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SRI SARABJIT SINGH LAMBA filed a consumer case on 22 Nov 2022 against UNITED INDIA INSURANCE COMPANY LTD. in the Dibrugarh Consumer Court. The case no is CC/4/2010 and the judgment uploaded on 23 Nov 2022.
Date of Argument – 19.09.2012
Date of Judgment – 03.09.2022
This C.P. Case has been filed under Section 12 of Consumer Protection Act, 1986 by the complainants claiming to direct the Opposite Parties a sum of Rs. 38,507/- with interest @ 18% incurred in the medical treatment of the complainant No.2 and to award a compensation of Rs.30,000/- on account of mental agony, physical harassment and financial loss and to award another sum of Rs.10,000/- only being the cost of the proceeding.
Judgement
The complaint No.1 is a business man by profession and the complainant No.2 is the wife of the complainant No.1 and both are resident of Dibrugarh District under the jurisdiction of this Forum/Commission. The Opposite Party No.1 is a general insurance company and the O.P. No.2 is the Third Party Administrator of O.P. No.1 who holds a valid licenseNo.008 from Insurance Regulatory and Development Authority to act as a Third Party Administrator and is empanelled by the Opposite Party No.1.
The complainants submit that they entered into an Insurance contract with the O.P. No.1 under Individual Health Insurance Policy being Policy No.130306/48/07/97/00000185 and the said policy was valid from 22.02.2008 till 21.02.2009 In the said policy the complainant No.1 was the Insured person and the complainant No.2 along with their two children was covered under the said policy. The complainants submit that the complainants had since 2002 been continuing the aforesaid Medi-Claim Policy with the Opposite Parties and since then had been paying Premiums at regular intervals.
The complainants submit that during the subsistence of the said policy the complainant No.2 suffered from an ailment/disease in the nature of Uterine Fibromyoma with Menorrhagia and for the same the complainant No.2 on 04.12.2008 approached one Dr. V.K. Bajaj, a registered Gynecologist for necessary advice and consultation and after such consultation the complainant No.2 was prescribed some tests and medicines. After completing the said course the complainant again visited the aforesaid Gynecologist on 05.01.2009 whereupon she was prescribed some medicines and was further advised hospitalization on 10.01.2009.
Accordingly the complainant No.2 was admitted in Srishti Hospital and Research Centre(P) Ltd., Paltan Bazar, Dibrugarh, Assam on 10.01.2009 and was discharged on 15.01.2009.
It is submitted by the complainants that during the treatment of the said disease/ailments the complainants had to incur medical expenses under various heads. The complainants at the time of admission had to deposit an amount of Rs.10,000/- (Rupees ten thousand) only as an Advance Admission charge. The complainant No.2 further stated that during her stay in the said Hospital she had incurred medical charges under various heads which amounted to Rs.38,507/- (Rupees thirty eight thousand five hundred seven)only.
The complainant No.2 submits that while she was undergoing the said medical treatment, she approached the Opposite Parties and according to the procedure in vogue she prepared and filed a Pre-Authorization details of the said treatment including all the details regarding the Name, age, policy No. name of the Hospital wherein she was to be admitted along with the Doctor’s name etc. were mentioned. In the said form the approximate package charge of the whole treatment was estimated to an amount of Rs.55,000/- (Rupees fifty five thousand)only. It is to be mentioned herewith that the Pre-Authorization Form is prepared in order to have a probable estimate of the costs and expenditures that will be incurred during the said Treatment.
The complainants also submit that while filing the said Pre-Authorization Form all the necessary documents such as Doctor’s Prescription, Pathological Reports etc. were submitted in original to the Opposite Parties and the same are still in their custody. The complainants pray that the Hon’ble Forum/Commission may at the time of hearing the case direct the Opposite Parties to produce the same from their custody.
The complainants state that on 09.01.2009 i.e. a day prior to admission of the complainant No.2 the Opposite Party No.2, Heritage Health Services Private Limited submitted an authorization letter for Cashless Hospitalization of the complainant No.2. The said Authorization letter was addressed to Srishti Hospital & Research Centre (P) Ltd. In the said letter the Opposite Party No.2 in a most arbitrary and illegal manner sanctioned an amount of Rs.15,000/-(Rupees fifteen thousand)only which was way less than the amount which was stated in the Pre-Authorization Form. The complainants reiterate that at the time of preparing the said Pre-Authorization Form the estimated cost of the whole Medical expenses was stated to be approximately Rs.55,000/- (Rupees fifty five thousand)only.
