Chandigarh

DF-I

CC/728/2019

Ms. Garima Batra - Complainant(s)

Versus

The SBI General Insurance Co. Ltd. - Opp.Party(s)

Sudhir Gupta

07 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

Consumer Complaint No.	:	CC/728/2019
Date of Institution	:	19/07/2019
Date of Decision	:	07/10/2022

 

Ms. Garima Batra daughter of Sh. Y.P. Batra, resident of House No.85, Palika Vihar, Ambala City-134103 (Haryana).

… Complainant(s)

V E R S U S

1. The SBI General Insurance Company Limited, 1^st & 2^nd Floor, SCO 335-336, Sector 35-B, Chandigarh-160022 through its Branch Manager.
2. M/s Paramount Healthcare Services (TPA) Pvt. Ltd., Plot No.A-442, Road No.28, MIDC, Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukmani Mandir, Thane (West)-400604, Maharashtra, to be served through its authorized signatory.

Local Address :

M/s Paramount Healthcare Service (TPA) Pvt. Ltd., Site 1 & 2, Sector 69, Near Gurudwara Singh Saheedan, Sahibzada Ajit Singh Nagar (Mohali) 160062, Punjab through its Manager.

… Opposite Parties

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

 

                                                                               

ARGUED BY	:	Sh. R.C. Gupta, Counsel for complainant
	:	Sh. J.P. Nahar, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Ms.Garima Batra, complainant against the 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, being a young lady of 32 years, on persuasion by OP-1 and her banker i.e. State Bank of India, Ambala City, had subscribed a Group Health Insurance Policy (hereinafter referred to as the Policy) valid from 21.7.2018 to 20.7.2019 covering the risk of hospitalization and other perils.  OP-1 had informed the complainant that OP-2 is the third party administrator whose representatives shall be available in the prescribed hospitals to help the customers for providing them cashless treatment facility.  The Policy (Annexure C-1) was purchased by the complainant on payment of advance premium of ₹2,500/- to OP-1 through State Bank of India, Branch Office Ambala City. On 6.6.2019, complainant was hospitalized in the Max Super Speciality Hospital, Mohali (hereinafter referred to as the “Hospital”) for Lap Myomectomy where she was given a package break-up of ₹1,32,000/- vide quotation bill (Annexure C-2). At the time of hospitalization of the complainant, persons available at the TPA desk of the Hospital at Mohali were duly communicated about the insurance facility availed by the complainant and the proposed surgery to be conducted upon her as per the package break-up and cashless approval of ₹95,000/- only was given by OP-1 in favour of the complainant. However, thereafter the complainant and her representative took up the matter with the TPA/insurer i.e. OPs who advised that the issue with respect to the balance amount shall be looked into and settled even thereafter as she had to undergo urgent surgery. Under the aforesaid circumstances, complainant had undergone surgery at Max Hospital and was discharged on 7.6.2019.  During the first day, complainant was kept in ICU and on the other day she was kept in a room and thereafter the hospital raised bill of ₹1,41,521.25 from her as per inpatient bill dated 8.6.2019 (Annexure C-4). It is further alleged that in fact the hospital authorities, in an arbitrary manner, had charged from the complainant a sum of ₹1,43,781/- despite of the fact that initially package of ₹1,32,000/- was given.  Despite of the approval of the cashless amount of ₹95,000/- by the OPs in favour of the complainant, to be paid to the Hospital, OPs had made payment of ₹56,492/- only through authorization letter to the Hospital which was valid w.e.f. 6.6.2019 to 21.6.2019. Thereafter when the Hospital authorities demanded balance amount, the complainant was compelled to make the said payment of ₹87,289/- from her own pocket.  In this manner, act of the OPs amounts to mis-selling, unfair trade practice and deficiency in service.   It is further alleged that once the hospital on behalf of the OPs raised the quotation bill of ₹1,32,000/- to the complainant, which was duly communicated to OPs 1 & 2, it was not justifiable by the Hospital to raise a larger bill of ₹1,43,781/-.  OPs were requested several times to release the aforesaid amount of ₹87,289/-, including by service of legal notice, but, with no result. Hence, the present consumer complaint. The consumer complaint is supported by the affidavit of the complainant.
2. OPs resisted the consumer complaint and filed their written reply, inter alia, taking preliminary objections of maintainability and non-joinder of necessary parties.  On merits, admitted that the complainant had subscribed the Policy in question effective from 21.7.2018 to 20.7.2019.  It is further admitted that the Max Hospital had quoted the amount of ₹1,32,000/- for treatment of the complainant.  It is further admitted that the amount of ₹95,000/- was earlier approved, but, alleged that the same was subject to furnishing proper receipts. It is further alleged that the authorization was subject to important note appended in the policy which clearly mentioned the manner in which the amount is to be calculated and paid to the insured.  It is further alleged that the guaranteed payment of ₹56,492/- was calculated and paid to the Max Hospital.  It is further alleged that as the hospital had overcharged the amount in excess to the estimated amount, OPs are not liable to pay the said amount.  It is also alleged that length of the stay of the complainant in the hospital was for two days and class of accommodation was ₹3,000/- per day maximum and accordingly the said amount was calculated and paid to the Max Hospital.  The cause of action set up by the complainant is denied. The consumer complaint is sought to be contested.
3. In rejoinder, the complainant re-asserted her 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, parties have tendered/proved their evidence by way of affidavits and their respective supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments. For the reasons to be recorded hereinafter, following points are formulated for discussion and proper adjudication :-

