IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 27th day of September, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 126/2019 (filed on 29-07-2019)
Petitioner : Tony Punnoose,
Panamkuzhakal House,,
Vakkad P.O. Monippally,
Kottayam.
(Adv. Denny Jose Mathew)
Vs.
Opposite Party : Oriental Insurance Company Ltd.
Rep. by Divisional Manger,
TRIO Chambers, Kanjikuzhy,
Kottayam.
(Adv. Agi Jospeh)
O R D E R
Sri. Manulal V.S. President
The case is filed under Section 12 of the Consumer Protection Act, 1986.
Crux of the complaint is as follows:
Complainant had subscribed the policy 44240/48/2019/1186 for himself and his family from the opposite party. The opposite party issued photo identity cards to each family member for cash less claim in hospitals and charged 7% extra premium for the same. Kurain Punose the father of the complainant was hospitalized in Matha hospital from 21-2-2019 to 22-2-2019 for adhesive obstruction and transferred to Rajagiri hospital Ernakulam, treated there from 22-2-2019 to 27-2-2019. In both hospitals, at the time of discharge the opposite party had not paid any amount as per their assurance. In Matha hospital the bill amount was Rs.22,151/- and Rajagiri hospital the bill amount was Rs.91,113/-. The complainant had waited till 7.pm on the date of discharge from Rajagiri hospital to get the cashless facility payment by using the identity card issued by the opposite party. But the opposite party had not paid the money so that the complainant had to issue cheque to the hospital to get his father discharged. After that the complainant had applied for reimbursement of the hospital bills. The opposite party had asked several documents and those were submitted to them. The opposite party had paid only Rs.10,156/- against the claim amount of Rs.22,151/-. The opposite party in several occasions informed the complainant that the claim for Rs.91,113/- had processed and the amount would be credited within two three days. But the bill amount was not credited to the account of the complainant. Though the lawyers notice issued by the complainant was received by the opposite party on 26-6-2019 the opposite party had not performed anything to redress the grievances of the complainant. It is averred in the complaint that at the time of purchase of the policy the company informed the complainant that he would get any hospital expenses and there was no written format except the receipt was issued. But thereafter when contacted the office of the Divisional Manager of the opposite party it is informed that they would indemnify only for medicine and medical tests and will not indemnify the nursing charge , room rent and other hospital expenses. According to the complainant the act of the opposite party amounts to unfair trade practice and deficiency in service. Hence this complaint is filed by the complainant praying for an order to direct the opposite party to pay Rs.3,83,648 on various heads. Upon notice opposite party appeared before the commission and filed version as follows:
The opposite party has not charged 7% extra premium as alleged in the complaint. The complainant claimed Rs.17,935/- as Mediclaim for the treatment of Kurian Punnoose at Matha hospital, Thellakom for the period of 21-2-2019 to 22-2-2019. Out of this the opposite party is liable to pay Rs.10,156/- and the said amount was paid as per the terms and conditions of the policy. The complainant has not claimed Rs.22,151/- as alleged in the complaint. The complainant has also claimed Rs.91,113/- for the treatment of Kurian Punnoose at Rajagiri hospital, for the period 22-2-2019 to 27-2-2019. Out of this opposite party has paid Rs.47,669/- as per the terms and conditions of the policy.
The liability of the insurance company is only as per the terms and conditions of the policy. The details of the reduction and its reasons are stated in the claim payment statement and the terms and conditions of the policy are produced along with the version. At the time of issuance of the policy opposite party has issued the policy, schedule and terms and conditions of the policy. There is no deficiency in service on the part of the opposite party.
Complainant filed proof affidavit in lieu of chief examination and exhibit A1 to A7 were marked. One M.G.Sajan who is the divisional manager of the opposite party filed proof affidavit and exhibits B1 to B3 were marked from the side of the opposite party.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
- Whether the complainant had succeeded to prove any deficiency in service or unfair trade practice on the part of the opposite party?
- If so, what are the reliefs and costs?
