THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 373-14
Date of Institution : 14.7.2014
Date of Decision : 27.03.2015
Tarlochan Singh son of late Sohan Singh, resident of 23-C,Guru Amar Dass Avenue,Ajnala Road, Amritsar
...Complainant
Vs.
United India Insurance Company Ltd., B-2/17, Mohan Coop.Area, Badarpur, New Delhi 110044 through its Manager/Divisional Manager/Officer Incharge
E-Meditek (TPA) Services Ltd., Plot No. 577, Udyog Vihar , Phase V,Gurgaon, Haryana 122002 through its Manager/Divisional Manager/Officer Incharge
Punjab & Sind Bank, H.O. Provident Fund Department, Commercial Complex, Siddhartha Enclave, New Delhi 110044 through its General Manager/Officer Incharge
....Opp.parties
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh. Rajinder Joshi,Adv
For the opposite party No.1 : Sh.K.K.Thakur,Adv
For opposite parties No. 2 & 3 : Ex-parte
Quorum : Sh. Bhupinder Singh, President,
Ms.Kulwant Kaur Bajwa,Member & Sh.Anoop Sharma,Member
-2-
Order dictated by :-
Bhupinder Singh, President
1 Present complaint has been filed by Tarlochan Singh under the provisions of the Consumer Protection Act alleging therein that he is ex-employee of opposite party No.3 i.e. Punjab & Sind Bank and got “Cashless Floater Group Mediclaim Policy” for Ex-employees of the bank bearing No.040600/48/13/41/00000068 for his family (himself and his spouse) for the period from 11.5.2013 to 10.5.2014 with sum assured Rs. 3,00,000/-. According to the complainant in the month of October 2013 he felt some urinary problems and consulted Dr. P.S.Mokha and Dr. Gurjit Singh, who advised the complainant to get biopsy and PSA tests. Accordingly the complainant got tests and was diagnosed to have Adenocarcinoma Prostate. . As such the doctors advised the complainant to take treatment from some cancer institute. The complainant consulted the doctors of Rajiv Gandhi Cancer Institute and Research Centre, Delhi ,who recommended surgery. As such the complainant admitted in the hospital on 26.12.2013 and underwent Robotic surgery on 27.12.2013 and was discharged from the hospital on 30.12.2013. The complainant spent Rs. 3,23,708/- on his medical treatment. The complainant then lodged the claim with opposite party No.1 alongwith all the original bills of payments, receipts and bills of medicines, etc. On 7.2.2014 complainant received a SMS on his cell phone that claim has been approved and settlement detail has been sent on his web link. The claim assessment sheet reveals that a sum of Rs. 1,68,265/- has been passed out of the total claim submitted by the complainant and deducted the remaining amount without any reason. The complainant wrote a letter dated 27.3.2014 which was posted on 31.3.2014 to opposite party No.2 requesting them to pay the balance claim amount upto the total sum insured Rs. 3,00,000/- . But the opposite parties did not pay any heed to the requests of the complainant. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite parties to pay the remaining claim amount of Rs. 1,31,735/- alongwith interest @ 18% p.a. Compensation of Rs. 1,00,000/- alongwith litigation expenses were also demanded.
2. On notice, opposite party No.1 appeared and filed written version in which it was submitted that complainant underwent Robotic surgery which was another option in compare to conventional surgery. It was the claimant himself who opted this costly surgery in compare to the other conventional surgery which is not allowed as per rules of the policy. It was submitted that the complainant was entitled to the cost of surgical/medical treatment which was necessary, customary and reasonable for treating the condition for which the insured person was hospitalized to the extent relatable to such condition. A thorough investigation was done by TPA i.e. opposite party No.2 and it was concluded that only conventional treatment expenses are payable as per guidelines. It was submitted that after processing the claim of the complainant subject to terms and conditions, limits, exclusions and capping of the policy, the claim calculation sheet was provided to the claimant. The payable claim was transferred in the bank account of the complainant through NEFT. It was denied that complainant is entitled to receive further balance of Rs. 1,31,735/-. It was denied that opposite party has deducted the claim amount without assigning any reason of deduction. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite parties No.2 & 3 did not appear and as such they were proceeded against ex-parte vide order dated 18.9.2014.
4. Complainant tendered into evidnce his affidavit Ex.C-1, copy of letter dated 16.5.2013 of Punjab & Sind Bank Ex.C-2, copy of discharge summary form F-68 Ex.C-3, copy of discharge summary form F-68 Ex.C-4, carbon copy of letter dated 12.1.2014 Ex.C-5, copy of claim Form Ex.C-6, copy of details of the bills for Rs.18058/- Ex.C-7, postal receipt dated 13.1.2014 Ex.C-8, copy of print out of SMS received on 7.2.2014 Ex,.C-9, copy of print out of SMS received on 6.3.2014 Ex.C-10, copy of claim assessment sheet Ex.C-11, copy of letter dated 27.3.2014 Ex.C-12, postal receipts Ex.C-13 and Ex.C-14, copy of letter dated 4.4.2014 Ex.C-15, copy of letter dated 17.4.2014 Ex.C-16, postal receipts Ex.C-17 and C-18, legal notice dated 13.5.2014 Ex.C-19, postal receipt Ex.C-20 to Ex.C-22, statement of account of bank account of the complainant Ex.C-23.
