PER:
Charanjit Singh, President;
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11 and 12 against the opposite parties on the allegations that the complainant has purchased a Mediclaim Insurance Policy from the opposite party No.1 for himself and his family members from the last year and lastly taken the policy covering risk period from 06.09.2016 to 05.09.2017 by paying a premium amount of Rs. 11906/- having policy No. 401900/48/16/8500001356. The complainant is consumer of the opposite party. Only cover note or schedule of the Insurance were supplied to the complainant, but the opposite party No.1 never supplied any terms and conditions of the impugned insurance to the complainant. During the validity period of above said policy, the son of the complainant namely Shivam Galhotra, who is also covered under above said policy, got pain in his nose, which was giving trouble while in breathing, went to the authorized Hospital i.e. Amandeep Hospital, Model Town, G.T. Road, Amritsar on 10.12.2016 and the concerned doctor advised Shivam Galhotra for treatment of Post Traumatic Nose Deformity and the complainant informed the opposite party No.1, who authorized the complainant vide letter dated 10.12.2016 for Rs.40,000/- against cashless treatment . The son of the complainant i.e. Shivam Galhotra admitted in the hospital of opposite party No.2 on 14.12.2016 for treatment of Post Traumatic Nose Deformity on the basis of letter dated 10.12.2016. The surgery was done successfully and on 15.12.2016, the son of the complainant got discharged from the hospital of Opposite Party No.2. The opposite party No.2 issued a bill of Rs.62,339/- dated 15.12.2016 , in which the opposite party No. 2 directed the complainant to pay Rs.50,000/-to the hospital authority i.e. opposite party No.1 and informed that the opposite party No.1 have authorized the opposite party No.2 with letter dated 15.12.2016 for Rs.17,000/- against this treatment/ surgery. The complainant paid Rs.50,000/- to the opposite party No.2 against the above said bill and also purchased the medicine as described by the doctor of opposite party No.2 for Rs.1,791/- In total the complainant has paid Rs.51,791/- against the above said cashless policy. From the above said amount of Rs. 51,791/- an amount of Rs. 3,024/- has been refunded/ credited in account of the complainant. Thereafter the complainant had filed the claim with the opposite party No.1 for Rs.48,766/- but the opposite party No.1 has not paid the genuine claim of the complainant . The complainant time and again approaching the opposite party No.1 for the payment of Rs.48,766/-, but the opposite party No.1 did not pay any heed to the genuine requests of the complainant, till the filing of the present complaint, which itself reflects the deficiency and unfair trade practice on the party of the opposite party No.1. The aforesaid act of the opposite party No.1 for not allowing the treatment expenses Rs.48,766/- paid by the complainant to the opposite party No.2 is deficiency in service, unfair trade practice on the party of the opposite party No.1. The complainant has prayed that opposite party No.1 may please be directed to pay the sum insured amount to the tune of Rs.48,766/- alongwith interest at the rate of 12% Per annum and compensation to the tune of Rs.50,000/- may also be awarded to the complainant which the complainant has suffered on account of mental agony and harassment.
3 After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 1 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the complainant has not come to this commission with clean hand and in fact , he suppressed the material facts in order to get wrongful gain and to cause wrongful loss to the replying opposite party and as such, the present complaint dismissal on the simple score only. As per the patient version, he was injured on 25.10.2016 and the injury was followed by bleeding. The opposite party No. 1 has been provided with an unsigned consultation dated 25.10.2016, where there is no mention of bleeding. The patient has been prescribed only one tab. Chymogram Forte, which is given for inflammation and there is not mention of bleeding on the consultation paper submitted by the insured. The patient has been advised X-ray to rule out any fracture of nasal bones. No X-ray report or film dated 25.10.2016 has been provided to safeway insurance TPA Pvt.Ltd. And even to the opposite party No. 1, inspite of request while processing cashless claim. Then the patient presented to Amandeep Hospital Plastic Surgery Department on 07.12.2016 nearly one and half month after injury and was consulted by Dr. Ravi K Mahajan,who diagnosed the Insured with Post-Traynatic Nose Deformity with breathing difficulty. The patient was advised to undergo Septorhinoplasty, but no medicines were prescribed . The patient was admitted in Hospital on 14.12.2016 and was discharged on 15.12.2016 and he underwent Septorhinoplasty and pre-authorisation request was sent to TPA, the claim only for septoplasty