FINAL ORDER/JUDGEMENT

SHRI REYAZUDDIN KHAN , MEMBER

This is a complaint case u/s 35 of the CP Act, 2019.The fact of the case in brief is that the complainant is a principal policy holder and other family members are the second policy holder of United India Insurance Company Ltd.The complainant renewed the policy on 2020-2021 by paying Rs,27,142/ as annual premium and Rs,8,732 is the additional top up to the OPs 1&2 vide family Medicare policy 2014 UIN No.IRDA/NL-HLT/UII/P-H/V.II/231/13-14,Policy No.0303002820P103401418 valid from 12.07.2020 to 11.07.2021.The sum assured of the

Mediclaim policy is Rs,10,00,000/.On 16.10.2020 the complainant admitted in ILS hospital,Howrah due to cold,cough and breathing problem and tested Covid positive. The complainant continued in hospital till 28.10.2020.Doctor advised for one month bed rest. complainant stated that the hospital authority raised bill of Rs,4,05,339/.Though the policy covered 100% cash less facility,the OP insurance company paid only Rs,1,36,950/ and as such the complainant arranged rest of the money through loans from their relatives with great difficulty.The complainant further stated that the OPs 1 & 2 harassed the complainant by not issuing the entire cash less payment of the hospital and denied rest amount on some false,baseless,whimsical,arbitrary and illogical grounds and as such it is deficiency in service and unfair trade practice.The complainant issued advocate’s demand notice on 02.12.2020 upon OP1 and asked for the rest of the payment as per the hospital bill within 15 days from the date of the receipt of the said notice.The OP1 through mail dated 09.12.2020 gave false and frivolous reply by stating that the hospitalization claim for Covid of the complainant was settled as per circular of GI council dated 20.06.2020.It was found after comparing with the settled claim to GI circular that there was huge irregularity on the part of the insurance company.So,there is deficiency is service and unfair trade practice on the part of the OP1 & 

 2.It is also stated by the complainant that the complainant has no allegation against performa opposite party no.3. The complainant further stated that they suffered mental agony and pain due to non receipt of the claim amount from the OPs Insurance company and hence prayed for to direct the OPs to pay the balance cashless claim of Rs,2,68,389/-with interest @18% per annum  to the complainant with the compensation of Rs,2,00,000 for mental agony,harassment and pain and Rs,20,000/ as litigation cost.

The OP1& 2 have contested the case by filing their WV contending inter alia that the case is not maintainable in law and fact,there is no cause of action and pretended issues raised in the instant complaint are baseless and arbitrary and hence is liable to be dismissed. The complainant was a policy holder of family Medical policy being No. 0303002820P103401418 valid from 12.07.2020 to 11.07.2021.The ILS hospital intimated the TPA company “Heritage Health InsuranceTPA Pvt.Ltd” regarding the admission in hospital  of the complainant due to Covid-19 positive,Pneumonia on 16.10.2020.On scrutiny the claim papers the TPA asked some additional documents from hospital and on receipt of the papers the claim was admitted for Rs,1,36,950/ after necessary deduction as per GI council rate/ Govt. rate for Covid-19.Therafter,insured submitted treatment documents along with completed claim form reimbursement of Rs,18,196/ and after scrutinizing the claim papers the claim had been settled by the TPA for Rs,15,511/ after necessary deduction credited on 01.02.2021 vide UTR No.21118274612.There is no deficiency in services on behalf of the company.The company has taken decision on the claim after due application of its mind and in good faith on the GI council rate/Govt.rate for Covid-19.OPs relies on decision reported in (1996) 3 SCR 500.General Assurance Society Ltd Vs Chandumull Jain and Anr.The OPs submitted as per provision of law and also relying upon ruling reported in 2013(4) CPR 165 NC .The decision of the OP1 & 2 for settlement of claim is correct and there is no deficiency,negligency on the part of the OP1 & 2 and claim was settled as per terms and condition of the policy and after proper calculation and verification.Hence,it is prayed the the complaint petition may graciously be dismissed in limini under section 26 of said consumer protection Act.

            The Performa OP3 (ILS Hospital) also contested the case by filing WV inter alia that the instant complaint is not maintainable against the pro-forma OP3.There is no deficiency in service is observed on the part of OP3.The complainant have not ever make any specific allegations,any grievance  against the pro-forma OP3.There is no such collusion with the said Insurance company with regard to exorbitant billing.Hence,the present case against the Pro-forma OP No.3 hospital may kindly be dismissed with compensatory cost.  

