BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSIN, FATEHABAD.
Complaint No.:217 of 2018.
Date of Instt.: 18.08.2018.
Date of Decision: 16.03.2021.
Girish Choudhary son of Sh.Nanak Chand resident of 901 Sector 3, HUDA, Fatehabad District Fatehabad.
…Complainant.
Versus
The Branch Manager, United India Insurance Company Limited, DSS-2 Town Centre Backside Bus Stand, Bhattu Mandi, Fatehabad Haryana.
…Opposite Party.
Complaint U/s 12 of the Consumer Protection Act, 1986
Before: Sh.Raghbir Singh, President.
Smt.Sukhdeep Kaur, Member.
Present: Sh. Amit Wadhera, counsel for the complainants.
Sh. N.D. Mittal, counsel for the OP.
ORDER:
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Party (hereinafter referred as OP) with the averments that the complainant is having medicare policy bearing No. 1119862816P118017986 and the same was in continuation for the last many years and was renewed for the period from 31.03.2017 to 30.03.2018 by paying a premium of Rs.26496/-. On 06.11.2017, the complainant felt discomfort, severe pain, burning and sensation in his chest and due to this he was taken to Escort Heart Institute and Research Centre, New Delhi. The doctors diagnosed him for Actue Coronary Syndrome, Coronary Artery Disease. The policy issued to the complainant was a package policy and all the expenses of treatment, medicine and hospitalization was to be borne by the Op as per contract and agreement of policy. The complainant was treated there and the doctor had calculated total bill of Rs.2,74,041/- but out of the total amount the OP had only paid an amount of Rs.1,59,894/- and the remaining amount of Rs.1,14,147/- has been paid by the complainant from his own pocket. The complainant requested the Op number of times to make the payment of remaining amount of Rs.1,14,147/- and visited the office of OP besides serving a legal notice upon it but all fell on deaf ears. The act and conduct of the OP amounts to deficiency in service on its part. Hence, this complaint. In evidence, the complainant has tendered affidavit and documents Annexure C1 to Annexure C9.
2. Op appeared and filed its reply wherein several preliminary objections such as locus standi, non-joinder of necessary parties and maintainability etc. have been taken. It has been further submitted that every claim arising out the policy was given to the TPA and all supporting documents relating to the claim were to be filed with TPA and all original bills, receipts and other documents on which the claim was based were also to be given to the TPA. The TPA on receipt of all the intimation and documents settled the claim and advised the respondent to pay Rs.1,59,894/- to the complainant and thus, the said amount has already been paid and now nothing remains to be paid. Since the amount was settled as per the advice of TPA, therefore, there is no occasion for the complainant to resubmit the claim for balance amount. There is no deficiency in service on the part of OP. Other contents have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OP has tendered affidavit Ex.RW1/A and documents Annexure R1 to Annexure R3.
3. Heard. The counsel for the complainant reiterated the averments made in the complaint and prayed for its acceptance whereas the counsel for OP-Insurance Company reiterated the averments made in the written statement and prayed for its dismissal.
4. Learned counsel for the complainant has argued that complainant is policy holder bearing No. 1119862816P118017986 which was renewed for the period from 31.03.2017 to 30.03.2018 and during subsistence of the policy the complainant felt pain in chest and on examination it revealed that it was heart disease, therefore, he was admitted in Fortis Escorts Hospital, Heart Institute, New Delhi where he was treated and an amount of Rs.274041/- was spent on the treatment. It has been further argued that the OP-insurance company had only paid Rs.1,59,894/- and rest amount of Rs.1,14,147/- was paid by the complainant from his own pocket and the Op had not made the payment of remaining amount despite repeated requests.
Per contra, learned counsel for the OPs has argued that an amount of Rs.1,59,894/- has already been paid to the complainant and now nothing remains to be paid to the complainant. Since the amount was settled as per the advice of TPA, therefore, there is no occasion for the complainant to resubmit the claim for balance amount. There is no deficiency in service on the part of OP.
5. Before proceeding further it is necessary to describe what is T.P.A. It is a Third Party Administrator who holds a valid license from Insurance Regulatory and Development Authority to act as a Third Party Administrator and is engaged by the company under the provisions of health services as specified in the agreement between the company and TPA. The duties and responsibilities of the Insurance Companies and TPA were also discussed by the Hon'ble Bombay High Court, in Public Interest Litigation No.12 of 2011 (Gaurang Dinesh Damani vs. Union of India & Ors.) in order dated 13.08.2015. It is a common practice that the TPA gives daily targets to its staff for approving claims, where they sanction total money in a day for and all the claims should not exceed particular limit. The hospital bill cannot be settled on the basis of targets fixed by the Insurance Companies. Otherwise, the TPAs have no authority to reject the claim. Such power lies, exclusively with the Insurance Companies. The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. Moreover, when the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice. In the present case there is nothing on the case file to show that the conditions/exclusions clauses were brought in the notice of the insured rather the less claim has been paid on the advice of the TPA despite the fact that the claim was to be decided by the competent authority of the insurance company but it is strange that the Op had not done so rather it appears that the TPA had worked like an agent of insurance company. In the present case the total bill was for Rs.2,74,041/- and the insurance company had only paid an amount of Rs.1,59,894/- and did not pay the balance amount of Rs.1,14,147/- without assigning any reason and fault on the part of the complainant. Though it is proved on the case file that the insurance company had not made understood the insured qua the exclusions clauses but despite that the insurance company cannot deduct around 40 % of the total amount on the ground of exclusions clauses and on other counts. Had it been so, the deduction upto 20 % was justified on the ground of exclusions clauses and on other counts. Therefore, this Forum has reached at a conclusion that the settlement of claim on the advice of the TPA by the insurance company is not justified and the deduction made by the Insurance Company on the advice of TPA is on higher side. Therefore, the end of justice could be met, if we direct the insurance company to pay a sum of Rs.60,000/- in lumpsum to the complainant. Accordingly, we allow the present and complaint and direct the OP to pay a sum of Rs.60,000/- to the complainant. Order be complied within 45 days of receipt of copy of order and if opposite party fails to comply with the order within stipulated period, in that eventuality, opposite party will pay interest @ 9% on the awarded amount. Copy of this order be supplied to both the parties free of costs.. File be consigned after due compliance
Announ in open Forum. Dated:16.03.2021
(Sukhdeep Kaur) (Raghbir Singh)
Member District Consumer Disputes
Redressal Commission, Fatehabad.
