Delhi

North

CC/169/2019

ASHOK KUMAR GUPTA - Complainant(s)

Versus

THE NEW INDIA ASSURANCE COMPANY LTD. AND ANOTHER - Opp.Party(s)

MUKESH GARG

13 Jun 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

CC No.: 169/2019

 

Sh. Ashok Kumar Gupta

S/o Sh. Chiranji Lal Gupta

B-38, East of Kailash,

New Delhi-110065                                                                                        …                              Complainant

 

                                                                                                Vs

 

The New India Assurance Co. Ltd.

Delhi Regional Office-1

2^nd Floor, R.G. City Centre,

LSC Block-B, Lawrence Road,

Delhi-110035                                                                                                   …                Opposite Party No.1

 

Health Insurance TPA of India Ltd.

2^nd Floor, Majestic Omnia Building,

(Behind HDFC Bank Building),

A-110, Sector-4,

Noida-201301

Uttar Pradesh                                                                                                                …                Opposite Party No.2

               

ORDER

13/06/2023

 

Ashwani Kumar Mehta, Member:

 

(1)          The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the complainant had taken a CASHLESS MEDICLAIM POLICY from OP No. 1 bearing no. 311900/48/99/09734 in the year 2000 which was renewed continuously till 17/06/2019. The present policy bearing No. 31150034189500000243  has also been renewed by the Complainant for the period 18-06-2019 to 17-06-2020 by paying a premium of Rs.1,15,000/- (Rupees One Lakh Fifteen Thousand Only) for a sum insured of Rs.8,00,000/ (Rupees Eight Lakh Only) plus bonus buffer Rs.1,25,000/- (Rupees One Lakh Twenty Five Thousand Only) for the Complainant and for a sum insured of Rs.8,00.000/- (Rupees Eight Lakh Only) plus bonus buffer of Rs.1,50,000/- (Rupees One Lakh Fifty Thousand Only) for his wife Mrs. Shashi Gupta.

 

(2)          The Complainant remained admitted in Sant Parmanand Hospital, Civil Lines, Delhi-110054 for B/L TOTAL KNEE REPLACEMENT for his both knees from 26/04/2019 to 03/05/2019. Vide pre-authorisation approval letter dated 02/05/2019, the Respondent/O.P. No. 2 (TPA of O.P. No.1) approved and authorised a cashless facility of Rs.3,80,398/- ( Rupees Three Lakh Eighty Thousand Three Hundred Ninety Eight Only) for the said treatment of the Complainant. At the time of discharge from the hospital on 03.05.2023, a final bill of Rs.7,30,398/- was raised by the hospital for the said treatment of the Complainant. The Complainant had to pay the balance sum of Rs.3,50,000/- (Rupees Three Lakh Fifty Thousand Only) to the said hospital after adjusting the sum of Rs.3,80,398/- (Rupees Three Lakh Eighty Thousand Three Hundred Ninety Eight Only) that was approved, authorized and promised to be paid to the hospital by the  O.P.s vide pre-authorisation approval letter dated 02/05/2019. It is also stated by Complainant that after the discharge, the Complainant had also incurred expenses of Rs.20,200/- towards the physiotherapy and attendant charges for his knees.

(3)         The complainant submitted his claim vide claim form dated 28/05/2019 to the O.P.s, for reimbursement of the balance amount of Rs.3,50,000/- (Rupees Three Lakh Fifty Thousand Only) paid by him to the hospital and other expenses of Rs.20,200/- for physiotherapy and attendant charges, total Rs.3,70,200/- (Rupees Three Lakh Seventy Thousand Two Hundred Only) but the balance amount of Rs. 3,70,200/- (Rupees Three Lakh Seventy Thousand Two Hundred Only) has not been received by the Complainant from the OPs. However, a sum of Rs.6,000/-  was received from O.P.s by way of RTGS in his account. The said amount was transferred by O.P.s without any intimation or details to the Complainant as on what basis this amount was transferred. Vide letter dated 07/08/2019, the Complainant informed the OPs that he was not ready and willing to accept this meagre sum of Rs.6,000/- only and further requested them that the entire claim should be settled and paid to the Complainant but has not been paid till date.

(4)         It has also been alleged by the complainant that the OPs have not remitted the pre-authorised amount of treatment to the Hospital well in time and the treating hospital kept on demanding this amount from the complainant which has affected the reputation of the complainant in the society.

