Punjab

Ludhiana

CC/20/13

R.K Bansal - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

Abhishek Sharma

06 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 13 dated 14.01.2020.                                                Date of decision: 06.02.2023.

 

Mr. R.K. Bansal S/o. Raghbir Chand Bansal, R/o.455/11-A, New Kidwai Nagar, Ludhiana.                                                                                                                                                                                ..…Complainant

1. United India Insurance Co. Ltd., Divisional Office at IV, Savitri Commercial Complex-I, Dholewal, G.T. Road, Ludhiana.               
2. Raksha Health Insurance TPA Pvt. Ltd., First Floor, 14/3, Main Mathura Road, Fairdabad-121003, through its Manager.                                                                                                          …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Abhishek Sharma, Advocate.

For OPs                          :         Sh. M.S. Jassal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant being employee of Punjab National Bank, Ludhiana is medically insured under Punjab National Bank’s group medical scheme for active employees in collaboration with opposite party No.1 who has further appointed opposite party No.2 who is a Third Party Administrator. The complainant was having medi-claim policy bearing No.5001002817P110672408 for the period from 01.10.2017 to 30.09.2018. The complainant stated that he was suffering from Microscopic Colitis and he went to Dayanand Medical College and Hospital, Ludhiana for his treatment. On 19.09.2018, the complainant was admitted in the said hospital and his son went to hospital’s TPA counter for availing his insurance. Son of the complainant handed over all the requisite documents at TPA counter of the hospital for initiating the process of medical insurance claim of complainant for which communication between hospital and insurance company started taking place and treatment of the complainant was finally finished and he was discharged on 22.09.2018. The complainant had availed cashless facility for treatment of the said disease and duly intimated the opposite parties within prescribed time as per policy. Opposite party No.1 told the complainant that at present cashless facility was not available and asked him to pay in cash the whole bill amount incurred on his medical expenses and get it reimbursed later on. The complainant has further stated that on 24.09.2018, opposite party No.2 communicated with DMC&H, Ludhiana vide which opposite party No.2 issued initial approval for Rs.13,000/- vide preauthorization No.256689389 which was never given to the complainant and the opposite parties were negligent in providing service. Thereafter, opposite party No.2 told the complainant that at present cashless facility is not available and the complainant had to pay cash for the whole bill amount incurred on his medical expenses. Further the opposite partied had put forward a condition to submit final bills of whole amount paid in cash by the complainant and get it reimbursed later on with condition that the amount will be enhanced after sending final bill and discharge summary.  The complainant sent emails dated 24.09.2018, 27.09.2018, 28.09.2018 to opposite party No.2 who had initiated the mediclaim process of the complainant and asked for PF number or ID number from the complainant which was duly communicated to opposite party No.1. The complainant further submitted that on 01.10.2018, opposite party No.2 again communicated with DMC&H, Ludhiana vide letter specifically stating that opposite party was unable to approve cashless hospitalization but same can be approved by sending the claim for reimbursement. Opposite party No.2 communicated with the complainant vide email dated 12.10.2018 admitting that they had received all documents and the claim is registered. Thereafter, vide email dated 25.10.2018 opposite party No.2 had asked for break-up of main hospital bills on Hospital’s Letter Head and the same were replied and documents were attached vide communication through email on 31.10.2018. Opposite party No.2 vide letters dated 06.11.2018 and 21.11.2018 had sent first and final reminder for demanding break up of main hospital bills on Hospital’s Letter Head respectively which the complainant had already sent the same on 31.10.2018 through emails to opposite party No.2. The complainant even visited office of opposite parties on 09.11.2018 and physically delivered breakup bill on hospital’s letter head as per demand letter dated 25.10.2018 of opposite party No.2 and also put their receiving stamp on the same. Even after communication and visit of the complainant to the office of opposite parties, the opposite parties failed to satisfy the complainant and have been deficiency in service. The complainant approached his bank and apprised the bank about the situation vide email dated 16.06.2019 and PNB Bank’s Human Resources Management Division, Hospitalization Cell through its Chief Manager had also sent complainant a letter dated 20.06.2019 confirming/assuring in which they had asked opposite party No.2 to take up the matter, consider and reimburse the claim amount but the opposite parties could not satisfy the complainant. Thereafter, the complainant after wait for one month finally communicated with bank through email dated 20.07.2019 and expressed his inability. The complainant has further stated that he has paid the total sum of Rs.30,750/- vide three different receipts minus the amount of Rs.2756/- which was refunded to the complainant and as such, a total amount of Rs.27,993/- was paid by him which was to be reimbursed to him by the opposite parties which they are liable to pay the same to the complainant. The complainant also served a legal notice dated 18.09.2019 upon the opposite parties to which opposite party No.2 gave evasive reply vide its reply dated 15.10.2019. Hence this complaint, whereby the complainant has sought direction to opposite parties to pay the amount of Rs.27,993/- incurred on his medical expenses along with interest @18% per annum and to pay legal expenses of Rs.22,000/- and compensation of Rs.25,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable and is barred under Section 26 of the Consumer Protection Act; the complainant estopped by his act and conduct and suppression of material facts. The opposite parties alleged that Indian Bank’s Association A/C Punjab National Bank had taken the Tailormade Group Mediclaim policy bearing No.5001002817P110672408 for the period from 01.10.2017 to 30.09.2018 from opposite party No.1 and Raksha Health Insurance TPA Pvt. Ltd. opposite party No.2 was appointed as TPA in the policy. The complainant remained admitted only for investigation from 18.09.2018 to 22.09.2018 in Dayanand Medical College and Hospital, Ludhiana for his diagnosis. Opposite party No.2 issued letters dated 25.10.2018, 06.11.2018 and 21.11.2018 to the complainant and requested for supply of breakup of main hospital bill on Hospitals Letter head for the settlement of the medi-claim within 15 days but he did not supply to opposite party No.2 the above said required documents within 15 days from the last reminder. The complainant had submitted only the diagnosis, x-ray or laboratory examinations or other diagnostic studies to opposite party No.2 who while going through the record of patient R.K. Bansal observed that C/O Acute gastroenteritis. Patient is admitted only for investigation. There is no active management. Hence claim non payable as per condition 4.7. Hence claim non payable as per policy condition and clause 4.7. So the claim of the complainant is not admissible as per exclusion clause 4.7 (pre existing disease) of the policy and the claim of the complainant has been repudiated by the opposite parties. The exclusion cause 4.7 is reproduced as under:-

