FINAL ORDER/JUDGEMENT

Smt. SAHANA AHMED BASU, Member,

The case of the Complainant, in brief, is that, the Complainant along with his family is insured with the OPs 1 to 4 under Family Mediclaim Facility being Policy No. 101101501710001476 for 10 years and have been paying Premiums without any default and the said Mediclaim Policy is being renewed from time to time. The total insured sum for the said Mediclaim Policy was Rs.4,25,000/- plus Cumulative Bonus of Rs.1,60,000/- and the Annual Premium  for the said Policy was Rs.22,036/-. The Complainant’s wife was admitted at ILS Hospitals at Salt Lake, Kolkata for the period of 09.05.2018 to 14.05.2018. During her stay at the said Hospital a total sum of Rs.1,37,091 was billed by the said Hospital and the same was paid by the Complainant. Thereafter, the Complainant approached to the OPs 1 to 4 for reimbursement of the paid amount with all papers and documents and paid Bill Receipt and the claim was registered by the OPs 1 to 4 as Claim Case ID No. NI-6-272633. Complainant’s Claim was Rs,1,37,091/-, however the Complainant has been reimbursed a sum of Rs.54,634/- by the OPs. Upon enquiry it has transpired that the 100 percent claim of the Complainant has been denied on the ground of Clause 3.29 of the said Policy. Therefore, the Complainant issued Legal Notice dated 28.01.2019 to the OPs. The OP5 replied the said notice vide letter dated 28.01.2019 denying the legitimate claim by showing the Clause 3.29 of the Policy. Hence, the Complainant approached this commission by way of consumer complaint seeking relief/reliefs.

OPs 1 to 4 contested the Consumer Complaint by filing WV and denied all allegations made out there. The case of the OPs is that the present Complaint is based on motivated grounds and concocted stories. There is no proximate cause of action arose against the OPs as alleged in the petition. The case of the OPs 1 to 4 is that the Complainant is having a National Mediclaim Policy being the policy No. 101101/50/17/10001476 with the OP2 for the period of 21.07.2017 to 20.07.2018 and accordingly the Certificate including policy terms & conditions has been issued by the OPs to the Complainant. According to the Complainant, his wife has been admitted into ILS Hospital, Salt Lake on 09.05.2018 for the treatment of Multiple Fibroid Uterus with Menorrhagia, Total abdominal Hysterectomy done and she has been discharged on 14.05.2018. Later the Complainant has submitted the Claim Papers along with relevant bills, reports, etc with the OP5. After examining the claim papers, the OP5 has settled the claim by reimbursing the maximum eligible amount of Rs.50,000/- as per policy terms & conditions and guidelines framed under policy for the total Procedure along with pre/post medical experts to the Complainant Rs.4634/- vide claim no. TPA CCN-NI-3-272633. Being dissatisfied with the claim settlement the Complainant has requested the TPA for review. Accordingly the TPA has placed the claim papers before its specialist doctors who have reviewed the same and communicated their observations to the Complainant vide its letter dated 17.08.2018 regarding claim-settlement. Therefore, there is no deficiency of service on the part of the OPs 1 to 4. Hence, the said Complaint is liable to be dismissed in limine.

Despite filing Vakalatnama the OP5 did not come forward to file any Written Version within the specified period. As such, the consumer case has proceeded ex-parte against the OP vide proceedings dated 12.07.2019.

In support of his case the Complainant has tendered evidence supported by affidavit and also relied upon documents annexed with the complaint petition. Complainant has also replied the questionnaire of the OPs set forth by their adversaries. OPs 1 to 4 have adduced thematerial documents with the E/chief, but failed to file BNA. The Complainant has filed written argument. We have heard argument on merit and have also perused the record.

Admittedly the Complainant is insured with the OPs 1 to 4 vide Policy No. 101101501710001476 and there is also no doubt that the wife of the Complainant was under treatment at ILS Hospital, Salt LakeFrom 09.05.2018 to 14.05.2018. On perusal of the document it is found that the said Hospital raised bill of Rs. 72,715.00 and doctor’s fees are of Rs.60,000/- as per money receipts issued by the treating doctors and expenses of medicines & dressing is of Rs.3,276/- i.e. total amounting to Rs.1,35,991/-. The Complainant has incurred the same and thereafter the Complainant Lodged a Claim for reimbursement to the OPs which registered as Claim CaseID No. NI-6-272633 on 28.05.2018. Fact also remains that OP5 vide letter dated 17.08.2018 settled the claim stating that.

