receipt was arbitrary and illegal but the TPA has maintained its wrong stand.
4. Bill ID No. 2445765 dated 12.06.2019 for Rs. 3,812: The bill has been kept pending over two months giving an untenable reason but the TPA has neither returned the bill nor given the require clarification sought for.
The complainant has also been harassed in case of one bill submitted by the complainant settled on 04.05.2018 with less amount of Rs. 3,051 without asking for any document and giving any valid ground. When asked the TPA cited the reasons which was not accepted by the complainant. However, the subsequent bill for Rs. 2,416/-was paid later on 11.07.2018.
The issues involved in the complaint are in the full knowledge of OP-3 and 4 but they have neglected to take appropriate steps to remove the pains of the pensioners.
In view of the above arbitrary and whimsical act on the part of the OP-1, there was deficiency in service on the part of the OPs for which the complainant has suffered monetary loss and huge mental agony and harassment for which he has approached the commission for justice with relief/ reliefs as detailed in the complaint petition.
The OP No. 1 to 3 have contested the case by filing their WV contending inter alia that the case is not maintainable in law and fact and is liable to be dismissed with cost. The OP 1 to 3 submit that the complainant and his wife are enrolled with them under the plan “State Bank of India: Retd. Emp. Policy-A” under group medical policy since 01.06.2016 and the same is renewed every year. The contesting OPs confirmed that the United India Insurance Ltd. has provided the coverage to both husband and wife but claim for the medical expenses shall be submitted separately to get the reimbursement. They further confirmed that they never endeavor to dismiss or to hold the claims without proper reason and they also confirmed that they always share the information regarding claim status to the complainant to each and every time with complete reason for holding the claim. The OPs are bound to abide by the terms and conditions of the policy and adhere to follow the guidelines issued by the IRDA.
1. Regarding bill ID No. 1427800 for Rs.1292/-.
The claim pertains to complainant’s wife Smt. Madhulekha Sarkar. The OPs raised query to submit the required information/document as per terms of the policy. In this case, the OPs received only cancelled cheque from the complainant. During the period from 01.06.2016 to 31.05.2017, the OPs have processed three claims submitted by the complainant.
2. Bill dated 05.12.2018 for Rs. 1,510/-: The bills were not supported within plan period and unable to trace. The breakup of 1,452 was that Rs.18/- towards medicine not related to prescription provided, Rs. 400/- consultation bill date is out of plan period and Rs. 1,034/- medicine bill dates false under out of plan period. All bills to be submitted to TPA for reimbursement should be within the plan period as per terms of the policy.
3. All the bills should be in proper format and the same should be supported by cash paid receipt in proper bill/receipt format.
4. Bill ID No. 2456065 dated 12.06.2019 for Rs. 3,812/-.
OPs confirmed that said bill is on hold for want for additional information “exact diagnosis to be certified by the treating doctor” which were requested by the OPs and the same is not submitted by the complainant till date.
(v) The OPs initially hold the claim for Rs. 2,146/- for additional information and once the complainant submitted the reply they will process the claim further
The contesting OPs submit that there was no deficiency in service on their part. They have settled all the eligible claims which were submitted by the complainants as per the policy terms and conditions. For information they have further stated that from 2016 to 2019 the OPs have processed ten claims till date. In view of the above submission they have prayed for dismissal of the complaint in limini.
The contesting OP No. 4 has filed their WV contending inter alia i.e. the case is bad in law and in facts stated in the complaint. They have also submitted that they are denying the allegation leveled against them save and except which are matter of record. The burden of proof is lying upon the complainant. There is no cause of action in the instant case for which the complaint petition is liable to be rejected.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OPs are deficient in rendering proper service to the complainant?
2) Whether the OPs have indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3:-
All the points are taken up together for sake of convenience and brevity in discussion.
The fact of the case in brief is that the complainant Mr. Sanjoy Chandra Sarkar being the pensioner of State Bank of India, is a member of a mediclaim policy issued by United India Insurance Company being the OP No. 2 where the wife of the complainant Smt. Madhulekha Sarkar is also the beneficiary of the said scheme. The complainant has come up with the allegation of non settlement of four bills placed before the TPA, being the OP No. 1. While perusing the reply of the OP No. 1 to 3. It is observed that the answering OPs have given clarification item wise in the manner mentioned above in their WV and evidence.
