Before  the District Consumer Dispute Redressal Commission [Central], 5th Floor                                         ISBT Building, Kashmere Gate, Delhi

                               Complaint Case No.303/29.10.2015

Gagan Chawla s/o Sh. C.P. Chawla,

r/o B-5/15, Paschim Vihar,

New Delhi-110063                                                                   ...Complainant

                                      Versus

OP1:  United India Insurance Company Limited

          2216, Hardhyan Singh Road, Karol Bagh,

Delhi-110005

OP2:  Vipul MedCorp TPA Private Limited

          515, Udyog Vihar, Phase 5, Gurgaon,

          Haryana

OP3:  Bhatia Global Hospital & Endosurgery Institute,

          305,307,308 Ambika Vihar, New Delhi-110087           ...Opposite Party

                                                                   Date of filing:            29.10.2015

                                                                   Order Reserved on:    28.12.2022

                                                                   Date of Order:            23.01.2023

Coram: Shri Inder Jeet Singh, President

              Shri Vyas Muni Rai,    Member

              Ms. Shahina, Member -Female

Inder Jeet Singh

                                             ORDER

1.1. (Introduction to dispute of the parties) : The complainant/Insured bought Family Medi-claim Policy 2014 for him and his family for insurance cover of Rs.3,00,000/- from Insurer/opposite party no.1 which provides cashless facilities, however, when his wife was hospitalized and treated as indoor patient in hospital/OP3, he was asked to deposit Rs.10,000/- (Rs.5,000/- at the time admission+ Rs.5,000/- at the time of discharge), which he had deposited under compulsion. The entire medical bill was not settled by the OP1 & OP2.  Whereas, the OPs had opposed the complaint that medical expenses bill was of Rs.33,238/-, out of which Rs.23,060/- was settled because of terms of policy contract, particularly the rent of room availed was Rs.3,500/- but eligible amount was 1% of sum assured of Rs.3,000/- per day. The other deductions were also made proportionately based on criteria of rent of Rs.3,000/-per day.

          The parties have also dispute on issue of deductions as well as issuance of two bills for different amounts and heads of charges.

1.2:    Otherwise, there is no dispute about relationship of complainant as Insured, OP1 is Insurer, OP2 is TPA and OP3 is treating hospital, where complainant's wife had undergone treatment. There is also no dispute about Family Medi-claim Policy 2014 no.0425002814P108040604 (Annex. A to complaint), tenure of insurance cover w.e.f. 31.12.2014 to 30.01.2015 against paid premium;  period of hospitalization from 06.09.2015 to 11.09.2015 of wife of complainant; the complainant was asked and he had also deposited Rs.10,000/- with the hospital, because entire bill  was not approved by TPA/OP2.

2.1 (Matrix of case of the parties) : It was 6.9.2015, when complainant's wife Ms. Bhanu Chawla was admitted for treatment of dengue fever in the hospital of OP3, the complainant had also given requisite papers of insurance cover to OP3. It was told, at the time of admission, that only room of higher category of rent of Rs.3,500/- per day was available, which complainant was constraint to concede and also deposited Rs.5,000/- (vide receipt Annex.B), but after admission,  it was asked to share the room with another patient. On 11.9.2015, the final bill was raised by OP of Rs.36.380/- but OP2 had approved amount of 26,380/-,  thus  an amount of Rs.10,000/- was lesser than the bill amount. The complainant had objections to it, thereafter another bill was issued for reduced amount of Rs.33,238/- (Annx C and D to the complaint). Then on 11.9.2015 at the time of discharge complainant was asked, that second bill of reduced amount was rejected by TPA/OP2 and complaint was asked to deposit Rs.5,000/- more, which he had deposited against receipt (Annx.E). OP3 also asked that since OP1 and OP2 have not approved the second reduced bill, they cannot accept the amount on that basis. When complainant contact customer care center, then it was told that since room  of higher rent was opted than entitlement thereof, the bill was  accordingly reduced on pro-rata basis, when inquired as to where it is so mentioned, it was told that it is written somewhere. Whereas nothing is mentioned in the policy about proportionate reductions.  The complainant had also sent e-mail to them (Annex E) but no result. Thence legal notice dated 24.9.2015 (Annx. G) was also sent by (Post/AD Card Annx. H & I) but no result. There was no justification of OPs to deny the claim and it is deficiency in services.  Complaint seeks  amount of Rs.10,000/-, damages in lieu of harassment, mental agony of Rs.50,000/- and litigation costs of Rs.11,000/- against OPs.