We have allowed Rs.50,000/- along with Rs.2,634/- for the pre/post expenses n first phase vide TPA CCN-NI-6-272633 & Rs.2,000/- as quantum amount vide TPA CCN-NI-6-272633, total Rs.52,000/- with pre/post expenses as per Reasonable and Customary clause 3.29 of National Mediclaim Policy. The same Organization addressed at Dumdum, charges same rate whereas this Hospital of same group charges higher rate for same procedure which is not Customary & Reasonable.

We also observed that as per policy documents some expenses are under exclusion which is amounting to Rs.4,448/-. Therefore the actual claim of the Complainant as per Policy Documents is (135991-4448) Rs.1,31,543/-.

Ld. Advocate for the Complainant has vehemently contended that the Complainant has taken a Mediclaim Policy No. 101101501710001476 from the OPs 1 to 4 for the sum assured Rs.4,25,000/- plus Cumulative Bonus of Rs.1,60,000/-.It is the case of the Complainant that during the policy period his wife had to undergone surgery from ILS Hospital, Salt Lake and spent the expenses and in this regard the Complainant lodged Claim by submitting all the required documents to the OPs for settlement of the claim. But OPs put off the matter on the ground of abovementioned Clause which according to Ld. Advocate for the Complainant argued that Clause 3.29 is contradictory to the Clause 2 of the policy wherein it is stated that.

2.OPERATIVE CLAUSE

 Now the policy witnessed that subject to the terms, definition, exclusions and conditions contained herein or endorsed  or otherwise expressed hereon, the Company undertakes that if during the Policy Period stated in the Schedule or during the continuance of the policy by renewal, any Insured Person shall contract any disease or suffer any illness (herein after called injury) or sustain any bodily injury due to an Accident (hereinafter called Injury)   and if such disease or injury shall require any such insured person, upon the advice of a duly qualified medical practitioner to be hospitalized for treatment at any hospital/nursing home (hereinafter called Hospital) in India as an inpatient, the company will pay to the hospital or reimburse the insured person, the amount of such expenses described below, reasonably, customarily and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum insured for the insured person of all such claims, during the policy period.

To establish the case Ld. Advocate for the Complainant has placed reliance upon the matter of Mr. Nitin Shroff Vs. National Insurance Co. Ltd (Complainant Ref: No: MUM-H-048-2021-1834, Award No: 10/MUM/A/HI/2021-2022) passed by Office of the Ombudsman, Mumbai & Goa, Mr. Nirmal R Thakkar Vs. The National Insurance Company Ltd.(Complainant Ref No. AHD-G-048-1617-0710, Award Date – 22.12.2016, Policy No. 300703/81/15/8500003554) , Mr. Bhaskar A Patel Vs. The National Insurance Company Ltd (Complainant Ref No. AHD-G-048-1617-0745 & 1060, Award Date- 22/12/2016, Policy No. 11700/48/14/85000010508).

On the other hand Ld. Advocate for the OPs 1 to 4 has repelled the aforesaid contention of the Ld. Advocate for the Complainant on the ground that an amount of Rs. 50,000/- has been sanctioned as per policy terms & conditions and guidelines framed under policy for the total procedure along with pre/post medical experts to the Complainant Rs.4634/- vide claim no. TPA CCN-NI-3-272633 as full and final payment pertaining to the treatment in question and the remaining amount has been deducted as per Clause 3.29 of the Insurance Policy which speaks that.

Reasonable charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved.

It is further submitted by the Ld. Advocate for the Complainant that, it is also defined as per the Guidelines on Standardization of Health Insurance of IRDA in chapter-1 of para 37 wherein it is stated that: 

To be deemed reasonable and customary, a charge must be with average charge of the same Medical procedures throughout specific medical community. This community incudes physicians, hospitals, laboratories and other providers involved in the health care with the same area.

In the instant case the patient is allegedly billed for Rs.1,37,091/- whereas the cost of the same procedure in similar kind of hospital having similar facilities is lesser rate for same procedure. Hence, the OP5 allowed Rs.50,000/- as per policy terms & conditions and guidelines framed under policy for the total Procedure along with pre/post medical experts to the Complainant Rs.4634/- vide claim no. TPA CCN-NI-3-272633 and the sanctioned amount is duly paid to the Complainant and the balance amount is disallowed under Reasonable and Customary Clause 3.29 of the Policy. The OPs having already paid the approval amount as far as liability of the Insurance Companyin accordance with terms, conditions and exclusion of the Policy and nothing remains due towards the OPs. It is also submitted by the Ld. Advocate for the OPs 1 to 4 that in the Policy Paper it is clearly mentioned that: Sub limit (as mention in 2.1,2.2, and 2.3) will not apply in case of Hospitalization in a preferred provider network (PPN). The Clause No. 3.22 of the Policy Paper speaks that.

