BEFORE THE DISTRICT CONSUMER REDRESSAL FORUM
(DISTRICT FORUM)
UNOKUTI DISTRICT : KAILASHAHAR
C A S E NO. C. C. 17/18
SRI BIDHAN DAS
Son of late Jamini Das
of Mohanpur,P.O. Kailashahar
P.S & Sub-Division – Kailashahar,
District- Unakoti ,Tripura.
Pin- 799277
…......COMPLAINANT
V E R S U S
United India Insurance Company Limited,
P.O & P.S- Kailashahahar
Sub-Div.-Kailashahar
District- Unakoti, Tripura.
Represented by :-
THE BRANCH MANAGER,
United India Insurance Company Limited,
Kailashahar Branch, Kailashahar,
Unakoti Tripura.
….....OPPOSITE PARTY
P R E S E N T
SHRI P. K. DUTTA
PRESIDENT
DISTRICT CONSUMER REDRESSAL FORUM
U NAKOTI DISTRICT::KAILASHAHAR
A N D
SMTI. S. DEB, MEMBER
&
SRI P. SINHA, MEMBER
C O U N S E L
For the Complainant : Shri C. Bhattacharjee Advocate
For the opposite party : Shri A. Bhattacharjee, Advocate
ORIGINAL DATE OF INSTITUTION :06-12-2017
JUDGMENT DELIVERED ON :26-04-2018
J U D G M E N T
This is a complaint U/S 12 of the Consumer Protection Act filed by the complainant Sri Bidhan Das against the opposite party claiming Rs.91,480/- for less payment along with 12 % interest and cost of litigation.
2. The case of the complainant, as revealed from the complaint petition, is that the complainant took an individual health policy under the OP vide policy No. 1309812815 P113022981, which was valid from 27-02-2016 to 26-02-2017 covering the complainant, his wife Mrs. Parijhat Biswas(Das) and his daughter Miss Bipasha Das. On 07-04-2016 the wife of the complainant got admitted at Apollo Hospital, Chennai with an ailment of Endometrial Polyp Seeding Fibroids and underwent major surgery of total laproscopic Hysterectomy, bi lateral Salpingcetomy and Cystoscopy on 08-04-2016 under supervision of Dr. Vishnu Vandana and was released from that hospital on 10-04-2016 . Before admission the complainant on 06-04-2016 informed the Registrar TPA of the OP, namely, “Heritage Health TPA Pvt. Ltd.” for cashless facilities. But there was no response from the Heritage TPA and as a result the complainant could not able to admit his wife on 06-04-2016, the scheduled date of admission. It is further stated in the complaint petition that after repeated telephonic calls of the complainant on 07-04-2016 TPA officials attended hospital and took a declaration/request letter for cashless facility. During hospitalization Heritage TPA approved an amount of Rs. 80,000/- towards cashless facility against complainant's total bill of Rs. 1,89,480/-. Thereafter on 25-04-2016 the complainant submitted his final bill along with all relevant papers to the office of the OP at Kailashahar, but surprisingly the OP sent Rs. 18,000/- in the bank account of the complainant from TPA towards final payment. Thereafter the complainant sought clarification from TPA through the Opposite party and finally the TPA through an e-mail informed him that an amount of Rs.81,746/- has been deducted as per policy condition and the amount which was paid earlier is the maximum amount paid in cashless part and no further payment allowed in pre/post part.” Thereafter the complainant wrote several letters for getting details of the payment, but he did not receive any reply. It is contented in the complaint petition that as per terms and conditions of the policy the insurer is liable to pay the total hospitalization cost but they have paid only Rs. 98,000/- and as such, an amount of Rs. 91,480/- is due to be paid by the opposite party. Therefore the OP is found deficient in service and as such the complainant along with the amount of Rs. 91,480/- has also claimed interest @ 12 % p.a. and cost of litigation.
3. On receipt of the notice, OP appeared before the Forum and by submitting written statement stated inter-alia that as per clause 3.38 of Health Insurance Policy-Gold “ TPA means a third party administrator who hold valid license from Insurance regulatory and development authority to act as a third party administrator and is is engaged by the Company for the provisions of Health Services as specified in the agreement between the Company and TPA”. In the terms and conditions of the policy it is clearly stated that as to who is the authorized TPA who has undergone agreement with the OP-Insurance Company to take the liability of issuing identity card, cashless approval and settlement of any claims. In the case at hand, TPA is Heritage Health Insurance Company Pvt. Ltd. and as such, the OP Insurance Company is not at all liable to pay any claimed amount to the complainant and whatever claim arises the insured will have to demand from the TPA and not from the OP and in the case at hand, the OP has been made party unnecessarily. It is further contended in the petition that the TPA had already settled the claim of the complainant and paid him total Rs. 98,000/- after deducting the non-entitled amount and as such, the complainant is not at all entitled to get further amount and ultimately, the OP has prayed for dismissing the claim of the complainant.
4. The complainant has examined himself and his wife as PW 1 and PW 2 recapitulating the same version as put down in the complaint petition and to avoid repetition the same are not discussed. During her re-examination the complainant has exhibited photocopy of Insurance policy for the period from 27-02-2016 to 26-02-2017 in the name of himself, his wife and his daughter, on admission by both the parties, the Insurance Policy in 31 sheets is marked Exbt. 1 series, photocopy of the Discharge Summary at the submission of his claim petition, marked Exbt. 2/1 to 2/4, photocopy of final bill of Apollo Hospital in 12 sheets marked Exbt. 3/1 to 3/12, later addressed to the Chief Regional Manager, United India Insurance Company Ltd. marked Exbt. 4/1 to 4/2.