2.2:  OP1 opposed the complaint. TPA/OP2 is  professional agency and it is under IRDA (Third Party Administrator - Health Services) Regulations 2001.  OP1 relies upon the professional recommendations and decision of TPA. The complainant had pressurised TPA/OP2, then revised reduced bill was issued. The complainant was provided cashless facilities of Rs.23,060/- (viz. of Rs.11,000/-+ Rs.1,240-/+Rs.10,820/-) as per terms of policy.  It was clearly mentioned in the policy in clause 1.2 - that room, boarding and nursing expenses as provided by the hospital/nursing home are up-to 1% of sum assured. Since the sum assured was Rs.3,00,000/-, thus the patient was entitled for room rent and its expenses only for Rs.3,000/-per day.  When the claim was processed, the excess rent amount from entitlement was deducted and 31.03% from other heads, except medicine and consumables. Some consumables and other charges were deducted as non-payable as per clause 4.20 and 4.21 of the policy. In this way, an amount of Rs.23,060/- was approved. OP1 had replied the legal notice of complainant. [OP1 had pleaded that calculation sheet were filed with the reply, but was not there with the reply]. Moreover, during  oral arguments, it was specifically inquired for want of calculation sheet on record from the counsel for OP1 at to how this figure of 31.03% was arrived, nothing could be suggested except that it was opined so by the OP1]. OP2/TPA had not filed any reply.

2.3:  However, OP3's simple stand and case is that it is treating hospital, the complaint does not make any allegations of deficiency of medical services by the hospital nor about any negligence on its part. The complainant has grievances against other OPs.

3. At the stage of evidence, Complainant himself led evidence, being Advocate by profession, his evidence is on the lines of complaint coupled with documents. Mr. Subodh Sharma, Divisional Manager/Authorized Representative of OP1 led evidence with copies of  insurance policy and reply to legal notice, but without details/break up as to how figure of 31.03% was deduced.  Shri R.S.Bhatia, Chairman of OP3 also filed affidavit of evidence, which reiterate the plea taken in its reply. Moreover,  record sheet of admission/discharge of patient Bhanu Chawla with details of hospital room tariff on its overleaf was  also placed on record.

4: Except OP2, the other parties also filed written submissions apart from their oral submissions.

5.1 (Findings) : The contentions of both the sides are considered, analyzed and assessed. Since there is documentary record, particularly insurance policy, its terms and conditions, final bills issued and tariff of rooms, by taking them together will resolve the controversy. However, OP1 has been emphasizing through-out that many charges of hospital varies/escalate with the nature of room (deluxe, private and semi-private etc.) corresponding to rent amount. The complainant availed room of Rs.3,500/-per day (against entitlement of Rs.3,000/- per day), the hospital's other charges would have been charged correspondingly rent of room, that is why proportionate deduction were calculated to figure out eligible amount on the basis of eligible rent of Rs.3,000/- per day.