Preferred Provider network (PPN) means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing.

Ld. Advocate for the Complainant strongly opposed this submission submitting that PPN is not applicable in this matter as the said claim is not cashless package.

In view of the abovementioned facts, we are not agreed with this plea of OPs on two counts. Firstly, the claim was lodged to the tune of Rs.1,37,091/- but OP5 has made payment of Rs.54,634/- and deducted the balance amount out of the total treatment cost who has no authority to reject/deduct the claim as only Insurance Companies after making investigations can decide the claim. In the matter of Neelam Vohra Vs. National Insurance Co, Hon’ble DCDRC, Amritsar, had Relied upon Sukhdev Singh Vs. New Karian Pehalwal Cooperative Agriculture Service Society and Othersin First Appeal No. 1105 of 2014 on 25.04.2017 passed by Hon’ble SCDRC, Chandigarh, wherein it was held that the TPAs have no authority to reject the claim. Such power lies exclusively with the Insurance Companies. The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. Therefore the claim of the Complainant is illegally and arbitrarily rejected by the TPA, against the instruction of the IRDA.

Secondly, the material documents furnished by the Complainant showing that the patient was billed for Rs.1,35,991/-. However the ground taken by the OPs is that, the cost of same procedure in similar kind of hospital is lesser. Hence, balance amount will remain disallowed under Reasonable & Customary Clause of the Policy. But we disagree with this plea of the OPs 1 to 4 as it was the duty on the part of the OPs 1 to 4 to make the insured aware about the abovementioned Clause at any point of time and once the insured has obtained the Policy for the Sum Assured of Rs.4,25,000/- plus Cumulative Bonus of Rs.1,60,000/- amounting to the total sum of Rs.5,85,000/-, the insured is entitled to the treatment cost uptoRs.5,85,000/- but not more than that. Ld. Advocate for the Complainant furnished the details of the Payment Terms of the Ops 1 to 4 as morefully described in the said Policy Document wherein it is found that.

Therefore it is found that, as per entitlement of the said Policy the Complainant is entitled to get Rs.3,40,000/-,whereas as per the policy documents the actual claim of the  Complainant is Rs.1,31,543/-. Moreover if the Hospital, from where the insured has taken treatment,has charged excess amount, it is not the fault of the insured. Therefore the OPs should not deduct the excess amount, if any, from the hospital expenses which the Complainant has incurred for the treatment of his wife.

Further, on perusal of the documents on record, we did not get a single scrap of paper on behalf of the OPs which can show that: The same Organization addressed at Dumdum, charges same rate whereas this Hospital of same group charges higher rate for same procedure which is not Customary & Reasonable. as OP5 mentioned in the letter dated 17.08.2018issued by them while settling the claim of the Complainant. Therefore, it appears to us as common practice on the part of the OPs to deduct the claim on flimsy ground without any justification. In this regard we may refer the matter of Dharmendra Goel Vs. Oriental Insurance Co. Ltd [2008(3) CPJ 377(SC)] wherein it was held by the Hon’ble Supreme Court that.

 being in a dominant position the insurance companies often act in an unreasonable manner and after having accepted the value of a particular insured good disown that very figure on one pretext or the other when they are called upon to pay compensation. This `take it or leave it' attitude is clearly unwarranted not only as being bad in law but ethically indefensible.

On this point, Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt. Usha Yadav & Others [2008(3) RCR (Civil) Page III] went on to hold as under.

It seems that the Insurance Companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus, pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

Under the above circumstances, unfair trade practice and the gross negligence and deficiency in service on the part of the OPs 1 to 4 is proved and the complainant is entitled to get relief/ reliefs.

In view of above discussion the consumer complaint is allowed on contest  against the OPs 1 to 4 and dismissed on ex parte against OP5 with the following directions-

1.         OPs 1 to 4 are jointly and severally directed to pay the balance amount of (131543-54634) Rs.76,909/- only together with simple interest @ 6 percent to the complainant from the date of  the payment.

2.         OPs 1 to 4 are further jointly and severally directed to pay Rs.20,000/- as compensation to the complainant on account of mental agony and physical harassment.

3.         OPs 1 to 4 are also jointly and severally directed to pay Rs.10,000/- only towards litigation cost to the complainant.

The above directions be complied by the OPs 1 to 4 within a period of 60 days from today failing which the balance amount shall attract the interest @ 12 percent till realization.

For failure or omission in compliance within the stipulated period, the complainant shall be at liberty to put the order in execution as per Consumer Protection Act, 2019.

Copy of the final order be supplied to the parties as per rules and also be uploaded to the website of this Commission forthwith.