Jharkhand

Bokaro

CC/17/5

Subhash Chand Singh - Complainant(s)

Versus

The Branch Manager, E-Meditek (TPA) Service Ltd. - Opp.Party(s)

Amardeep Jha and Poonam

24 Sep 2022

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-As mentioned with the Case No.

Date of Judgement-24-08-2022

Consumer Complaint No. 77/2016 Filed on - 09-07-2016

Rajendra Sharma S/o Pushpa Sharma

R/o Qr.No. 28, Sector-3/B, P.O.- P.O- Sector-3, P.S.- B.S.City

District- Bokaro, (Jharkhand)

With

Consumer Complaint No. 83/2016 Filed on- 13/07/2016

Mahesh Prasad Sharma S/o Late Anandi Prasad  Sharma

R/o- Qr.No. 2-149, Sector-2/C, P.O.-Sector-2, P.S.- B.S.city

District- Bokaro, (Jharkhand)

With

Consumer Complaint No.84/2016 Filed on - 13-07-2016

Sri C.S. Singh S/o Late Gaya Prasad Singh

R/o Qr.No. 1182, Sector-9/D, P.O.- Sector-9, P.S- Harla

District- Bokaro, (Jharkhand)        

With

Consumer Complaint No.120/2016 Filed on – 04-10-2016

Tripit Prasad Singh

R/o Sector-4/D, Qr.No. 2073, P.O. & P.S.- Sector-4,

District- Bokaro, (Jharkhand ) 

With

Consumer Complaint No. 132/2016 Filed on – 18-11-2016

Sri Aditya Vishwakarma S/o Sri Kamal Deo

R/o- Qr.No. 2-185, St-3, Sector-2/C, P.O.-Sector-2, P.S.- B.S.city

District- Bokaro, (Jharkhand)

With

Consumer Complaint No. 05/2017 Filed on- 06-01-2017

Subhash Chand Singh S/o Late S.N. Singh

R/o Qr.No. 1266, Sector-XII/F, P.O. & P.S- Sector XII

District- Bokaro, (Jharkhand)

With

Consumer Complaint No. 33/2017 Filed on- 16-02-2017

Deo Raj Singh S/o Late Baleshwar Singh

R/o Qr.No. 593, Sector – III/B, P.O.- Sector-2, P.S.- B.S.City

District- Bokaro, (Jharkhand)

With

Consumer Complaint No. 37/2017 Filed on -16-02-2017

Nagendra Pandey S/o Late Shiv Sampat Pandey

R/o- Qr.No.-823, St-36, Sector-IX/D, P.O.-Sector-IX, P.S.- Harla

District- Bokaro,( Jharkhand)        ……………. Complainant

                  

Vs.

1. The Branch Manager, E-Meditek (TPA) Sevices Ltd.

Plot No. HD-11, Ground Floor, Sector-IV, P.O. & P.S.- Sector-IV, District- Bokaro.

2. The E-Meditek (TPA) Services Ltd.

Plot No. 577, Udyog Vihar, Phase-V, Gurgaon, Hayana.

3. The Branch Manager, National Insurance Co. Ltd.

Bye Pass Road, Chas, P.O. & P.S.- Chas, District- Bokaro

                                                                   Opposite Parties

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

   Shri Bhawani Prasad Lal Das, Member

          Smt. Baby Kumari, Member

 