1. Whether there is deficiency in service or unfair trade practice on the part of OPs?
2. Whether the complainant is entitled for claim as prayed for?
3. Whether the consumer complaint of the complainant is bad for non-joinder of necessary party?
4. Relief.

Point No.1 & 2

4. Both these points are interconnected, hence are taken together to avoid repetition of facts and evidence.
5. Admittedly, complainant was having the Insurance Policy from OP-1 valid from 21.7.2018 to 20.7.2019 as is also evident from Annexure C-1. It is further an admitted case of the parties that when the complainant approached the Max Hospital on 6.6.2019 for Lap Myomectomy, the said hospital had given a package break-up of ₹1,32,000/- for the said treatment, as is also evident from copy of the quotation bill (Annexure C-2).  It is further an admitted case of the parties that the OPs had first given cashless approval of ₹95,000/- only to the complainant for the said treatment, as is also evident from the approval letter dated 29.5.2019 (Annexure C-3), and later on the Max Hospital had raised bill of ₹1,43,781/- which was in excess to package break-up earlier given by them.  It is further an admitted case of the parties that despite of the approval given by the OPs for a sum of ₹95,000/-, they had released an amount of ₹56,492/- only.  The case of the complainant is that since she was covered under the Insurance Policy with the insured amount of ₹3 lacs and she had undergone treatment for Lap Myomectomy in the Max Hospital where the hospital authorities had given a package break up of ₹1,32,000/- and later on raised the bill to the tune of ₹1,43,521.25 and despite of the fact that earlier the OPs had given cashless approval of ₹95,000/- for the treatment of the complainant in the said Hospital and later on had released only an amount of ₹56,492/- as a result of which she was compelled to make the payment of ₹87,289/- from her own pocket,  the complainant has successfully proved deficiency in service and unfair trade practice on the part of the OPs.  On the other hand, the defence of the OPs is that since the aforesaid amount was calculated as per the entitlement of the complainant covered under the Policy and also as per the terms and conditions of the Policy, the complaint of the complainant being false and frivolous be dismissed with costs.
6. Close scrutiny of the entire evidence on record of the case file, coupled with the rival contentions of the learned counsel for the parties, are discussed as under:-

1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had subscribed the Policy (Annexure C-1) valid from 21.7.2018 to 20.7.2019 and had undergone treatment for Lap Myomectomy  in the Max Hospital on 6.6.2019 and cashless approval of ₹95,000/- was given by the OPs in favour of the complainant and later on only an amount of ₹56,492/- was released by the OPs to the aforesaid Hospital and the complainant had paid the balance amount of ₹87,289/- from her own pocket, the case is reduced to a narrow compass, as it is to be determined if there is any deficiency in service or unfair trade practice on the part of the OPs, as is the case of the complainant, or if the OPs had paid the amount of ₹56,492/- in terms of the Insurance Policy, as is the defence of the OPs.
2. From the pleadings of the parties coupled with the evidence in the shape of affidavits and documents tendered by the parties, one thing stands clear on record that the real controversy between the parties is revolving around the terms and conditions mentioned in the Insurance Policy (Annexure C-1), especially when as per the case of the complainant she is entitled for the insured sum to the extent of ₹3.00 lakhs whereas the defence of the OPs is that whatever amount has been released by the OPs that was in pursuance to the terms and conditions of the Policy and the consumer complaint of the complainant is not maintainable. In such a scenario, the terms and conditions of the Policy are required to be scanned carefully.
3. The learned counsel for the complainant has drawn our attention to scope of cover as referred in page No.14 of the Policy (Annexure C-1) and the relevant portion of the same, for convenience, is reproduced as under:-

