Chandigarh

DF-I

CC/352/2023

JAGMOHAN SINGH MANN SON OF KARTAR SINGH - Complainant(s)

Versus

THE ORIENTAL INSURANCE COMPANY LIMITED THROUGH ITS MANAGING DIRECTOR/DIRECTOR/GENERAL MANAGER/MANAGE - Opp.Party(s)

VIKRAM TANDON

01 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/352/2023
Date of Institution	:	25/07/2023
Date of Decision	:	01/08/2024

Jagmohan Singh Mann son of Kartar Singh, resident of House No. 954, Phase IV, SAS Nagar, Mohali 160059.

… Complainant

V E R S U S

1.     The Oriental Insurance Company Limited, Head Office, Plate-A, Office Block-4, NBCC Complex, Kidwai Nagar East, New Delhi-110023 through its Managing Director/Director/General Manager/Manager/Authorised Representative.

2.     Raksha Health Insurance TPA Pvt. Ltd., SCO No.39, 1^st Floor, Sector 26, Madhya Marg, Chandigarh-160019 through Regional Head Dr. Aman.

3.     The Oriental Insurance Company Limited, Regional Office, SCO No.109-111, Surendara Building, Sector 17-D, Chandigarh-160017.

4.     The Oriental Insurance Company Limited, Branch Office SCO No.325, IInd Floor, Sector 9, Panchkula through its Branch Manager/ Authorised Representative.

… Opposite Parties

5.     M/s Berkeley Insurance Brokers Ltd., Plot No.24, 6^th Floor, Industrial Area Phase-1, Chandigarh through its Manager/ Authorised Representative

… Proforma OP

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Gaurav Bhardwaj, Advocate for complainant
	:	Sh.Atul Goyal,  Advocate for OPs No.1, 3 & 4.
	:	OPs 2 & 5 already ex-parte.

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Jagmohan Singh Mann, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant had obtained a cashless health insurance policy namely “Happy Family Floater-2015” (hereinafter referred to as “subject policy”) from the insurers/OPs 1, 3 & 4 for himself and his wife, Smt. Amrit Kaur Mann on payment of premium of ₹41,315/-, which was valid w.e.f. 13.12.2021 to 12.12.2022 (Annexure C-1) with basic sum insured of ₹6,00,000/-.  In the month of November 2022, complainant was admitted in the Paras Hospitals, Panchkula (hereinafter referred to as “Treating Hospital”) for unstable angina, DM Type 2 and Essential HTN and accordingly Coronary Artery Angiography (CAG) was performed which revealed Tripple Vessel Disease (LM-TVD).  Thereafter Optical Coherence Tomography (OCT) was performed which revealed calcific nodule at left main bifurcation which required IVL (Intravascular lithotripsy) for lesion preparation prior to stenting. On 21.11.2022, complainant went under PTCA and stent to LM to LAD and LCx with IVL support under OCT guidance and he was discharged on 23.11.2022 as per discharge summary (Annexure C-2). The Treating Hospital had raised bill of ₹7,56,612/- (Annexure C-3).  On this, OP-2 issued letter for cashless authorization dated 23.11.2022 (Annexure C-4) for ₹1,82,168/- only and rest of the amount of ₹5,59,444/- was paid by the complainant from his own pocket vide receipt (Annexure C-5). Thereafter complainant approached the OPs and sent claim form (Annexure C-6) upon which vide letter dated 28.12.2022 (Annexure C-7), OP-2 further sanctioned an amount of ₹88,000/- towards full and final settlement of claim and the balance amount of ₹4,71,444/- was still unpaid.  The complainant again approached the OPs through letter dated 3.2.2023 (Annexure C-8/8A) with the request to pay the balance amount and the OPs in response had specifically mentioned that it seems that the complainant had been overcharged by the network hospital i.e. Paras Hospitals and, therefore, he should approach RO office for his grievance.  Not only this, even in the authorization letter (Annexure C-4), OP-2 had specifically mentioned in paras 3 and 5 that the network provider cannot overcharge the policy holder and in case overcharged, then the said amount should be got refunded to the policy holder by the insurer.  In this manner, the aforesaid act of OPs in only partially settling the claim of complainant amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs 1, 3 & 4 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action, locus standi, concealment of facts and also that the present consumer complaint is an abuse of process of law. However, it is admitted that the answering OPs had issued the subject policy to the complainant.  It has been alleged that the claim of the complainant has been settled in full and final as per the terms and conditions of the subject policy on making payment to the complainant.  It is further alleged that the answering OPs are not liable to reimburse any further amount to the complainant as his claim has already been settled.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OPs 2 & 5 did not turn up before this Commission, despite proper service, hence they were proceeded against ex-parte vide order dated 19.9.2023.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the contesting parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the contesting parties that the complainant had obtained the subject policy from the contesting OPs which was valid w.e.f. 13.12.2021 to 12.12.2022 with basic sum insured of ₹6,00,000/- and the complainant was diagnosed  with Unstable Angina, CAD-LM-TVD, DM type 2, essential hypertension etc. for which he had taken treatment from the Treating Hospital where he was admitted on  21.11.2022 and was discharged on 23.11.2022, as is also evident from the discharge summary (Annexure C-2)  and the Treating Hospital had raised bill of ₹7,56,612/-, as is also evident from the In-patient bill (details) (Annexure C-3) and initially the contesting OPs/insurer had allowed cashless facility to the tune of ₹1,82,168/- only and later on had also paid an amount of ₹88,000/- by revising the claim of the complainant vide claim settlement voucher dated 28.12.2022 (Annexure C-7), being full and final, and in this manner had paid total amount of ₹2,70,168/- only out of the claimed amount of ₹7,56,612/-, the case is reduced to a narrow compass as it is to be determined if the contesting OPs/insurers are unjustified in not settling the entire claim of the complainant and the same amounts to deficiency in service and unfair trade practice on their part, and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the contesting OPs/insurers are justified in partially allowing the claim of complainant and the instant consumer complaint, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the documentary evidence placed on record by them and the same is required to be scanned carefully to determine the real controversy between the parties.
   3. Perusal of the cashless authorization letter dated 23.11.2022 (Annexure C-4) clearly indicates that OP-2 had intimated the complainant by giving reference of the terms and conditions of the authorization under Para 3 & 5 that in case the network provider i.e. the Treating Hospital charged excess than the agreed package rates, the authorised TPA and Insurance Company reserves the right to recover the same or get the same refunded to the policy holder from the network provider. Para 3 & 5 ibid are reproduced below for ready reference :-

