Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 192/2019
1. Mr. M.S. Bedi S/o Late Sh. Kartar Singh Bedi
R/o Flat No. 146, Sunehri Bagh Apartments
Sector-13, Rohini, Delhi-85 ...Complainant No. 1
2. Mrs. Chanchal Bedi w/o Mr. M.S. Bedi
R/o Flat No. 146, Sunehri Bagh Apartments
Sector-13, Rohini, Delhi-85 ...Complainant No.2
Versus
OP1: The Oriental Insurance Co. Ltd.
Oriental House, A 25/27 Asif Ali Road,
New Delhi-110002
2nd address: The Oriental Insurance Co. Ltd.
88, Janpath, Ground Floor New Delhi-110001
OP2: Medi Assist Insurance TPA Pvt. Ltd.
8-B, Second Floor, Tej Building I.T.O, New Delhi
OP3: B.L. Kapoor Memorial Hospital
(BLK Super Specialty Hospital), through its
Medical Superintendent, Pusa Road, New Delhi-05
OP4: Punjab National Bank (D. No. 0617)
D-1, Rana Pratap Bagh, Delhi-110007 ...Opposite Party
Senior citizen case
Date of filing: 15.06.2019
Order Reserved on: 27.12.2022
/ 07.01.2023
Date of Order: 09.01.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. (Introduction to case of parties) : The complainants filed their joint complaint against their insurer/OP1, its TPA/OP2, treating Hospital/ OP3 and underwriter/OP4 with OP1 for allegations of deficiency of services and of unfair trade practice. The complainant has sought refund of Rs. 2,06,507/- (viz. Rs. 2,00,400/- as hospitalization charges + Rs. 5,590/- as TEE test + Rs. 517/- as cost of medicine) as the amount of treatment paid by the complainant, besides damages/ compensation of Rs. 5,00,000/- for causing them mental torture, harassment and mental stress because of non-payment of amount directly to the OP3/hospital and also claim of litigation expenses of Rs. 55,000/-.
Whereas, it is OP1 and OP3 who had opposed the claim of complainants. The OP3 opposed it on the ground that it had tendered all treatment and necessary services to the complainant no. 2 as required from the hospital, there was no deficiency in the medical services on its part or any negligence to make out any compensation. In fact, the dispute is inter-se between the complainants and other OPs. Whereas the OP1 opposed the complaint on the basis of invoking the exclusion clause 4.7 of insurance policy, since it was a known-case of Ostium Secundum ASD with Moderate Tricusid Regurgi, even prior to commencement of the subject insurance policy, there was concealment of material facts, consequently the OP1 is not liable for any claim nor there is any unfair trade practice on its part nor deficiency in service. The claim of complainant was repudiated in terms of insurance policy.
1.2: The complainant has filed the documentary records, consisting original as well as photocopies, besides certificate u/s 65 B of the Indian Evidence Act, in respect of hardcopy of received messages generated from mobile phone no. 7042560033. Similarly, OP1 has also filed record of terms and conditions of policy [Annexure-OP1/A] qua PNB Oriental Royal Insurance Policy with Family Floater.
2.1 (case of complainant ) : The complaint no. 1 took insurance policy from OP1 vide policy no. 272301/48/2011/480 known as PNB Royal Medi-claim Policy with insured code no. 36278421 and lastly paid premium was of Rs. 6,990/- on 13.04.2017 for policy no. 272900/48/2018/1620, for period 27.04.2017 to 26.04.2018. The policy extends to the cover risk of domiciliary hospitalization expenses to the extent of Rs. 5,00,000/-. The complainant was assured (while obtaining the policy) for cashless treatment covering risk of Rs. 5,00,000/-.
2.2: It was 25.04.2017, when during the course of routine medical check-up of complainant no. 2, [who is wife of complainant no.1], it was deducted by doctor of OP3 that she was suffering from disease ASD 2.1 CM L-R shunt, she was advised for medical treatment.