for Rs.17,000/- was approved by the TPA in cashless claim. The Septoplasty was required in this case as the patient was having breathing problem, but the amount for Rhinoplasty was denied by TPA due to Cosmetic Nature of Surgery. The Total bill in cashless claim (N1-10-45) was for Rs.62,339/- less Rs.3,000/- discount given by the hospital on overall bill, so the Net billed amount of Rs.59,339/-and deduction of Rs.42,339/- was made. The amount allowed under cashless claim of Rs.17,000/- which is an agreed PPN rate with the hospital for Septoplasty and balance amount of Rs.42,339/- was charged by the hospital for the procedure done for Rhinoplasty. The post claim was for Rs.3,024/- and the same was allowed and paid by the TPA to the Insured. The conduct of the complainant can be well judged that no X-ray films or report has been provided to TPA inspite of query raised by them dated 8.12.2016. If there was a fracture when the patient got admitted and even no explanation has been given that why did the patient went to plastic surgery department after one and half month of injury, when he was sent to Orthopaedician on the day of injury, if he had nose problem, he could have gone to ENT specialist after his initial visit to orthopaedician. It is obvious that there was no fracture, if not he would have consulted an ENT specialist and to immediately after the injury and not to plastic Surgeon after one and half month of injury. Even, post claim treatment has been taken in R.M. Aesthetic Plastic Surgery and Cosmetic Laser Centre. The patient has taken treatment post injury as evidenced by dental implant seen in the digital X-Ray done on 15.12.2016 and the treatment record were not shared with the TPA/ opposite party No. 1 and the same reflects that the dental implants was done after injury and as such, the information has not been shared by the complainant with TPA/ opposite party No. 1 and even otherwise, it is doubtful case whether the alleged treatment relates to the accident or correction of teeth beauty and even the complainant be put to place on record X-ray reports before operation which will enable this commission in order to adjudicate the real controversy between the parties. The insured has submitted a certificate dated 15.12.2016 from the treating doctor that patient does not require any immediate post-op-x-ray, contrary which patient has undergone 3 X-ray on 15.12.2016 showing the dental implant. It becomes quite evident that there is neither any deficiency in service nor any unfair trade practice on the part of the opposite party No. 1 and the present complaint being false, vexatious, merits dismissal with special costs. The complainant has not placed any cogent and convincing material in order to substantiate the pleas as alleged in the complaint and more particularly the X-ray reports before operation, as stated above. The complainant has miserably failed to furnish the documents to TPA of the opposite party No. 1 inspite of specific requests much less the requisite queries raised were replied by the complainant and same reflects the act and conduct of the complainant. The complainant cannot wriggle out from the terms and conditions of the insurance coverage and false pleas have been taken just to defeat the spirit and substance of the insurance obtained by the complainant and even otherwise, the pleas raised are concocted, afterthought without any basis much less any such objections were raised by the complainant earlier. The opposite party No. 1 has denied the other contents of the complaint and prayed for dismissal of the same.
4 The opposite party No. 2 appeared and filed written version and contested the complaint by interalia pleadings that the complainant is not competent to file the present complaint against the party No.2. There is not deficiency is service on the part of the opposite party No.2 as claimed in the complaint by the complainant, therefore the present complaint is liable to be dismissed on this score. This Commission has no jurisdiction to try and entertain this present baseless complaint against the opposite party No.2. The complainant came to the Hospital of Opposite Party No.2 and the paid fee of Rs.300/- on 10.12.2016. The complainant was admitted to the Hospital of opposite party No.2 and his post traumatic Nose deformity Surgery was performed upon the complainant and he was discharged on 15.12.2016.For the treatment and surgery of complainant, proper bills were issued to the complainant. Some payments made by the complainants in cash. The complainant came to the hospital of opposite party No.2 for his treatment and he paid OPD opposite for Rs.300/- on 10.1.2015. He admitted in the hospital of opposite party No.2 and hip replacement surgery was performed upon the complainant and he was discharged on 11.02.2015 for the treatment and surgery of complainant, proper bills were issued to the complainant. The opposite party No. 2 has denied the other contents of the complaint and prayed for dismissal of the same.
