Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 87
Instituted on : 07.02.2022.
Decided on : 12.07.2023.
Nirmala age 57 years, w/o Sh. Dayanand Singh r/o H.No.2228,. Sector 2-3, Part Rohtak.
.......................Complainant.
Vs.
The Branch Manager, The National Insurance Company, Outer Quilla road, Near Kalra Petrol Pump, Rohtak.
……….Opposite party
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR.TRIPTI PANNU, MEMBER
DR. VIJENDER SINGH, MEMBER
Present: Sh.S.K.Hooda, Advocate for the complainant.
Dr.Deepak Bhardwaj, Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that son of complainant namely Sudhir Kumar had purchased a Mediclaim policy from the respondent vide policy no.361900502010002201 for the period of 17.02.20221 to 16.02.2022. Complainant was nominee in that policy. The son of complainant had suffered with Covid-19 disease on 2 May 2021 and was admitted in Sunflag Hospital, Rohtak with indoor number 05/21/8791 and remained under treatment till 14.05.2021. He was declared dead on 14.05.2021 at 7:00P.M. The complainant spent an amount of Rs.367196/- on the treatment of his son . Out of which Rs.200000/- were hospitalization expenses and remaining amount of Rs.167196/- was of medicines, medical test etc. Complainant submitted all the required documents, medical bills, certificates etc. with the respondent for the claim but the respondent had processed the claim only for Rs.195487/- with the deduction of Rs.171709/-. Complainant approached the opposite parties several times for approval of claim but any heed was not paid to her requests. The act and conduct of the opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the remaining claim amount of Rs.171709/- alongwith interest @ 12% p.a. from the date of claim, compensation of Rs.20000/- on account of mental tension, harassment and Rs.10000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that after receiving claim intimation regarding the mediclaim of insured, the claim was processed by TPA i.e. MDINDIA Health Insurance TPA Pvt. Ltd. of the answering opposite party. The claim of the insured was non cashless claim and the claim was intimated to the answering respondent on 13.06.2021 for the treatment period of the insured from 02.05.2021 to 14.05.2021 at Sunflag Global Hospital for the treatment of Covid-19+ve. After perusal of treatment documents and considering the terms and conditions of the insurance policy, the clam was settled for an amount of Rs.161531/- which was duly disbursed to the claimants. It is pertinent to mention here that the bills/expenses which are already covered in package are deducted from the total amount and the details of the bills allowed and deducted are properly explained and mentioned in the Claims Payment Statement which may kindly be read as part and parcel of this written statement. Thereafter the claimant also submitted medicines bills etc. and the answering respondent also disbursed payments of Rs.33956/- and the claim has been settled for Rs.195487/- against the claimed amount of Rs.367196/- towards medical expenses incurred for treatment of insured. As per terms and conditions of the policy in different Sections, the claimed amount are as follows: Section A Rs.39000/-, Section B Rs.52000/-, Section C Rs.280916/- and Extra bills received(Excluding Lodge Amount) Rs.4720/-, total claimed amount is Rs.367196/- out of which the amount claimed under Section C is payable which has been settled for an amount of Rs.166251/- and Extra amount of Rs 4720/- is deducted i.e. Rs.4720/-, therefore the net payable amount comes Rs.161531/- + Rs.33956/- = Rs.195487/- to the claimant. It is further submitted that description of Section A-All admissible claims under (i) and (ii) during the policy period - Up to 25% of Sum insured and Section B Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees-Upto 25% of Sum Insured and Section-C Anesthesia, Blood, oxygen, Operation Theatre Charges, Surgical Appliances & Drugs, Diagnostic Materials, X-ray, Dialysis Chemotherapy Radiotherapy, cost of Pacemaker, artificial limbs and any material expenses incurred which is integral part of the operation/treatments-Up to 50% of Sum Insured. The settled claimed amount has already been disbursed due to which complainant is not entitled for any further claim amount from the answering opposite party. There is no deficiency in service on the part of opposite party. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Learned counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A, documents Ex.C1 to Ex.C9 and has closed his evidence on dated 31.10.2022. Learned counsel for the opposite party tendered affidavit Ex. RW1/A, documents Ex. R1 to Ex.R8 and closed his evidence on 27.01.2023.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case it is observed that all the expenses have been mentioned in Ex.C6 & Ex.C7 having 29 pages each. These are the bill of medicines, tests etc. which were borne by the complainant. As per complaint, the complainant has spent an amount of Rs.367196/- on the treatment of her deceased son Sudhir Kumar. Rs.2 lacs have been spent on Covid ICU Room rent, Covid Nursing Charge, Covid Doctor Visit C, CT Scan Chest. The remaining amount of Rs.167196/- has been spent on medicines and tests etc. On the other hand the respondent have submitted that the deceased was under treatment of Covid and a package of treatment has been given after considering the terms and conditions of the policy. The TPA of respondent calculated the total payable amount Rs.161531/- + Rs. 33956/- which comes to Rs.195487/-. As per the respondent they have disbursed an amount of Rs.161531/- to the complainant against the treatment initially and thereafter the respondent officials paid further an amount of Rs.33956/-. The respondent further submitted that nothing is due against respondents.