5. Opposite party No.1 tendered affidavit of Sh. Surinder Singh, DM Ex.OP1/1, copy of terms and conditions of the policy Ex.OP1/2, copy of reply to notice Ex.OP1/3.
6. We have carefully gone through the pleadings of the complainant and opposite party No.1 arguments advanced by the ld.counsels for the complainant and opposite party No.1 and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsels for both the parties.
7. From the record i.e.pleadings of the complainant and opposite party No.1 and the evidence produced on record by both the parties, it is clear that complainant who is a ex-employee of Punjab & Sind Bank got Cashless Floater Group Mediclaim Policy for Ex-Employees of the bank bearing No. 040600/48/13/41/00000068 for his family i.e himself and his spouse with sum assured Rs. 3,00,000/-for the period from 11.5.2013 to 10.5.2014 from opposite party No.1. The complainant suffered some urinary problem in October 2013 and consulted Dr. P.S.Mokha and Dr. Gurjit Singh, who advised the complainant to get biopsy and PSA tests.Accordingly, the complainant got tests and diagnosed to have ADENOCARCINOMA PROSTATE . The complainant was advised by the doctors to take treatment from some cancer institute. Resultantly the complainant approached Rajiv Gandhi Cancer Institute & Research Centre, Delhi where he was admitted on 26.12.2013 where he underwent Robotic surgery on 27.12.2013 and the complainant was discharged on 30.12.2013 with advice to come up on 4.1.2014 for check up/follow up. The complainant spent Rs. 3,23,708/- on his treatment in the aforesaid Rajiv Gandhi Cancer Institute. He submitted claim with opposite party No.2, who is TPA of opposite party No.1 alongwith all the receipts, bills etc., vide letter dated 12.1.2014 posted on 13.1.2014. On 7.2.2014 complainant received SMS on his cell phone that the claim of the complainant has been approved and from the web link, complainant got the print out of the claim assessment sheet which reveals that asum of Rs. 1,68,265/- has been passed out of the total claim submitted by the complainant and that amount was transferred by the opposite party No.1 in the bank account of the complainant on 15.3.2014 through NEFT. But the opposite party did not pay the balance claim amount of Rs. 1,31,375/- to the complainant without any rhyme or reason. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party.
8. Whereas the case of the opposite party No.1 is that the complainant underwent Robotic surgery which was another option in compare to conventional surgery. It was the claimant himself who opted this costly surgery as against the conventional surgery which is not allowed as per rules of the policy. So the complainant was entitled to cost of surgical/medical treatment which was necessary, customary and reasonable for treating the condition for which the insured person was hospitalized, to the extent relatable to such condition. Thorough investigation was done by TPA i.e. opposite party No.2. The amount of Rs. 1,53,100/- was deducted i.e. amount payable to the surgeon. Resultantly a sum of Rs. 1,68,265/- was paid to the complainant. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.
9. From the entire above discussion, we have come to the conclusion that the complainant was insured with the opposite party vide policy No. 040600/48/13/41/00000068 with sum assured Rs. 3,00,000/- for the period from, 11.5.2013 to 10.5.2014 and during this period from 26.12.2013 to 30.12.2013 the complainant was admitted in Rajiv Gandhi Cancer Institute & Research Centre, Delhi where he underwent Robotic surgery on 27.12.2013 and spent Rs. 3,23,708/- on his medical treatment. The complainant submitted claim with the opposite party No.1. Opposite party No.2 TPA of opposite party No.1, investigated the matter and vide their assessment sheet Ex.OP1/3, deducted a sum of Rs. 1,53,100/- on account of surgeon charges paid by the complainant to Rajiv Gandhi Cancer Institute,Delhi for Robotic surgery on the ground that Robotic surgery is an expensive surgery than conventional surgery. The opposite party has deducted this amount and paid to the complainant relatable amount of conventional surgery. But the opposite party could not produce any evidence as to whether Robotic surgery was not allowed /permissible under the policy in question. Further the opposite party also could not produce any evidence as to what is the difference between Conventional surgery and Robotic Surgery . Rather it is the prerogative of the insured to undergo surgery best available because the policy in question does not debar the insured from undergoing Robotic surgery. No where in the policy terms and conditions produced by the opposite party Ex.OP1/2, it has been mentioned that the insured shall be paid only charges of conventional surgery and not of Robotic surgery. The opposite party has wrongly deducted this amount of surgeon charges Rs. 1,53,100/- as per assessment sheet Ex.OP1/3. The opposite party paid only a sum of Rs. 1,68,265/- out of the total amount of Rs. 3,23,708/-.However, the complainant is entitled to claim upto Rs. 3 lacs i.e. sum assured under the policy in question. As such the complainant is entitled to the balance amount of Rs. 1,31,735/-which has been wrongly with-held by the opposite party.
10. Consequently we partly allow the complaint with costs and the opposite party No.1 is directed to pay the balance amount of Rs 1,31,735/- to the complainant alongwith interest @ 9% p.a from the date of filing of the complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
11. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
