THE PRESIDENT

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA

 

CASE No. CC- 81 of 2021

 

Sri Asutosh De,

S/O- Late Kamalhari De,

Kumari Tilla, Abhoynagar,

P.O. Abhoynagar,

P.S. New Capital Complex,

Agartala, West Tripura,

Pin- 799005. ..................Complainant.

 

-VERSUS-

 

1. The HDFC ERGO General Insurance Co. Ltd.,

    2nd Floor, Techno Building, Sadar-1,

    Mantri Bari Road, P.O. Agartala,

    P.S. West Agartala, District- West Tripura,

    Pin-799001.

 

2. The Regional Manager,

    HDFC ERGO General Insurance Co. Ltd.,

    Adityam Building, 6th Floor,

    G.S. Road, Lachit Nagar,

    Guwahati, Assam- 781007. ..............Opposite Parties.

 

         __________PRESENT__________

 

 SRI RUHIDAS PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION

      WEST TRIPURA, AGARTALA.

 

Dr (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

C O U N S E L

 

For the Complainant : Sri Debjyoti Debnath,

  Learned Advocates.

  

For the Opposite Parties : Sri Prabal Kumar Ghosh,

  Sri Sampad Choudhury,

  Learned Advocates.

 

 

JUDGMENT  DELIVERED  ON :  19.01.2023.

J U D G M E N T

The case led to the proceedings due to a complaint petition filed by Sri Asutosh De, S/o Late Kamalhari De, Agartala (here-in-after referred to as 'Complainant') against the HDFC ERGO General Insurance Co. Ltd., Agartala (here-in-after referred to as 'O.P.1') and the Regional Manager, HDFC ERGO General Insurance Co. Ltd. Guwahati (here-in-after referred to as 'O.P.2') u/s 35 of the Consumer Protection Act, 2019.

2. The averments of the case put forth by the Complainant, in short, are that the Complainant had availed a Health Insurance Policy, namely, HDFC ERGO Health Insurance (Optima Restore Floater Two Year Policy) from the O.Ps by paying a premium amount of Rs.92,306/-. Thereafter, a cashless card and a policy document were issued by the O.Ps. The policy period of coverage was from 03.01.2020 to 02.03.2022. The policy covered the petitioner along with his wife and two daughters. During the policy period of coverage, the Complainant had fallen sick seriously and subsequently according to the advice of a private doctor he was admitted in the ILS Hospital, Agartala and, the incident of his admitting to the hospital was duly informed to the O.P.1. At the time of his discharge from the ILS Hospital the Complainant produced the cashless card, issued by the O.Ps, to the hospital authority but the hospital refused to accept the cashless card. Thereafter, having no other alternative, the Complainant himself paid Rs.52,202/- as being the medical treatment charges. Upon discharge from the hospital, the petitioner contacted the O.P.1 and placed a demand for reimbursement of the amount spent by him towards payment of hospital bills. Thereafter, at the instance of the O.P.1, the Complainant submitted bills, vouchers and discharge certificate pertaining to his treatment at ILS hospital to them. The matter was pursued regularly with the O.Ps by the Complainant for release of payment but to no avail. O.P.1 had finally expressed their inability to make any payment against the Complainant’s demand of medical expenses and returned all documents to the Complainant.  Subsequent to that, the Complainant sent two Legal Notices on 29.05.2021 and 25.06.2021 to the O.Ps. In reply, the O.Ps stated that they did not receive any claim under the policy nor had they been given any intimation by the hospital authority as such and which is why the claim was rejected by them. Being aggrieved so, the Complainant filed this petition before this Commission for redress and remedy of his grievances stating that the O.Ps were deficient in rendering committed service to the Complainant and, sought a relief amounting to Rs.1.50 lac for being the expenses incurred during the treatment at ILS hospital along with an amount of Rs.1.00 lac for mental agony and pain suffered by him due to the negligence and deficiency of service committed by the O.Ps for settling his claim with respect to medical expense bills. Hence, this case.

3. The O.Ps initially failed to contest the case by appearing and filing written statement and due to such default, the case was proceeded exparte against both the O.Ps. But, consequent to the appeal filed by the O.Ps with the Hon'ble State Commission for quashing the exparte order, the Hon'ble State Commission passed an order dated 19.04.2022 setting aside the order of this Commission allowing them to file written objection and contest the case as per the prevailing process of trial pursued by this Commission. Accordingly, the O.Ps contested the case by filing written statement whereby they have disproved and refuted all the allegations and charges being made/ levelled against them by the Complainant. It is submitted by the O.Ps that they did not receive any cashless claim at the behest of the Complainant from the hospital concerned. They have also averred that the hospital alone is liable for deficiency of service as being communicated by the Complainant. It is also averred by them that they did not receive any formal claim accompanying requisite documents from the Complainant for reimbursing the expenses incurred for medical treatment bills. It is also averred that they did not have any knowledge whatsoever that the Complainant paid the medical bills from his own source. Furthermore, it is submitted that the onus to prove that any claim was ever intimated in writing to the Company is rested with the Complainant and the Complainant is bound by strict prove to establish the same by submitting documentary evidence. It is also submitted that the documents of the Complainant, as being contended, were either incomplete or not adequate for the purpose of assessing the hospital expenses and thus not valid within the policy coverage.

 

4. The Complainant filed his evidence-in-chief by way of an affidavit. The documents submitted by the Complainant by way of firisti dated 30.03.2022 have been exhibited and marked as Exhibit- 1 Series. One Bhubeswari Das of HDFC ERGO General Insurance Company Ltd. has submitted evidence-in-chief on behalf of the O.Ps. The documents submitted by the O.Ps  have been exhibited and marked as Exhibit – A Series.