(4)         Due to the aforesaid Deficiency in Services, the Complainant has filed the present complaint against the OPs praying for direction to the OPs, to pay to the Complainant jointly and severally:-

1.  Rs.3,70,200/- (Rupees Three Lakh Seventy Thousand Two Hundred Only) as requested by the Complainant vide his claim form dated 28.05.2019 i.e. balance amount of Final Bill of Rs.3,50,000/- and the amount of Rs.20,200/- for physiotherapy and attendant.
2.  Rs.2,00,000/- (Rupees Two Lakhs Only) as compensation for irreparable mental tension, immense pain, agony, under harassment, inconvenience, financial burden and loss of reputation caused to the Complainant by the OPs.
3.  Rs.45,000/- (Rupees Forty Five Thousand Only) as litigation expenses.
4. Interest on these amounts @ 15% per annum from the date of discharge of the Complainant till payment.
5. Any other and/or further order(s) as may be deemed fit, proper and appropriate, in the facts and circumstances of the case.

(5)         Accordingly, notices were issued to the OPs and in response to the Notice issued, the OP-1 has filed its reply stating that out of the total Pre-Authorization given for Rs.3,80,398/-, an amount of Rs.3,72,762/- only has been settled details given below:

1. Rs.22,762/- settled on 06.06.2019 vide UTR No.  
2.  
2. Rs.3,50,000/- settled on 05.12.2019 vide UTR No.       

                                      CITIN19074229986

3. Deductions of Rs.7,636/- GST charges on Implant purchased  

by the hospital and billed in impatient hospitalization bill is not payable as per the Gazette of India, extraordinary, Part II Section 3, Sub Section (i) dated 28.06.2017 and as per the ruling and clarification given by Authority of Advance Ruling Kerala, on 19.09.2018 via order no. “Advance Ruling No. Ker/16/2018.”

(6)         It is further stated by the OP that patient/complainant stayed in Maharaja Room, which is over and above his eligibility of single Room, hence, hospital has billed accordingly. As hospital has billed in accordance with patient’s stay in Maharaja Room, which is over and above patient’s eligibility of GIPSA PPN PKG as per Single Room, thus, it has collected Rs.3,50,000/- from the patient for charges over and above GIPSA PPN PKG for Single Room. The copy of Package Rates of Sant Parmanand Hospital, Delhi is has been filed with the reply. In this regard, it is further stated that as per communication received from the hospital in this case, Complainant had requested to provide the Maharaja Room instead of single room and our TPA team had explained to patient that he was not eligible for Maharaja Room category and TPA will deduct the difference amount but he replied that he will pay the deducted amount from his pocket. Therefore, the billing was done as per Maharaja Room category and patient had paid difference of Rs.3,50,000/-. The hospital has also provided PPN Network – Declaration Form signed by Patient/ Patient’s Attendant giving an undertaking as per wording given below:-

“On my own option, I wish to avail above better facility and I hereby agree to pay on my free will, after being explained in detail by the Hospital authority in my own and understandable language about the above mentioned Additional Facility/ Procedure/ Treatment and associated cost of it, which is over and above the agreed PPN tariff. Further, if I opt to go for final bill reimbursement with insurance company, respective insurance company will reimburse only as per agreed PPN tariff rates and balance amount will be borne by myself or patient only. I have also been explained that when room service of a category better than eligible room rent is availed by the patient, not only the difference in room rent but also an equal proportion of all other charges associated with the treatment shall be borne by me.”

 

7.            The OP-1 has also filed Copy of “PPN Network – Declaration by Patient/patient’s Attendant” with the complaint and has contended that in view of the undertaking/declaration given by the complainant/patient, the balance amount of Rs.3,50,000/-,claimed by complainant/Insured patient, is not payable and is to be borne by him. Regarding claim of bills for Post hospitalization Physiotherapy Expenses for Rs.13,000/-, it has been clarified by OP-1 that Rs.6,000/- has been paid to Complainant on 30.07.2019. Therefore, there has been no deficiency of services on the part of the OP-1.

