Chandigarh

StateCommission

A/216/2023

ANIL GARG - Complainant(s)

Versus

THE BRANCH MANAGER THE ORIENTAL INSURANCE COMPANY LTD - Opp.Party(s)

Advocate (In person)

15 Dec 2023

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

Appeal No.	:	216 of 2023
Date of Institution	:	04.09.2023
Date of Decision	:	15.12.2023

 

Anil Garg Advocate H. No.1004, Sector 9, Panchkula.

 ……Appellant/Complainant

V e r s u s

 

1. The Branch Manager, the oriental Insurance Company Ltd. SCO No. 48-49, Sector 17-A, Chandigarh 160017.
2. Health Insurance TPA Pvt. Ltd. SCO No.39, 1^st floor, Sector 26, Madhya Marg, above Barbeque Nation, Chandigarh 160019, Mr. Ravi.
3. The Manager, OJAS Medical Service Private Ltd. H-1, Sector 26, Panchkula 134116.  

…..Respondents/opposite parties

 

BEFORE:    JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                   MR.RAJESH K. ARYA, MEMBER

                            

Present:-    Sh.Anil Garg, appellant in person.

Sh.Krishan Kant, Advocate for respondent No.1.

Ms.Ritika Garg, Advocate for respondent No.3.

Respondent No.2 exparte vide order dated 19.10.2023.

 

PER JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                   The complainant has assailed the order dated 14.08.2023 passed by the District Consumer Disputes Redressal Commission-I, U.T., Chandigarh (in short the District Commission), vide which consumer complaint bearing no.263 of 2022 filed by him was dismissed, while observing as under:-

“…On perusal of terms and conditions annexed as R/1 by the OP No.1, it is observed that there is a condition with regard to payment of expenses, based on the room rent limit. An extract of the same is reproduced here below:-

Sr. No.	Expenses Covered	Silver	Gold	Diamond
i.	Room, Boarding and Nursing expenses as provided by the hospital/Nursing Home	1% OF THE SUM INSURED PER DAY	XXXXX	XXXXX
Ii	Intensive care Unit(ICU) Expenses  as provided by the Hospital/Nursing Home	2% of the sum insured  per day	Xxxxxx	XXXXX

 

Number of days under ‘i’ and ‘ii’ above should not exceed total number of days of admission in the hospital. All related expenses (including iii and iv below) shall also be payable as per the entitled room category based on the room rent limit as mentioned above. This will not apply on medicines/pharmaceuticals and body implants. 

On perusal of Annexure C-6 which is a detailed statement of reimbursement of claim, containing details of expenses, bills, deduction, approved amount and reasons for deductions if, any, it is observed that necessary deductions have been made as per  terms and conditions of the policy.  The said statement contains, the reason of deductions as well.

Hence, in view of the foregoing, we are of the view that the deductions have been made in pursuance to the terms and conditions of the policy. Thus, the complainant  has failed to prove his case  

In view of the aforesaid discussion, the present consumer complaint, being devoid of any merit, is hereby dismissed leaving the parties to bear their own costs.…..”

 

Factual scenario:-

2.           Before the District Commission it was the case of the complainant that  he purchased a mediclaim policy from opposite party no.1 on paying premium of Rs.10,730/- which was valid for the period from 17.12.2020 to 16.12.2021. The complainant suffered from Dengue fever and admitted in OJAS Hospital Sector 26 Panchkula/ opposite party no.3  on 14.10.2021 and was  discharged on 17.10.2021. Since the policy was cashless therefore the complainant submitted all the documents with the insurance company, however, at the time of discharge,  the  hospital  demanded an amount of Rs.14065/-  from the complainant, on the ground that opposite party no.1 has not cleared the said outstanding amount. Legal notice served upon the opposite parties in the matter did not yield any result.   Hence, consumer complaint was filed before the District Commission.