“Scope of cover

Benefit	Coverage details
Room boarding and Nursing charges	1%/day for Non ICU and 2%/day for ICU.  All incremental Expenses pertaining to room rent, medical practitioners/specialists fees and other incidental Expenses to be borne by the insured.
ICU charges
Medical Practitioner and Specialists Fees.
Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Physiotherapy, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, prosthesis/internal implants and any medical expenses incurred which is integral part of the operation.
Pre-hospitalization Expenses – We shall pay for expenses as defined in the policy and incurred up to 30 days prior to the date of admission into the hospital
Post-hospitalization Expenses – We shall pay for expenses as defined in the policy and incurred Up to 60 days after the date of discharge from the hospital.
Day Care Expenses (As per our Day Care List)
Ambulance Charges – Up to 1% of Sum Insured (Maximum 1500)
Domiciliary Hospitalisation – We will cover Reasonable and Customary Expenses towards Domiciliary Hospitalisation as defined in definition subject to 20% of the Basic Sum Insured or a maximum of up to Rs.20000, whichever is lesser.
Non Network Hospitalisation Co-pay : For all admissible claims where treatment is taken at hospitals/nursing homes which are not in the list of network hospitals empaneled by the Us/Administrator, insured person shall bear 10% of the eligible admissible claim.”

4. On the other hand, learned counsel for OPs has drawn our attention to page No.19 of the Policy and the relevant portion of the scope of work, for convenience, is reproduced as under :-

“SCOPE OF COVER

Insurer shall pay the expenses reasonably and necessarily incurred by or on behalf of the Insured Person under the following categories but not exceeding the Sum Insured and subject to deduction of any deductible as reflected in the policy schedule in respect of such Insured person as specified in the schedule :

1. Room, Board & Nursing Charges as provided by the hospital: up to 1% of the Sum Insured max Rs.1500/- for Normal Room per day. If admitted into Intensive Care Unit up to 2% of the Sum Insured per day max Rs.2500/-. In case the insured opts for a higher room category than his eligibility the same can be covered upon specific acceptance by the insurer or Administrator. In such a case all incremental Expenses pertaining to room rent, medical practitioners/specialists fees and other incidental Expenses to be borne by the insured.

2. Medical Practitioner and Specialists Fees.

3. Anesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, prosthesis/internal implants and any medical expenses incurred which is integral part of the operation.

4. Pre-hospitalisation Expenses - Insurer shall pay for expenses as defined in the policy and incurred 30 days prior to the date of admission into the hospital.

5. Post-hospitalisation Expenses - Insurer shall pay for expenses as defined in the policy and incurred 60 days after the date of discharge from the hospital.

6. Day Care Expenses - Insurer shall pay for Day Care expenses incurred on advanced technological surgeries and procedures requiring less than 24 hours of hospitalisation as per the attached list and subject to the condition that prior approval is obtained by the Insured Person/Insured from the Administrator/Insurer for such a Day Care Procedure/Expense.

7. Non Network Hospitalisation Co-pay: For all admissible claims where treatment is taken at hospitals which are not in the list of network providers empanelled by the Company/Administrator, insured person shall bear 10% of the eligible admissible claim as per terms of insurance or shall bear a % of the eligible admissible claim as stipulated in the schedule for the said purpose.

8. Domiciliary Hospitalisation- Insurer will cover Reasonable and Customary Charges towards Domiciliary Hospitalisation exceeding 3 days as defined in definition subject to 20% of the Basic Sum Insured or a maximum of up to Rs.20000, whichever is lesser, however domiciliary Hospitalisation benefits shall not cover:-

i. Expenses incurred for pre and post domiciliary hospitalisation treatment or

ii. Expenses incurred for treatment for any of the following Diseases

a. Asthma

b. Bronchitis

c. Chronic Nephritis and Nephritic Syndrome

d. Diarrhea and all type of Dysenteries including Gastro-enteritis

e. Diabetes Mellitus and Insipidus

f. Epilepsy

g. Hypertension

h. Influenza, Cough and Cold

i. All Psychiatric or Psychosomatic Disorders

j. Pyrexia of unknown Origin for less than 10 days

k. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharingitis

l. Arthritis, Gout and Rheumatism.”

