Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-309/24.08.2016
Sh. Jasvinder Singh Baweja s/o Mr. Varinderpal Singh,
r/o 14B/1, D.B. Gupta Road, Dev Nagar
Karol Bagh, Central Delhi-110005 ...Complainant
Versus
United India Insurance Company Limited
Having its register office at:
24, Whites Road, Chennai-600014
And branch office at:
213-215, Namdhari Chambers, D.B. Gupta Road
Karol Bagh, Central Delhi-110005 ...Opposite Party
Order Reserved on: 15.02.2023
Date of Order: 15.05.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Vyas Muni Rai
ORDER
1. The instant complaint has been filed by Sh. Jasvinder Singh Baweja [in short ‘complainant’] against United India Insurance Company Ltd. [in short ‘OP’].
2. The complainant had subscribed a ‘family medicare policy 2014’ having policy no. ‘0404012815P109945117’ from the OP and its validity period was from 25.11.2015 till 24.11.2016. In the said policy Sh. Jasvinder Singh Baweja [self], Mrs. Maneet Kaur [spouse] and master Parbhash Singh Baweja [son] were the insured [policy document at page no. 10-11 of the complaint]. The said policy for complainant family members was against any disease, illness or any bodily injury which may require hospitalization, treatment etc.
3. During the validity period of the policy, the minor son of the complainant was diagnosed with Chronic Adenotonsillitis and was advised by the medical practitioner for undergoing an Adenoidectomy; upon such medical advice, the complainant got his son Parbhash Singh Baweja admitted to B.L. Kapoor Hospital at Pusa Road, Delhi which is a PPN [Preferred Provider Network] hospital empanelled with the OP and therefore, eligible for providing cashless health insurance facilities.
4. Complainant’s son was admitted to the hospital on 14.03.2016 for undergoing Adenoidectomy and on 15.03.2016, after the said medical procedure was performed on son of the complainant, the complainant was informed by the hospital administration that insurance company had processed only Rs. 21,711/- from the total bill amount of Rs. 78,146/- and until and unless the balance amount of Rs. 56,436/- is paid, they will not discharge the son of the complainant from the hospital. Such facts brings out the deficiency in service by the OP as the said policy was cashless and the said procedure was covered under the insurance policy and the medical facility being performed at PPN hospital.
5. The complainant, in order to get his son discharged having no alternative, was compelled to pay remaining amount of Rs. 56,436/- in spite of the fact that the performed procedure was covered by the said insurance policy subscribed by the complainant [discharge summary is annexure-C/2].
6. Further, it is the case of the complainant that he had made numerous requests and reminders to the OP to pay the remaining amount of the medical bills as the same was unreasonably approved being part of the total claim after making arbitrary deductions without giving any explanation of the same and the complainant has further alleged that OP indulged in deceptive and unfair trade practices as they had falsely represented at the time of selling the insurance policy that it was purportedly a cashless facility at PPN Hospital covering diseases and injuries which may require hospitalization etc., the sum insured in the policy under reference is Rs. 2,50,000/-, since OP has failed to discharge its part of obligation and wrongly declined the claim of the complainant by arbitrarily reducing it to Rs. 21,711/- from Rs. 78,146/-.
7. The aforesaid alleged deficiency of service on the part of OP, constraint, the complainant to file this complaint for directions to OP for claim of Rs. 78,146/- instead of Rs. 21,711/-; Rs. 1,00,000/- towards mental agony and trauma suffered by the complainant in addition to pay the costs of petition and litigation expenses incurred by the complainant and any other order which the Court/ Commission deems just and proper in the facts and circumstances of the case.
8. OP has filed his reply under two heads 1. Preliminary Objections and 2. Reply on merits. OP has filed the reply supported by affidavit under the signature of Shri Jagdish Narang, Deputy Manager in the office of OP. In the preliminary objection it has taken the stand that the complaint is false, frivolous and the complainant has not come before this Commission with clean hands, therefore, it is liable to be dismissed; complainant has concealed the material facts; OP company had already paid the mediclaim amount as per the terms and conditions of the policy to the complainant, therefore, no cause of action arises in favour of complainant, as per the opinion given by TPA, the complainant has raised highly excessive bill amount, which was not payable as per the package rates for the diseases suffered by the son of the complainant, therefore, the OP paid eligible amount as per the terms and conditions of the policy; TPA of OP also sent mail to the nodal TPA (Raksha) but no reply was sent by the nodal TPA. OP denies deficiency of services on its part, the said insurance policy was cashless and also the said procedure being performed at PPN hospital. OP rightly and correctly paid the amount as per the terms and conditions of the policy. It has been denied that having no other alternative, the complainant was compelled to pay the remaining amount of Rs. 56,436/-, in spite of the fact performed procedure was covered by the said insurance policy which had been subscribed by the complainant; as alleged and legally payable amount has already been paid. It has also been denied that the complainant has made numerous request and reminders to the OP to pay the remaining amount of the total medical bills, allegation of unfair trade practices has also been denied by the OP; rest of the allegations in the body of the complaint has been denied by the OP to be wrong and false.
