BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 121 of 2018
Date of Institution : 09.04.2018
Date of Decision : 11.06.2019
Tarsem Jindal aged about 75 years son of Des Raj Jindal c/o M/s Goria Mal Budh Ram # 61, Grain Market, Mandi Dabwali, District Sirsa-125104.
……Complainant.
Versus
- United India Insurance Company Limited Opposite Civil Hospital, Above Hyundai Showroom, Main Chautala Road, Mandi Dabwali District Sirsa-125104 through its Branch Manager.
- E-Meditek Solutions Ltd.E-Meditek Insurance TPA Ltd. Plot No.577, Udyog Vihar Phase -5, Gurgaon, Haryana, 1222016, through M.D/Director/Auth. Signatory.
- Fortis Hospital Mohali, Sector 62, phase VIII, Sahibzada, Ajit Singh Nagar (Punjab) 160062, through MD/Director/Auth. signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH.R.L.AHUJA………………. ……PRESIDENT.
SH.ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. Manish Gupta, Advocate for the complainant.
Sh. A.S.Kalra, Advocate for opposite party No.1.
Sh.Rishi Sharma, Advocate for opposite party No.3.
OP No.2 exparte.
ORDER
The case of the complainant, in brief, is that the complainant purchased one cashless insurance continuous mediclaim policy No.1119012816P106989817 w.e.f. 27.08.2016 to 26.08.2017 and the said insurance is continuous one of medi-claim policy purchased by the complainants in the year 2012, 2103, 2104 and 2015 and earlier the same were with National Insurance Company Limited. In August, 2016, the Op No.1 charged Rs.18269/- from complainant and insured complainant and his wife for Rs.2,50,000/- and + Rs.40,000/- each. On 30.04.2017, the complainant suffered heart attack and he was immediately shifted to Jindal Heart Institute & Test Tube Baby Centre, Bhatinda where Rs.63760/- were charged from the complainant as the Ops did not release the cashless payment to the said hospital. After that the complainant was shifted to Fortis Hospital, Mohali on 03.05.2017 and took treatment but the Ops have only sanctioned meager amount of Rs.1,12,000/-against the hospital bill of Rs.2,77,230/- and Rs.63,760/- issued by the Op No.3. The complainant submitted complete bill alongwith second claim form, after his discharge, with Op Nos.1 & 2 with a request to release the balance payment of Rs.1,65,230/- as the insurance policy was cashless but the Ops refused to release the same. The complainant got served legal notice upon the Ops to no avail. The claim of Rs.1,78,000/- is still pending with the Ops which they illegally charged from the complainant in connivance with each other. The act and conduct of the Ops clearly amounts to deficiency in service and unfair trade practice on their part.
2. On notice, Ops No.1 & 3 appeared and filed their separate replies. OP No.1 in its reply has submitted that there is no deficiency in service on the part of replying OP as third party/OP No.2 has been deputed under the IRDA regulation for decision on the third party claim lodged according to the clause 5.14 of the policy. The complainant has lodged two different claims in one complaint. First claim was with regard to the hospitalization period for 30.04.2017 to 02.05.2017 bearing claim No.103051700238 and second claim with regard to the hospitalization period for 02.05.2017 to 12.05.2017 bearing claim No.103051700071/71A and in both the claims amount of Rs.1,12,000/- has already been paid as per terms and conditions of the policy as per exclusion clause and cost sharing basis to the extent as referred in detail in policy clause 1.2, 1.2.1, 1.3 and applying the provisions of co-pay as per clause 3.9 and exclusion clause mentioned in clause 4 & 4.1 considering the clause 5.12. The amount of Rs.1,12,000/- has been paid by the Op No.2 exercising the powers given to them by the IRDA/Govt. of India while appointing as TPA, who decided the claims according to terms and conditions of the policy. It has been further averred that cashless policy does not mean that anything more than the entitlement, will be paid and the complainant has also not submitted the requisite documents. Whatever was admissible has been paid by the TPA for the cashless facility of any individual and so was paid to the hospital with regard to the claim of the complainant as full and final as sum insured exhausted, sum insured restricted to 2012-13 i.e. 2 lakh 70 % of sum insured and 20 % co-pay in package applied as per policy terms and conditions which cannot be termed as a meager amount. The claims have been decided on merits and writing the letter dated 17.06.2017 does not make any difference. No amount of Rs.1,78,000/- is pending with the Ops as the claim has already been settled and paid. Other contentions have been controverted and prayer for dismissal of the complaint has been made.