 

Written reply filed by opposite party no.1:-

3.           Opposite party no.1 contested the complaint and filed written reply wherein it was stated that  the total expenses incurred by the complainant in the hospital was to the tune of Rs.51,704/- out of which Rs.14065/-  was repudiated  by opposite party no.1 as after going through the documents it was observed that cashless claim settlement in respect of the hospitalization was done according to terms and conditions of the policy. Sum insured under the policy is Rs.4.00 lakh  so eligibility for the room rent is limited upto Rs.4000/- per day and all other expenses need to be deducted proportionately as per the policy conditions.  Thus the claim of the complainant was settled after due consideration of the claim by TPA thereby reimbursing reasonable charges and as such the amount of Rs.14,065/- was repudiated as per clause 1.2 of the terms and conditions of the policy.

 

Written reply filed by opposite party no.2:-

4.           Opposite party no.2 in its written reply stated that it has no role to play in the instant dispute as the medi-claim policy was issued by opposite party no.1  and it acted only as a facilitator for processing of the claim as per terms and conditions of the policy laid down by opposite party no.1.

 

Opposite parties no.2 and 3 were proceeded exparte:-

5.           Despite service none put in appearance on behalf of the respondent no.3. At the same time, after filing reply and evidence opposite party no.2 also did not put in appearance, as a result they both were proceeded against exparte by the District Commission.

 

Rejoinder:-

6.           In the rejoinder filed, the complainant reiterated all the averments contained in his complaint and controverted those of opposite parties no.1 and 2.

 

Evidence filed by the parties

7.           The contesting parties led evidence by way of affidavits and numerous documents before the District Commission.

 

Decision of the District Commission:-

8.           The District Commission after hearing the contesting parties and on going through the material available on record, dismissed the consumer complaint, in the manner stated above.
9.           Hence this appeal.
10.           Record of the District Commission has been requisitioned.
11.           Despite service none put in appearance on behalf of the respondent no.2, as a result whereof it was proceeded against exparte  vide order dated 19.10.2023.
12.           We have heard the contesting parties and have scanned the entire record of this case, including written arguments filed by respondent no.1.

 

Submissions of contesting parties:-

13.           During arguments, the appellant/complainant vehemently contended that by dismissing the consumer complaint, the District Commission fell into a grave error, as it failed to take note of the fact that it was a mediclaim policy under which the entire treatment taken by him was covered there-under upto the sum assured to Rs.4 lacs and the insurance company was wrong in deducting substantial amount of Rs.14,065/- out of the total amount incurred on his treatment.     
14.           On the other hand, counsel for respondent no.1 submitted that the order passed by the District Commission being based on the correct appreciation of facts and law on the point needs to be upheld. 
15.           Counsel for respondent no.3 submitted that it has no relation whatsoever with the amount deducted by respondent no.1. She further submitted that the appellant did not level any specific allegations against respondent no.3 either in the consumer complaint or in this appeal, as such, case against respondent no.3 deserves to be dismissed.

Observations and findings of this Commission:-

16.           The moot question which needs to be decided in this appeal is, as  to whether, the insurance company/respondent no.1 was right in deducting an amount of Rs.14,065/- out of the total amount of Rs.51,704/- incurred on the treatment of the appellant/complainant in the said hospital or not? Before deciding this question, it is significant to mention here that it is coming out from Cashless Authorization Letter dated 17.10.2021, Annexure C-3 that the total billed amount towards the treatment taken by the appellant in the OJAS Hospital was Rs.51,704/-, yet, out of that amount only an amount of Rs.31,051/- was passed by the insurance company/respondent no.1 and the amount of Rs.14,065/- stood deducted by  respondent no.1. The fact that the total billed amount against the treatment taken by the appellant in the respondent no.3-hospital was to the tune of Rs.51,704/-  and that only an amount of Rs.14,065/- stood deducted by  respondent no.1 has not been disputed by the contesting parties. It is also not in dispute that the said amount of Rs.14,065/-  stood paid by the appellant to the respondent no.3-hospital from his own pocket before he was discharged on 17.10.2021.  In the present case also, the appellant is seeking relief of refund of the Rs.14,065/- alongwith interest, compensation and litigation expenses.
17.           We have perused the detail of deductions made by respondent no.1 in Annexure C-3, which is reproduced hereunder:-

 

 