9. Complainant has also filed rejoinder to the reply of OP, which is based on the facts and features of complaint and contents of the reply have been denied, no new facts has surfaced in the rejoinder of the complainant.
10. Both the parties have filed affidavits of evidence, complainant has filed the affidavit for evidence under his signature and affidavit of OP has been filed under the signature of Sh. Jagdish Narang, Deputy Manager, contents of the affidavits of both the parties are the narrations of the facts given in the complaint and reply of OP respectively.
11. Written arguments from both the parties have also been filed, which are on the line of contents of the complaint and reply. Sh. Harish Kumar, Advocate made oral submissions on behalf of the OP, oral submissions were not advanced on behalf of the complainant, despite opportunities.
12. We also find on record an application dated 18.04.2022 filed on behalf of the OP, vide which list of documents i.e. list of PPN(GIPSA Procedures) issued to BL Kapoor hospital along with claim settlement advise dated 04.05.2016 and the said documents was allowed to be taken on record by proceedings dated 18.04.2022.
13. We have examined and analysed the contentions and rival contentions of the parties, contents of the documents filed by the parties on record and the pleadings/ reply of both the parties.
14. It is admitted facts that the complainant had subscribed the ‘family medicare policy 2014’ which was valid from 25.11.2015 till 24.11.2016, the said policy was for complainant himself and his family member as detailed in para 2 above. It is also admitted facts that complainant’s son was admitted to the BL Kapoor hospital for the treatment, part amount was paid by the OP, apart from, the policy was cashless, sum insured was Rs. 2,50,000/-. The complainant’s son was admitted in the hospital on 14.03.2016 during the validity of the policy, and he was discharged from the hospital on 15.03.2016 being admitted facts. Nature and type of the illness is also a admitted fact. As per the Annexure-C/2 [page no. 21-22 of the complaint]; the total bill amount raised by the hospital was Rs. 78,147/-; out of which Rs. 56,436/- was paid by the complainant at the time of discharge, since it was approved and Rs. 21,711/- was approved claim amount [ Rs. 56,436/-+ Rs. 21,711/-=Rs. 78,147/-]. OP has not given grounds of deduction of the claimed amount, as the complainant has stated so. OP has also alleged of concealment of material facts on the part of the complainant but OP failed to prove or explain as to what material facts were concealed by the complainant. It is also the stand of the OP that complainant submitted highly excessive bill amount but could not p rove it since as the claim of the complainant is based on the bills amount raised by OP’s empanelled hospital i.e. PPN. OP in its reply has pleaded that it paid the payable amount as per the terms and conditions of the policy but details (in terms of the policy) has also not been explained by the OP. OP has also submitted in its reply that as per opinion of TPA, complainant had raised highly excessive bill amount but details of the same has not been given.
15. According to the PPN (Gipsa procedure) having PPN Code; amount is to charged by the BL Kapoor hospital for different medical parameters but it has not been clarified and codified as to which medical parameters and the chargeable amount given therein are applicable in case of complainant son; in the said PPN(Gipsa procedure) at the last running page under the head ‘Note’, it has been written that “1. The validity of this MOU will be for two years, however, the date of MOU said of PPN(Gipsa Procedure) is not given so as to reach at a conclusion whether the details given therein is within the validity period of 2 years or beyond.
16. We also find on record an email dated 02.04.2016 from one Sh. Devender Dubey (TPA) addressed to the Jaswinder Bewaja/the complainant, wherein, inter alia, it is written that “we have also asked the insurer and tried our level best to get this case settled by the time of discharge in cashless. But did not get any revert from the nodal TPA. In fact, United India Insurance Company, Regional Office also intervened to resolve the case, but all in vain; nodal TPA could not give any response” if that is so, it is not for the complainant to suffer. The OP has also been categorically not substantiated its stand regarding settlement of the claim amount of the complainant as the reply of the OP is in stereotype manner, specially to the effect that the deductions in the claim amount has been resorted in accordance with the terms and conditions of the policy
17. In view of the aforesaid discussion and deliberation, complainant has succeeded to prove his claim, we allow the complaint in favour of the complainant and against the OP and order as under:
(i). OP shall pay the complainant Rs. 56,436/- i.e. the amount complainant paid from his own pocket;
(ii). OP shall also pay Rs. 10,000/- to the complainant towards damages for mental agony and harassment; apart from Rs. 5000/- as litigation cost.
(iii). OP is directed to pay to the complainant balance amount of Rs. 56,436/-; Rs. 10,000/- to the complainant towards damages for mental agony and trauma faced by him, apart from Rs. 5,000/- as litigation cost within 30 days from the date of receipt of this order.
However, if the claim amount of Rs. 56,436/- is not paid by the OP to the complainant within 30 days from the date of receipt of this order, then said amount would be payable to the complainant with interest at the rate of 6% p.a. from the date of filing of the complaint till its realization.
18. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
19: Announced on this 15th May, 2023.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
