Jharkhand

Bokaro

CC/17/129

Savitri Singh - Complainant(s)

Versus

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

Amardeep Jha and Poonam

07 Nov 2022

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-30-08-2017

Date of final hearing-21-09-2022

 Date of Order-07-11-2022

Case No. 129/2017

Smt. Savitri Singh W/o late Dr. Krishnandan Singh

R/o- Q.No. 1016, Sector-IV/C, B.S.City,

District- Bokaro, Jharkhand.

Vs.

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

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

2. The Divisional  Manager,

United India Insurance Co. Ltd.

Plot No. A/17, City Centre, Sector-4, P.O.& P.S.-Sector-4,   District- Bokaro (JH)

 

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

 

PER- J.P.N Pandey, President

-Judgement-

1. Complainant has filed this case with prayer to direct the O.Ps. to pay Rs. 51,773/- on account of amount paid to the hospital for his treatment and to pay Rs. 20,000/- as compensation and Rs. 10,000/- as litigation cost.
2. Case of the complainant is that she being spouse of retired SAIL, BSL employee is entitled to get medical facilities for herself and her husband as per norms of the company, on making payment of the premium to the insurance co. (O.P.). Further case is that complainant has paid premium of her 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 hospitals for which MIN No. 04709099 was allotted to him by the O.P. Insurance Co. Further case is that due to some illness as mentioned in the complaint petition she was admitted in Shivam Hospital at E-2, Laxmi Market, Sector-4, B.S. City, District Bokaro (here in after referred as Shivam Hospital) on 18.03.2016 and discharged on 26.03.2016 and paid the amount Rs. 51,773/- related to medical expense to the Shivam Hospital, for which she submitted duly filled up claim form in the office of the O.Ps. but her claim has not been rejected 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 complainant has not been redressed, hence this case has been filed with prayer for re-imbursement of the amount Rs. 51,773/-paid to the Hospital and further for payment of compensation Rs.20,000/- and litigation cost Rs. 10,000/-as mentioned in the complaint petition.
3. Inspite of due service of notice O.P. No.1 has not preferred to appear and file W.S. in this case hence case is being proceeded against him Ex-parte without W.S.
4. O.P. No.2 Insurance co. has filed W.S. in this case 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 applicant 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 this case is time barred ?
2. Whether the repudiation of the claim of the complainant in this case is justifiable or not?
3. Whether complainant is 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 this case.

1. That the husband of the complainant was earlier employee of SAIL, BSL, Bokaro and he 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 with their spouse 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 complainant has deposited the required premium and was being covered by the mediclaim policy of the O.P. No2.
4. That said mediclaim policy of the complainant was effective for the period for which claim has been made.
5. That complainant was allotted MIN number by the insurance co. as mentioned in the complaint petition.
6. That the complainant suffered with illness as mentioned in the complaint petition and she was admitted in Shivam Hospital for the period as mentioned in the complaint petition.
7. That the complainant has made payment of the amount to the Shivam Hospital as mentioned in the complaint petition on account of medical expense incurred on her treatment.
8. That the claim of the complainant has been denied by the O.Ps.

 

7.     Complainant has filed photo copy of papers related to her 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 complainant 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 complaint is well within limitation period, hence case is not barred by the limitation. On this aspect O.Ps. have not given more stress. Record shows that O.P. Insurance Co. has filed investigation report dt. 22.09.2016 submitted by the Private Investigator engaged by O.P. No.1 hence after submission of investigation report claim has been repudiated. It is apparent that after filing of the claim form repudiation of the claim was made later on complaint was filed on 30.08.2017 hence cause of action for filing the case was arised after repudiation of the claim after submission of the investigation report dt. 22.09.2016, in this way this case has been filed well within prescribed period of limitation. Accordingly we are of the view that this case is not time barred. Hence this point is being decided in favour of the complainant.
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 to investigate the matter) 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 complainant has 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 complainant 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 the same TPA  which show that O.P. No.1 is also admitting the fact that said hospital is/was fulfilling all the criteria of the hospital and he has 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 complainant her claim has not been allowed though it was on same footing of those persons whose claims have been allowed by O.P. No.1 E-Meditek (TPA) Services Ltd.
16. Complainant has 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.P. was working arbitrarily and he was 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 complainant has based her claim on the papers issued by the competent authority of the State Govt. who is having jurisdiction to do it. O.P. (TPA) has 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 O.P. No.1 (TPA) 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 claim of the complainant by the O.Ps. is arbitrary and not based on evidence. Accordingly this point is being decided in favour of the complainant and against the O.Ps.
18. Point No. C:- This point is related to prayer of the complainant of this case. On this aspect we would like to mention here that mediclaim policy, period of enforcement of mediclaim policy, entitlement of the claimant, her illness and admission in the hospital for period as mentioned in complaint petition and payment made by her towards medical expense to the hospital as mentioned in complaint petition 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 complainant of this case is also entitled to get re-imbursement of her medical expense as claimed by him. Accordingly this point is being decided in favour of the complainant and against the O.Ps.
19. Accordingly prayer of the complainant named above is being allowed in the following manner :-

O.P. No.2 (United India Insurance Co. Ltd.) is directed to pay Rs. 51,773/- to the complainant of within 60 days from the date of receipt/ production of the copy of this judgment, failing which she will be entitled to get interest @ 10% per annum from the date of filing of the case as mentioned above. Further O.P. No.2 is directed to pay compensation to the complainant Rs. 5000/- and to pay Rs. 3000/- as litigation cost to the complainant within 60 days from the date of receipt/production of the copy of this judgment.

 

(J.P.N. Pandey)

                                                                                President

 

                                                                                               

 

 

                                                                              (Baby Kumari)

                                                                                  Member