Delhi

North East

CC/54/2018

Shri Hans Raj Gupta - Complainant(s)

Versus

The New India Insurance Co. - Opp.Party(s)

06 Nov 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 54/18

 

In the matter of:

 

	Shri Hans Raj Gupta S/o Late Raghunath Dass Gupta R/o :- A-804, Tower –A, The Forest Spa, near Omaxe Grand Sector-93 B, Noida Gautam Buddha Nagar Uttar Pradesh-201301	Complainant
	Versus
	New India Assurance Co. Ltd. Scope Minar, Laxmi Nagar Delhi-110092	Opposite Party

 

DATE OF INSTITUTION:      JUDGMENT RESERVED ON:               DATE OF DECISION      :

23.03.2018 06.11.2020 06.11.2020

 

Mr. Arun Kumar Arya, President (Addl. Charge)

Ms. Sonica Mehrotra, Member

 

ORDER

Ms. Sonica Mehrotra, Member

 

1. Facts in brief made out in the present complaint are that the complainant is a senior citizen aged more than 90 years and has been a customer / consumer of OP since 2009 by virtue of having availed mediclaim policy from it uninterruptedly till 2016-17 and the last policy bearing No. 32030134142500001072 availed by him for himself and his wife for a total sum assured of Rs. 1,50,000/- each on payment of premium of  Rs. 19,764/- paid by him to OP. The said policy was valid from 20.12.2016 to 19.12.2017. The complainant suffered an acute stroke on 14.12.2017 for which he was admitted to Jaypee Hospital, Noida where he underwent treatment and was discharged on 15.12.2017 vide discharge summary No. DS-JP-00116617262. The complainant incurred a total expenditure of  Rs. 65,925/- on treatment and medication undergone in the said hospital which was duly paid by him. The complainant thereafter lodged a mediclaim reimbursement with OP through its TPA Vipul Medicare Pvt. Ltd. and submitted a treatment related documents for process of claim and refund of the amount paid. As per the complainant, in addition to hospital expenses of Rs. 65,925/-, the complainant also incurred post hospitalization expenses by way of medication and doctor visit to the tune of Rs. 56,614/- and therefore a consolidated claim of Rs. 1,26,539/- was lodged by him with OP. However the dispute arose when OP reimburse only Rs. 18,445/- against total hospital bill of Rs. 65,925/- which it paid to the hospital concerned directly and approved claim of Rs. 7,234/- only towards post hospitalization, medication etc. as against total claim lodged under the said head for a sum of Rs. 56,614/- by the complainant and the approved amount was transferred into the complainant’s account through NEFT by OP. On clarification sought by the complainant from OP’s TPA for such deductions, he was informed that against the daily room rent of  Rs. 4,000/- charged by the said hospital, TPA had approved daily room rent @ of Rs. 1,500/- per day. The complainant has urged that his sickness was not hit by any exclusion clause mentioned in the policy and had even otherwise never lodged any claim for hospitalization with OP since 2009 and this was the first time that the complainant was hospitalized but OP paid hardly 20% of the total claim amount (Rs. 1,26,539) compelling the complainant to discontinue availing of its services any further. Lastly, complainant submitted that despite letters dated 09.01.2018 and 25.01.2018 written by him to OP requesting reimbursement of balance amount, no action was taken by OP. Therefore, the complainant was compelled to file the present complaint against OP under tremendous mental pressure and has prayed for issuance of directions to OP to pay the balance amount of Rs. 1,00,860/- alongwith interest @ 15% and compensation of Rs. 25,000/- for mental agony.  

Complainant has attached copy of Mediclaim Policy Cover Note, original discharge summary issued by Jaypee Hospital Noida alongwith final bill for admission, room rent medication etc. to the tune of Rs. 65,925/-, post hospitalization expenses sheet prepared by the complainant and copy of letters dated 09.01.2018 and 25.01.2018 by complainant to OP alongwithspeed post dispatch slips.