Op No.3 in its reply has taken preliminary objections such as that the complaint is not maintainable; that the complainant has not approached to this Forum with clean hands and the complainant is estopped from filing the present complaint by his own act and conduct. It is submitted that on 03.05.2017, the complainant was admitted in the hospital of replying OP with complaint of left side chest pain and he had visited Jindal Hospital, Bhatinda where Angiography was done. Thereafter, the complainant visited the replying OP where HM Coronary Artery Bypass Graft (CABG) was done on 04.05.2017. The complainant was discharged in stable condition on 12.05.2017 and on discharge the patient’s bill was for Rs.2,77,230/- out of which the insurance company has only paid Rs.1,12,000/- and the reason given for deduction by the insurance company was exhaustion of sum insured. There is no deficiency in service and unfair trade practice on the part of replying Op. Summons sent to the Op No.2 through registered post but after lapsing of mandatory period none had turned upon on behalf of Op No.2, therefore, it was proceeded against exparte vide order dated 16.10.2018.
3. Thereafter, the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. Learned counsel for the complainant has strongly contended that it is proved case of the complainant that the complainant had purchased insurance policy for the last about 10 years and lastly was insured for the period from 27.08.2016 to 26.08.2017. Earlier the policy was issued for Rs.2 lakhs and lateron they were insured for Rs.2.5 lakhs on payment of premium amount of Rs.18,269/- + Rs.40,000/- each and they were insured for Rs.2,90,000/-. The complainant suffered heart attack and he was immediately shifted to Jindal Heart Institute & Test Tube Baby Centre, Bhatinda where he remained there from 30.04.2017 to 02.05.2017 and thereafter he was shifted to Fortis Hospital, Mohali on 03.05.2017 and in this way he spent Rs.63760/- in Jindal Hospital, Bhatinda and Rs.2,77,230/- in Op no.2 on account of treatment charges, but however, the OP Nos. 1 & 2 in arbitrarily manner paid only Rs.1,12,000/- to the Op No.3 on behalf of the complainant and withheld Rs.1,65,230/-. There was no liability of the complainant to co-pay the amount of Rs.28,000/- and also entitled to pay Rs.40,000/- the bill of medicines which the Ops was liable to pay as per terms and conditions of the policy. The insured value of the policy was duly extended by the OP No.1/insurance company at their own being senior citizen without receiving any premium Now, the Ops cannot escape from their liability by taking lame excuses.
On the other hand, learned counsel for the OP No.1 has contended that there was insurance contract between the complainant and Op No.1 and by virtue of that both the parties are bound by the terms and conditions of the insurance contract. As per the terms and conditions of the insurance policy, in case of major surgery, the liability of the insurance company was only to pay the actual expense of treatment or 70 % of the insured value whichever is less. Since, the policy was to the extent of insured value of Rs.2 lakhs, as such, the liability of the insurance company was only to pay Rs.1,40,000/- out of which, the insured was entitled to deduct 20 % of the payable amount on account of co-pay as provided under the policy for the pre existing disease of the complainant of hypertension. In this way, the insurance company has rightly settled the claim and paid the amount of Rs.1,12,000/- to the Op No.3 on behalf of complainant. There is no other liability of the insurance company to pay any further amount and the complaint of the complainant is liable to be dismissed.
6. Learned counsel for the Op No.3 has strongly contended that the Op No.3 only gave treatment to the complainant and discharged him in stable and satisfactory condition and there is grievance against the Op No.3 and reasonable amount of treatment charges were received by the Op No.3 from the complainant and the insurance company. No relief has been sought against the Op No.3, as such, the complaint is liable to be dismissed against the Op No.3.
7. We have given considerable thought to the rival contentions of the parties.
8. Admittedly, the complainant had been getting insurance policy for the last about 10 years and lastly he and his wife have been insured with Op No.1 for the period w.e.f. 27.08.2016 to 26.08.2017. The complainant and his wife were insured for Rs.2,50,00/- + 40,000 but the basic policy for sum of Rs.2 lakhs. It is further admitted fact that the complainant suffered heart attack on 30.04.2017 and he was immediately shifted to Jindal Heart Institute & Test Tube Baby Centre, Bathinda and remained there till 02.05.2017 and from where he was referred to OP No.3/Fortis Hospital, Mohali and got his treatment and paid Rs.63760/- to the Jindal Heart Institute, Bhatinda. A sum of Rs.2,77,230/- were claimed by the OP No.3 qua the treatment charges of the complainant and out of which Rs.1,65,230/- were paid by the complainant and remaining amount of Rs.1,12,000/- was paid by the insurance company.
