Delhi

North

CC/276/2017

KAILASH ROOPCHANDKA - Complainant(s)

Versus

THE ORIENTAL INSURANCE CO. LTD. - Opp.Party(s)

MOHIT AGARWAL

19 Oct 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

 

Consumer Complaint No.: 276/2017

 

Kailash Roopchandka

S/o Lt. Parmeshwar Lal,

B-144, Gujranwala Town,

Part-I, Delhi-110009.                                                                               …                          Complainant

                                                          Vs

 

The Oriental Insurance Co. Ltd.

Through

Managing Director/ Chairman,

Regd. Office:

Oriental House,

A-25/27, Asaf Ali Road,

New Delhi-110002.                                                                                  …                 Opposite Party No.1

 

The Branch Manager,

The Oriental Insurance Co. Ltd.

30/26, First Floor,

Nangia Park, Shakti Nagar,

Delhi-110007.                                                                                          …                 Opposite Party No.2

 

M/s Park Mediclaim TPA Pvt. Ltd.

Through its Managing Director,

702, Vikrant Towers,

Rajinder Place,

Delhi-110008.                                                                                               …                 Opposite Party No.3

ORDER

19/10/2023

 

Ashwani Kumar Mehta, Member:

 

1.       The brief details of facts, as alleged in the Complaint in hand, are that the complainant has taken a Mediclaim policy from the OP-1 & 2  for himself and his family vide policy number 271400/48/2017/1509 which was valid for the period from 03/07/16 to 02/07/17. The OP-1 and OP-2 have engaged the TPA service provider i.e. OP-3 to receive claim papers on behalf of OP-1 and OP-2.

 

2.       The complainant’s daughter was admitted in Uday ENT Hospital on 02/03/2017 and discharged on 03/03/2017. Accordingly, the complainant submitted all the claim papers, original bills and other relevant papers to OP-3 on 06/03/17 for the claiming sum of Rs.47,879/-. In response, the complainant’s claim was allowed for Rs 23,990/- only on 23/03/17 through NEFT. The complainant contacted the OPs so many times, even wrote letters and mail to them for disbursing the remaining amount but no reply received. On 20/05/17, complainant received a mail from OP-3 which stated that the deduction is due to the footnote given under Coverage 1.2 (Hospitalization benefits) of Oriental Mediclaim Insurance Policy. The complainant has stated that no such clause given in the policy and the enclosed documents of the said policy. The complainant contends that all the claimed amounts are as per the clauses as mentioned in the policy and there is no clause mentioned nor attached with it. The complainant has also stated that the OP failed to determine the very fact that the sum assured is Rs 2,00,000/- and therefore, the liability arises for the amount up to Rs.2,00,000/-. The complainant mentions that after receiving the mail dated 20/05/17, he tried to contact all the OPs many times and even wrote a letter to OP-1 and OP-2 dated 25/05/17. After this, the complainant tried to contact via telephone but no reply was received. The complainant has further stated that from the conduct of the OPs, it is clear that they are illegally avoiding to pay the benefits of the policy in order to compensate the damages as suffered by complainant. The complainant claims that there is deficiency of service on the part of the respondent and they failed to settle the claim of Complainant.

 

3.       The Complainant has filed copies of the Mediclaim policy issued to him, card issued by OP-3 for cashless treatment, claim submission by the complainant to the OP-3, letter written by the complainant to the OP-3 asking for description of amount paid, mail received from OP-3 to complainant where they have given the justification for deduction in the claim amount, letter dated 25/05/17, legal demand notice dated 29/06/17 and reply of legal notice dated 11/07/2017. The complainant has prayed to:-

1. Direct the OPs to pay the compensation of Rs.21,889/- to the Complainant as per the mediclaim policy and other consequential damages to the Complainant.
2. Direct the OPs to further pay the interest at the rate of 24% per annum from the date of claim till the date of realization of the amount.
3. Pass such other and further order as this Hon’ble Court may deem fit and proper in the circumstances of the case.
4. The cost of the complaint may be awarded in favour of the complainant and against the OPs.

 

4.       Accordingly, notices were issued to the OPs and in response, the OP-1 & 2 have filed joint reply stating that the complaint is without any ‘cause of action’ since the amount payable under the terms and conditions of the policy has already been paid and there is no deficiency of service on their part. The OP states that after receiving the medical record and bills from the complainant, OP-3 processed the complainant’s claim on the basis of terms and conditions  of the policy, which came out to be Rs.23,990/- to be payable to complainant as against the claim of complainant amounting to  Rs.47,878/-. The OP-1 & 2 have further stated that the amount payable under different heads as provided in Mediclaim policy is to be assessed and paid on the basis of the sum assured as provided under Clause 1.2 and its sub-clauses as provided under the terms and conditions of the policy. In the present case, the sum insured is Rs.2,00,000/- and accordingly, as per clause 1.2 (a), room, boarding and nursing expenses as provided by the hospital/nursing home are 1% of the sum insured per day and other expenses are in proportionate to the room, boarding and nursing expenses charges as provided in clause 1.2. The complainant has been paid the amount payable based on the sum insured and terms and conditions of the policy. Since the complainant had opted for a higher category of room for which the complainant wasn’t entitled to, the expenses over and above the permissible limit are to be borne by the insured/complainant himself. The OP-1&2 have also filed photocopies of the documents given by the OP-3 where the assessment of reimbursed amount of Rs.23,990/- is made and Mediclaim policy issued by them laying emphasis on point (c), (d) under Hospitalization Benefits in the terms & conditions.