On 13.06.2017 complainants handed over their medi-claim policy to OP3 for ensuing treatment of complainant no.2. An authorised request for cashless facility was lodged by OP3 for total estimate treatment bill of Rs. 2,51,202/- to the OP2, who approved amount of Rs. 1,00,000/- vide cashless claim no. 14682312 on 13.06.2017. Thence request of OP3 to 80% of estimate of bill was enhanced only for Rs. 31,200/-. Thus, total advance authorised cashless facility was sanctioned for Rs. 1,31,200/-. On that basis complainant no. 2 was admitted in the hospital on 16.06.2017 and she was discharged on 17.06.2017 after medical treatment.
2.3: When complainant no. 2 was discharged from ICU, then complainant no. 1 approached the billing sanction window of OP3, it shocked the complaint no. 1 to know that advance cashless authorization of Rs. 1,31,200/- was cancelled and complainants were asked to pay total final medical bill of Rs. 2,04,000/- in respect of treatment of complainant no. 2. The complainants were helpless as all of sudden OP3 has raised demand of entire medical bills, OP3 was requested to accept the balance amount of Rs. 72,800/- after deducting the sanctioned amount of Rs. 1,31,200/-, however, OP3 refused it and insisted for full payment of the bills. Complainant no. 1 immediately requested OP2 on the phone to reconsider it, it agreed to consider the request but at 16:45 hour of 17.06.2017, it sent message on mobile phone of complainant no. 1, its text is "Enhancement request of INR 2,04,000/- has been denied. However, your cashless claim 14682312 stands authorized for INR 1,31,200/-.". When Complainant forwarded OP2's this SMS message to the OP3 and also show them, but they refused to consider it and insisted to make the entire payment of Rs. 2,04,000/-. The Complainants had no option but to call police for help and the official of Delhi Police also reached, the police also asked the OP3 to consider the SMS sent by OP2, but OP3 refused it. The Complainants were not having huge amount of Rs. 2,04,000/- with them in the hospital, they have to pay balance amount of Rs. 72,800/-. Then complainants contacted their relatives and friends; one of the relatives came forward and agreed to help. It was 08:00pm and full payment of Rs. 2,04,000/- was paid to OP3 through credit card. Whereas as per the policy, the complainants were not required to pay any amount to the hospital for treatment and all the expenses of hospital were to be met by the OPs. When complainants lodged their claim along with documents for reimbursement of amount but on 20.07.2017, their claim was denied by OP1 and OP2 on the ground of exclusion clause 4.7, which was mentioned as:-
"clause no.4.7 - Convalescence, general debility, “run down” condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injuries/ suicide, all psychiatric and psychosomatic disorders and diseases/ accident due to and/ or use, misuse or abuse of drugs/ alcohol or use of intoxicating substances or such abuse or addiction etc.”
2.4: The complainants were never disclosed about the exclusion clause nor they were explained or asked to sign any declaration when subject policy PNB Oriental Royal medi-claim policy was taken by them, otherwise it has been held by Hon'ble Supreme Court that when there is acceptance of premium without medical examination, the condition stands waived on acceptance of premium. The OP had no right to reject or repudiate the claim of complainants the Complainants were compelled to pay the medical bill demanded by OP3 despite Complainants were having insurance policy with facility of cashless upto Rs. 5,00,000/-. It was also the duty of OP1 and OP2 to inform the complainants in advance before hospitalization and admission of complainant no. 2 if the OP1 and OP2 were not willing to pay the sanctioned amount.
2.5: The complainants have not suppressed any material from the OPs, even doctors could not detect that complainant no. 2 is suffering from such disease, which is stated to be not covered under the insurance policy. However, by invoking the exclusion clause, without notice to complainants, is arbitrary and it is also against the principles of nature justice. There is deficiency in service on the part of OPs and they are guilty of unfair trade practice.
Moreover, there is also unfair trade practice by OP3 that when complainants had brought it to the knowledge of OP3 to correct the bill since the bill was paid by the complainants by borrowing the amount within a short period through credit card but the bill was prepared & issued as the payment were made by OP1 and OP2, even that correction in bill was not done by OP3, despite written letter dated 20.06.2017, which was also acknowledged by the OP3. They failed to honour their commitments under the insurance policy, there is deficiency in service apart from unfair trade practice and that is why the present complaint was filed. The treatment was got from OP3 and because of non-payment of claim amount by the OPs, Complainant no. 1 had undergone depression. complainant.
