Complainant Samir Gupta has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to reimburse the amount of Rs.11,000/- to him. Opposite parties be further directed to pay Rs.50,000/- for mental harassment, financial burden, mental stress, torture and deficiency in service alongwith Rs.10,000/- as litigation expenses.
2. The case of the complainant in brief is that he has obtained- Mediclaim policy of PNB- Oriental Mediclaim Policy-2017 Group Health Insurance Product (Policy for Bank Account Holders of PNB only) UIN:OICHLGP18074V011718 through Punjab National Bank, Dhangu Road, Pathankot as he is the account holder of that Bank. He had obtained the policy of cashless on 25.1.2018 bearing policy no.233106/48/2018/1276 vide Member ID No.055619404891 which was for the period of 25.01.2018 to 24.01.2019 Ex.C-1. The policy was again renewed by paying premium of Rs.8670/- for the period 25.1.2019 to 24.01.2020 Ex.C-2, this shows that the policy is in continuity. He has further pleaded that in the morning of 2nd May 2019 he suddenly felt uneasy due to mild pain in his chest and he was rushed to Sri Nangli Hospital where he was referred to Amandeep Hospital, Dalhousie Road, Mamoon, Pathankot. He was admitted in ICU with CAD and Coronary Angiography was conducted as advised by the concerned doctors. He has further that the opposite parties no.3 and 4 working as TPA of the Oriental Insurance Co. Amandeep Hospital is in the list of networking hospital of the opposite party no.1- Oriental Insurance Co. He got admitted in the Amandeep Hospital as he had purchased the cashless policy from the opposite party no.1 through Punjab National Bank, Dhangu Road, Pathankot i.e. opposite party no.5. He submitted his Insurance Card in Amandeep Hospital, who sent the proposal on 3.5.2019 to the opposite party no.3 i.e. with all the medical records and necessary documents. The opposite party no.3 i.e. TPA has given reply vide letter No.Raksha/Ref-556191 920091200/3713770 in which they had demanded some particulars from the Hospital, which were completed with all the formalities. He has further pleaded that on 4th May 2019 opposite party no.3 has demanded the policy of 2017-2018 by letter No.Raksha/ Ref-556191 920091200/3713770. It was very strange for the complainant because he was insured in 2018, how can he provide the policy of 2017-18, in the same letter the opposite party has also asked about his age. His age is at present 50 years and would be 51 years on 10th August 2019. His age has been corrected by making endorsement by the Insurance Company which has been earlier got wrongly mentioned by the Insurance Company. He has next pleaded that on 04th May 2019 vide TPA letter No.Raksha/Ref-556191 920091200/3715746, opposite party no.3 stated that they are unable to approve cashless hospitalization and further stated that according to the policy Terms and Condition, policy in second year, CAG Non-payable, hence cashless denied. Amandeep Hospital, has provided all the necessary intimation and documents but opposite parties have wrongly denied the cashless claim. Opposite parties asked him to send his case for reimbursement but the opposite parties are not entitled to ask from him to apply for reimbursement when he has obtained the cashless policy. He has further pleaded that it was very unprofessional on the part of the opposite parties that they reject his proposal vide letter dated 4.5.2019 with malafied intention. Because if the rejection of the policy was due to the terms and conditions of the insurance company it should be mentioned in their first letter dated 3.5.2019. The above detailed facts clearly established that is a deficiency in service, harassment, unwanted financial burden and mental stress on the part of the opposite parties without any reason. There is no cogent and convincing cause to reject his cashless claim. He spent the total amount of Rs.11,000/- for his medical treatment at Amandeep Hospital. He also served a legal notice dated 15.5.2019 to the opposite party but they had not replied the notice. He approached the opposite party time and again but the opposite party is adamant and with the malafide intention and by this act of the opposite party he suffered mental agony and harassment at the hands of the party which amounts to deficiency in service. Hence this complaint.