During cross examination from the said of the O.P, the complainant admitted that he did not read the contents and terms and conditions of the Insurance Policy. During cross, complainant stated that his wife was operated Cystoscopy and admitted that part payment was made by Heritage Health TPA Pvt. Ltd at the hospital. He denied that as per assessment of Heritage Health TPA Pvt. Ltd. the amount has already been paid by the Insurance Company.
During cross examination, PW 2 denied that total amount of expenditure for her operation was paid by Heritage Health TPA Pvt. Ltd. and that total expenditure incurred by them for her operation was duly paid by Heritage Health TPA Pvt. Ltd.
From the side of the OP, Sri Harisankar Deb, In-charge, Kailashahar Branch of the O.P has been examined as OPW No.1 and in his examination- in-chief he has stated the facts as stated by him in the W.S. and for the sake of brevity the same is not repeated.
During re-examination OPW No.1, has exhibited self contained note relating to claim of Mrs. Parijat Biswas(Das) with Medical Officer's review sheets in two sheets marked Exbt as A/1 to A/2.
During cross examination, OPW admitted that the person who claimed the mediclaim was an insured person.
5. Following point is required to be adjudicated in the case :-
Whether the complainant is entitled to claimed amount of Rs. 91,480/- from the OP as legitimate amount ?
DECISION AND REASONS FOR DECISION
6. From the copy of Insurance Policy (Exbt 1 series) it is found that the complainant procured a policy of Insurance, namely, Individual Health Policy issued by the OP- United India Insurance Company Ltd. vide Policy No. 130 981 281 5 P 113022981 for himself, his wife Mrs. Parijat Biswas (Das) and his daughter Miss Bipasha Das. The policy was valid for the period from 27-02-2016 to 26-02-2017. The sum insured was Rs. 2,25,000/- respectively for each of the insured. Therefore, it is found that the wife of the complainant was under coverage of insurance policy issued by the OP as her operation was done during the period of insurance coverage. In clause 1.1 of the said policy it is termed as follows :-
“ …..................during the period stated in the schedule, if any insured person(s) contracts any disease or suffers from any illness (hereinafter called disease) or sustains any bodily injury through accident (hereinafter called injury ) and if such disease or injury requires such insured person, upon the advice of a duly qualified physician/medical specialist/medical practitioner (hereinafter called medical practitioner) or of a duly qualified surgeon (herein after called surgeon) to incur hospitalization/ domiciliary hospitalization expenses for medical/ surgical treatment at any Nursing Home/Hospital in India as herein defined as an inpatient, the Company will pay through TPA to the Hospital/ Nursing Home or the insured person, the amount of such expenses as are reasonably and and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of Insurance stated in the schedule hereto.” From the copy of final interim bill (Exbt 3/1 to 3/12) it is found that the wife of the complainant was operated in the Obstretics and Gynaecology for TAH/BSO/ADHESIOLYS and Urology for Cystoscopy(Thera Peutic) issued by Apollo Hospitals, Chennai in favour of OP - United India Insurance Company Pvt. Ltd. showing the TPA, Heritage Health Pvt. Ltd. and total billed amount is Rs. 1,59,480/- . In the policy of Insurance at Clause 2.1 there is no mention that the insured will not be entitled to hospitalization/surgical charge for Obstretics and Gynaecology for TAH/BSO/ADHESIOLYS and Urology for Cystoscopy(Thera Peutic) and as such, the insured is entitled to the amount spent in this behalf. The bill is raised in favour of OP, that means OP is liable to pay the amount. The OP could not refute it. From the clause 1.1, it is clear that the Company will pay through TPA to the Hospital/ Nursing Home or the insured person, the amount of such expenses as are reasonably and and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of Insurance stated in the schedule hereto. Therefore, it is the obligatory part of duty of the OP to pay the amount of such expenses to the insured not exceeding the sum insured. From the copy of Insurance Policy it is found that the insured sum is Rs. 2,25,000/- for each of the insured. From the documents submitted by the complainant it is found that he has submitted bill for an amount of Rs. 1,59,480/-, though the complainant in his complaint petition and also in the evidence stated that he has submitted a bill of Rs. 1,89,480/-. As per agreement the OP is to pay the sum of amount incurred by the insured for medical expenses and the insured persons are entitled to cash less payment and whatever the amount, if it is within insured amount, the OP has to pay it to the insured and as such, the complainant is entitled to get Rs. 1,59,480/- and in absence of any cogent document he is not entitled to Rs. 30,000/-. By denying to pay the amount the OP has been proved to be deficient in rendering service to the complainant. The complainant has admitted that he has already received Rs. 98,000/- from the O.P. and as such, he is entitled to Rs. 61,480/- from the O.P Insurance Company. The complainant is not entitled to any other relief.
The point is decided accordingly.
ORDER
7. In the result, the complaint filed by the complainant stands allowed. The OP-United India Insurance Company Ltd. Kailashahar Branch, Kailashahar is directed to pay Rs. 61,480/- to the complainant within a period of two months with interest at the rate of 7 % p.a. from the date of filing of this claim petition i.e. on and from 06-12-2017, failing which the complainant shall be entitled to further interest of 9 % from the O.P. till the date of final payment.
8. Furnish copy of this judgment to the complainant and the O.P free of cost through their respective learned counsels.
ANNOUNCED
(P. K. DUTTA)
PRESIDENT
(P. SINHA) (S. DEB)
MEMBER MEMBER