3.1 (Case of OP1) : The OP1 does not deny the fact of issue insurance policy to the Complainant, however, it denies the allegations of deficiency of services and of unfair trade practice alleged against OP1. The terms and conditions of insurance are binding on the parties. There is exclusion clause no. 4.7 and complainant no. 2 was known case of ASD on 21.04.2017, which was not disclosed by the complainants to the insurer. Therefore, there were justifiable reasons for invoking exclusion clause in terms of policy and on 16.06.2017, the complainant no. 2 also underwent the procedure of ASD device.
The PNB Oriental Royal medi-claim policy was available on very nominal premium to customers and staff of the PNB only, accordingly, policy schedule along with its terms and conditions and exclusions were issued to the insured. The reply also produces the contents of clause no.4.7 (already reproduced above). The claim lodged is wrong, false, exorbitant, excessive, imaginary, improper, arbitrary and baseless and the complaint has been filed to gain the sympathy of Hon'ble Commission. This Commission lacks jurisdiction to try and decide the Complaint. The complaint is liable to be dismissed.
3.3: (case of OP3): OP3 by way of its reply through its Additional Medical Superintendent, opposed the complaint that on plain reading of complaint there is no allegations against OP3 of deficiency in service in rendering the medical treatment or otherwise or unfair trade practice. The medial bills were raised as per norms and the patient has to pay the amount as per medical bills in lieu of services provided by the hospital since the OP1/ insurance company and OP2/ TPA were just instrumental in facilitating of information, the OP3 has no other role. The OP3 has been unnecessarily impleaded in the complaint. The complaint deserves dismissal.
However, there is no reply to the allegation mentioned in a part of paragraph 22 of the complaint that complainants had paid the bill amount through their known person by using the credit card ( after refusal of bills by OP1 & OP2) but the receipt was issued in the name of OPs despite it had not paid the amount and when request was made orally as well as in writing to do necessary correction, it was not done by OP3.
3.4:There was no reply or appearance of OP2 and OP4.
4. (Replications of complainant) : The complainants filed separate replications to the reply of OP1 as well as to the reply of OP3; the replications are replica of complaint. They denies the allegations mentioned in the replies. It is also supplemented that complainants had been obtaining insurance policy since 2011, which is more than 3 years and the complainants never informed about the exclusion clause no. 4.7 from commencing the policy from the year 2011 till date and no document has been produced by the OP1 to show that complainant will not be compensated due to clause 4.7. Further, doctors did not diagnose any symptoms of the disease initially. The hospital/OP3 started the treatment only after receipt of authorisation for treatment. The complaint is correct.
5. (Evidence) : Complainant no.1 M.S. Bedi filed his detailed affidavit in support of the complaint, its features are on the lines of complaint and documents annexed. Shri Deepak Mittal, Senior Divisional Manager, Divisional Office-29 of OP1 filed his affidavit of evidence, which is also reproduction of reply of OP1. Dr. Nikhil Tiwari, Additional Medical Superintendent of OP3 also filed his affidavit of evidence to oppose the claim of complainant as well as to explain other circumstances, as mentioned in the reply.
6. (Submission of Parties) : The complainants, OP1 and OP3 filed their written submissions. The complainant no.1 made oral submissions too for himself and for complainant no.2, Shri Bhupesh Chandna, Advocate for OP1 and Shri Rahul Sharma, Advocate for OP3 also made their submissions. The other OP2 and OP4 had not appeared nor they led the evidence nor made the submissions finally.
7.1 (Findings) : The contentions of both the sides are considered keeping in view the case of parties, the evidence led and the point raised during arguments. The contentions of both the sides are not being reproduced, the same will be referred appropriately while discussing the points on merits of the case.
7.2.: Although, issue of territorial jurisdiction was raised in the reply to complaint by the OP because of the issuing office of policy is 88, Janpath, New Delhi, having its head office and registered office at Asaf Ali Road, however, it was not pressed for when inquired during arguments. Thus, this contention disposed off as not pressed for.