The complainants state that as a consequence of such arbitrary and illegal action on part of the Opposite Parties, the complainants had to deposit the remaining dues to the said Hospital and then only they were able to get discharge from it on 15.01.2009. The complainant further submit that they were put to great financial hardships as a result of such actions of the Opposite Parties.
The complainants state that the Opposite Party No.2 vide a letter dated 07.12.2009 sent an intimation to the complainant No.1 wherein the Opposite Party No.2 stated that they are paying an amount of Rs.15,000/- against the full and final settlement of the claim made by the complainants. In the said settlement letter addressed to the complainant No.1 the Opposite Party No.2 stated that the total amount of all the Bills submitted amounted to Rs.37,395/- (Rupees thirty seven thousand three hundred ninety five)only. The complainants submit that at the time of claiming the policy they had submitted various Bills which amounted to Rs.38,507/- (Rupees thirty eight thousand five hundred seven)only. Moreover in the said settlement/forwarding letter the Opposite Party had shown details of deduction which if considered in their own calculations is totally wrong and vague. It is also stated by the complainants that the O.P. No.2 along with the said settlement/forwarding letter had annexed an Account Payee Cheque bearing No.421438 dated 07.12.2009 of Rs.15,000/- (Rupees fifteen thousand)only drawn on Bank of America and issued in favour of the complainant No.1.
On being aggrieved and dissatisfied by the above arbitrary and illegal actions of the Opposite Parties, the complainant No.1 filed a representation to the Opposite Party No.2 wherein the complainant No.2 had expressed his displeasure with the Opposite Party. In the said letter dated 13.01.2010 addressed to the O.P. No.2 the complainant No.1 had clearly stated that he had deposited various bills amounting to Rs.38,507 and further requested the O.P. No.2 to settle his claim in a just manner. The said letter was sent to the O.P. No.2 along with the account payee cheque bearing No.421438 dated 07.12.2009 drawn on Bank of America.
Filing this complaint the complainants pray before the Forum/Commission to pass the following orders, directions and grant the following reliefs:
After registering the case notices were issued to all the Opposite Parties of which O.P. No.1, United India Insurance Company Ltd. contested the case and submitted their W/S. O.P. No.2, Heritage Health Services Pvt. Ltd. was absent before the Forum after due receipt of notice for which the Ld. Forum was pleased to pass ex-parte order against O.P. No.2 on 30.03.2010 and the case was proceeded ex-parte against the O.P. No.2. Submitting W/S the O.P. No.1 stated interalia that the case is not maintainable under law as well as on facts as there was no deficiency of services on the part of this O.P., as the O.P. No.1 processed the claim of the complainants under the terms and conditions of the Individual Health Insurance Policy No.130306/48/07/97/00000185 with the period of insurance w.e.f. 22.02.2008 to 21.02.2009, assessed the liability of the Insurer under the terms and conditions of the said policy at Rs.15,000/- being the maximum amount payable @ 20% of the sum insured of Rs.75,000/- on the basis of Pre and Post Hospitalization Reimbursement bill submitted by the complainants and sent the cheque for the settled amount vide letter dtd. 07.12.2009 of O.P. No.2, but the complainants had refused to accept the same. This O.P. admitted the fact that the issuance of Individual Health Insurance Policy No.130306/48/07/97/00000185 to the complainants’ family for a sum insured of Rs. 75,000/- each on receipt of premium of Rs.3,764/- covering four persons mentioned therein is true. In their W/S the O.P. No.1 submitted that except statements made in column No. 8,9,10, and 11 of the complaint as to approaching the O.Ps, submission of pre-authorization details for an estimate of Rs.55,000/-, sanction of Rs.15,000/- by O.P. No.2. It was submitted and admitted to the extent that the complainants submitted pre-authorization form signed by the attending Doctor for an approx. package rate of Rs.55,000/- and O.P. No.2 on receipt of the same processed the same as per terms and conditions of the policy and granted an amount of Rs. 15,000/- and informed Srishti Hospital & Research Centre(P) Ltd. vide letter dtd. 09.01.2009 mentioning clearly that “Conditions applicable as per (Gold Policy): Any kind of service charges, surcharges, admission fees/registration charges etc. will not be payable. It is specifically denied that O.P. No.2 has sanctioned the amount of Rs.15000/- in the most arbitrary and illegal manner.