9. The bone of contention between the parties qua the claim of reimbursement of the remaining amount of Rs.1,65,230/-, which has been claimed by the complainant. The complainant in order to prove his case has furnished his affidavit Ex.CW1/A, in which, he has reiterated the contents mentioned in the complaint and also tendered documents such as insurance policies and schedules Ex.C1 to Ex.C5, bills of Forts hospitals, Jindal Hospital and other medicines and tests Ex.C6 to Ex.C23, application Ex.C24, postal receipt Ex.C25, legal notice Ex.C.26, postal receipts Ex.C27 to Ex.C31, email correspondence Ex.C32 to Ex.C41 and pre-approval certificate Ex.C42. On the other hand the, the Op No.3 has tendered the affidavit of Sh.Abhijit Singh, Ex.RW1/A, in which he has reiterated the contents mentioned in the reply and also tendered documents such as bill Ex.R1, pre approval certificate Ex.R2 and power of attorney Ex.R3 whereas Op No.1 has tendered affidavit of Sh.Bal Ram Bhadu, Sr.Divisional Manager Ex.R4, in which he has deposed in terms of facts mentioned in the reply and also tendered documents such as pre approval certificate Ex.R5 and insurance policy and schedule Ex.R6 to Ex.R9. In the affidavit Ex.R4, Sh.Bal Ram Bhadu, Sr.Divisional Manager has deposed that initial coverage for Rs.2 lacs for both husband and wife but the sum of which was enhanced and can only be according to clause 5.12 and complainant was having pre-existing disease, so there was restriction with regard to the payment according to the terms and conditions of the policy as per exclusion 4.1 and reimbursement of the covered expenses has been made on the cost sharing basis as referred in 1.2 (a) & (b), 1.2.1 and amount has been paid on co-pay basis as referred and mentioned in the policy clauses, which is also referred in letter dated 06.05.2017 vide which an amount of Rs.1,12,000/- in total has been paid on co-pay basis by the Op No.2 exercising the powers given to them by the IRDA/Govt. while appointing as TPA, who decided the claims according to the terms and conditions of the policy. He has further deposed that heart attack is always a result of pressure, stress, hypertension etc. and complainant was suffering from hypertension etc. before the inception of the policy, when he got risk covered for Rs. 2 lakhs and at the time of enhancement of the sum insured, he was very much aware about the restriction applicable over the reimbursement of claim by the TPA or insurance company. The perusal of the evidence of the OP No.1 reveals that they have not furnished the affidavit of any official of TPA, who settled the claim of the complainant while exercising the powers under the IRDA rules and had paid Rs.1,12,000/- to the Op No.3 on behalf of OP No.1 by deducting an amount of Rs.28,000/- on co-pay basis and the ground that the complainant was having pre-existing disease of hypertension prior to inception of the policy. Nor, the Op No.1 has placed on record any such document from which it could be presumed that the complainant was suffering from any pre-existing disease prior to inception of the policy before the issuance of the policy by the Ops for the first time to the complainant. It is admitted fact on record that the complainant and his wife were getting the medi-claim policy for the last more than 10 years and prior to getting the policy from Op No.1; they were getting the policy from some other insurance company and this fact has not been denied by the OP No.1 in its written statement. It is a matter of common sense that before accepting the proposal of a person, insurance company always prefer to get proposed person medically examined from their penal doctors, who evaluate the health condition of the person before accepting the proposal and issuing the insurance policy. The silence on the part of the OP No.1 that they had got the complainant medically examined or not, itself reflects the lapses on the part of the Op No.1 and now the Op No.1 cannot take such plea of pre-existing disease of hypertension of the complainant and cannot arbitrarily deduct the amount of Rs.28,000/- from the claim amount of the complainant by exercising their powers to deduct on the basis of co-pay. This act of the Ops No.1 & 2 clearly amounts to deficiency in service and unfair trade practice. Though the Op No.1 has stated that the claim of the complainant being 70 % of the insured value of Rs.2 lakhs comes to Rs.1,40,000/-, but however, it only paid Rs.1,12,000/- to the Op No.3, Fortis Hospital, Mohali and remaining amount of Rs.28,000/- remains to be paid by the insurance company to the complainant.
10. However, during the course of arguments the complainant has pointed out that the OP No.1 has not considered the bills of medicines of Rs.40,000/- which has not been considered and paid, though the complainant is entitled for the same. The complainant has not sought any relief against the Op No.3 nor has led any evidence against Op No.3 nor alleged any grievance against Op No.3, therefore, the complaint against Op No.3 stands dismissed.
11. In view of the above discussion, we hereby allow the present complaint with a direction to the OP No.1 & 2 to pay a sum of Rs.28,000/-, which has been deducted by the Ops No.1 & 2 on account of co-pay basis with interest @ 7 % per annum from the date of payment of Rs.1,12,000/- till its realization. The Ops No.1 & 2 are further directed to re-examine the bills of medicines and pay the same, if the same are payable under the terms and conditions. The Ops are further directed to pay Rs.10,000/- as compensation and Rs.2,000/- as litigation expenses to
A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:11.06.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