PER- J.P.N Pandey, President

-Judgement-

1. Since the facts, circumstance and evidence related to above mentioned cases are identical to each other and issues/points to be decided in each case are also identical/similar hence above mentioned all cases are being taken up together for decision by this common judgment.
2. Case of all the complainants is that they being retired SAIL, BSL employee are entitled to get medical facilities for themselves and their wives as per norms of the company, on making payment of the premium to the insurance co. ( O.P.). Further case is that in all cases complainants have paid premium of their share to the Insurance co. as per norms and being covered by mediclaim policy of O.Ps. covering OPD treatment as well as indoor treatment in the hospital for which different MIN Nos. as mentioned in column No. ‘4’  of the table below have been allotted to them by the O.P. Insurance Co. Further case is that due to some illness as mentioned in the complaint petition they got admitted themselves in Shivam Hospital at E-2, Laxmi Market, Sector-4, B.S. City, District Bokaro (here in after referred as Shivam Hospital) for the period as indicated at column No. ‘5’of the table below and paid the amount related to medical expense as mentioned in column no. ‘6’of the table below to the Shivam Hospital, for which they submitted duly filled up claim form in the office of the O.Ps. but their claim has not been allowed  on the ground related to eligibility criteria of the Shivam Hospital concerned in which treatment was done. Further case is that inspite of issuance of legal notice grievance of the complainants have not been redressed, hence these cases have been filed with prayer for re-imbursement of the amount paid to the Hospital (as mentioned at column No. ‘6’of the table below) and further for payment of compensation and litigation cost as mentioned in the complaint petition.

TABLE SHOWING ALL DETAILS RELATED TO THE CASE NO., NAME OF THE COMPLAINANT, MIN NUMBER, PERIOD FOR WHICH COMPLAINANT WAS ADMITTED IN THE SHIVAM HOSPITAL AND THE AMOUNT PAID TO THE SHIVAM HOSPITAL FOR WHICH CLAIM HAS BEEN MADE FOR ITS RE-IMBURSEMNT.

Table showing details related to above mentioned cases
Sl. No.	C.Case. No.	Name of the  Complainant	MIN NO.	Date of admission & Discharge of the complainant in the Hospital	Amount Paid to the Hospital for treatment for which reimbursement has been prayed
1	2	3	4	5	6
1	77/2016	Rajendra Sharma	4708238	02/04/2014 to 12/04/2014	46500
2	83/2016	Mahesh Prasad Sharma	4708183	19/04/2014 to 27/04/2014	45000
3	84/2016	Sri C.S. Singh	4711046	23/04/2014 to 09/05/2014	41500
4	120/2016	Tripit Prasad Singh	4710593	24/06/2014 to 03/07/2014	48900
5	132/2016	Sri Aditya Vishwakarma	4733022	27/08/2014 to 04/09/2014	47000
6	5/2017	Subhash Chand Singh	4724712	19/09/2014 to 28/09/2014	39000
7	33/2017	Deo Raj Singh	4732945	21/09/2014 to 28/09/2014	36000
8	37/2017	Nagendra Pandey	4720861	01/11/2014 to 08/11/2014	37000

 

1. oint W.S. has been filed by O.P. No. 1 & 2 in all the cases and it is mentioned in all W.S. of above mentioned cases that these O.Ps. are agent of O.P. No.3 and were working on behalf of O.P. No.3 on his directions hence as per settled principle of law they are not liable in this case. Hence it is prayed to dismiss the case against these O.Ps.
4. O.P. No.3 Insurance co. has filed W.S. in above cases mentioning therein that case is not maintainable, which is barred by limitation. Further reply is that as per rules of IRDA “Hospital” means any institution established for in-patient care and day care treatment of sick-men and for injuries and which has been registered as a hospital with the local authority wherever applicable and is under the supervision of registered and qualified medical practitioner,

   And Must comply with all minimum  as under:-

1. Has at least 10 inpatient bed in those towns having a population of at least 10,00,000 and 15 inpatient beds in all other places.
2. Has qualified nursing staff under its employment round the clock.
3. Has qualified practitioners round the clock.
4. Has fully equipped operation theater of its own where surgical procedures are carried out.
5. Maintain daily records of patients and will make their accessible to the insurance authorized personal.

It has been further replied that on investigation it has been found that Shivam Hospital is not maintaining the norms of IRDA where applicants claimed to be admitted and treated, therefore, said hospital does not comes under category of hospitals hence re-imbursement is not acceptable, hence it has been repudiated and case is liable to be dismissed.