"3. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates except costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility choosing separate line of treatment which is not envisaged/considered in package).

5. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates, the authorized TPA/Insurance Company reserves the right to recover the same or get the same refunded to the policyholder from the Network Provider and/or take necessary action, as provided under the MOU."

4. As it is an admitted case of the parties that the Treating Hospital had charged an amount of ₹7,56,612/- and as per the defence of the contesting OPs/insurers they have settled the claim of the complainant as per the terms & conditions of the subject policy and had paid total amount of ₹2,70,168/- to the complainant, which fact has also not been disputed by the complainant, contesting OPs/insurers are bound to first pay the excess amount paid by the complainant to the Treating Hospital towards the settlement of his claim with right to recover the same from the Treating Hospital/ Network provider as provided under the MOU.  Hence, it is unsafe to hold that contesting OPs/ insurers were justified in only partially allowing the claim of the complainant and the present consumer complaint deserves to succeed. 
5. Now coming to the quantum of amount to be awarded in the instant case, since the sum insured under the subject policy is ₹6,00,000/-, it is clear that the contesting OPs/insurers are not liable to pay anything in excess of the aforesaid amount and further when it has come on record that an amount of ₹2,70,168/- has already been paid to the complainant towards partial settlement of his claim, therefore, contesting OPs are liable to pay the balance amount of ₹6,00,000 – 2,70,168 = ₹3,29,832/- alongwith interest and compensation etc. for the harassment caused to the complainant. It is, however, made clear that the contesting OPs/insurers shall be at liberty to recover the alleged excess amount from the Treating Hospital, at their own, and the complainant shall have no right, whatsoever, over the same. 

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1, 3 & 4/insurers are directed as under :-

1. to pay ₹3,29,832/- to the complainant alongwith interest @ 9% per annum (simple) from the date of claim settlement voucher i.e. 28.12.2022 onwards.
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the aforesaid contesting OPs/insurers, jointly and severally, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Since no deficiency in service or unfair trade practice has been proved against OPs 2 & 5, the consumer complaint against them stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

01/08/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member