2. Notice was issued to the OP on 10.04.2018. OP entered appearance and filed written statement vide which it took the preliminary objection that the complainant had room eligibility of Rs. 1,500/- per day i.e. 1% of the sum insured (Rs.1,50,000/-) as per policy condition 3.1(a) and since the insured i.e. the complainant had availed of a room with rent @ of  Rs. 4,000/- per day which was higher than the entitled category, the reimbursement, payment of all other expenses incurred at the said hospital with exception of medicine as under 3.1(d) of the policy terms and conditions shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent. According to the said applicable clause and calculation therefore, out of the bill dated 15.12.2007 of Rs. 65,924/-, Rs. 52,625/- was disapproved by OP and only Rs. 13,298/- was held payable in accordance with pro rata deduction in ratio of 2250 / 12000 in view of room rent entitlement of Rs. 1,500/- but room availed of for the rent Rs. 4000/- to 8000/- per day as per Clause 3.1 (d) of policy terms and condition. In so far as post hospitalization bill is concerned, OP urged that doctor home visit charges are excluded as per Annexure II  of the policy terms and conditions and therefore out of the total pay amount of Rs. 48,728/- ,only Rs. 7,234/- was payable which was then credit in complainant’ account. On merits too, OP justified the amount approved / sanctioned and paid to the complainant towards hospitalization and post hospitalization expenses as per policy terms and conditions. For the said defence, OP prayed for dismissal of the complaint.
3. Rejoinder in rebuttal to the defence taken by OP was filed by the complainant in which the complainant stated that he was not advised of any basis for settlement of claim which also does not find any mention in the policy and all along that he was insured with OP for last three decades, he was given to understand that he was entitled to reimbursement of medical expenses upto the sum assured. The complainant submitted that on previous 3-4 mediclaims lodged by him with OP, such a rejection was never made by OP and this was the first time that complainant came to know of such a condition and that too only from the written statement filed by OP. Complainant urged that the insured is not expected to know of any conditions or term outside the policy and had this conditions be known to him, he would not have availed of the insurance cover from the OP. complainant therefore prayed for grant of relief claimed by him against OP.
4. Evidence by way of affidavit was filed by the complainant exhibiting the documents relied upon as Ex-C1 to C6.
5. Evidence by way of affidavit was filed by the OP sworn by its Administrative Officer exhibiting the policy terms and conditions alongwith calculation sheet already filed with the written statement in support of the quantum paid under hospitalization and post hospitalization expenses to the complainant.
6. Written arguments were filed by the complainant in which the complainant submitted that he had never opted for a policy in which insured is only eligible for room rent of RS. 1,500/- per day and hardly 20% of medical expenses reimbursement is allowed. He further urged that he had always understood insurance policy as complete contract between the insurance company and complainant and therefore was entitled to complete reimbursement of Rs. 1,26,539/- as claimed out of which shall be deducted Rs. 25,000/- approx. already paid by OP and was therefore entitled to the remaining payment of Rs. 1,00,860/- from OP.
7. Written arguments were filed by OP in reiteration of the defence taken.
8. On completion of pleadings and on scrutiny of the case file, it was observed by this Commission that there was a discrepancy between amount claimed by the complainant to have been received from OP which was  Rs. 25,000/- approx. (rounded of) and that averred by OP to have been paid to the complainant which was Rs. 20,000/- approx. (rounded of). Therefore directions was issued to both parties vide order dated 09.07.2019 to clarify the exact amount paid and received. In compliance of the said order, complainant submitted in writing that out of the total expenses incurred by him to the tune of Rs. 1,26,539/-, OP only paid Rs. 25,679/- (Rs. 18,445/- paid directly to Jaypee Hospital + Rs. 7,234/- remitted in complainant’s bank account). OP filed affidavit of its Administrative Officer deposing that  it had paid Rs. 13,298/-to Jaypee Hospital towards medical expenses incurred by the complainant and Rs. 7,234/- was paid to the complainant as settlement of post hospitalization bill in accordance with pro rata deduction as provided under clause 3.1(a) read with 3.1(d)  of policy terms and conditions.
9. We have heard the arguments addressed by complainant in person and counsel for OP through video conferencing and have given due consideration to the pleadings filed by both sides.

On perusal of the entire record of the case, the pleadings of concerned parties, their respective affidavits in evidence, documents on record and written as well as oral arguments submitted by the parties, we now proceed to record our observation and findings on overall merits of the case as would appear in the forgoing paras of this order.