3. Notice of the complaint was issued to the opposite parties. Opposite party no.1 appeared through its counsel and filed its written reply taking the preliminary objections that the complaint filed by the complainant against the opposite party is hopelessly Pre-Mature. The complainant had made the request for cashless facility for his treatment on 3.5.2019, which was refused by M/s.Raksha Health Insurance TPA Pvt.Ltd. vide letter dated 04.05.2019, after perusal of the documents on the ground that under the terms and conditions of the company, the CAG is non-payable in 2nd year of the policy; the complainant is stopped to file the instant complaint, as there is no deficiency in service, on the part of the opposite party as defined in section 2 (i) (g) of the Consumer Protection Act, 1986 under the heading ‘Deficiency’. And no cause of action has accrued against the opposite parties, hence the present complaint is liable to be dismissed on this score only. On merits, it was submitted that M/s.Raksha Health Insurance TPA Pvt.Ltd. which is Third Party Claim Settling Authority, settles the claim as per the medical treatment record of the complainant under the terms and conditions of the company, but in the present case, the complainant neither lodged his claim with the M/s.Raksha Health Insurance TPA Pvt.Ltd, nor supplied his medical treatment record and other requisite document for settlement of his reimbursement claim. So far as the question of Amandeep Hosptial is concerned, it is an empanelled hospital of insurance company. It was correct that the complainant had purchased the cashless policy from the opposite party through opposite party no.5 Bank, but due to non-coverage of the CAG in 2nd year, the M/s.Raksha Health Insurance TPA Pvt.Ltd, refused for cashless facility to the complainant under the terms and conditions of the policy. Ex.OP-1/1 is the Letter of denial of Cashless Access dated 4.5.2019 issued by M/s.Raksha Health Insurance TPA Pvt.,Ltd. And Ex.OP-1/2 is the copy of Terms and Conditions of the Policy. It was admitted that the complainant had made the request for cashless facility for his treatment on 3.5.2019, which was refused by M/s.Raksha Health Insurance TPA Pvct.Ltd. vide letter dated 4.5.2019, after perusal of the documents, on the ground that under the terms and conditions of the company, the CAG is non-payable in 2nd year of the policy. The M/s.Raksha Health Insurance TPA Pvt.Ltd. had further cleared vide his above mentioned letter that the denial of cashless facility does not means the denial of treatment, but it is the denial of credit facility. He was requested to make the payment of his treatment to the hospital and submit his claim after discharge from the hospital alongwith the medical bills and other requisite documents and the reimbursement claim will be proceeded subject to admissibility as per policy terms and conditions, But till the date, the complainant has not lodged his claim alongwith the requisite documents, with the opposite parties, for settlement the claim of reimbursement. It was further admitted that the policy in question is cashless and the hospital where the complainant was admitted is empanelled hospital of the opposite party, but due to non-coverage of the CAG in 2nd year, the M/s.Raksha Health Insurance TPA Pvt.Ltd, refused for cashless facility to the complainant under the terms and conditions of the policy. It was submitted that the request of the complainant for cashless facility was refused by M/sRaksha Health Insurance TPA Pvt.Ltd, vide letter dated 04.05.2019, after perusal of the documents, which were supplied by the hospital, on the ground that under the terms and conditions of the company, the CAG is non-payable in 2nd year of the policy. Thus, there is no deficiency in service on the part of the opposite party. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Opposite parties no.2,3 and 4 appeared through their cousin and filed their joint written reply submitting therein that complainant has filed the case against the opposite parties no.1,2,3,4 & 5 whereas the fact is that the Medicalim Policy which the complainant had filed the claim, was issued by The Oriental Insurance Co. Ltd. It was next submitted that by the virtue of the Memorandum of the understanding, signed with the Oriental Insurance Company Ltd. (opposite party no.1), opposite parties no.2,3 & 4 is nominated as the Third Party Administrator for arraying to process the claims of the Insurance Company as per the terms and conditions laid down by the opposite party no.1. Opposite parties no.2,3 & 4 would like to apprise that complainant was covered under the Mediclaim Policy no.233106/48/2018/1151 period of 25.1.2019 to 24.1.2020 issued by the Oriental Insurance Co.Ltd. The cashless claim is in respect of Mr.Samir Gupta towards his hospitalization in Amandeep Hospital – Pathankot, for the treatment of CHRONIC ISCHAEMIC HEART DISEASE, UNSPECIFIED. The policy is running in the 2nd year since date of inception of policy, as per document provided by the claimant. The cashless claim was denied according to policy terms and condition no.4.1 of the opposite party no.1 i.e. The Oriental Insurance Co. Ltd. as CAG is not payable in the 2nd year of policy. It was further submitted that the opposite parties no.2,3 & 4 is just a third party administrator who act as a facilitator for the processing of the claims as per the policy terms and conditions laid down by the opposite party no.1. The name of the opposite parties is liable to be deleted as respondent, as opposite parties no.2,3 & 4 is neither a proper nor necessary party to the present complaint.
