Chandigarh

StateCommission

CC/136/2020

Jatinder Kumar - Complainant(s)

Versus

medi Assist india TPA Pvt.Ltd - Opp.Party(s)

Pardeep Sharma Adv.

10 May 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T. CHANDIGARH

============

Consumer Complaint No.	:	CC/136/2020
Date  of  Institution	:	03/11/2020
Date   of   Decision	:	10/05/2022

 

 

 

 

 

Jatinder Kumar son of Sh. Ravinder Kumar, Resident of House No. 2052, Pipliwala Town, Manimajra, U.T. Chandigarh.

…. Complainant

 

Vs.

 

1.     Medi Assist India TPA Pvt. Ltd., Tower D, 4^th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, K.M. Layout, Bangaluru, Karnataka 560029, through its Directors Dr. Vikramjit Singh Chhatwal, Satish Venkata Naga Gidugu, Prasad Venkatasiva Tatineni, Srimathi Ranganathan, Dayanand Annaya Kallianpur.

 

2.     New India Assurance Co. Limited, Regd. & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai – 400001, through its Chairman & Managing Director Sh. Atul Sahai.

 

3.     M/s Jones Lang Lasalle Building Operations Pvt. Limited, Level 16 Tower C Epitmo Building No.5, DLF Cyber City III, Gurgaon, Haryana – 122002, through its Director Sh. Dinesh Wadhera.

…… Opposite Parties

 

 

BEFORE: JUSTICE RAJ SHEKHAR ATTRI    PRESIDENT

MRS. PADMA PANDEY                   MEMBER

                MR.RAJESH K. ARYA                     MEMBER

 

PRESENT	:	Sh. Pardeep Sharma, Advocate for the Complainant.
	:	Opposite Party No.1 ex-parte vide order dated 8.3.2021.
	:	Sh. Vinod Chaudhari, Advocate for Opposite Parties No.2
	:	Sh. Rahul Garg, Advocate for Opposite Party No.3.

 

PER PADMA PANDEY, MEMBER

 

 

 

The succinct facts of the present complaint are the Complainant had been working as Shift Engineer (Employee No. 275604) with Opposite Party No.3 (M/s Jones Lang Lasalle Building Operations Pvt. Ltd.) since 05.06.2018 and resigned from the said Company on 30.09.2020. The Opposite Party No.3 being the employer of Complainant had taken Group Medi-Claim Insurance Policy for the period 27.01.2020 to 26.01.2021 (Annexure C-1) from Opposite Party No.2 (New India Assurance Co. Ltd.) for its 2361 employees and their families. The Opposite Party No.1 (Medi Assist India TPA Pvt. Ltd.) being Third Party Administrator (TPA) was responsible for processing the medical claims for Opposite Party No.2. During the currency of the aforesaid policy, the Complainant suffered heart attack and was admitted to Alchemist Hospital, Panchkula on 30.01.2020 where 2 PTCA Stents were placed in his heart. For the said procedure, a bill of Rs.1,80,513/- was raised (Annexure C-4). However, due to suspension of cashless facility for General Insurance Public Sector Association (GIPSA) at the aforesaid Hospital, the Complainant had to foot the entire expenses from his own pocket. Thereafter, the Complainant escalated his grievance with the Opposite Parties No.1 & 2, but the same failed to fructify. Eventually, after issuance of legal notice by the Complainant, the Opposite Parties No.1 & 2 reconsidered their decision and made a partial payment of claim by wrongly deducting a sum of Rs.32,226/- by giving unjustified reasoning.   With the cup of woes brimming, the complainant has filed the instant consumer complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the opposite parties. 

 

2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, nobody appeared on behalf of Opposite Party No.1 despite service, therefore, it was proceeded ex-parte on 08.03.2021.

 

3.         Opposite Party No.2 contested the Consumer Complaint and filed its reply, inter alia, admitting the factual matrix of the case. It has been pleaded that the claim put forward by the Complainant was processed in accordance with the standard procedure and proper deductions were made as per the contract of indemnity in accordance with set parameters. Pleading that there was no deficiency in service or unfair trade practice on its part, a prayer has been made for dismissal of the complaint.
4.         Opposite Party No.3 also filed its reply, inter alia, admitting that it had taken a Group Medi-Claim Insurance Policy (for the period 27.1.2020 to 26.1.2021) from Opposite Party No.2 for its 2361 employees and their family totaling 9364 persons and the Complainant being its employee was a beneficiary under the said policy. It has been pleaded that since as per the contents of the Complaint filed by the Complainant neither deficiency in service nor unfair trade practice has been alleged against Opposite Party No.3, therefore, there is no cause of action in favour of the Complainant qua Opposite Party No.3. In this backdrop, Opposite Party No.3 has prayed for dismissal of the Complaint.  

 

5.         Controverting the allegations contained in the reply and reiterating the pleadings in the Complaint, the Complainant filed the rejoinder.

 

6.         Parties led evidence by way of affidavits and documents.

 

7.         We have heard the learned counsel for the parties and gone through the record of the case, including the written arguments advanced on behalf of all the parties.