Point number 1 and 2
Before dealing with the rival submissions and contentions advanced by the learned advocate appearing for complainant as well as opposite parties, it will be pertinent to point out certain undisputed facts. There is no dispute that the complainant had taken the policy 44240/48/2019/1186 for himself and his family
from the opposite party and it would expire on 18-11-2019. There is also no dispute that Kurian Punnoose who is the father of the complainant is an insured in the said policy and he was hospitalised in Matha hospital from 21-2-2019 to 22-2-2019 for adhesive intestinal obstruction and thereafter hospitalised in Rajagiri hospital Ernakulam and treated there from 22-2-2019 to 27-2-2019.
The specific case of the complainant is that out of Rs.22,151/- which is the bill amount from the Matha hospital the opposite party reimbursed only Rs.10,156/- and the opposite party had not paid any amount against the bill amount of Rs.91,113/- of Rajagiri hospital. The opposite party denied the cashless facility also to the complainant. Exhibit A1 is the copy of the happy Family floater 2015 silver plan policy. On perusal of exhibit A1 we can see that the insured amount is Rs. 1,00,000/- for each person.
Complaint is resisted by the opposite party on the ground that the liability of the insurance company is only as per the terms and conditions of the policy and opposite party had paid all the admissible claim in accordance with the policy terms and conditions.
On perusal of Exhibit A1 we can see that the insured person has the obligation to pay 10% of claim amount as co –payment. Co-pay (co-payment) in health insurance is the percentage of the claim amount that the policyholder has to pay from their own pocket under a health insurance policy. The rest of the amount is paid by the health insurance company.
Clause 1.2 of exhibit B3 terms and conditions of the policy defines the coverage under the policy as follows:
1.2 COVERAGE –
The benefits under this Policy are available under three plans, viz Silver, Gold & Diamond as opted by the Insured in the proposal form.
The Policy covers reasonable and customary charges in respect of Hospitalization and / or Domiciliary Hospitalization for medically necessary treatment only for Illnesses / diseases contracted / suffered or Injury sustained by the Insured Person(s) during the Policy Period, up to the limit of Sum Insured, as detailed below:
Clauses 1.2A for silver plan thereof are significant and are laid down as under: -
i Room, boarding and nursing expenses as provided by the Hospital/Nursing Home not exceeding 1.0% of the sum insured per day.
ii. Intensive Care Unit (ICU)/ Intensive Cardiac Care Unit (ICCU) expenses 2.0% of the sum insured per day.
iii Surgeon, Anaesthetist, Medical Practitioner, Consultant’s Specialist fees are as per the limits of the sum assured.
Number of days of stay under i and ii above should not exceed total number of days of admission in the hospital. All related expenses (including iii and iv) below shall also be payable as per the entitled room category based on the room rent limit as mentioned above. This will not apply on medicines /pharmaceuticals and body implants. iv Anaesthesia, Blood, Oxygen, Operation Theatre Charges,
Surgical Appliances, Medicines & Drugs, Dialysis, diagnostic Material and X-Ray, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Pacemaker, and similar expenses, as per the limits of the sum assured.
v. ambulance service charges per illness Rs.1000/- maximum ii. Per policy period 1% of the sum insured, subject to a maximum Rs.3,000/-.
vi. Pre and post hospitalization medical expenses incurred 30 days prior to hospitalization and up to 60 days post hospitalization.
The above-referred charges are legally admissible and reimbursable under the policy. As per clause 1.2.A i, room, boarding and nursing expenses as provided by the hospital/nursing home, not exceeding 1.0% of the sum insured per day. Admittedly the complainant was admitted in Rajagiri hospital from 22-2-2019 to 27-2-2019. On perusal of exhibit B4 claim payment statement we can see that out of these 7 days one day he was admitted in the ICU and the opposite party had made payment of Rs.2000/-as ICU charges as per policy. Thus, the opposite party is bound to pay Rs.1000/- per day for room rents and nursing charges for remaining 5 days. On a scrutiny of exhibit B4 we can see that the total claim amount towards the rom rent and nursing charges was Rs.10,900/- out of which the complainant is entitled only for an amount of Rs.5,000/- as per policy. Instead of deducting 5090 from 10900 the opposite party had deducted Rs.6,090/. This excess deduction will reflect in processing the other claimed amount. On close scrutiny of Exhibit B4 we can see that the opposite party had deducted 68.8
% of the all the claim amounts except the expenses for medicine and pharmaceuticals. However, the opposite party is entitled to deduct only 45.87%(5,000/10900x100) from the bill amount as per clause 1.2 A of policy terms and conditions.