While perusing the reply of the OP No. 1 to 3 for payment of Rs. 1,292/- filed by the complainant along with complaint petition, it is observed that they are not interested to go through the papers submitted by the claimants with the right spirit. The prescription issued by Dr. Prabir Biswas MD (Medicine) dated 22.06.2016 was also for the patient Mrs. M Sarkar, wife of Sri S Sarkar. The said prescription has not been taken care of by the OP No. 1 to 3 and the same has been ignored by the OP No. 1 to 3 in the matter of consideration of payment of the cost of medicine. The printed bill of the medicine purchased is also perused. There is no application of mind in taking the refusal decision. This is a gross deficiency on the part of the OP No. 1 to 3.
Regarding refusal of the payment of Rs.3,812/- it is observed from the letter issued by the OPs dated 06.07.2019 that the reason for holding the payment of Rs. 3,182/- is “exact diagnosis to be certified by the treating doctor”. Against that we find that the complainant has annexed the prescription of Prof. Dr. Sivaji Choudhary, MS (Ortho). where the disease has been mentioned on the left hand side of prescription in some abbreviated medical format which ought to be interpreted by the medical expert of the TPA. The non interpretation of the abbreviated form of the name of the disease should not be ground of repudiation of a genuine claim. The general conception so far prevailed in the society is that there are so many medical experts working with the TPA for clarifying all such medical terminology along with related medical issues. But we do not find the presence as well as existence of such medical experts on observing the actions and inactions being rendered by the TPA. Instead of getting clarified by the medical team the TPA is simply passing the responsibility to the complainant. This is a gross deficiency as well as unfair trade practice.
The claim of Rs. 4,000/- has been rejected on the ground that the money receipt of the physiotherapist was not in proper format. We have seen the money receipt issued by Mr. Abhijit Saha DPT,CPT, CWYS, Physio and Yoga therapist dated 10.01.2019 where he has clearly acknowledged receipt of Rs. 4000/- for his technical service. We also cannot understand the defects in the said bill format. Moreover, the proper format has also not been provided by the TPA to resolve the issue. This is a clear denial of making the genuine payment without valid ground.
Regarding reason for refusal of claim of Rs. 1,510/- it is understood that the bills should be within the plan period as per policy terms and conditions. We have perused the records and have not found any such document of the relevant terms and conditions furnished by the OP No. 1 to 3 in this regard. From the submission of the OP No. 4 being the State Bank of India, it is understood that the renewal of the said scheme is in between the insurer and the insured. So, the rejection of claim of any beneficiary of the scheme cannot be ruled out simply for the reason that the bills are not within the plan period. It is absolutely an unreasonable ground for not considering the claim where the claimant has no role to play with in the matter of renewal of the policy.
Considering all the actions and inactions of the OP No. 1 to 3 against the claims submitted by the complainant we are of the opinion that there is deficiency in service as well as unfair trade practice on the part of the OP No. 1 to 3. The poor application of mind on the part of TPA should be seriously viewed by the Insurer herein the United India Insurance Company Ltd. being the OP No. 2. They cannot escape their responsibility by simply forwarding the ball to the court of the TPA for taking exclusive decision on their behalf. The IRDA guidelines dated 19.03.2021 to all the CEOs of Life, General and Standalone Health Insurance Companies Ltd. and TPAs is very much relevant where it is specifically mentioned in point No. 4 that “Insurer shall ensure that the repudiation of the claim is not based on presumptions and conjectures”. It has been clearly mentioned in another circular of IRDA dated 20.09.2011 that “the insurer’s decision to reject a claim shall be based on sound logic and valid grounds”.
In view of the above facts and circumstances, the complainants is entitled to get the bills of Rs. 1,292/- + Rs. 1,510/- + Rs. 3,812/- + Rs. 4,000/- as pointed out by the complainant in his complaint petition totaling a sum of Rs. 10,614/- along with compensation and litigation cost.
In the result, the consumer complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed on contest against OP No. 1 to 3 and dismissed against OP No. 4 with the following directions.
- The OP No. 1 to 3 are directed to reimburse jointly and severally a sum of Rs. 10,614/- as mentioned above to the complainant.
- The OP No. 1 to 3 are further directed to pay jointly and severally a sum of Rs. 15,000/- to the complainant as compensation towards harassment and mental agony.
- The OP No. 1 to 3 are also directed to pay jointly and severally a sum of Rs. 5,000/- to the complainant as litigation cost.
The above order is to be complied by the OPs within a period of 45 days from the date of this order. In default, the complainant will be at liberty to put the order into execution.
Copy of the judgment be delivered to the parties free of cost as per the C.P. Act and Judgment be uploaded in the website of the Commission for perusal of the parties.