5.2: Thus, it required to see the medical bills. There are two final bills of same date/hour/seconds being bill no.15001015. The first bill is of Rs.36,380/- and second/revised bill is of Rs.33,238/-. However, at the time of discharge, the complainant was informed by OP3 that revised bill was rejected by TPA/OP2, then he was asked to deposit Rs.5,000/-, which he had deposited. Whereas, the OP1's stand is that the revised bill was considered, when amount of Rs.23,060/- was approved.  By looking into the first bill and the revised bill, for some heads [viz. diagnostic charges, admission charges, accommodation charges and consultant charges], there are identical charges/amount. However, in the first bill for Ward medicine charges are Rs.2,500/- but in the revised/second bill, increased amount of Rs.3608/- were mentioned. Moreover, in the first bill there are nursing care charge of Rs.2,000/- and RMO charges of Rs.2,500/-, which are not mentioned in the revised bill.

5.3:    On the over-leaf of the Admission/Discharge record of OP3, schedule of hospital room tariffs are mentioned in detail, which enumerate category of room (deluxe, private, semi-private etc.) and correspondingly other charges are mentioned ( viz. RMO Charges, Nursing charges, consultant charges). The rent for deluxe room is Rs.3,500/- per day and rent for private room is Rs.3,000/- per day. However, RMO Charges (Rs.450/- per day), Nursing Charge (Rs.400/- per day) and Consultant Charges  are same for deluxe rooms and private rooms.

5.4: As per clause 1.2(A) of insurance policy, boarding and nursing expenses as provided by the hospital/nursing home is up-to 1% of sum assured per day. Since the sum assured is Rs.3,00,000/-, therefore, room charges eligible for complainant's wife was Rs.3,000/- per day, whereas the room availed or made available was of Rs.3,500/- per day. In both the bills the accommodation charges mentioned are Rs.17,500/- [Rs.3,500/-per day x 05 days]. As  per policy terms, the entitlement of complainant was of Rs.15,000/- (Rs.3000/- per day x 05 days), which the OP1 has emphasizing.

5.5.1: OP1 contended that it was complainant, who had pressured the OP2 to revise the bill and then revised bill was issued.  It is material to refer insurance policy. Its   clause no.3:34, reads as  "Room Rent - Room rent shall mean the amount charged by hospital for the occupancy of a bed on per day (24 hours) and shall include associated medical expenses".  Generally, RMO and Nursing charges are included in the room charges. In the first bill issued by the OP3, it shows RMO charges of Rs.2250/- (i.e. Rs.450/-per day) and Nursing charges of Rs.2000/- (i.e. Rs.400/-per day) separately but such charges are not mentioned in the revised bill, the reasons is culling out from clause no.3.34 of insurance policy.  Moreover, OP2 had not filed any grievances that complainant had pressured the OP2 to issue revised bill nor there is any record, which may show that complainant had pressurized OP2/TPA nor there is any record that OP2 and complainant were face to face.

5.5.2: The  eligible room rent is 1% of sum assured, however, as per OP1 the other deductions were done @ 31.03%. It was inquired from the parties as to how this rate of 31.03% was deduced. It is mystery for the complainant and he contended that even he had asked the OPs but he was told that it was written somewhere, which was not shown or referred . On the other side, OP1 refers clause 4.20 and 4.21 (being exclusions clauses) of insurance policy, which are in respect of deductable in respect of non-medical expenses, tax etc.. There are exclusions clauses 4.20 and 4.21 in the policy but no such percentage rate or 31.03%  is mentioned therein.  OP1 had stated in its reply that calculation sheet was attached with reply but no such sheet was attached and when counsel for OP1 was inquired during phase of oral submission, on what basis 31.03% was devised as a proportionate rate, there was no such information provided to counsel by OP1. 5.6.1:  This Commission tried to explore it, by applying OP1's basis of entitlement of rent of Rs.3,000/- per day and the room availed was of  Rs.3,500/-. Then excess amount of Rs.500/- comes to 14.680% (round off to 15%). So, this does not spell out rate of 31.03%.