8.            Since OP-2 has opted not to participate in the proceedings despite service, it was proceeded ex-parte. However, In the rejoinder to the above reply of OP-1, the Complainant has stated that the form -“PPN Network – Declaration by Patient/patient’s Attendant” dated 12/06/2019 is a printed form got signed from the complainant under undue influence and taking advantage of dominating position of OP's stating/ threatening that his claim would not be paid unless and until this form is signed by him. As such, the complainant had no alternative but to sign it under compulsion and undue influence otherwise his claim would have not been paid by OPs. Moreover, in this form dated 12/06/2019, it is only mentioned that additional facility that the patient wishes to avail - "As per policy conditions”. Moreover, it is printed that the "reimbursement of agreed tariff rates”. It is further contended by the complainant that the alleged GIPSA PPN PKG rates was not a part of the policy issued by the OP's to the complainant nor the alleged GIPSA PPN PKG rates were communicated or intimated to the complainant by the OPs. Hence, the alleged GIPSA PPN PKG rates are not applicable to the policy of the complainant and therefore, alleged GIPSA PPN PKG rates cannot be made applicable to the policy of complainant by form dated 12/06/2019 (taken after the treatment of complainant from 26/04/2019 to 03/05/2019).

9.           The parties have also filed evidences by way of affidavit affirming their above submissions and argued the matter also. Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence/arguments put forth by both the parties and it has been observed that:-

1. The copy of the policy schedule filed by the Complainant alongwith the complaint contains only four pages which were supplied to the Complainant by the OP-1 whereas in the written statement, the OP-1 has filed 30 pages of terms & conditions which starts from page 1 to 30. Had it been the part of the policy schedule, the policy schedule should have total 34 pages with the terms & conditions starting from page 5 of 34 to 34 of 34.

 

2. The OP-1 has failed to prove that the policyholder/Complainant was informed/communicated about his eligibility/admissibility of claims as per GIPSA PPN PKG at the time of issuance of the policy in question.

 

3. It has also been held in the judgment passed  by the Hon’able Supreme Court of India in the matter of Texco Marketing Pvt Ltd Vs Tata AIG General Insurance Co. Ltd & others - (2023) I SCC 428 that the Insurance Company cannot rely upon the terms and conditions  if the same had not been supplied to the insured.

 

4. “PPN Network – Declaration by Patient/patient’s Attendant” dated 12/06/2019 filed OP-1, does not contain the details of additional facility/ provisions/ procedures/ treatments, desired to be availed by the patient. It simply mentions “as per policy conditions”. In case, the patient had desired to avail the facility of Maharaja room, it should have been clearly mentioned in this column. This is a printed format containing the wording of undertakings for payment of the balance amount over and above the agreed PPN Tariff. As such, it is not sufficient to prove that the patient/insured person was well-informed about the non-admissibility of the Maharaja room in the package of treatment admissible in the policy owned by him.

 

5. At Sr. No. 2 of “PPN Network – Declaration by Patient/patient’s Attendant” dated 12/06/2019 filed OP-1, it is mentioned that the patient has opted for eligible Room category under the policy.

 

6. The date of declaration given on “PPN Network – Declaration by Patient/patient’s Attendant” filed by the OP-1, is 12.06.2019 whereas the treatment period of the Complainant/ patient was from 26.04.2019 to 03.05.2019 which clearly proves that this undertaking has been obtained from the patient/ Complainant under coercion or undue influence.

 

7. The cost of Rs.500/- was imposed upon the OP-1 on 18.02.2020 which was to be paid to the Complainant but has not been paid by the OP-1 till date.

 

8. The pre-authorised amount of treatment was remitted by OP-1 to the Hospital in two instalments i.e. Rs.22,762/- on 06.06.2019 and  3,50,000/- on 05.12.2019 and in the meantime, the treating hospital kept on demanding this amount from the complainant.

 

(10)         In view of the above observations, we are of the considered view that the complainant has suffered directly due to deficient service of the OP-1 (M/s New India Assurance Co. Ltd.) in terms of the deficiency defined in the Act which includes  any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer. Therefore, we feel appropriate to direct the OP-1 (M/s New India Assurance Co. Ltd.) to :-

a)    pay Rs.350000/- (Rupees Three Lakhs fifty Thousand only) within thirty   (30) days from the date of this order, with interest at the rate of 9% p.a. from 11-10-2019 (date of filing of complaint) till the date of the payment;

b)   pay Rs.50000/-(Rupees Fifty Thousand only) as compensation to the Complainant, for the mental pain, agony and harassment; and

c)    pay additional cost of Rs.5000/- alongwith cost of Rs.500/- imposed upon the OP-1 on 18.02.2020, (which has not been paid by the OP-1 till date) to the Complainant.

(11)        It is clarified that if the above ordered amount(s) is not paid by the OP-1 to the Complainant within the period as directed above, the OP shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

(12)        Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

 

   ASHWANI KUMAR MEHTA                                                                                DIVYA JYOTI JAIPURIAR  

Member                                                                                                               President       

                              DCDRC-1 (North)                                                                                                 DCDRC-1 (North)