5. As per report of Ahlmad R.C. of opposite party no.5 had not been received back. Case called several times, but none had appeared on behalf of opposite party no.5. Hence, the opposite party no.5 was ordered to be proceeded against exparte vide order dated 24.9.2019.
6. Alongwith the complaint, complainant has filed copies of documents Ex.C-1 to Ex.C-20.
7. Alongwith the written statement ld.counsel for the opposite party no.1 filed affidavit of Sh.Harbans Lal, Senior Divisional Manager, O.I.C. Ltd. Pathankot Ex.OP-1 alongwith documents Ex.OP-1/1 to Ex.OP-1/2.
8. Alongwith the written reply, ld.counsel for the opposite parties no.2,3 and 4 filed affidavit of Sh.Vinay Batra General Manager, Raksha TPA Pvt.Ltd. Ex.OP-2,3,4/1.
9. Written arguments have been filed by complainant and opposite party no.1.
10. We have carefully gone through the pleadings of counsel for the complainant; written arguments as well as oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the complainant for the purposes of adjudication of the present complaint.
11. The complainant Samir Gupta had a valid PNB- Oriental Mediclaim Policy-2017 Group Health Insurance Product (Policy for Bank Account Holders of PNB only) UIN:OICHLGP18074V011718 through Punjab National Bank, Pathankot, on the date of his hospitalization i.e. 1.5.2019 he got treatment at Amandeep Hospital on emergency basis at the said hospital which is on the panel of PNB Insurance Company. On 3.5.2019 his claim of treatment was conveyed to the Insurance Co. by the hospital as the said policy was under cashless scheme of the Insurance Company. The claim was duly submitted with documents and identity proof and cashless card. Insurance Co. had sought few details regarding the aforesaid treatment to Sh.Samir Gupta on 3.5.2019 from Amandeep Hospital, Pathankot and again on 4.5.2019 while communicating with the hospital authorities and conveying to Sh.Samir Gupta also denied the claim on the ground that the treatment sought by him CAG being non payable as the policy is in second year. Company has failed to put on record the reasons for denial of the claim with any documentary evidence. The said act of the Insurance Company without any logic and evidence is not accepted in principle of law.
12. Hence, the complaint of Samir Gupta is partly allowed U/s 12 of CPA and the claim of his hospitalization for the period from 1.5.2019 to 4.5.2019 for his treatment at Amandeep Hospital, Pathankot is allowed to the extent of bills submitted at Ex.C-15. Opposite party no.1 is further directed to pay an interest of 9% per annum on the amount of bills claimed on account of delay from the date of this claim before the DCRC, Gurdaspur, to the complainant. An additional amount of Rs.10,000/- is also ordered to be paid by opposite party no.1 on account of harassment and willfully denying rightful claim of Samir Gupta complainant.
13. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
14. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.
(Naveen Puri)
President
Announced: (R.S.Sukhija)
April 28, 2022 Member
*MK*