 

5.       Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the complainant & OPs and it has been observed that:-

A    The OPs has deducted the amount taking into consideration the rent of the room selected by the Complainant. Since the Complainant was entitled to room rent only at Rs.2000/- but has opted for the room carrying rent of Rs.4000/-, the amount of treatment, therefore, was charged on the basis of higher category of room opted by the Insured. We are failed to understand as to how the quality & type of treatment and consultation/visiting charges of a doctor etc. could vary from a room of carrying rent of Rs.2,000/- to another adjoining room carrying rent of Rs.4,000/- in the same hospital? If this has been the practice in the hospitals empanelled by the Insurance Company, this vital fact must be disclosed to the patient/insured before  start of the treatment in writing so that consent of the insured could be given to pay the balance amount of treatment on higher rates which were not permissible as per the terms & conditions of the policy issued to insured.

B    It has also been found that the OPs have failed to prove that Complainant/insured was  informed before start of the treatment that opting higher category of room will increase the amount of treatment which shall not be paid by the OP- insurance company.

C   In this regard, judgment passed by the Hon’ble NCDRC in RP No.766 of 2011  on 02.06.2015 in the matter of New India Assurance Co. Ltd. Vs. A. K. Kariappa Kaveri Niwas [2015 SCC Online NCDRC 2568] is relevant wherein the following observations have been made at para 8 with regard to the proportionate deductions of the claim of treatment on the basis of rent of the room opted by the Insured:-

“The procedure adopted by the insurance company in my view was faulty.  Instead of making a proportionate deduction from the charges paid by the complainant to the hospital, it ought to have inquired from the concerned hospital as to what exactly would be the charges payable in case the room rent was Rs.1,000/- per day.  It is quite possible that the said charges would remain same irrespective of whether the room rent is Rs.1,000/- or Rs.2,000/- or even Rs.5,000/- per day.  Another possibility is that the charges would vary with the room rent charged by the hospital, but the variation may not be proportionate for the variation in the room rent, yet another possibility is that the charges would be directly proportionate to the room rent.  Therefore, it would be necessary for the Insurance Company to make an inquiry in this regard from the Hospital and find out what would be the applicable charges for the room to which the insured is entitled under the terms of the policy.  However, since no such exercise was undertaken by the Insurance Company, the deduction made by it except in respect of room rent was not justified.”

From the perusal of the reply of the OP, it has been found that no such exercise was carried out by the OP insurance company.

D The complainant has contended in Para No.10 and 11 of the complaint that no such terms & conditions ( regarding proportionate deductions) were communicated to him and the OPs have neither rebutted this allegation in Para No.9 and 10 of the reply nor filed any documents proving that the terms & conditions referred in the reply, were communicated to the complainant. In this regard, It has also been held in the judgment passedby the Hon’ble 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 conditionsif the same had not been supplied to the insured.

6.       In view of the above observations, we are of the considered view that the deduction of Rs.21,889/- from the claim by the OPs, on the basis of proportionate deduction clause (which has not been communicated to the Complainant at the time of issuing the policy) is unjustified which amounts to deficiency in service and the Complainant has suffered directly due to deficiency in service on the part of the OP (M/s National Insurance 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.

        

7.       We, therefore feel appropriate to direct the OPs-1 & 2 to pay Rs.21,889/- (Rupees Twenty One Thousand Eight Hundred Eighty Nine Only) jointly and severally within thirty (30) days from the date of this order, with interest at the rate of 9% p.a. from 11.07.2017 (date of repudiation of the claim) till the date of the payment. Besides, the OP is also directed to pay Rs. 15,000/- (Rupees Fifteen Thousand only) as compensation to the Complainant for the mental pain, agony and harassment. It is clarified that if the abovesaid amount is not paid to the Complainant within the period as directed above, the rate of interest shall be increased to 12% per annum from the date of expiry of 30 days period.

 

8.       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                                      HARPREET KAUR CHARYA

Member                                                                       Member

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

 

 

DIVYA JYOTI JAIPURIAR  

President  

                                                                                            DCDRC-1 (North)