Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-133/19.07.2018
Dear Gupta son of Late H.L. Gupta
r/o 3845, Tel Mandi, Pahar Ganj, Delhi-110055 ...Complainant
Versus
OP1: The New India Assurance Company Ltd
C-30, III floor, Community Center, Naraina,
New Delhi-110028
Head Office: 87, Mahatma Gandhi Road, Mumbai
OP2: E-Meditek Insurance TPA Ltd.,
577, Udyog Vihar, Phase-V, Gurugram, Haryana
OP3: Sir Ganga Ram Hospital
Rajender Nagar, New Delhi
OP4: Sir Ganga Ram City Hospital, Pusa Road,
Rajender Nagar, New Delhi ...Opposite Parties
Date of filing: 19.07.2018
Date of Order: 19.05.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. The complainant (Shri Dear Gupta) purchased medi-claim policy no. 32350434172800000260 valid from 29.10.2017 to 28.10.2018 from OP1 (the New India Assurance Co. Ltd) against payment of premium. OP2 (E-Meditek Insurance TPA Ltd.) is TPA/agent of OP1. The complainant has been taking insurance policy for the last so many years and he is regular customer of OP1. Moreover, the complainant has been availing cashless facility of OP, arising out of policy and also got treatment from penal hospital, there was never any dispute in respect of treatment or payment of hospital bills including the facilities availed from Sir Ganga Ram Hospital/ OP3.
1.2. The complainant visited emergency of Sir Ganga Ram Hospital, however, for treatment the beds were not available and it was shifted to its group hospital Sir Ganga Ram City Hospital/ OP4 on 29.10.2017 in the night at about 09:50pm and he was assured that cashless facility are available. It was also confirmed that OP3 and OP4 are on the panel of OP1 and OP2 but the complainant was pressurised and also his attendant to deposit cash for admission in the hospital otherwise he/ patient will not be entertained. Since the complainant was serious, he required intensive care immediately, there was no option with the attendant but to acecede to the pressure of OP3 and deposited the amount; whereas OP3 being empanelled hospital of OP1/OP2 did not agree to extend cashless facility. The initial amount of Rs. 25,000/- was deposited followed by deposits demands from time to time till final bill. The OP3 did not process the cashless treatment bill. The OP3 raised final bill which was cleared by the complainant.
1.3. The complainant was discharged from OP3 hospital and then he submitted his claim to TPA/ OP2 to get reimbursement of expenses, however, he was paid Rs. 59,165/- out of total bill of Rs. 1,80,797/- and remaining amount of Rs. 1,21,632/- was deducted illegally and his claim was rejected arbitrarily the complainant had furnished all the record inclusive of certificate dated 03.02.2018 from treating doctor that it is not a known case of CKD but his claim was not reimbursed. There was no reasons for justification of OP1 and OP2 for rejection of the claim and acts of OP1 to OP4 are illegal and improper and bad in law. They had acted in collusion of each other. The complainant is a consumer but his claim was not reimbursed. That is why, the complaint to reimburse his balance amount of Rs. 1,21,632/- out of bill amount of Rs. 1,80,797/- apart from Rs. 10,000/- incurred after discharge from OP4. The complainant also claims damages of Rs. 3,00,000/- for causing mental tension, pain and agony and Rs. 50,000/- as costs.
1.4. The complaint is accompanying with the copies of schedule of New India Floatter Mediclaim Policy, the bills paid by complainant, certificate dated 03.02.2018 issued by OP4, deductions made by the OP1 and OP2, copy of legal notice and other correspondence exchanged, post-discharge bills of medicine and treatment.
2.1 The OP1 opposed the complaint vehemently that questions of fact and law involved required elaborate oral and documentary evidence, which cannot be adjudicated in summary proceedings. There is no deficiency in services on the part of OP1. The complainant has made claim of Rs. 1,80,797/- out of Rs. 59,165/- was allowed and paid, which was calculated as per terms and conditions of policy.
The complainant took the said policy for period from 29.10.2017 to 28.10.2018 with the coverage of four family members (self, spouse and two children) for total sum insured of Rs. 5,00,000/- to be governed by terms and conditions of policy. Whereas the complainant was insured for Rs. 1,50,000/- only till 28.10.2015, he is entitled for Rs. 1,50,000/- for all pre-existing disease prior to 29.10.2015, as per exclusion clause 4.1 of the policy. The amount assessed, allowed and disbursed of Rs. 59,165 /- is within the parameter of policy and its terms and conditions.