5 To prove his case, the complainant has tendered in evidence his affidavit Ex. CW1/A, copy of the policy schedule Ex. C-1, copy of authorization letter for treatment and guarantee of payment Ex. C-2, copy of the invoice Ex. C-3, copy of the authorization letter for treatment and guarantee of payment Ex. C-4, copy of receipt dated 15.12.2016 Ex. C-5, copy of retail invoice Ex. C-6 to C-9 copy of certificate issued by Amandeep Hospital Ex. C-10 and closed the evidence. Ld. counsel for the opposite party No. 1 tendered in evidence affidavit of Punee Kandia Divisional Manager Ex. OP1/1, copy of claim information sheet Ex. OP/2, copy of discharge summary Ex. OP1/3, copy of the certificate/ prescription Ex. OP1/4, copy of invoice Ex. OP1/5, copies of X-rays Ex. OP1/6 to OP1/8, copy of letter dated 15.12.2016 Ex. OP1/9, copy of certificate Ex. OP1/10, copy of the prescription Ex. OP1/11, copy of the claim information sheet Ex. OP1/12, copy of the letter dated 8.12.2016 Ex. OP1/13, copy of the insurance policy documents alongwith terms and conditions Ex. OP1/14, copy of authorization limit Ex. OP1/15, copy of prescription slip Ex. OP1/16 and closed the evidence.
6 Previously the opposite party No. 2 appeared and filed written version but later on did not appear and proceeded against exparte.
7 We have heard the Ld. counsel for the complainant and opposite party No. 1 and have gone through the record on the file.
8 Ld. counsel for the complainant contended that the complainant has purchased a Mediclaim Insurance Policy from the opposite party No.1 himself and his family members from the last year and lastly taken the policy Ex. C-1 covering risk period from 06.09.2016 to 05.09.2017 by paying a premium amount of Rs. 11,906/- having policy No. 401900/48/16/8500001356. Only cover note or schedule of the Insurance were supplied to the complainant, but the opposite party No.1 never supplied any terms and conditions of the impugned insurance to the complainant. During the validity period of above said policy, the son of the complainant namely Shivam Galhotra, who is also covered under above said policy, felt pain in his nose, which was giving trouble while in breathing, went to the authorized Hospital i.e. Amandeep Hospital, Model Town, G.T. Road, Amritsar on 10.12.2016 and the concerned doctor advised Shivam Galhotra for treatment of Post Traumatic Nose Deformity and the complainant informed the opposite party No.1, who authorized the complainant vide letter dated 10.12.2016 Ex. C-2 for Rs.40,000/- against cashless treatment . Shivam Galhotra admitted in the hospital of opposite party No.2 on 14.12.2016 for treatment of Post Traumatic Nose Deformity on the basis of letter dated 10.12.2016. The surgery was done successfully and on 15.12.2016, the son of the complainant got discharged from the hospital of Opposite Party No.2. The opposite party No.2 issued a bill Ex. C-3 of Rs.62,339/- dated 15.12.2016 , in which the opposite party No. 2 directed the complainant to pay Rs.50,000/-to the hospital authority i.e. opposite party No.1 and informed that the opposite party No.1 have authorized the opposite party No.2 with letter dated 15.12.2016 Ex. C-4 for Rs.17,000/- against this treatment/ surgery. The complainant paid Rs.50,000/- to the opposite party No.2 against the above said bill vide Ex. C-5 and also purchased the medicine as described by the doctor of opposite party No.2 for Rs.1,791/- vide retail invoice Ex. C-6 to Ex. C-9. In total the complainant has paid Rs.51,791/- against the above said cashless policy. From the above said amount of Rs. 51,791/- an amount of Rs. 3,024/- has been refunded/ credited in account of the complainant. Thereafter the complainant had filed the claim with the opposite party No.1 for Rs.48,766/- but the opposite party No.1 has not paid the genuine claim of the complainant . The complainant time and again approaching the opposite party No.1 for the payment of Rs.48,766/-, but the opposite party No.1 did not pay any heed to the genuine requests of the complainant and prayed that the present complaint may be allowed.