Clause iii of 1.2A of Ex.3 lays down that Surgeon, Anaesthetist, Medical Practitioner, Consultants; Specialist fees are reimbursable. As per Clause iv of clause 1.2A charges for Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines Drugs, Dialysis, diagnostic Material and X-Ray, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Pacemaker, and similar expenses, are admissible. Consequently, deduction of amount of Rs.250 for oxygen charges/- and Rs.550/- for blood grouping and cross matching is not legally permissible. Consequently, we find the amount of Rs.250 and Rs.550 have been wrongly deducted by opposite party from the admissible amounts payable to the complainant.
Now the point is with regard to deduction of amount in claim for investigation, professional fees, procedures/treatments, and professional fees. On a close scrutiny of the calculation sheet which is attached to Exhibit B4 we can see that the opposite party deducted 68.8% from an amount of Rs.4,415/- whereas they are entitled to deduct only Rs.2,022/- i.e., 45.8% of Rs.4,415/-. Thus there is an excess deduction of Rs.2393 from the investigation charges towards bill no. RHIC78228-6. Similarly, from the bill no. RHIC78228-7 there is excess deduction of Rs.69.
From the professional fees opposite party is entitled for deducting only Rs.13,602(29,700x45.8/100). However, the opposite party had made a deduction of Rs.20434/-. Thus there is an excess deduction of Rs.6,832/-. From the bill for procedures /treatments the opposite party had made a deduction of Rs.619 than Rs.297/-. There is also an excess deduction of Rs.322/- by the opposite party. Similarly, from bill no RHIC78228 the opposite party had made a deduction of Rs.1,342 instead of Rs.893/- which is the amount opposite party can deduct from the total bill amount of Rs. 1950. Thus the opposite party wrongly made deduction of an amount of Rs.11,309/- than the amount for which they are entitled to deduct as per the clause 1.2.A of exhibit B3 terms and conditions of the policy. This amounts to imperfection and inadequacy in service assured by the opposite party and amounts to deficiency in service.
On perusal of exhibit A2 identity cards we can see that there is an endorsement that the cashless hospitalization in network hospital can be in conjunction with this card. The opposite party has no case that Rajagiri hospital is not included in their network hospital. The opposite party did not give any explanation for the denial of cashless facility to the complainant. The denial of the cashless policy against the assurance given by the opposite party amounts to deficiency in service. No doubt, said act caused much mental agony and hardship to the complainant for which the opposite party is liable to compensate.
In the light of above discussed evidence and considering the nature and circumstances of the case we allow this complaint and pass the order as follows:
- We hereby direct the opposite party to pay Rs.11,309 i.e., the amount which the opposite party deducted from the bill amount of Rajagiri Hospital with 9% interest from 27-2-2019 till realization.
- We hereby direct the opposite party to pay Rs. 20,000 to the complainant as compensation for deficiency in service and unfair trade practice on the part of the opposite party.
Order shall be complied within 30 days from the date of receipt of Order. If not complied as directed, the compensation amount will carry 9% interest from the date of Order till realziaiton.
Pronounced in the Open Commission on this the 27th day of September, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Policy document issued by opposite party
A2 – Photocopies of premium card issued by opposite party (3 nos.)
A3 – Copy of e-mail dtd.29-05-2019 by opposite party
A4 –Copy of e-mail dtd.31-05-19 by opposite party
A5- Copy of lawyers notice dtd.25-06-19 to opposite party
A6 – Postal receipt
A7 – Postal AD card
Exhibits marked from the side of opposite party
B1 – Copy of claims payment statement – Deduction payment claim
B2 - Copy of policy No.442400/48/2019/1186
B3 – Copy of Happy Family Floater Policy – 2015 – Prospectus issued by
opposite party
B4 – Copy of claims payment statement – reconsideration claim
By Order
Assistant Registrar