 

5. Now it is to be decided as follows in respect of the case:

(i) Whether the O.Ps have committed any deficiency of service against the Complainant?

(ii) Whether the Complainant is entitled to receive the relief, as being sought for?

  (iii) If the answer of the column 5(ii)  is 'Yes' then what would be the magnitude of relief?

 

6. We have heard the arguments of both the parties and the points and substance of the arguments are as under:

(i) It has been argued by the Complainant that despite his possessing valid insurance policy issued by the O.Ps, the Complainant was denied to get his medical expenses re-imbursed which was incurred by him owing to his treatment in the ILS Hospital. Firstly, though the cashless card was issued against the purchase of the policy but the same card was refused by the ILS Hospital to accept for making the payment of the medical expenses. Thereafter, the Complainant had to pay the expenses amounting to Rs.52,202/- from his own source as he had no other alternative then. Upon discharge from the hospital, the matter was taken up with the O.Ps for releasing the admissible payment towards medical bills issued by the hospital but no result could achieve thereon. Even at the instance of the O.P.1, the Complainant filed copies of bills, documents, discharge certificate etc. with respect to his undergone treatment in ILS Hospital. But, repeated persuasions with the O.P.1 for the release of the payment did not fetch any result to the Complainant. The O.Ps were, all through, in a mood to deny the payment and never ever cooperated with him. It is submitted that the O.Ps acted in violation of  the terms and conditions and assured benefits, as envisaged in the policy. The infringement caused by the O.Ps in respect of policy benefits promised is a clear indication of deficiency of service being committed on their part. It has also been submitted that denial of the cashless benefits by the hospital, though it had been a promise towards extension of such service by the O.Ps, is an adoption of unfair trade practice by the O.Ps.

(ii) It has been argued by the O.Ps that they had no information and idea about the refusal of the cashless payment by the hospital. Furthermore, it is submitted that the Complainant never filed any formal claim along with requisite documents for facilitating the settlement of the claim. The Complainant submitted few documents only in support of his claim which were not sufficient for assessing the exact amount of claim and, therefore, of no use. Had the O.Ps been received the claim as per the format with  essential documents, they could have taken the appropriate steps for assessing the entitlement amount of such claim.

 

7. We have heard arguments of both the parties and meticulously examined the documents relied upon by them. We have taken all the points together to decide the case for comprehensive addressal of issues raised by the parties. It is an admitted fact that the Complainant had a valid medical insurance policy, namely, Optima Restore Floater Two Year Policy issued by the O.Ps. The medical expenses cover upto 1.50 lac is assured under the policy and the policy was valid from 03.01.2020 to 02.01.2022.  But, it is observed that the Complainant was denied to avail the cashless benefit by the enlisted hospital of O.Ps, namely, ILS Hospital, Agartala upon his discharge from there. Due to surfacing such awkward situation, the Complainant had to pay the entire medical bills amounting to Rs. 52,202/- to the hospital from his own source. Therefore, it is completely unwarranted and indefensible action on the part of the O.Ps towards such committed non delivery of service. The Complainant, upon discharge from the hospital, contacted to the O.Ps to get his medical expenses reimbursed by the O.P. The Complainant, at the suggestion of O.P.1, submitted medical bills, voucher and other documents to them for getting his medical expenses reimbursed by O.Ps but there was complete absence of action on the part of the O.Ps to settle the claim. The O.Ps mentioned that they did not receive any formal claim from the side of the Complainant as well as no intimation had been provided by the treating-hospital for the medical bills, in question, and hence no question does stand against them for non-settling of claim. We view such statements as an exhibition of an unprofessional approach and an act done in defiance of the terms and agreement entered between the insured and the insurer. It has been submitted by O.Ps that they have suggested/insisted the Complainant to furnish the cash-less claim intimation/ number whereas the Complainant had reported to them regarding denial of providing cash-less benefit by the treating-hospital by refusing to accept such card. We, therefore, hold that such counter-statement of O.Ps does not hold water. We consider that the role of O.Ps in this case was not coactive and friendly towards assisting the Complainant for settlement of the claim. In the eventual surfacing situation in this case, there was no scope from the side of the Complainant to file a formal claim since in a cashless system, the treating-hospital is supposed to prefer medical reimbursement claim at the behest of the patient but; the treating-hospital (ILS hospital), in this case, has refused to accept the cash-less card to provide the cashless claim benefit. Hence, we unhesitatingly hold that the roles of the O.Ps were not conducive to settle the claim which relates to medical treatment underwent by the Complainant within the validity period of the policy and despite being the claim amount within the ambit of the assured insured amount. We, therefore, conclude that the O.Ps were deficient in providing service to the Complainant. 

 

8. Now, on the basis of the points out-lined in the foregone paras, we are of the opinion that the Complainant has been successful to prove his points of contention in regards to deficiency of service to our satisfaction and; thus the O.Ps are liable to reimburse the entire hospital bills to the Complainant. Therefore, we direct the O.P.1 and O.P.2 to pay the medical expenses Rs. 52,202/- to the Complainant and a compensation of Rs.7,000/- due to mental harassment and agony being subjected by the Complainant due to refusal of cashless benefit and the non-cooperation being done by the O.Ps during subsequent occasions along with a litigation cost of Rs.3,000/- within two months from the date of this judgment, failing which the amount shall carry an interest @ 9% P.A. till realization.

 

9. Accordingly, all the points are decided in this case in favour of the Complainant. Supply certified copy of the judgment to the parties free of cost.

 

Announced.

 

 

 

SRI R. PAL

PRESIDENT,

DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA.

 

 

 

Dr (SMT) B. PAL

MEMBER,

  DISTRICT CONSUMER

DISPUTES REDRESSAL COMMISSION,

  WEST TRIPURA,  AGARTALA.

 

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.