The reply is accompanied with documentary record of calculations to show entitlement of complainant, terms and conditions of policy to fortify its stand.
2.2. There is no reply by OP2, it abstained from appearing in the proceedings.
2.3. OP3 filed its detailed reply, it opposed the complaint that the same is without cause of action and there is no iota of fact of deficiency of services. The dispute appears to be between the complainant/ insured and insurer. Rather when complainant reported in the emergency on 29.10.2017 at 03:39pm, he was provided initial treatment, admission in the hospital was advised but for want of availability of bed with OP3, he was offered bed in City Hospital/ OP4, which is affiliated to OP3 and complainant was shifted there with his consent. He was given treatment by OP4, bills were also paid to them and no bill was paid to OP3 by the complainant. The OP3 also narrates facts about its goodwill/reputation as well as services being rendered to the Society. There is request to dismiss the complaint.
2.4. The OP4 also opposed the complaint that there is no deficiency of services on its part nor any amount was asked illegally nor he was pressurized to deposit the amount. The complainant himself deposited the amount and represented that it may take time in approval/authorization, let time shall not suffer for treatment. The OP4 is not liable for any damages or liability or any interest on any amount. The complainant had sent legal notice to OP1 and OP2, which also infers that there was no deficiency of services or any grievances against OP4. OP4 also request for dismissal of the complainant.
3. The complainant Sh. Dear Gupta filed his detailed affidavit, it narrates evidence of facts and documents on the line of compliant. OP1 tendered evidence by way of affidavit of Ms. Kavita Jain, Admin. Officer and it is also replica of reply and documents filed with the reply. OP3 also tendered evidence by way of affidavit of Dr. (Birg.) Satendra Katoch, Additional Director Medical and affidavit is in compact form being reflection of the reply. OP4 also led evidence by way of affidavit of Sh. Satender Kumar, AR of OP4 and it is on the lines of reply.
5. The complainant, the OP1, the OP3 and the OP4 have filed their respective written arguments, it is reiteration of their cases in the pleading and evidence. However, the complainant has also relied upon New India Assurance Co. Ltd. vs Chetan Gunwantlal Modh (R.P., dod 05.09.2017 by Hon’ble National Commission) that terms and conditions no. 4.3 of policy were not given to the complainant and it was held that claim of complainant was wrongly repudiated, it was also held deficiency in services. The complainant also filed two more cases, but they were on some other points, the same are not being referred here.
The parties were given opportunity to make oral submissions. Sh. Bharat Deep Singh, Advocate for the complainant; Sh. Dheeru Nigam, Advocate for the OP1 and Sh. Kapil Kher, Advocate for the OP4 made their respective submissions. It is not being repeated here as the same will be discussed appropriately.
6.1 (Findings)- The case of each party is considered and analysed by taking into account the stock of all material proved and established by the parties. In fact, both sides refers documentary record, its contents as well as terms and conditions of policy, it will also be discussed.
6.2 On plain reading of the case of parties, the dispute is to what extent the complainant would be entitled for reimbursement of medical bills, or whether or not complainant is entitled for further reimbursement after initial settlement of claim?
Otherwise, the complainant has been taking insurance policy for long period is not disputed, there was initially medi-claim policy and later it was floater medi-claim policy, there is also no dispute that he had been to the emergency of OP3 on 29.10.2017, then he remained an indoor patient from 29.10.2017 to 05.11.2017 in hospital of OP4. There was no cashless facility extended and complainant paid entire medical bills of Rs. 1,80,797/- till his discharge, out of which an amount of Rs. 59,165/- was reimbursed to him by OP1 after his discharge and filing of claim.
6.3. There is an objection by OP1 that the case involves elaborate examination and cross examinations of witnesses, the consumer Fora lacks the jurisdiction to decide them, however, this perception is misplaced, since the case involves documentary record, which parties have placed with their respective pleading and evidence, it can be determined by the consumer Fora/Commission even by summary procedure. The case is simply to compare facts & case of parties with the insurance contract as well as its terms and conditions between the parties, apart from the roles of OP3 and OP4. Therefore, the contention of OP1 does not sustain that it needs adjudication by some other Forum than the consumer Fora/ Commission. This contention is disposed off.