9 Ld. counsel for the opposite party No. 1 contended that the complainant that as per the patient version, he was injured on 25.10.2016 and the injury was followed by bleeding. The opposite party No. 1 has been provided with an unsigned consultation dated 25.10.2016, where there is no mention of bleeding. The patient has been prescribed only one tab. Chymogram Forte, which is given for inflammation and there is not mention of bleeding on the consultation paper submitted by the insured. The patient has been advised X-ray to rule out any fracture of nasal bones. No X-ray report or film dated 25.10.2016 has been provided to safeway insurance TPA Pvt. Ltd. And even to the opposite party No. 1, inspite of request while processing cashless claim. Then the patient presented to Amandeep Hospital Plastic Surgery Department on 07.12.2016 nearly one and half month after injury and was consulted by Dr. Ravi K Mahajan,who diagnosed the Insured with Post-Traumatic Nose Deformity with breathing difficulty. The patient was advised to undergo Septorhinoplasty, but no medicines were prescribed. The patient was admitted in Hospital on 14.12.2016 and was discharged on 15.12.2016 and he underwent Septorhinoplasty and pre-authorisation request was sent to TPA, the claim only for septoplasty for Rs.17,000/- was approved by the TPA for cashless claim. The Septoplasty was required in this case as the patient was having breathing problem, but the amount for Rhinoplasty was denied by TPA due to Cosmetic Nature of Surgery. The Total bill in cashless claim (N1-10-45) was for Rs.62,339/- less Rs.3,000/- discount given by the hospital on overall bill, so the Net billed amount of Rs.59,339/-and deduction of Rs.42,339/- was made. The amount allowed under cashless claim of Rs.17,000/- which is an agreed PPN rate with the hospital for Septoplasty and balance amount of Rs.42,339/- was charged by the hospital for the procedure done for Rhinoplasty. The post claim was for Rs.3,024/- and the same was allowed and paid by the TPA to the Insured. The conduct of the complainant can be well judged that no X-ray films or report has been provided to TPA inspite of query raised by them dated 8.12.2016. If there was a fracture when the patient got admitted and even no explanation has been given that why did the patient went to plastic surgery department after one and half month of injury, when he was sent to Orthopaedician on the day of injury, if he had nose problem, he could have gone to ENT specialist after his initial visit to orthopaedician. It is obvious that there was no fracture, if not he would have consulted an ENT specialist and to immediately after the injury and not to plastic Surgeon after one and half month of injury. Even, post claim treatment has been taken in R.M. Aesthetic Plastic Surgery and Cosmetic Laser Centre. The patient has taken treatment post injury as evidenced by dental implant seen in the digital X-Ray done on 15.12.2016 and the treatment record were not shared with the TPA/ opposite party No. 1 and the same reflects that the dental implants was done after injury and as such, the information has not been shared by the complainant with TPA/ opposite party No. 1 and even otherwise, it is doubtful case whether the alleged treatment relates to the accident or correction of teeth beauty and even the complainant be put to place on record X-ray reports before operation which will enable this commission in order to adjudicate the real controversy between the parties. The insured has submitted a certificate dated 15.12.2016 from the treating doctor that patient does not require any immediate post-op-x-ray, contrary which patient has undergone 3 X-ray on 15.12.2016 showing the dental implant. It becomes quite evident that there is neither any deficiency in service nor any unfair trade practice on the part of the opposite party No. 1 and the present complaint being false, vexatious, merits dismissal with special costs and prayed that the present complaint may be allowed.
10 In the present case, it is not disputed that the complainant took insurance policy from the opposite party No. 1 and after admitting the insurance, Rs.17,000/- was approved by the TPA in cashless claim. The total bill for treatment of son of the complainant was made by the opposite party No. 1 to the tune of Rs. 62,339/- out of which Rs. 3,000/- was given as discount and Rs.17,000/- was approved by the TPA for cashless claim and Rs. 3,024/- were given as post claim to the complainant which have been credited to the account of the complainant and this fact has also been admitted by the replying opposite party. Now question arises that as to whether the complainant is entitled to the remaining amount of Rs. 39,315/- from the opposite party No. 1 or not. The stand of the opposite party No. 1 is that the complainant was entitled to only Rs. 17,000/- and Rs. 3,024/- which was post claim and allowed and paid by the TPA to the insured. But the opposite party No. 1 has not made the payment of remaining amount of Rs. 39,315/- to the complainant. The complainant has placed on record Ex. C-10 certificate issued by Amandeep Hospital and clinics which is reproduced as follows:-
This is to certify that patient Mr. Shivam Galhotra age 25y/m S/o Mr. Vikram Galhotra, Resident of H. No. 63/1, Near Model Town, Mata Ji Mandir, Rani ka Bagh, Amritsar, was admitted in our hospital on 14-12-16 for Septorhinoplasty. He had injury of nose 2 months before admission, following which he developed difficulties in breathing because of nasal obstruction. He was operated upon on 14-12-16 and was discharged on 15-12-16. He was advised bed rest for a period of 2 weeks w.e.f. 16-12-2016.