The O.P. No.1 stated that in respect of the statements made in columns No. 12 and 13 of the complaint as to submission of various bills amounting to Rs.38,507, filing of representation by the complainant No.1 vide letter dtd. 13.01.2010, it is submitted that the Regional Office of the O.P. No.1 took up the matter with the O.P. No.2 who explained the basis of settlement and payment of the complainants’ claim at Rs.15,000/- vide their letter dtd.13-02-2010. The said letter of the O.P. No.2 says that an amount of Rs.15,000/- was granted vide letter dtd. 09-02-2009 against the policy No.130306/48/07/97/00000185 for sum insured of Rs.75,000/- for Hospitalization Operation. Since as per policy provision (Gold policy) for Hospitalization Treatment of Hysterectomy, maximum 20% of sum insured is allowable and thus, an amount of Rs.15,000/- was granted under cashless hospitalization bill. The treating Nursing Home vide letter dtd. 17.11.2009 informed the O.P. No.2 that the insured had not taken the cashless facility and cleared the hospital bill on his own.
Subsequently, while Pre and Post Hospitalization Reimbursement Bill has been submitted, the claim has been settled for an amount of Rs.15,000/- (Maximum 20% of sum Insured of Rs.75,000/-) and cheque as mentioned was sent. The reason for settlement of the amount of Rs.15,000/- (Maximum) has also been communicated to the complainants vide their letter dtd. 01-02-2010. As per provision no additional payment can be made under the said claim.
This O.P. claims that the complainants are not entitled to the reliefs as prayed in their complaint as there was no deficiency of service on the part of the Opposite Parties in rendering service under the insurance policy for which the claim is denied and claims to dismiss the complaint of the complainants.
In this case from the complainant’s side evidence in affidavit of two CWs were filed. CW-1 is Shri Sarabjit Singh Lamba, the complainant No.1. CW-1 in his evidence stated that he himself along with his wife Smti. Dolly Lamba had instituted this case against the O.Ps. The O.P. No.1 is a nationalized insurance company and O.P. No.2 is the Third Party Administrator of the O.P. No.1. The Third Party Administrator holds a valid license bearing license No.008 from Insurance Regulatory Authority to act as a Third Party Administrator and is empanelled by O.P. No.1.
This complainant Shri Sarabjit Singh Lamba had entered into an insurance contract with the O.P. No.1 under the Individual Health Insurance Policy being Policy No.130306/48/07/97/00000185 and the said policy was valid from 22.02.2008 till 21.02.2009. Mr. Lamba was the insured person in the said policy and his wife Mrs. Dolly Lamba and their two children were covered under the said policy and since 2002 the complainant had been continuing the mediclaim policy with the O.Ps. paying premium at regular intervals. Ext. 1 is that insurance policy.
Mrs. Dolly Lamba, wife of complainant No.1 during subsistence of the said mediclaim policy suffered from ailment/disease in the nature of Uterine Fibromyoma with Menorrhagia and his wife approached one Doctor V.K. Bajaj, a registered Gynecologist for advice and consultation and after such consultation complainant No.2 was prescribed some tests and medicines. After completing the said course complainant No.2 again visited the consulting Doctor on 05.01.2009 whereupon she was prescribed with some medicine and advised hospitalization on 10.01.2009. Ext. 2 and 3 are the copies of the doctor’s prescription dtd. 04.12.2008 and 05.01.2009 respectively. After that the complainant No.2 was admitted in Shristi Hospital and Research Centre Pvt. Ltd., Dibrugarh on 10.01.2009 and was discharged on 15.01.2009. Ext. 4 is the copy of the discharge certificate.
That complainant No.1deposited a sum of Rs.10,000/-(Rupees ten thousand)only at the time of admission of his wife in Shristi Hospital and Research Centre Pvt. Ltd. as advance admission charge. He also deposed that during the stay of his wife in the said hospital he had incurred various medical charges under various heads amounting to Rs.38,507/-(Rupees thirty eight thousand five hundred and seven)only. Ext. No.5 to 16 are the medical bills of the complainant No.2.
That the wife of the complainant No.1 as per procedure in vogue of the O.Ps. prepared and filed pre-authorization details regarding the name, age, policy No., name of the hospital along with the name of the doctor etc. were mentioned and in the said form the approximate package charge of the whole treatment was estimated at Rs.55,000/- (Rupees fifty five thousand)only and the said pre-authorization form is prepared in order to have a probable estimate of the cost and expenditure that will be incurred during the said treatment. Ext. 17 is the copy of the pre-authorization form prepared and filed by the complainant No.2. The CW-1 declares that the original documents of the doctor’s prescription, pathological reports, bills etc. were submitted to the O.Ps. and those are still in their custody.