7.3: There is no dispute that OP1 and OP4 had issued subject insurance policy, which was for the period from 27.04.2017 to 26.04.2018, it was for covering risk to the extent of Rs. 5,00,000/-, OP2 is TPA of OP1. This is renewed policy, which was renewed on 17.4.2017 against payment of premium of Rs.6,990/- to be effective from 27.04.2017 for a period of one year. It is also not disputed that complainant had been availing insurance policy from the year 2011 being 'PNB Oriental Royal Medi-claim Policy'. There is also no dispute that OP3 had treated the complainant no. 2, who remained indoor patient from 16.06.2017 to 17.06.2017.
It is also not disputed that there was final bill of Rs. 2,0,400/- and it was paid to the OP3 by the complainants vide transaction receipt (page 63) and advance payment receipt dated 17.06.2017 08:49 PM (page 64 to the complaint) of Rs. 2,00,400/- was issued by OP3 after receipt of amount by credit card. It is also not disputed that there was pre-authorisation sanctioned of Rs. 1,00,000/- on 13.06.2017, prior to admission of complainant no. 2 on 16.06.2017 in the hospital and then it was enhanced for Rs. 31,200/- and total sanctioned amount was Rs. 1,31,200/- being 80% of bill of Rs. 2,51,200/-. The complainants had to pay the bills amount themselves as the sanctioned was repudiated by OPs.
7.4: Other dispute emerging are of exclusion clause 4.7, unfair trade practice, and deficiency in services by the OPs. According to complainant, the complainant no. 2 was never known about the disease ASD since inception of taking the policy in the year 2011, the policy was being renewed from time to time and there was no claim lodged prior to the issue under consideration. Complainants were never informed of the exclusion clause being relied upon by OP1, it is just to deny the valid claim. The complainants had gone to hospital for routine check-up, it was advised test of TEE , then it could be known about the diagnose of disease. The complainant no.2 got those test done by depositing the charges. There was no question of suppression or concealment of any fact. Had it been the case of pre-existing disease, complainant no.2 would not have led that healthy life till time it was discovered, when she was taken to hospital for routine check-up. In fact, OP1 and OP4 have sold this type of Royal Medi-claim policy to millions of people, collected the premium and when stage for reimbursement comes for valid claims, the same are being avoided like in the present case. The complainants were never informed of this exclusion clause nor they have signed any declaration nor the policy issued mentions such exclusion clause. When complainant no. 1 had pointed out to OP3 about mentioning the name of OP1 and OP2 in the payment receipt in respect of amount deposited by the complainants, the officer/authority of OP3 had uttered that once a receipt has been issued, it will not be corrected under any circumstances.
Moreover, in United India Ins. Co. Ltd. vs Jai Prakash Tayal [2018 (247) DLT 379] it has been held by Hon'ble High Court of Delhi that exclusion of genetic disorder is discriminatory since right to health is a fundamental right and right to healthcare is also a fundament right, by excluding any particular category of individuals who are with genetic disorders, from obtaining health insurance or having their claims honored based on genetic disposition would be discriminatory and violative of citizens right to health. Further, reliance is also place on Srinivas vs SBI Life Ins. Co. Ltd and Ors. [2018 (2) Apex Court Judgment (SC) 81] that if underwriter is to accept the premium based on the medical examination and not otherwise, it was held that very fact they accepted the premium waived the condition precedent of medical examination.
Whereas, Ld. Counsel for OP1 has reservations to the claim of complainants, while referring complainant's record as well as terms and conditions of the policy. Firstly, the policy period was from 27.04.2017 to 26.04.2018 and as per complainants' own documents of 25.04.2017 on the letter head of OP3 and discharge summary that she was found known case of ASD, it means that complainants were knowing about the disease prior to commencement of policy on 27.04.2017. It was also known to complaint on 21.4.2017, which is also prior to effective date of policy from 27.4.2017. It is a material concealment of pre-existing disease and when there is suppression of such material fact, the claim is not tenable. (reliable is place on Bajaj Allianz Life Insurannce Co. Ltd. and others Vs Dalbir Kaur 2020 STPL 7535 SC; there was similar case of ASD disease dealt in Oriental Insurance Co. Ltd. vs Pankaj Jain 2011 STPL 17727 NC, which was not disclosed in the proposal form and claim was repudiated).