In this said certificate it is clearly mentioned that the patient had injury of nose 2 months before admission, following which he developed difficulties in breathing because of nasal obstruction, hence he was treated for post traumatic nose deformity . He was operated upon on 14-12-16 and was discharged on 15-12-16. He was advised bed rest for a period of 2 weeks w.e.f. 16-12-2016. The opposite party No. 1 has also placed on record one certificate dated 15.12.2016 Ex. OP1/10 in which it is clearly mentioned that patient underwent surgery Rhinoplasty on 14.12.2016. Rhinoplasty with the use of spreader grafts was necessary alongwith septoplasty for improving his breathing problem….But the stand of the opposite party that the Septoplasty was required in this case as the patient was having breathing problem, but the amount for Rhinoplasty was denied by TPA due to Cosmetic Nature of Surgery. Rather this stand of the opposite party is contrary to the document placed by them on record Ex. OP1/10 in which the doctor has specifically mentioned that Rhinoplasty with the use of spreader grafts was necessary alongwith septoplasty for improving his breathing problem. The certificate of doctor has been placed on record by both the parties as Ex. C-10 and Ex. OP1/10. In these certificates it has been clearly written that the patient has been diagnosed with post traumatic nose deformity and patient underwent surgery which is called Rhinoplasty. Meaning thereby the Rhinoplasty which was conducted by the hospital is due to injury on nose and the opposite party cannot take the plea that it is a cosmetic surgery. The certificates issued by Amandeep Hospital have not mentioned that patient was operated for cosmetic surgery, though the patient was underwent Rhinoplasty which is due to nose injury. The opposite party has mentioned that the patient is not provided the X-ray Film but Ex. OP6, Ex. OP7 and Ex. OP8 are copies of the X-ray and placed by themselves on record. The opposite party No. 1 has firstly denied the whole claim of the complainant and later on credited amount of Rs. 3,024/- in the account of complainant. The opposite party has also not placed on record any terms and conditions on the basis of which the complainant is not entitled to full amount of his treatment. Moreover, Ld. counsel for the complainant has contended that the opposite parties have not explained the terms and conditions of the policy in question to the complainant and same are not supplied or explained to him at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns 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. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
11 The opposite party No. 2 has taken contradictory stand in its written version because in Para No. 4 of on merits of the written version, the opposite party No. 2 pleaded that Nose Deformity Surgery was performed upon the complainant and he was discharged on 15.12.2016 and in Para No. 5 of on merits of the written version it is pleaded that he admitted in the hospital of Opposite party No. 4 and hip replacement surgery was performed upon the complainant and he was discharge on 11.2.2015. The opposite party No. 2 has filed the written version without application of mind because at one place the opposite party No. 2 alleges that hip replacement surgery was performed and on the other hands alleges that Nose Deformity Surgery was performed. There is no opposite party No. 4 in the present complaint as alleged by OP No. 2 and the Nose Deformity Surgery was performed upon the son of the complainant and not upon the complainant. As such, the written version filed upon the opposite party No. 2 is vague and ambiguous. Furthermore, the opposite party No. 1 by with-holding the remaining amount of the claim of the complainant has committed deficiency in service and unfair trade practice.
12 The complainant has prayed Rs. 48,766 as remaining amount of treatment but bill of Rs. 62,339/- was prayed by OP No.2 for treatment and Rs. 3,000/- was given as discount and Rs.17,000/- was approved by the TPA for cashless claim and Rs. 3,024/- were credited to the account of the complainant which is admitted by the complainant. As such, now remaining amount is due Rs. 39,315/- and the complainant is entitled for the same from the opposite party No. 1
13 In view of the above discussion, the present complaint is partly allowed and the opposite parties No. 1 is directed to make the payment of Rs.39,315/- to the complainant. The complainant has been harassed by the opposite party No. 1 for a long time therefore, the complainant is also entitled to Rs.6,000/-(Rs. Six Thousand only) as compensation and Rs. 5,000/- (Rs Five Thousand only) as litigation expenses. Opposite Party No. 1 is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. The present complaint against the opposite party No. 2 is dismissed. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
21.10.2022