The O.P. No.2 vide letter dtd. 09.01.2009 for cashless hospitalization of the complainant No.2 addressed to the Shristi Hospital and Research Centre Pvt. Ltd., Dibrugarh sanctioned an amount of Rs.15,000/- (Rupees fifteen thousand)only which the complainant claims was less than the amount which was stated in the pre-authorization form. Ext. 18 is the authorization letter.
As a consequence of such arbitrary and illegal action on the part of the OPs the complainants had to deposit all the dues of the hospital personally to get discharge complainant No.2 from hospital on 15.01.2009.
In para 10 of his evidence in affidavit the CW-1 states that the O.P. No.2 vide letter dtd. 07.12.2009 sent an intimation to him stating that they were paying Rs.15,000/-(Rupees fifteen thousand)only as full and final settlement of the claim made by the complainants and also said that the total amount of all the bills submitted amounted to Rs.37,395/- was no correct. Moreover in the said letter the O.P. had shown details of deductions which if considered in their own calculation is totally wrong and vague. The O.P. No.2 had sent and annexed an A/c payee cheque bearing No.421438 dtd. 07.12.2009 for Rs.15,000/- (Rupees fifteen thousand)only drawn on Bank of America issued in favour of the CW-1 along with the settlement letter. Ext. No.19 and 20 are the copies of the settlement letter and the A/c payee cheque. Being aggrieved and dissatisfied with the attitude of the O.Ps. the complainants filed a representation before the O.P. No.2. Ext. No.21 is the copy of that letter dtd. 13.01.2010.
The acts of the O.Ps. amount to deficiency in service, restrictive trade practices and unfair trade practices under the purview of Consumer Protection Act for which the complainants had to suffer unavoidable mental agony, physical harassment and financial loss for which the complainants have filed this complaint claiming Rs.38,507/- as expenses incurred in the medical treatment along with 18% interest from the date of filing till realization and a compensation of Rs.30,000/- only for mental agony, physical harassment and financial loss.
CW-2 Mrs. Dolly Lamba is wife of complainant No.1 Shri Sarabjit Singh Lamba. In her evidence in affidavit Mrs. Dolly Lamba reiterated the same evidences as advanced by CW-1, Shri Sarabjit Singh Lamba. In her evidence also it is exhibited the same exhibits given by CW-1 as exhibit No. 1 to 17 and hence we feel it not necessary to discuss her evidences once again.
In this case on behalf of OP No.1, United India Insurance Company Ltd. gave evidence in affidavit of one Shri Sankar Mazumdar, the then Asstt. Branch Manager of Moran Branch.
In his evidence he denied any deficiency of services on their part, as the OP had processed the claim of the complainants in terms and conditions of the Individual Health Insurance Policy No.130306/48/07/97/00000185 for the period of insurance w.e.f. 22.02.2008 to 21.02.2009, assessed the liability of the insurer under the terms and conditions of the said policy at Rs.15,000/- (Rupees fifteen thousand)only being the maximum amount payable @ 20% of the sum insured of Rs.75,000/- on the basis of pre and post hospitalization reimbursement bill submitted by the complainants and sent the cheque for the settled amount vide letter dtd. 07.12.2009 of the O.P. No.2 (TPA) but the complainants refused to accept the same.
The DW stated in his evidence that the complainants submitted pre-authorization form signed by the attending doctor for an approximate package rate of Rs.55,000/- and the OP No.2 on receipt of the same processed it and as per terms and conditions of the policy granted an amount of Rs.15,000/- and informed Shristi Hospital and Research Centre Pvt. Ltd. vide letter dtd. 09.01.2009 mentioning clearly that “conditions applicable as per (Gold Policy) : any kind of service charges, surcharges, admission fees/registration charges etc. will not be payable”. He admitted the claim of the complainants that all the original documents submitted by the complainants in support of their claim are in exclusive possession of OP No.2.