The terms and conditions of insurance policy are known to the complainants, complainant is an educated person and they can have easily access to the terms and conditions of the policy by writing to Insurer, meaning thereby they are aware of clause 4.7 of the policy. They cannot take the shelter of ignorance to the terms and conditions of the policy nor they can raise grievances in respect of exclusion clause of the policy, (reliance is placed on Sunita Bhalla vs United India Ins. Co. Ltd. 2020 STPL 7816 NCDRC and Kamlesh Gupta vs ICICI Lombard General Insurance Co. Ltd. 2017 STPL 1826 NCDRC that they can at least write letter to the insurer to have terms and conditions of the policy). Lastly, the terms and conditions of PNB Oriental Royal Medi-claim Policy (Annex. OP1/A) filed are referred by OP for the purposes of exclusion clause to show that claim was rightly repudiated by the OP1. The complaint is liable to be dismissed.
At this stage, complainant request that on the same very document of 25.04.2017, the doctor had advised tests inclusive of TEE, it was told to them the purpose of those tests and TEE test was to ascertain and diagnose the disease, without that test it was not possible to ascertain the disease, then how OP1 may allege that it was known case of ASD.
Ld. Counsel for OP3 also submitted that the role of OP3 is of hospital, the complainant was provided all medical treatment & facility required and all services were also given to her, there was no deficiency in the treatment or any unfair trade practice and for all these reasons, the OP3 is not liable on any count. The documentary record does not show any lapse on the part of OP3, while treating the complainant no. 2 as well as rendering the services.
The complainant made supplementary submissions that the policy was initially taken in the year 2011, it was being renewed regularly against payment of premium. The complainants have three children, all were born in their normal delivery to complainant no. 2 and had it been the case of pre-existing disease, she would not have led that healthy life till time it was discovered. Other-wise, plea of pre-existing disease is not tenable, since from the date of treatment, the policy was being taken for more than 3 years. The complainants' valid claim is being denied without any merits.
7.4A: It is apparent as to how the parties are making rival stand to each other. It was inquired from OP1, what is status of proposal forms, whether signed at each renewal or at the inception, it was explained that OP4 is custodian of record. However, as clarified that OP4 had not forwarded any proposal form to the OP1. It is known fact and practice that proposal forms are provided by the insurers or underwriters, which are signed by the aspirants of policy. This establish the plea of complainants that no declaration was got signed from them at the time renewal of policy nor any proposal form was provided to the complainant prior to renewal of policy.
Moreover, the complainants got renewed their policy on 13.4.2017 against payment of premium, which was effective from 27.4.2017, therefore, OP1's contention is not tenable that it was known case of ASD on 25.4.2017 or 21.4.017 or it was concealed by the complainant. In the letter head of 25.4.2017, while writing advices/tests and prescription that there is complaint of ASD. Further, there is no record proved by OPs that complainant no.2 was detected of ASD one year back, rather it was observed by the doctor in discharged summary that it is case having history of ASD. Thus, to that extent, the complainants have established their case that there was no concealment of disease.
7.5: There is much emphasis by OP1 on the terms and condition of insurance policy, particularly exclusion clause no.4.7 (already reproduced in paragraph no.2.3 above). It is claimed that terms and conditions would have been provided by OP4 to the complainants. Otherwise complainant is educated person, they would have been knowing the terms of policy, there is no excuse from ignorance of law. OP1 has fortified its contentions while relying upon the case law. Whereas, complainants have juxtaposition stand that they were never informed of terms and condition of policy or exclusion clause at any point of time; it was invoked to deny the claim even after sanction of amount. Complainants also rely upon the case law that for genetic disorders, which were not known, the claim cannot be denied.
7.5A: This dispute needs discussion. First of all, 'ignorance of law is no excuse' is different from 'ignorance of terms and conditions of policy', former is principle that law enacted by the legislature is for all and was made known to all, whereas the later being insurance policy is 'agreement or contract between the parties' and its terms & conditions are to be specified and recorded so that parties may knew them for compliance. To elucidate it, 'ignorance of law is no excuse' is based on the maxim 'ignorantia juris non-excusat' being of presumption that every subject is aware of law and cannot claim ignorance of law as defence to escape liability. In common parlance, law means, the law enacted by the legislature. It could be statutory, customary, moral or ethical etc and by looking from the situation in hand terms and conditions of insurance policy cannot stand on the same footing as the law, while the terms and conditions of the insurance policy is neither sustentative law nor procedural law, rather it arises out of the contract/agreement between the parties and such terms of contract confines only to such parties to the contract, whereas law applies to all subjects intended in the legislation. Thus, OP1's invoking the principle of 'ignorance of law is no excuse' to the 'insurance cover' is misplaced. The OP4 abstained from proceedings to establish that terms and conditions were given to the complainant when policy was handed-over or posted.