5. On careful perusal of pleadings of the parties following points are to be considered by this Commission:-

1. Whether above cases are time barred ?
2. Whether the repudiation of the claim of the complainants in above mentioned cases is justifiable or not?
3. Whether complainants are entitled to get re-imbursement of medical expense and other amount as claimed or not?

6. On careful perusal of the pleadings of the parties it is apparent that either following facts have been admitted or have not been controverted/disputed or specifically denied by the parties of above mentioned cases.

1. That complainants were earlier employee of SAIL, BSL, Bokaro and they retired from the service of SAIL, BSL, Bokaro.
2. That as per policy of the SAIL, BSL, Bokaro all retired employees of the SAIL,BSL, Bokaro are entitled for medical insurance coverage to the some extent on contributing premium  towards it.
3. That as per norms of the SAIL, BSL, Bokaro complainants of above mentioned cases have deposited the required premium and were being covered by the mediclaim policy of the O.P. No.3.
4. That said mediclaim policies of the complainants were effective for the period for which claim has been made.
5. That all the complainants have been allotted different MIN numbers by the insurance co. as mentioned in column No .’4’of above mentioned table.
6. That the complainants of different cases suffered with illness as mentioned in their complaint petitions and they got themselves admitted in Shivam Hospital for the period as mentioned in column No. ‘5’ of above mentioned table.
7. That the complainants of above mentioned cases have made payment of the amount to the Shivam Hospital as mentioned in column No. ‘6’ of above mentioned table on account of medical expense incurred on their treatment.
8. That the claim of all the complainants has been denied by the O.Ps.

 

7.     Complainants have filed photo copy of papers related to their treatment, photo copy of claim form duly received by the O.Ps. but the facts related to treatment, payment made to the hospital and submission of claim form and other documents before the O.Ps. are not under dispute. Hence on these aspects detail discussion in this judgment is not being made.
8. Now, in light of above mentioned admitted or not disputed facts we would like to discuss the case point wise as it has been framed for decision.
9.  Point No. A:- this point is related to limitation in filing of the case. During argument it has been shown by the complainants that the period of limitation for filing the case will start from the date of denial of the claim, therefore, from the date of repudiation of the claim complaints are well within limitation period hence case is not barred by the limitation. On this aspect O.Ps. have not given more stress. The papers submitted by O.Ps. itself sufficient to show that their investigator had submitted his report sometime in the year 2016 mentioning therein that concerned hospital does not come within the purview of the definition of the hospital. Therefore, this letter itself shows that cause of action for filing the case was arised in the year 2016, in this way all above mentioned cases have been filed well within prescribed period of limitation. Accordingly we are of the view that none of the case is time barred. Hence this point is being decided in favour of the complainants.
10. Point No.B:- This point is related to criteria of the hospital. As per O.Ps. Shivam Hospital, E-2, Laxmi Market, Sector-4, B.S. City is not fulfilling the criteria of the hospital as per definition of hospital mentioned in IRDA rules. As per rules of  IRDA “Hospital” means any institution established for in-patient care and day care treatment of sickness and/ or injuries and which has been registered as a hospital with the local authority wherever applicable and is under the supervision of registered and qualified medical practitioner,

     And must comply with all minimum  as under:-

1. Has at least 10 inpatient bed in those towns having a population of at least 10,00,000 and 15 inpatient beds in all other places.
2. Has qualified nursing staff under its employment round the clock.
3. Has qualified practitioners round the clock.
4. Has fully equipped operation theater of its own where surgical procedures are carried out.
5. Maintain daily records of patients and will make their accessible to the insurance authorized personal.