6.4. The OP1 has applied two criteria for deductions of the amount of medical expenses, which complainant opposes, first the criteria of sum insured of Rs. 1,50,000/- in the previous policy prior to floater policy from 29.10.2017 to 28.10.2018 and secondly, proportionate expenses were considered on the basis of sum insured of Rs. 1,50,000/- in the previous policy and not on the basis of floater medi-claim policy having sum insured of Rs. 5,00,000/-. Thus it becomes incumbent to reproduce clause no. 4.1 of insurance contract (being part of clause 4- what are excluded under this policy, no claim will be payable under this policy). Clause 4.1 reads as “treatment of any pre-existing condition/disease, until 48 months of continuous coverage of such insured person have elapsed, from the date of inception of his/ her first policy as mentioned in the Schedule.”
6.5. By taking into consideration totality of circumstances and evidence, it is held that complainant has succeeded in proving his case and claim of balance amount of Rs. 1,21,632/- of pre-discharge medical bills and medical bills & expenses of Rs.10,000/- post hospital/discharge against OP1 for the following reasons:-
(i). The OP1 took the plea of condition of insurance policy of exclusion clause 4.1 when there is treatment of pre-existing condition/disease, then 48 months of continuous coverage of such insured person has to be elapsed from the inception of first policy. The OP1 has not proved any pre-existing disease of complainant.
The complainant has proved certificate dated 03.02.2018 issued by OP4 that CKD is diagnosed in this admission, which was from 29.10.2017 to 05.11.2017. Thus, according to complainant there was no pre-existing disease, when the policy was taken and on the other side OP1 has not led any evidence of pre-existing disease nor rebut the certificate dated 03.02.2018 issued by OP4,
(ii). since, there is no proof of either pre-existing condition disease nor proof of pre-existing condition/disease, consequently clause 4.1 is not applicable as it was invoked by OP1,
(iii). since, the insurance policy clause 4.1. is not applicable, therefore, the proportionate amount allowed on the basis of previous sum insured of Rs. 1,50,000/- prior to 29.10.2015, is not justified and the case of complainant is governed by the terms and condition of family floater medi-claim policy, which is for sum insured of Rs. 5,00,000/-,
(iv). total medical bill amount paid by complainant was Rs. 1,80,797/- , however, OP1 and OP2 considered and allowed partly bill of Rs. 59,165/- on the basis of sum insured Rs. 1,50,000/- and proportionate expenses on that basis, however, that criteria has already been held to be not justified. Therefore, on the basis of sum insured of Rs. 5,00,000/- of family floater medi-claim policy, the complainant is held entitled for balance bill amount of Rs. 1,21,632/- as record of the medical bill have already been filed and proved in the complaint,
(v). in the term and condition of policy, there is provision of pre-hospitalization medical expenses as well as post hospitalization medical expenses, as mentioned in clause 3. The complainant has proved medical bills & expenses for post- hospitalization, which he is entitled in terms of the insurance policy; the complaint has also proved it against OP1 and
(vi). the complainant claims interest on the amount spent by the as cashless facility was not extended to him, it is manifest that for want of cashless facility the complainant has to part with his money, therefore, interest at the rate of 5% p.a. from the date of complaint till realization of the amount will meet both ends.
6.3 The complainant claims compensation/damages of Rs. 3,00,000/- on account of mental tension, pain and agony apart from cost of Rs. 50,000/- , however, this amount is mentioned in general parlance, without specifying complainant's income, source of income, or other special criteria for such amount. However, he faced the trauma when cashless facility was not extended and thereafter his claim was partly allowed by OP1/OP2, therefore, compensation of Rs. 15,000/- and cost of Rs. 5,000/- in favour of complainant and against OP1 will meet the situation of both ends.
6.4 The OP2 is TPA of OP1, being facilitator. OP3 and OP4 have rendered their medical services, there is no proof of deficiency of services against them. The complaint is liable to be dismissed against OP2, OP3 and OP4.
7.1 Accordingly, the complaint is allowed in favour of complainant and against the OP1, to pay balance medical bills amount 1,21,632/- along-with simple interest of 5% p.a. from date of complaint till realization of amount, apart from damages of Rs. 15,000/- and cost of Rs. 5,000/-. The amount will be payable by OP1 within 30 days from the receipt of this order, otherwise rate of interest will be 6%p.a. amount of Rs.1,21,632/-.
7.2 The complaint against OP2, OP3 and OP4 is dismissed.
8. Announced on this 19th May, 2023 [वैशाख 29, साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [Shahina] [InderJeet Singh]
Member Member (Female) President