7.5B: The complainants have filed original insurance policies, the last policy is of 27.4.2017 to 26.4.2018 [3 pages] and similarly the OP1 has also filed insurance policy with book-let of terms and conditions of policy [ Annex. OP1/A, pages 1-13]. The policy issued to complainants, does not depict/contain any such terms and condition of policy nor that book-let of terms and condition is part of policy nor any exclusion clause(s) are mentioned on the policy nor clause no.4.7 nor any indication/endorsement that there exists exclusion clause(s). Policy mentions that there is a web-site, which may be visited. It was emphasized that complainant no.1 is educated person and he may obtain terms and conditions of policy, however, it would not fulfill vacuum in contract entered, like to issue insurance policy first and remaining things are to be ascertained by visiting the web-site. The terms and conditions are settled, then policy contract happens, generally mode is proposal form and its acceptance with insurance premium. Since, it is first time that OP1 is taking plea that complainant no.1 is educated person, which was not core aspect when policy was started and taken by him in 2011. Moreover, policy cover is printed under heading 'PNB Royal Medi-claim Policy' apart from general unilateral conditions printed of name of TPA (by rubber stamp) [i.e. OP2] that other things are to be ascertained by visiting the web-site, which also communicates that complainants were actually not supplied with the terms and conditions of policy nor of exclusion clause or book-let of terms and conditions relied upon. What prevented OP1 & OP4 from furnishing such terms & conditions in policy itself or with the policy issued? There is no reason or explanation appended to policy nor any answer for it? So far OP4 is concerned, it abstained from the proceedings.
In fact, as appearing the unilateral policy cover is meant for all - whether literate or illiterate, what will happens to those beneficiary of policy, who had obtained the policy but they are illiterate or no tools or knowledge to access web site? In Manmohan Nanda Vs United- India Assurance Co. [Civil Appeal no. 8386/2013) decided on 6.12.2021 by Hon'ble Supreme Court of India has also dealt the regulations 'the IRDA (Protection of Policyholder' Interests) Regulations 2002' and it was held (in paragraph 34 thereof) "that just as insured has a duty to disclose all material facts, the insurer must also inform the insured about the terms and conditions of policy that is going to be issued to him and must strictly confirm to the statement in the proposal form or prospectus or those made through its agents. Thus, principle of utmost good faith imposes meaningful reciprocal duties owned by the insured to the insurer and vice-versa". Therefore, the complainant has established that they were not made aware by OP1 & OP4 about the terms and condition of policy or of exclusion clause no.4.7 at any point of time either at the inception of first insurance policy cover in 2011 or at any subsequent stage till subject renewed policy of 2017-18. It is also deficiency of service as well as unfair trade practice on the part of OP1 and OP4 by not providing complete insurance policy. The complainant cannot be bound for what they were not made agreed upon.
7.5C: Since, the case of complainant no.2 was discovered to be case of ASD. It was pleaded and also not disputed that it comes in genetic disorder, however, OP1 has reservation on exclusion clause. But it would not help the OP1 in view of law laid down in United India Ins. Co. Ltd. vs Jai Prakash Tayal [supra] 'that exclusion of genetic disorder is discriminatory since right to health is a fundamental right and right to healthcare is also a fundament right, by excluding any particular category of individuals who are with genetic disorders, from obtaining health insurance or having their claims honored based on genetic disposition would be discriminatory and violate of citizens right to health'. Moreover, law declared in "Srinivas vs SBI Life Ins. Co. Ltd and Ors. [2018 (2) Apex Court Judgment (SC) 81] that if underwriter is to accept the premium based on the medical examination and not otherwise, it was held that very fact they accepted the premium, it waived the condition precedent of medical examination".