He deposed that their Regional Office took up the matter with OP No.2, who explained the basis of settlement and payment of the complainants’ claim at Rs.15,000/- vide letter dtd. 13.02.2010. The said letter of the OP No.2 says that an amount Rs.15,000/- was granted vide letter dtd. 09.02.2009 against the policy No.130306/48/07/97/00000185 for sum insured of Rs.75,000/- for hospitalization operation. Since as per clause 1.2(C) of the Health Insurance Policy provision (Gold Policy) for hospitalization treatment of hysterectomy, maximum 20% of sum insured is allowable and thus an amount Rs.15,000/- was granted under cashless hospitalization bill. The original insurance policy is in possession of the complainants. Paper exhibit No.A is a certified true copy of the policy with all terms and conditions and exhibit A(1) is the signature of Shri Bhulendra Chandra Das, the Branch Manager of Moran Branch with seal. The treating nursing home vide letter dtd. 17.11.09 informed OP No.2 that the insured had not taken the cashless facility and cleared the hospital bills on his own.
He claimed, the claim of the complainants had rightly been settled at Rs. 15,000/- as per terms and conditions of the policy by the TPA who is duly licensed under IRDA for the purpose of settlement of all claims made and arising out of Health Insurance Policy. The complainants are not entitled to Rs.38,507/- or interest or compensation of Rs.30,000/- or cost of Rs.10,000/- as there was no deficiency of service on the part of the OPs in rendering service under the insurance policy and as such the claim of the complainants was denied.
In this case the complainants after repeated directions did not file their written argument till 15.06.2016. OP No.1 submitted written argument on 19.09.2012. Considering the absence of the complainants since long period, the then President of the Forum passed order closing argument by fixing the case for judgement vide order dtd. 15.06.2016.
POINTS TO BE DECIDED
POINTS DECIDED
In this regard we have carefully gone through the Individual Health Insurance Policy No.130306/48/07/97/00000185 which was exhibited as OP’s exhibit No.A, dtd. 08.12.2010. Clause 1.2 of that policy clearly states that –“In the event of any claim(s) becoming admissible under this scheme, the company will pay through TPA to the Hospital / Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.
Expenses in respect of the following specified illnesses will be restricted as detailed below :
Hospitalization Benefits | LIMITS RESTRICTED TO |
|
|
(N.B.) : Company’s Liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured per person as mentioned in the schedule)”.
This clause does not excluded clearly the admission fees/registration fees, service charges, surcharges etc. Moreover, clause 1.2(C) clearly says that for Hysterectomy the limit of company’s liability is restricted to 20% of the SI or maximum Rs.50,000/-. The Complainant No.2 Mrs. Dolly Lamba was admitted in Shristi Hospital and Research Centre Pvt. Ltd. for Uterine Fibromyoma with Menorrhagia for Hysterectomy. She was admitted in that hospital on 10.01.2009 and was discharged on 15.01.2009.
The sum assured of the policy of the insured Shri Sarabjit Singh Lamba was for Rs.75,000/- and the total premium was Rs.3764/- covering both the complainants and their two children. It is worth mentioning that the complainant No.1 Shri Sarabjit Singh Lamba had contracted the aforesaid medical policy with the OPs since 2002 and since then paid the policy premium at regular interval. As the SI of the concerned policy was Rs.75,000/-, it is crystal clear that the complainants claim should not be settled at 20% of the SI as the maximum limit is Rs.50,000/-. The complainants claim Rs.38,507/- as full and final settlement of their claim
From the above observations, it can be said that the calculation and settlement of the claim of the complainants by the OPs was not just and proper and they did it for their own benefit.
During preparation of this judgement and in some other judgements also we have seriously noticed that general insurance companies like this have gradually failed to keep the hope and aspirations of their valued customers, in solving their insurance/health insurance claim which may create a sign of doubt in the ‘good will’ of such companies during this ongoing era of competitions. Common people invest in such polices like life/property/health insurance to get support at the time of need. But it is unfortunate that many of such companies give more importance in getting the policy premiums, instead of offering timely service to their customers in times of need. This Commission expects that the Insurance Companies be vigilant and be prompt in solving the consumer complaints to minimize the litigation in consumer commission or in any other bodies/courts.
From all above discussion and observations this Commission comes to the conclusion that the complainant is really entitled to get the reliefs as prayed for and the Commission directs the opposite party- United India Insurance Co. Ltd., Moran Branch –
+
All the above mentioned amounts be deposited into the credit of this Commission by the O.P. within 30(thirty) days from the date of receipt of this judgement.
Send copy of this judgement to the O.P. for compliance.
The instant C.C. No.04/10 is accordingly disposed of on contest.
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