Points for Determination

In the light of the above pleadings, the following points necessarily have come up for determination.

1) Whether the OPs are deficient in rendering proper service to the complainant?
            2) Whether the OPs have indulged in unfair trade practice?

3) Whether the complainant is entitled to get relief or reliefs as prayed for?

Decision with Reasons

Point Nos. 1 to 3:-

All the points are taken up together for sake of convenience and brevity in discussion. We have travelled over the documents placed on record. The complainant and the OPs have filed their Evidences supported by affidavit.Both parties have submitted their BNAs.

The fact of the case in brief is that the complainant availed a mediclaim policy from the OP 1& 2 for himself and his family members since 2005.The policy was renewed for the financial year 2020-2021 by paying an annual premium of Rs,27,142/ and further sum of Rs,8,732/ for additional top up. On 16.10.2020 the complainant was tested positive and was admitted in ILS Hospital,Howrah.The hospital raised the bill for a sum of Rs,4,05,339/.Though the policy was 100% cashless and the hospital was within the network of hospitals covered by OP 1,only an amount of Rs,1,36,950/ was paid by the OP 1out of total claim of Rs,4,05,339 and refused to give entire claim.

The OPs argued that the company has taken decision on the claim after due application of its mind and also based on GI council rate/Govt.rate for Covid-19.

It is admitted that the complainant was a active policy holder of family medicare policy with sum insured of Rs,10,00,000/ effective from 12.07.2020 to 11.07.2021.

It is also admitted that the complainant was admitted in ILS Hospital due to Covid-19 positive and accordingly TPA company was intimated.

It is admitted that the OP 1& 2 disbursed only Rs,1,36,950/ out of total claim amount of Rs,4,05,339/ which is  the bone of contention of both the complainant and the OPs.

   If we analyze the Final IP summary Bill dated 28.10.2020 issued by ILS Hospitals,Howrah.we find that the payment of Bed charges of Rs,79,800 and Pharmacy of Rs, 1,77,058 is completely denied by the TPA and only Rs,1470/ paid against the Doctor fess out of Rs,13,000/

Now if we analyze the GI council rate/Govt.rate for Covid-19 we are unable to trace the details of deduction related to above mentioned details of bill.There is no whisper of 100% deduction in Bed charges and Pharmacy. There is no whisper of such deduction in Doctor’s fees in their WV and evidence too.so,it is established that the OPs rejected the further payment in order to avoid their liability.

 Considering all the actions and inactions of the OPs against the claims submitted by the complainant we are of the opinion that there is deficiency in service as well as unfair trade practice on the part of the OPs. The poor application of mind on the part of TPA should be seriously viewed by the Insurer herein the United India Insurance Company Ltd.being the OPs. They cannot escape their responsibility by simply forwarding the ball to the court of the TPA for taking exclusive decision on their behalf. The IRDA guidelines dated 19.03.2021 to all the CEOs of Life, General and Standalone Health Insurance Companies Ltd. and TPAs is very much relevant where it is specifically mentioned in point No. 4 that “Insurer shall ensure that the repudiation of the claim is not based on presumptions and conjectures”. It has been clearly mentioned in another circular of IRDA dated 20.09.2011 that “the insurer’s decision to reject a claim shall be based on sound logic and valid grounds.

“A pedantic and hyper-technical approach would cause damage to the very concept of consumerism”.

In the result, the consumer complaint succeeds.

Hence,

Ordered

That the complaint case be and the same is allowed on contest against OP 1& 2 and dismissed against OP3 with the following directions.

1.The OP 1 OP 2 are directed  to pay jointly or severally a sum of Rs. 2,68,389/ (Rupees Two Lakh Sixty eight thousand Three hundred eighty nine)only as mentioned above to the complainant.

2.The OP 1 & 2 are further directed to pay jointly and severally a sum of Rs. 25,000/- to the complainant as compensation towards harassment and mental agony.

3.The OP 1& 2 are also directed to pay jointly and severally a sum of Rs.  10,000/- to the complainant as litigation cost.

The above order is to be complied by the OPs within a period of 45 days from the date of this order. In default, the complainant will be at liberty to put the order into execution.

Copy of the judgment be delivered to the parties free of cost as per the C.P. Act and Judgment be uploaded in the website of the Commission for perusal of the parties.