7.5D: So far medical treatment & medical services given by OP3 is concerned, there are no such allegations by the complainants against OP3 and it is held accordingly.
7.6: Therefore, the complainants have established their case of deficiency of services and of unfair trade practice against OP1,OP2 and OP4 for refund of Rs. 2,06,507/- (being Rs. 2,00,400/- as hospitalization charges + Rs. 5,590/- as TEE test + Rs. 517/- as cost of medicine) as the amount of treatment paid by the complainant, which is within the limits of sum insured of Rs.5,00,000/-. They are held liable pay the amount jointly and severally.
8.1: Now issue of damage is taken. The matrix of plea of parties have already been referred in paragraphs no.2, 3 and 4 above. The complainant no. 2 was admitted in hospital on 16.6.2017 after pre-admission sanction on 13.6.017 for Rs.1,00,000/- and then it was enhanced further by Rs.31,200/- being 80% estimate bill, however, later the complainant was asked to deposit the entire amount of medical bills. The complainant no.1 had moved pillar to post to convince OP1,OP2 and OP3 for payment of entire medical bills or accept balance medical bills after adjustment of sanctioned amount but it did not yield result. When complainant arranged to make payment at night hours by credit card, the receipt was issued by OP3 as if payments were made by OP2, despite OP2 was not credit card holder. When OP3 was requested to rectify the error, it was refused that once the receipt was issued, it will not be corrected. Whereas it is same OP3, who had received pre-admission sanction of Rs.1,00,000/- and later-on another sanction of Rs.31,200/- from OP2 but accepted repudiation by OP2. If OP3 can consider review of OP2, then why OP3 refused to entertain its own mistake to rectify the billing, which was done wrongly in name of OP2 in place of complainant, despite it was requested and protested in writing. The omission and commission of OP3 is perpetuating that payment was made by OP2 as receipt issued is in favour of OP2. There may be human error but not rectifying that error despite knowing it and bringing it to knowledge, it does not remain an error but unfair trade practice & deficiency in services on the part of OP3; the OP3 cannot escape from that liability.
8.2.1: This clearly shows what trauma was actually faced by the complainants from the stage the sanction was repudiated, when .complainant no.2 was indoor patient, she was not discharged in time as payment was arranged after refusal of cashless facility. It was further followed by other inconveniences & stress too to seek reimbursement from OP1,OP2 & OP4. To that extend, OP1, OP2 and OP4 has to pay compensation of Rs.25,000/-jointly and severally to the complainants.
8.2.2. So far OP3 is concerned, it has also to separately compensate the complainants for said harassment, stress & difficulties, the amount of damages is quantified as Rs.15,000/-against the OP3 and in favour of complainant.
8.2.3: The complainants also deserves litigation expenses, the same are quantified as Rs.10,000/- in favour of complainant and against OP1, OP2 and OP4.
8.2.4 Since the complainants were deprived of cashless facility, they were constrained to pay the medical bills, thus it is appropriate to allow simple interest @ 6% p.a from the date of complaint till realization of amount in favor of complainants and against the OP1, OP2 and OP4.
9.1: In view of the findings drawn in paragraph 7 & 8, above, the complaint is allowed in favor of complainants and against the OP1, OP2 and OP4 while directing them to pay jointly and severally a sum of Rs. 2,06,507/- alongwith simple interest @ 6% p.a from the date of complaint till realization of the amount, apart from Rs. 35,000/-( being damages of Rs.25,000/- and cost of Rs.10,000/-).
The OP1,OP2 and OP4 shall pay the amount within 30 days from the date of receipt of copy of this Order. In case, the complainant is still maintaining bank account with PNB Branch, as policies were meant for account holder, then amount may be deposited in that bank account with information to the Complainant & to this Commission in writing about the amount deposited and date of deposit.
9.2: Similarly, in view of the findings drawn in paragraph 7 & 8, above, the complaint is allowed in favor of complainants and against the OP3 , by quantifying the damages as Rs.15,000/- while directing the OP3 to pay this amount within 30 days from the date of receipt of copy of this order.
9.3: Copy of this sent/provided forthwith to the parties free of copy as per Regulations.
10: Announced on this 9th day of January 2023 [ पौष 19, साका 1944].
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