 

8.         After scanning of record, including written arguments, our findings are as under:-

 

9.         The main grouse of the Complainant is that the Opposite Parties No.1 & 2 who initially refused the genuine medi-claim of the Complainant, re-considered their decision to make payment and that too partial payment after issuance of legal notice by withholding/ deducting Rs.32,226/- by giving unjustified reasoning. The policy attached at Annexure C-1 does not show any applicability of the alleged deductions particularly room rent capping and co-pay clause. Further, we observed that the Opposite Parties No.1 & 2 have not annexed any such terms and conditions to justify their claim.  

 

10.         It is pertinent to mention here that the Complainant suffered heart attack and was admitted in Alchemist Hospital, Panchkula on 30.01.2020. The total payment of hospitalization expenses was to the tune of Rs.1,80,513/-, but the cashless approval of insurance claim was not taken by the hospital due to suspension of cashless for GIPSA (General Insurance Public Sector Association). Therefore, the Complainant was forced to make the entire hospitalization expenses amounting to Rs.1,80,513/- from his own pocket as well by borrowing from his friends & relatives.  The investigation report attached with the Complaint has clearly mentioned that the claim is genuine and it is nowhere stated that claim is not payable under any clause of the policy.  

 

11.         The Opposite Parties No.1 & 2 repudiated the claim of the Complainant vide letter (Annexure C-7) stating that claim is not admissible as, “as per investigation report case is non-genuine hence claim is recommended for repudiation as per clause no. 4.4.11”. It is observed that the said repudiation letter mentioned only Clause No. 4.4.11 without describing/explaining and without mentioning the grounds under which the claim was not payable.

 

12.         Opposite Party No.2 vide e-mail dated 17.06.2020 highlighted the Clause No. 4.4.6 instead of Clause No. 4.4.11, which reads as “convalescence, general debility, “Run-down” condition or rest cure, Obesity treatment and its complications, congenial external disease/ defects or anomalies, treatment relating to psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/ alcohol, use of tobacco leading to cancer”. It is the case of the Complainant that out of the twelve grounds mentioned in the aforesaid Clause No.4.4.6, no specific ground was mentioned for rejection of his claim. The Complainant issued legal notice dated 05.08.2020 (Annexure C-16) and further to that the claim of the Complainant was processed and was settled for an amount of Rs.1,48,287/- instead of Rs.1,80,513/- leaving a gap of Rs.32,226/- to be paid to the Complainant for which the Opposite Parties could not give satisfactory answer why the said deduction has been done.    

 

13.         Certain important points emerge while perusing the documents; one is that the date of admission in the hospital was 30.01.2020, but partial claim was settled only on 24.08.2020 i.e. after almost seven months. Secondly, no such terms & conditions have been placed on record by Opposite Party No.2 to prove the applicability of any such deductions in the claim amount. Further, Opposite Party No.2 has even failed to prove the delivery of terms & conditions and also as to whether it was ever sent to Opposite Party No.3 or the Complainant. Thirdly, the GIPSA Network Declaration Form (Annexure C-2) has not been got signed from the Complainant and hence not applicable on Complainant and therefore deduction of 15% charges on account of room rent eligibility is totally wrong.    Thus, the act of the Opposite Parties No.1 & 2 in not settling the entire claim of the Complainant and wrongly withholding an amount of Rs.32,226/- therefrom, amounts to gross unfair trade practice and deficiency in service on their part.

 

14.         The sequence of the events of the present case, clearly establishes the highhandedness of the Opposite Parties No.1 & 2 of which the complainant became the victim and felt the brunt, as a result the complainant has been left with no alternative, except to knock the doors of this Commission, which clearly shows his pain & harassment.

 

15.         For the reasons recorded above, the present complaint of the Complainant deserves to succeed against the Opposite Parties No.1 & 2, and the same is partly allowed. The Opposite Parties No.1 & 2, jointly & severally, are directed:-

[a]     To pay the withheld/wrongly deducted amount of Rs.32,226/- to the Complainant, within a period of 30 days from the date of receipt of a certified copy of this order failing which the said amount shall carry interest @9% p.a. from the date of passing of this order, till realization. 

[b]     To pay Rs.25,000/-, in lumpsum, towards compensation for causing mental agony and harassment to the complainant and cost of litigation, within a period of 30 days, from the date of receipt of a certified copy of this order, failing which, the said amount of Rs.25,000/-, shall carry interest @9% p.a. from the date of passing of this order, till realization.

                The complaint against Opposite Party No.3 fails and is accordingly dismissed with no order as to costs. 

16.         Certified copies of this order, be sent to the parties, free of charge.

 

17.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

 

Pronounced

10^th May, 2022                                                         

Sd/-

(RAJ SHEKHAR ATTRI)

PRESIDENT

 

 

Sd/-

                                                        (PADMA PANDEY)

MEMBER

 

 

Sd/-

                                                        (RAJESH K. ARYA)

MEMBER

 “Dutt”