5. Learned counsel for the complainant has further contended that as the stay of complainant in the hospital as per terms and conditions of policy was covered to the extent of 1%/day of the insured amount for non ICU and 2%/day of the insured amount for ICU and admittedly the complainant remained in the hospital for one day in ICU and for one day in non ICU and in this manner 3% of the total insured amount comes to ₹9,000/- whereas the hospital has charged ₹8,400/-, OPs have wrongly made deduction while releasing the amount even for which the complainant was entitled to. 
6. On the other hand, learned counsel for the OPs contended that since page No.19 of the policy under the head of scope of cover clearly provides that 1% of the sum insured maximum ₹1,500/- for normal room per day and 2% of the sum insured per day maximum of ₹2,500/- if the patient is admitted into intensive care unit is payable to the patient and in this manner the complainant was entitled for the said charges to the extent of ₹4,000/- and accordingly all incremental expenses were calculated by the OPs and since it comes to ₹56,492/-, the same was released in favour of the Hospital authorities. However, there is no force in the contention of the learned counsel for the OPs since the scope of cover at page No.14 nowhere prescribes that the maximum limit of ₹1,500/- for non ICU and ₹2,500/- for ICU room is to be paid, rather it prescribes that 1%/day for non ICU and 2%/day for ICU will be paid by the insurer.  So far as the contention of the learned counsel for the OPs that all incremental expenses pertaining to room rent, medical practitioner/specialist fee and other incidental expenses to be borne by the insured is concerned, it seems that the OPs have come up with the defence that other incremental charges are also to be calculated as per the percentage of charges on non ICU and ICU, which cannot be acceptable in this case especially when the OPs have specifically pleaded in para No.3 of their written reply that cashless approval of ₹95,000/- had already been given by the OPs and nothing has been explained by the OPs why the amount for which the approval had already been sanctioned was not later on released in favour of the Hospital authorities.  Not only this, when it is an admitted case of the parties that the insured amount was ₹3 lacs and in the present case the complainant has not claimed more than the insured amount, rather she is claiming an amount of ₹1,32,000/-, as has also been contended by the learned counsel for the complainant at the time of arguments that he presses the claim of complainant for the sum of ₹1,32,000/- which was the initial estimated amount given by the Hospital and he is not claiming any relief against the Hospital, who had raised the bill to the tune of ₹1,43,781/- i.e. in excess to the earlier amount of ₹1,32,000/-. Not only this, the contention of learned counsel for the OPs that an amount of ₹56,492/- was paid to the Hospital by making deduction as per auto capping being not payable, is of no help to the OPs when the policy itself nowhere prescribes that the expenses for the medical health will be paid only as per the auto capping formula.
7. Learned counsel for the complainant has relied upon the order of Hon’ble State Commission, Punjab in New India Assurance Co. Ltd. & Anr. Vs. Suman Devi, First Appeal No.964 of 2012 decided on 4.12.2015  which had also considered the defence of the OPs in the similar case where the OPs had come up with the plea of deduction on the basis of auto capping expenses and the same was not considered.

7. In view of the foregoing discussion, it is safe to hold that OPs indulged in deficiency in service and unfair trade practice as they wrongly deducted an amount of ₹87,289/- from the total medical expenses given by the Hospital in the package break-up of ₹1,32,000/- for the treatment of the complainant, and duly conveyed to OPs, by only releasing an amount of ₹56,492/-. However, as discussed above, since the complainant has pressed her claim to the extent of ₹1,32,000/- only, therefore, she is certainly entitled to the amount of ₹75,508/- (i.e. ₹1,32,000 – ₹56492 = ₹75,508/-) alongwith reasonable interest and compensation etc.

Point No.3

8. As already discussed in the discussion on points No.1 & 2 that the complainant has given up her claim exceeding to ₹1,32,000/- against the Hospital authorities, in our opinion the Hospital is not a necessary party as the complainant has been pressing her claim only to the extent of ₹1,32,000/- which was earlier considered by OPs and sanction was wrongly given to the extent of ₹95,000/- only.  Accordingly, it is safe to hold that the complainant is not bad for non-joinder of necessary parties.

Relief

9. In the light of the aforesaid discussion, the present consumer complaint partly succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. to pay ₹75,508/-  to the complainant alongwith interest @ 9% per annum from the date of making payment by the complainant to the Hospital i.e. 8.6.2019 till realization of the same.
2. to pay an amount of ₹25,000/-  to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹10,000/- to the complainant as costs of litigation.

10. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
11. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 07/10/2022 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member