6. We have minutely perused the reply filed by opposite party. As per written statement, affidavit and documents placed on record by the respondent, the claim has been settled as per term and conditions of the insurance policy in different sections which is mentioned as under:-
Section A Rs.39000/-, Section B Rs.52000/-, Section C Rs.280916/- and Extra bills received(Excluding Lodge Amount) Rs.4720/-, total claimed amount is Rs.367196/- out of which the amount claimed under Section C is payable which has been settled for an amount of Rs.166251/- and Extra amount of Rs 4720/- is deducted i.e. Rs.4720/-, therefore the net payable amount comes Rs.161531/- + Rs.33956/- = Rs.195487/- to the claimant. It is further submitted that description of Section A-All admissible claims under (i) and (ii) during the policy period - Up to 25% of Sum insured and Section B Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees-Upto 25% of Sum Insured and Section-C Anesthesia, Blood, oxygen, Operation Theatre Charges, Surgical Appliances & Drugs, Diagnostic Materials, X-ray, Dialysis Chemotherapy Radiotherapy, cost of Pacemaker, artificial limbs and any material expenses incurred which is integral part of the operation/treatments-Up to 50% of Sum assured.
Sectionwise payment is given on page no.3 of Ex.R3, which is as under:-
Sections | Eligible Amount | Claimed Amount | Payable Amount | Deducted Amount |
A | 126875 | 39000 | 0 | 39000 |
B | 126875 | 52000 | 0 | 52000 |
C | 253750 | 280916 | 166251 | 114665 |
Extra Bill received (Excluding lodge amount | 0 | (4720) | -4720 | 0 |
Total | 507500 | 367196 | 161531 | 205665 |
7. We have minutely perused the document Ex.R5. Upon page No.2 some calculation and remarks have been mentioned. Under the head room, no amount has been mentioned, under the head ICU & under the head professional fee, no amount has been mentioned.
8. After perusal of above mentioned two documents we have came into the conclusion that in fact the insurance company or TPA of the insurance company allowed the package to his consumer/deceased regarding the ailment/disease which was not within the knowledge of consumer that how the insurance company assessed the claim. In the present case the complainant submitted the actual expenditure with the insurance company but the TPA of the insurance company assessed the claim on package basis. The perusal of documents shows that after applying package the insurance company paid less amount to the hospital or to the complainant. In fact in the present case the complainant spent an amount of Rs.371916/- on his treatment and after considering package of Covid the insurance company only allowed the claim of Rs.195487/- to the deceased.
9. As per our opinion there is deficiency in service on the part of TPA and insurance company and complainant is entitled for whole amount spent on his treatment under different heads as per limitation of the policy. As per Ex.R2, sectionwise payment has been shown which is as under:
Sections | Eligible Amount | Claimed Amount | Payable Amount | Deducted Amount |
A | 126875 | 39000 | 0 | 39000 |
B | 126875 | 52000 | 0 | 52000 |
C | 253750 | 280916 | 166251 | 114665 |
Extra Bill received (Excluding lodge amount | 0 | (4720) | -4720 | 0 |
Total | 507500 | 367196 | 161531 | 205665 |
Perusal of alleged sectionwise payment shows that under the head of Section A eligible amount is Rs.126875/- and the claimed amount is Rs.39000/-. Hence the complainant is entitled for Rs.39000/-, under Section B Eligible amount is Rs.126875, claimed amount is Rs.52000/-, hence complainant is entitled for Rs.52000/- and under the section C the eligible amount is Rs.253750/- whereas the complainant claimed an amount of Rs.280916/-. As per our opinion, the complainant is entitled under section C an amount of Rs.253750/-. Hence the total amount comes to Rs.253750/- + Rs.39000/- + Rs.52000/- = Rs.344750/- less Extra bill received Rs.4720/- which comes to Rs.340030/-. As per written statement they have paid an amount of Rs.195487/- to the complainant. As such complainant is entitled for the remaining amount i.e. Rs.144543/-(Rs.340030/- less Rs.195487/-)
10. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay Rs.144543/-(Rupees one lac forty four thousand five hundred and forty three only) alongwith interest @ 9% p.a. from the date of payment of filing the present complaint i.e. 07.02.2022 till its realization and shall also pay Rs.15000/-(Rupees fifteen thousand only) as compensation on account of deficiency in service and Rs.10000/-(Rupees ten thousand only) as litigation expenses to the complainant within one month from the date of decision.
11. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
12.07.2023
.....................................................
Nagender Singh Kadian, President
............................................
Tripti Pannu, Member
……………………………….
Vijender Singh, Member