S.N	Description	Bill amount	Deduction amount	Admissible amount	Deduction reason
	Semi-Private Room	5000	1000	4000	1% OF SI AS PER POLICY CONDITIONS
	Semi-Private Room	5000	1000	4000	1% OF SI AS PER POLICY CONDITIONS
	Blood Bank	3780	1230	2550	BLOOD GROUPING CHARGES NOT PAYABLE Pro rata deduction done as per room rent eligibility
	Blood Bank	12500	1875	10625	Pro rata deduction done as per room rent eligibility
	Blood Bank	300	300	0	BLOOD BANK CHARGES NOT PAYABLE
	Doctor Fees	4300	645	3655	Pro rata deduction done as per room rent eligibility
	Hospital Services	11060	1659	9401	Pro rata deduction done as per room rent eligibility
	Medication Charges	5289	1630	3659	NON MEDICAL ITEMS NP
	Non-Medical Items	600	600	0	DIETICIAN NOT PAYABLE
	Non-Medical Items	675	675	0	GENERAL SERVICE CHARGES NOT PAYABLE
11.	Co-Pay		3451

     

18.           It may be stated here that we have gone through the terms and conditions of the policy, Annexure R-1/1 and are of the considered view that following deductions totaling to Rs.5680/- have been made wrongly made by respondents no.1 and 2 as under:-

 

S.N	Description	Bill amount	Amount deducted	Admissible amount	Reason for wrong deduction
3.	Blood Bank	3780	1230	2550	Wrongly deducted an amount of Rs.1230/- because as per clause 1.2 (iv) of the policy, expenses for blood was covered as per the limits of the sum assured.
4.	Blood Bank	12500	1875	10625	Wrongly deducted an amount of Rs.1875/-  because as per clause 1.2 (iv) of the policy, expenses for blood was covered as per the limits of the sum assured.
5.	Blood Bank	300	300	0	Wrongly deducted an amount of Rs.300/-  because as per clause 1.2 (iv) of the policy, expenses for blood was covered as per the limits of the sum assured.
6.	Doctor Fees	4300	645	3655	Wrongly deducted an amount of Rs.645/-  because as per clause 1.2 (iii) of the policy, expenses for Surgeon, Anesthetist, Medical Practitioner, Consultants and Specialist fee was covered as per the limits of the sum assured.
8.	Medication Charges	5289	1630	3659	Wrongly deducted an amount of Rs.1630/-  because as per clause 1.2 (iv) of the policy, expenses for Medicines and Drugs were covered as per the limits of the sum assured.
		Total	5680/-

 

19.           Thus, by deducting an amount of Rs.5680/- illegally and arbitrarily, respondent no.1 is deficient in providing service to the  appellant and also adopted unfair trade practice, which has definitely caused agony, harassment and financial loss to the appellant, which forced him to enter into this litigation. However, the District Commission fell into a grave error in dismissing the consumer complaint, while holding to the contrary. The appellant is therefore held entitled to an amount of Rs.5680/- alongwith interest, compensation and litigation expenses.
20.           Keeping in view the above discussion, we are of the considered view that the impugned order passed by the District Commission, dismissing the consumer complaint, being not based on the correct appreciation of evidence and law on the point, suffers from illegality and perversity needs interference of this Commission.  Consequently, this appeal stands allowed and the impugned order is set aside. The consumer complaint filed by the complainant/appellant stands partly allowed against respondent no.1 only and dismissed against respondents no.2 and 3. Accordingly, respondent no.1-insurance company/opposite party no.1 is directed as under:-
    1. To pay/reimburse the amount Rs.5680/- alongwith interest @9% p.a. from 17.10.2021 (date of discharge of the appellant from hospital) onwards.
    2. To pay compensation to the tune of Rs.3000/- to the appellant/complainant, for causing him mental agony, harassment and also deficiency in providing service, negligence and adoption of unfair trade practice.
    3. To pay cost of litigation to the tune of Rs.3300/- to the appellant/complainant.
    4. This order be complied within a period of 30 days from the date of receipt of a certified copy thereof, failing which the awarded amounts shall further entail interest @12% p.a. from the date of default till realization.
21.           Certified copies of this order be sent to the parties, free of charge, forthwith.
22.           The concerned file be consigned to Record Room, after completion and record of the District Commission be sent back immediately.

Pronounced

15.12.2023

Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

Sd/-

(RAJESH K. ARYA)

MEMBER

Rg