DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 86/2021

Date of Institution: 12.02.2021

Judgment Reserved on: 14.02.2024

Judgment Passed on: 14.02.2024

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member) - On Leave  

Ms. Rashmi Bansal (Member)

Order By: Shri S.S. Malhotra (President)

JUDGMENT

1. By this judgment the Commission shall dispose off the complaint of the complainant alleging deficiency on the part of OPs in not reimbursing the full amount of the bill spent on his treatment against a valid policy.
2. Brief facts as stated by the complainant in the complaint are that he is a regular mediclaim policy holder of OP1 for which OP2 is its TPA and he purchased Group Health Scheme Vide Policy No. 2215032819P113344201 which was effective from 08.02.2020 to 07.02.2021 and he paid annual premium of Rs.11,141/-, however on 18.09.2020 he suffered a severe chest pain and was immediately taken to Balaji Max Hospital, I.P. Extension, Patparganj, Delhi where he was asked to deposit Rs.50,000/- which was deposited but on the very same day he was shifted to Max Hospital, Saket, New Delhi, where he was asked to deposit Rs.20,000/- immediately which was deposited and the hospital authority told to deposit the whole amount of the treatment but when the request for cashless was made to OP1, it declined the same on the ground that “Given hospital is not in their panel” and ultimately the complainant has to pay the entire amount of Rs.4,00,875/-, and was  discharged. After the discharge he approached the OP2 for reimbursing the claim and submitted all the documents whereafter OP2 asked him as to why he/complainant has not utilised the cashless facility to which OP2 was explained all these facts including the fact that complainant was told by OP2 itself that the given hospital was not on their panel, to which OP2 did not reply and thereafter, after exchanging of various letters and after much delay, the OP reimbursed the amount of Rs.2,22,358/- only and did not reimburse, remaining amount of Rs. Rs.1,78,499.54/- and as such the complainant has filed the present complaint thereby alleging deficiency on the part of OPs and claiming Rs.1,78,499.54/- with interest @24% p.a. and compensation of Rs. 5 Lakh with litigation charges.  
3. The OP has filed its reply taking preliminary objection that the present complaint is not maintainable as it is sheer abuse of the process of law, complaint is mis-conceived and groundless, amount of Rs. 2,22,358/- which was payment has been given to complainant as per GIPSA package and insured was also paid Rs. 4396/- as post-hospitalisation bill and now complainant is not entitled for any further amount of Rs. Rs.1,78,499.54/- as alleged therefore complaint of the complainant be dismissed.
4. As far as merits are concerned, the facts are not disputed i.e. the facts w.r.t. the policy, premium, the validity of policy, part payment made by OP2 to complainant etc and it is reiterated that as per GIPSA conditions whatever was payable has already been given and therefore complaint of the complainant be dismissed.
5. Complainant has filed rejoinder interalia stating that if payment made by OP are as per the GIPSA terms & conditions as alleged, then whatever the terms & conditions, the OP had with GIPSA, were never conveyed to the complainant at the time of granting the policy and therefore non reimbursing of the amount of Rs.1,78,499.54/- amounts to deficiency of service and complainant has denied all contents of written statement and contents of complaint are reiterated.
6. Complainant has filed his own evidence by way of affidavit whereas OP has filed evidence of Sh. Anil Kanojia, Deputy Manager and both the parties have filed their written arguments. The Commission has heard the arguments and perused the record.
7.  The complainant has placed on record receipt of Rs.50,000/- from Balaji Max Hospital, I.P. Extension, Patparganj, Delhi whereafter the treatment bill was only Rs.16,956/- and Rs.33,043.96- were refunded to the patient. Thereafter the complainant has filed another bill from Max Hospital, Saket, New Delhi for an amount of Rs. Rs.3,63,919.20/- which includes Rs.20,000/- as deposited by complainant on 18.09.2020, and after all the adjustment of Rs.20,000/- and even after discount given by hospital the complainant has paid the amount of Rs. Rs.3,63,919+16,956=3,80,875/- towards the treatment. The complainant has not filed any further bill w.r.t. post medical charges alongwith prescription therefore the total amount which the complainant has paid to the OP is only to the extent Rs.3,80,875/- out of which (Rs.2,22,358+4,396) Rs.2,26,754/- towards hospitalization have already been paid & therefore an amount of Rs. 3,80,875-2,26,754=Rs.1,54,121/-  have not been paid.
8. The Commission has heard the arguments at length and during the argument the Commission has enquired from the Ld. Counsel for OP as to why this amount has been deducted by the OP to which he submits that amount has been deducted as per the GIPSA terms & conditions and therefore no further amount is payable. When confronted by Ld. Counsel for complainant as well as by the Commission as to whether the terms & conditions of GIPSA were ever conveyed to the complainant before or even after the policy was given to him to which Ld. Counsel for OP has candidly submits that it might have been conveyed but there is no document on record from which it can be ascertained that such terms & conditions were given to the complainant.
9. The Commission is therefore of the opinion that if there is any agreement in between OP and some third person then they are binding upon them only and would not be binding upon the complainant unless & until such terms & conditions have been explained to the complainant or given in writing to the complainant so as to the complainant be made aware w.r.t. product/policy he has purchased and he cannot be allowed to be taken by surprise by such terms & conditions at the time of reimbursement.
10. Keeping in view all this fact the Commission is of the opinion that OP was deficient in its services in not completing reimbursing the amount particularly in the circumstances when the terms & conditions of GIPSA agreement were not conveyed to the complainant. Accordingly the OP is directed to pay Rs.1,54,121/- with compensation of Rs.15,000/- and legal expenses of Rs.7,500/- alongwith interest @12% p.a., with effect from date of repudiation till the actual payment is made.

This Order is to be complied within 30 days from the receiving the same & in case the OP could not pay the amount within 30 days the rate of interest would be @15% from the date of repudiating upto the date of realization on the entire amount.

Copy of the Order be supplied/sent to both the Parties free of cost as per rules.

Announced on 14.02.2024.

File be consigned to Record Room.