11. Now we have to see whether the Shivam Hospital is fulfilling the criteria of above mentioned definition of hospital or not?
12.  On this aspect attention of the Commission has been drawn on photo copy of the investigation report dt. 22.09.2016 submitted by one Ashok Kumar Mishra (the private investigator appointed by the O.Ps.) and he has mentioned that said hospital is a type of small clinic or nursing home, there are three rooms in the hospital and each room contains three or four beds, where patients are kept for treatment, there is no ward in the hospital containing 10 in patient bed, there is no separate ward for the patients of different type of diseases such as ortho ward, ICU, CCU etc., all patients are kept in same ward or in a small single room containing three or four beds, as per the norms of IRDA no any doctor around the clock is available, the records of patients are not maintain as per the norms of IRDA and all medical devices and equipments have been kept in a single room and no separate room has been allotted for each device and half part is under construction. No any parameter of IRDA is maintained for hygiene etc. Hence said hospital does not come under the definition of the hospital. It appears that said report has been submitted mere on the basis of oral unrecorded information obtained from some nearby people but it is not based on any concrete and authentic  evidence.
13. Contrary to above investigation report Learned counsel for the complainants have filed photo copy of certificate of registration of the hospital issued by the State Govt. Authority under the provision of section 15 of the Clinical Establishments (Registration and Regulation) Act. 2010 by which said hospital has been registered for the period of one year from 27.03.2014 vide registration number 2035500119. He has also filed the photo copy of proof regarding deposit of requisite registration fee, photo copy of form SG1, SG5, photo copy of information related to hospital submitted before the local authority, photo copy of the application for renewal of the registration for the period of 2015 & onward etc. From those papers it is apparent that said hospital is functional since 10.09.2003 and it is having 20 beds, two OPD Clinics and also fulfilling all criteria of a hospital and after full satisfaction by the competent authority of the State said hospital has been registered and its registration has been renewed time to time.
14. As per photo copy of letter No. 755 dt. 27.03.2017 of the office of the CMO, Bokaro said hospital is fulfilling all criteria of the hospital and at serial no. 51 of the list of the hospitals registered in the District Bokaro all details of Shivam hospital have been described. Papers filed by the complainants show that for the subsequent period also said hospital has been registered with the competent State Authority. Though photo copy of some other criminal cases has been filed but it is having no relation with merit of this case hence discussion in this regard is not being made in this judgment.
15. Photo copy of letters dt. 27.05.2016, 13.04.2016, 21.05.2016,  21.05.2016, 25.06.2016, 18.09.2015, 17.11.2016 and  02.08.2016 written by O.Ps. to different insured persons are showing that the claims of Alakh Raj Singh admitted in said hospital from 22.02.2016 to 04.03.2016, claim of Ghanshyam Singh admitted in said hospital from 22.01.2014 to 30.01.2014, claim of Gulabi Devi admitted in said hospital from 15.12.2013 to 23.12.2013, claim of Niranjana Devi admitted in said hospital on 11.11.2013 to 19.11.2013, claim of Moinuddin Ansari admitted in that very hospital from 21.09.2015 to 26.09.2015,  claim of Awadhesh Kumar admitted in that very hospital from 13.12.2014 to 20.12.2014, the claim of Pandit Shiv Shankar admitted in that very hospital on 15.09.2016 to 20.09.2016 and claim of Gopal for treatment of his wife Sweta Gupta admitted in said hospital from 04.06.2016 to 11.06.2016 respectively have been allowed by these O.Ps. which show that O.Ps. are also admitting the fact that said hospital is/was fulfilling all the criteria of the hospital and they have allowed the claims of above mentioned period starting from the year 2013 till the year 2016 related to other different persons as mentioned above but in respect to above mentioned complainants their claim has not been allowed though it was on same footing of those persons whose claims have allowed by these O.Ps.
16. Complainants have drawn attention of this Commission on photo copy of the letter dt. 20.03.2018 issued by the Insurance Regulatory And Development Authority of India by which certificate of registration of O.P. E-Meditek Insurance TPA Limited has been suspended with immediate effect till further orders, on the grounds that during inspection grave irregularities such as irregularities in respect of policy/claim servicing, irregularities in respect of accounting practices and other irregularities, which were found in violation of various provisions of IRDAI (TPA Health Services) Regulations 2016 finding that continuance of said TPA will have adverse impact on the policy holders and insurers. This letter itself sufficient to show that O.Ps. were working arbitrarily and they were not working in a just manner, hence in the interest of policy holders and insurers registration of TPA E-Meditek Health Services Ltd. has been suspended. Therefore, it appears that conduct of the O.Ps. was also not found just and proper by their regulatory authority.
17. On careful scrutiny of above mentioned papers it appears that O.Ps. have placed reliance on the investigation report of a private person based on speculation without any concrete evidence. On the other hand complainants have based their claim on the papers issued by the competent authority of the State Govt. who is having jurisdiction to do it. O.Ps. have also recognized the competence of the hospital for treatment of the patients by acceptance of claim of Alakh Raj Singh, Ghanshyam Singh, Gulabi Devi, Niranajana Devi, Moinuddin Ansari, Awadhesh Kumar, Sweta Gupta W/o Gopal etc. for the period starting from the year 2013 till the year 2016 which  is pre & post claim period related to this case. Therefore, on careful perusal of the documents issued by the O.Ps. in respect to acceptance of the claims of so many people of different period in respect to same hospital it appears that principle of Estoppel will apply against the O.Ps. and they will be stopped from saying anything else than the acceptance made earlier. IRDAI itself has not found the conduct of these O.Ps. fair and has passed order for suspension of registration of TPA.  In view of above discussion we are of the view that denial of the claims of the complainants by the O.Ps. is arbitrary and not based on evidence. Accordingly this point is being decided in favour of the complainants and against the O.Ps.
18. Point No. C:- This point is related to prayer of the complainants of above mentioned cases. On this aspect we would like to mention here that mediclaim policy, period of enforcement of mediclaim policy, entitlement of the claimants, their illness and admission in the hospital for period as mentioned in column 5 of above mentioned table and payment made by them towards medical expense to the hospital as mentioned in column 6 of the above table are not in dispute. Only rejection of the claim has been made on the basis of the criteria of the hospital on the ground that it does not fulfill the criteria as per IRDA norms. About this aspect detail discussion has already been made in respect to point No. B and it has been held that said hospital is fulfilling all the criteria of a hospital as per norms of the IRDA and it has been admitted by O.Ps. by allowing the claims of other persons who were treated in the Shivam Hospital for the period of the year 2013 to 2016. Therefore, we are of the view that complainants of above mentioned cases are entitled to get re-imbursement of their medical expense as claimed by them. Accordingly this point is being decided in favour of the complainants and against the O.Ps.
19. Accordingly prayer of the complainants named above is being allowed in the following manner :-