The aspect of mediclaim cover extended to the complainant by OP and factum of hospitalization of the complainant on 14.12.2017 at Jaypee Hospital, Noida are admitted by both parties as also the reimbursement towards hospitalization and post hospitalization expenses incurred by the complainant though there is a discrepancy between the amount reimburse by the OP in pleadings of both parties. The dispute arose when there were deductions made by OP under both heads in reimbursement of hospitalization as well as post hospitalization expenses in respect of which claim was raised by the complainant which led to filing of the present complaint. The complainant has contended that there was no such clause in the policy for such deduction. Per Contra, OP relied upon and also filed copy of the terms and condition of the policy on scrutiny of which as per clause 3.1(a), it was stipulated that the room rent as provided by the hospital shall not exceed 1% of the sum insured per day. Clause 3.1 (d) stipulated that expenses towards medical procedures, treatment and medication provided for reimbursement/payment of room rent shall not exceed 1% of the sum insured per day and in case of admission to a room at rates exceeding the aforesaid limit, the reimbursement/payment of all other expenses incurred at the hospital, with the exception of cost of medicines shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of room rent. The complainant was assured for a sum of Rs. 1,50,000/- and therefore as per clause 3.1 (a), he was entitled to a room of rent Rs. 1,500/- per day whereas he stayed in hospital room (deluxe room / single room) for one and half days, per day rent of which was Rs. 4,000/- to Rs. 8,000/- amounting to Rs. 12,000/- as is revealed by the hospital bill No. INV-JP00117018392 dated 15.12.2017 and all other medical expenses came to the tune of Rs. 51,640/-. Therefore applying the pro rata deduction principal, the approved amount of room allowance came to Rs. 2,250/- as against the billed amount of Rs. 12,000/- and all other expenses were reimbursed on pro rate deduction basis as per clause 3.1. (d) by applying the calculation formula:

Rs. 51,640 x Rs. 2,250 divided by Rs. 12,000/- = Rs. 9,682/- as against the billed amount of Rs. 51,640/- disallowing Rs. 41,958/- as per the calculation chart. To the above two heads was added medicine allowance of Rs. 1,366/- (excluding non-payable item like gloves, thermometer and urine jug) as against the billed amount of Rs. 2,184/- and OP therefore paid / allowed Rs. 13,298/- to the hospital where complainant was admitted. In addition to the above reimbursement, post hospitalization the complainant raised a claim of Rs. 48,728/- towards pharmacy, doctor visit, radiology, consultation etc. on the OP but OP allowed reimbursement of Rs. 7,234/- against the said claim disallowing reimbursement of doctor visit and radiology etc. on grounds of exclusion made as per item No. 63 in annexure II: list of expenses excluded i.e. home charges. The OP has already reimbursed under both heads i.e. hospitalization as well as post hospitalization, amounts approved and given are admitted by the complainant as well. However such payments have not been accepted as full and final by the complainant who has filed the present complaint for the balance sum under both heads. It is not the case of the complainant that the was not provided with the policy terms and conditions since as per his own admission he was a policy holder since 2007 and therefore cannot urged that the terms and conditions of the said mediclaim policy were not mentioned or attached with the insurance policy. He has sufficient time/ years to ask for the same in case OP had not provided the same but it is a far thought. Moreover the complainant is a qualified Chartered Accountant and Commerce and Law Graduate and is therefore well read and educated to understand and decipher the policy clause specially emphasis clause 3.1 (a) allowing room rent @1% of sum insured per day and in the event of availing of a room exceeding the allowance, clause 3.1(d) is attracted which allow the reimbursement / payment of other expenses excluding medicines in the same proportion as the admissible rate per day bears to the complainant actual rate per day of room rent.

We are guided in this regard by judgment of Hon'ble National Commission in Jyoti Rungta Vs ICICI Prudential Life Insurance Co. Ltd I (2016) CPJ 340 (NC) in which the Hon'ble National Commission dealt with similar facts of dispute pertaining to partial sanction of reimbursement and Hon’ble NCDRC after having read the insurance policy and clauses pertinent was of the view that the complainant had accepted the policyknowing the benefits allowed under the hospital care policy and benefits entitled thereto as also the room rent and upheld the judgment of Hon’ble SCDRC Delhi which had dismissed the appeal by the insured reversing the order of District Forum on grounds that since the complainant had already received the settlement amount, there remains nothing payable by insurance company as per terms and conditions. Applying the ratio of the aforecited / relied upon judgment to the present case, since the complainant has already received the reimbursement of hospitalization and post hospitalization expenses from OP as per clause 3.1(a) and 3.1(d) of the policy, nothing remains payable to him by OP and therefore we do not find any merits in the present complaint and dismiss the same with no order as to costs.

10.  Let a copy of this order be sent to each party free of cost as per Regulation  21 (1) of the Consumer Protection Regulations, 2005.
11.   File be consigned to record room.
12.   Announced on 06.11.2020 

 

(Arun Kumar Arya) President(Addl. Charge)

(Sonica Mehrotra)      Member