“Charges incurred at Hospital or Nursing Home primarily for diagnosis, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness of injury, for which confinement is required at a Hospital/Nursing Home.”

The opposite parties further alleged that the insurance policy is a contract between the insurance company and the insured person and each other are bound by the terms and conditions of the insurance policy. So, the case of the insured has been decided as per terms and conditions of the insurance policy. The Raksha Health Insurance TPA Pvt. ltd. has repudiated the claim of the claimant on 27.11.2018 also conveyed the repudiation of claim to the complainant and as such, the complainant is not entitled for the medi-claim as per terms and conditions and exclusion cause of the insurance policy.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                The complainant has filed rejoinder to the written statement reiterating the facts mentioned in the complaint and controverting those mentioned in the written statement.

4.                In support of his claim, the complainant tendered his affidavit Ex. CW1/A in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. CA/1 is the copy of HRMD circular No.404 of Human Resources Management Division, Hospital Cell of Punjab National Bank, Ex. CA/2 is the copy of discharge summary, Ex. CA/3 to Ex. CA/11, Ex. CA/13 to Ex. CA/17 are the copies of correspondence between the parties, Ex. CA/12 is the copy of bill dated 222.09.2018 of DMC & Hospital, Ludhiana, Ex. CA/18 is the copy of letter dated 20.06.2019 issued by Punjab National Bank, Human Resources Management Division, Hospitalization Cell to the complainant, Ex. CA/19 is copy of email dated 20.07.2019, Ex. C20 to Ex. C22 are the copies of receipts dated 19.09.2018 issued by DMC & Hospital, Ludhiana, Ex. CA/23 is the copy of In-patient final bill dated 22.09.2018 issued by DMC & Hospital, Ludhiana, Ex. C24 is the legal notice dated 18.09.2019, Ex. C25 and Ex. C26 are the postal receipts, Ex. C27 is the reply to legal notice dated 15.10.2019, Ex. C28 is the certificate of the complainant under Section 65-B of Indian Evidence Act and closed the evidence.