O.P. No.3 (National Insurance Co. Ltd.) is directed to pay Rs. 46500/- to the complainant of C.C. No. 77/2016 , to pay Rs. 45000/- to the complainant of C.C. No. 83/2016 , to pay Rs. 41500/- to the complainant of C.C. No. 84/2016 , to pay Rs. 48900/- to the complainant of C.C. No. 120/2016,to pay Rs. 47000/- to the complainant of C.C. No. 132/2016,to pay Rs. 39000/- to the complainant of C.C. No. 5/2017 , to pay Rs. 36000/- to the complainant of C.C. No. 33/2017 , to pay Rs. 37000/- to the complainant of C.C. No. 37/2017 within 45 days from the date of receipt/ production of the copy ofthis judgment, failing which they will be entitled to get interest @ 10% per annum from the date of filing of the case as mentioned above. Further O.P. No.3 directed to pay compensation to each of the complainant named above @ Rs. 5000/- each and to pay Rs. 3000/- as litigation cost to each of the complainant within 45 days from the date of receipt/production of the copy of this judgment.

This Judgment will kept in the file of C.C. No. 77/2016 and will also be treated as judgment in C.C. No. 83/2016, 84/2016, 120/2016, 132/2016, 5/2017, 33/2017 & 37/2017. O.C. to keep certified copy of this judgment in each concerned record.

 

 

(J.P.N. Pandey)

                                                                                President

 

                                                                                               

     (B.P.L Das)

    Sr. Member

 

 

                                                                              (Baby Kumari)

                                                                                  Member