The titled complainant, aggrieved at the non-payment of her hospitalization-claim, in full, for replacement of her knee-joints, has filed the present complaint. The OP insurers through the OP4 Govt. Health Deptt. (tie-up joint venture partners) had issued the family-health med-claim policy with a Sum Insured (S.I.) of Rs 3.0 Lac, to all its Govt. Employees/ Retirees under the cash-less medical treatment at all its designated hospitals, in the state. The complainant being a retired JBT Teacher was also covered under the above health scheme and she got both her knee-joints replaced at the Max Hospital, Mohali who had billed her treatment @ Rs.382,704/- out of which the OP insurers reimbursed Rs.148,624/- only, instead of the sum-assured limit @ Rs.3.0 Lac.
- The complainant paid the balance amount of hospitalization Bill amounting to Rs.231,552/- from her pocket and filed her insurance-claim for balance eligible amount of Rs.151,376/- with the OP Insurers that was arbitrarily repudiated by them (as alleged) hence prompted the present complaint seeking refund of the repudiated amount of Rs.151,376/- along with interest besides the cost of litigation @ Rs.10,000/- and compensation @ Rs.15,000/-. And, to support the above pleadings and also the contents of their present complaint, the complainant has produced the following documents, in evidence.
i) Ex.C1 the Affidavit;
ii) Ex.C2 the Health Insurance Scheme (PGEPHIS) Photo ID Card;
iii) Ex.C3 the Courier Receipt evidencing dispatch of the claim to the TPA ;
iv) Ex.C4 the Hospital IPD Bill (30.12.2016) For Rs.382,704/-Policy Risk Details;
v) Ex.C5 the Settlement Receipt exhibiting Rs.198,148/- paid by the insurer to another insured Smt. Saroj Bala for the same treatment.
3. The titled opposite parties, in response to the commission’s summons appeared through their respective counsels and filed their respective written reply stating therein preliminary as well as other objections, on merits as:
By OP1 to OP3 the Insurers:
i) No cause of action arises in favor of the complainant as the OP insurers have paid under the applicable tender rates in terms of the policy applicable under the Govt. Scheme PGEHIS.
ii) As no contract exists between the insurer and the insured so there has been no contractual liability as no payments have been paid by the insured.
iii) The contractual liability, if any, exists towards the Punjab Govt., only.
On merits:
iv) The OP insurers have denied all the contents/ allegations as put-forth in the complaint and has further stated that the hospitalization claim has been rightly appropriated by its TPA (Third Party Administrator) in terms of the terms of the applicable policy that allows payments on tender rates, only.
v) Lastly, the OP insurers have sought dismissal of the present complaint with costs and have also produced the following two documents in support of its defense:
i) Ex.OP1,2,3/A Affidavit deposing contents of written statement;
ii) Ex.OP1,2,3/1 Payment Details of Rs.148,624/- by PGEPHIS;
By the OP4 Civil Surgeon Gurdaspur:
vi) The OP4 has preliminarily objected that the complainant had not hired any medical/ health/ insurance services from them but from the OP insurers so they alone are liable to pay the treatment bills etc and that too in terms of the applicable policy.
Vii) Further, on merits, the OP4 in its written statement have either denied or have shrugged off the contents/ allegations of the complaint addressing these as matters of records, only;
viii) Finally, the OP4 has prayed dismissal of the complaint with costs being bereft of any merit. The OP4 in support of its version as well as defense has put for its Notification of 20th October' 2015 pertaining to the PGEPHIS Scheme;
4. We have examined the available documents/ evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ of the hospitalization-claim pertaining to the Policy in question, by the OP insurers.
5. We observe that the OP Insurers as well as the TPA facilitator have both admitted that the hospitalization bills were sanctioned as per the tender rates in terms of the policy but they have neither produced the tender rates nor the terms of the policy. Thus, the OP insurers have failed to prove that the hospitalization claim was sanctioned in terms of the tender rates and in terms of the policy. Moreover, the Ex.C5 proves that different rates were applied to different claims for the same and similar treatments in an arbitrary manner. We find it to be a glaring instance of ‘unfair trade practice’ on the OP insurers' part amounting to ‘deficiency in service’. Neither, the complainant was provided with the tender rates and the terms of the related policy nor these were produced during the proceedings.
6. Thus, the OP insurers have failed to produce on record some cogent evidence, to its prime assertion of tender rates in terms of the policy. The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial review and thus need be determined with due application of mind and not in an arbitrary manner and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law.
7. Finally, reverting to the matter pertaining to the present complaint and in the light of the all above, we set aside the OP insurers' impugned repudiation of the complainants’ hospitalization-claim being arbitrary (and in contravention to laws of natural justice) and amounting to ‘unfair trade practice cum deficiency in service’. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ to the tune of full sum assured of Rs.3.0 Lac along with other accrued benefits, if any, pertaining to the related policy with interest @ 6% PA w e from the date of filing of the present complaint besides Rs.10,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract additional interest @ 3 % PA form the date of the orders till actually paid.
8. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
9. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (R.S.Sukhija)
MAY 26, 2022. Member.
YP.