5.6.2: When other factors were explored, by way of permutation and combination, then it was discovered that by adding of rent of Rs.3,500/-+ RMO charges of Rs.450/-+Nursing charges of Rs.400=Rs.4,350/- per day and putting is corresponding to rent of Rs.3000/-; then excess amount of Rs.1,350/- comes to 31.03%.  Whereas in the second bill, there was no RMO charges and Nursing charges.  Therefore, for want of any other proof or criteria by the OP1,  the circumstance are suggesting that OP1 devised a way of deduction in the aforesaid manner based on first bill and then invoked it as deductions for revised bill.  Simultaneously,  it is clashing OP1's own method based on eligible rent of room of Rs.3,000/- per day but for deduction other criteria @ 31.03%, was applied. It is not fair on the part of OP1 to apply two formula?

5.6.3:  It may happens, that more facilities are provided with the nature of room and there may be escalated rates for  corresponding the higher category of room. Does it exist in the present case? It needs to be ascertained. Firstly, the revised bill does not depict RMO & Nursing charges, otherwise for first bill the RMO & Nursing charges are same for deluxe, private & semi private room as per schedule of tariffs of OP3.  Moreover,  consultation charges are also same  for  deluxe and private rooms, same charges are also mentioned in both the bills issued.

5.6.4: In the revised bill, the ward medicine charges are Rs.3,608/-, they cannot  be put to escalations as per policy conditions. The Laboratory tests (X-ray etc.) charges are of Rs.6,380/-, they are also not co-related with extra services with the deluxe room to be escalated and to be deducted.

5.6.7:  It is apparent, when there are specific tariff for each item, would it be appropriate to cull out 31.03% rate for deductions? Why not to apply the actual available rates, or if rates are to applied then it should be followed in uniformly on basis of eligible rent vis a vis room actually availed (which come to 15%).

5..6.8: As per tariff, the patient has to deposit Rs.5000/- at the time of admission. As per policy admission charge are deductable, which is  Rs.250/- apart from other consumable & non-medical items. Whereas, the other consumable & non-medical item are not mentioned in the first bill or in the revised bill nor other record is proved by OPs.

5.6.9: Thus, in view of the detailed discussion and analysis, by considering the revised/second bill, the entitlement of complainant is of  Rs.30,488/- [viz  (i) Rs.15,000/-room rent + Rs. 3,608/- Ward Medicine + Rs.6,380/- Laboratory tests +Rs.5,500/- consultants charges)], out of which complainant had received Rs.23,060/- and remaining balance amount is of Rs.7,428/-, for which complainant is held entitled thereof, which is valid claim of the complainant but it was denied to him. What prevented the OP1 and OP2 to explain in reply to e-mail and reply to legal notice the criteria/formula adopted for deduction, however, it has been kept suppressed even in reply to complaint. It has  definitely caused harassment to the complainant, it is also unfair practice on the part of OP1 & OP2 as well as deficiency in services.  Because of this situation, this Commission has to explore permutation and combination just to satisfy as what was considered by the OP1 to figure out 31.03% & also was it appropriate?.

6.1:  The gravity of situation is abundantly clear to what extent sufferings,  trauma and inconvenience had been faced by the complainant for seeking relief of his valid medical claim, which was with-held by OP1 & OP2, thus the complainant deserves damages, which are quantified as Rs. 7,000/- in his favour and against the OP1 & OP2, apart from costs of  Rs.3,500/-in favour of the complainant against the OP1 & OP2. No order against OP3 under these circumstances.

6.2: Hence, the complaint is allowed in favour of complainant and against the OP1 and OP2, to pay jointly and severally a sum of Rs. 17,928 /- (viz. Rs.7,428/-+Rs.7,000/-+Rs. 3,500/-) within 30 days from the date of receipt of this order. 

          In case, OPs do not pay the amount within the period prescribed, then OP1 and OP2 will be liable to pay interest @ 07% pa from the date of order till its realization of amount. 

7. Copy of this Order be sent/provided forthwith to the parties free of cost as per Regulations within 4 days. Complainant's counsel's request (DLSA) extra copy is allowed since it is to be furnished in the Office DLSA.

8:  Announced on this 23nd day of  January, 2023 [माघ 3, साका 1944]