5.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Ms. Rekha Mathur, Manager, Legal Cell, United India Insurance Company Ltd., Surya Tower, Mall Road, Ludhiana along with documents Ex. R1 is the copy of Tailormade Group Mediclaim Policy (Employees) No.5001002817P110672408, Ex. R2 to Ex. R6 are the letters dated 25.10.2018, 06.11.2018, 21.11.2018, 27.11.2018 and 24.09.2018 issued by Raksha TPA to the complainant, insurance company and DMC Hospital respectively, Ex. R7 is the copy of claim form, Ex. R8 is the copy of guidance for filling claim form, Ex. R9 is the copy of letter dated 03.05.2019 written by the complainant to Raksha TPA, Ex. R10 to Ex. C12 are the copies of discharge summary including investigations and follow up advice etc. and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, rejoinder, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties. We have also gone through the written arguments submitted by the complainant.   

7.                The claim of the complainant has been repudiated by the opposite parties by invoking exclusion clause No.4.7 of the insurance policy Ex. R1 which reads as under:-

4. Exclusions

4.7 Charges incurred at Hospital or Nursing Home primarily for diagnosis, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness of injury, for which confinement is required at a Hospital/Nursing Home.”

 

The claim has been repudiated on the premise that the patient admitted only for investigation and there is no active management and treatment for any ailment.

8.                Now the point for consideration arises how it is required to be assessed that the admission is primarily for evaluation and investigation purpose only?

9.                Perusal of the discharge summary Ex. CA/2 = Ex. R10 where the reasons for admission is mentioned loose stool 40 episodes x yesterday, which reads as under:-

          “Reasons for admission:

          Loose stool 40 episodes x yesterday

          Fever with chills”

It reflects the medication administered by the treating doctors which is in the form of Injection Monicef. So it is evident that the disease was treated with the help of injectables and the administration of the same is possible by admitting the patient in door. Moreover, except the affidavit Ex. RA of one Ms. Rekha Mathur, Manager, Legal Cell of the opposite parties, no other medical evidence has been adduced by the opposite parties to rebut the specific opinion of the medical experts that it was fit case for indoor treatment in the hospital. The affidavit Ex. RA is also verbatim reproduction of the averments of written reply. The opposite parties have also not relied upon in medical literature  or authority to support their claim. In the given facts and circumstances, it cannot be said that the repudiation of the claim is justified and as such, it would be just and appropriate if the opposite parties are directed to pay the medical expenses of  Rs.27,993/- spent on treatment of the complainant along with interest @8% per annum from the date of admission i.e. 19.09.2018 till date of actual payment along with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is partly allowed with an order that the opposite parties shall pay the claim of medical expenses of Rs.27,993/- spent on treatment of the complainant along with interest @8% per annum from the date of admission i.e. 19.09.2018 till date of actual payment.  The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. The opposite parties are jointly and severally liable to pay the said amounts to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

 

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:06.02.2023.

Gobind Ram.

 

 

R.K. Bansal Vs United India Insurance Co. Ltd.             CC/20/13

Present:       Sh. Abhishek Sharma, Advocate for complainant.

                   Sh. M.S. Jassal, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the opposite parties shall pay the claim of medical expenses of Rs.27,993/- spent on treatment of the complainant along with interest @8% per annum from the date of admission i.e. 19.09.2018 till date of actual payment.  The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. The opposite parties are jointly and severally liable to pay the said amounts to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

                

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:06.02.2023.

Gobind Ram.