Date of Filing 29.01.2024

                                                                                                             Date of Disposal: 29.04.2024

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

BEFORE TMT. Dr.S.M. LATHA MAHESWARI, MA. ML, Ph.D (Law),                                         …….PRESIDENT

               THIRU.P.VINODH KUMAR, B.Sc., BL,                                                                               ……MEMBER-I

               THIRU.P.MURUGAN, M.Com., ICWA(Inter), BL.,                                                          …….MEMBER-II

CC.No.83/2023

THIS MONDAY, THE 29^th DAY OF APRIL 2024

Mr.K.N.Srinivasan, S/o.Shri. K.C.Nagalingam,

G-407, IV Floor,

S&P Living Spaces, kamarajar Street,

Ayanambakkam, Chennai 600 095.                                                  ......Complainant.

                                                                        //Vs//

1.The Officer -in- Charge -IBA Group Insurance,

   M/s. National Insurance Company Limited,

   Registered and Head Office, 3 Middleton Street,

   P.O.Box No.9229, Kolkatta -700 071.

2.The officer - in - Charge -Claims,

    Heritage Health Insurance TPA Private Limited,

    Prince Center, No.709/710,

    1^st Floor, 102 &103, Mount Road,

    Thousand Lights, Chennai 600 006.                                             …..Opposite parties.

Counsel for the complainant                                                                : Party in Person.

Counsel for the opposite parties 1 & 2                                               : Exparte.

This complaint coming before us on various dates and finally on 26.04.2024 in the presence of party in person/complainant and the opposite parties were set exparte for non appearance and upon perusing the documents and evidences of complainant’s side this Commission delivered the following:

ORDER

PRONOUNCED BY Tmt. Dr.S.M. LATHA MAHESWARI, PRESIDENT.

1. This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service against the opposite parties with regard to the failure of reimbursement of Medical Insurance Claim made by the opposite party along with a prayer to direct the opposite parties to pay the balance amount of Rs.75,435/- along with compensation and cost of the complaint.

Summary of facts culminating into complaint:-

2. Aggrieved by the partial reimbursement of Medical Insurance Claim made by the opposite party the present complaint has been preferred.

3. The complainant, a retired Chief Manager of Punjab National Bank and a policy holder of National Insurance Company Limited under IBA Group Insurance scheme meant for Bank retirees had come up with the case that when the policy was in force his wife S.Kalpanadevi underwent Hysterectomy operation at Noble Hospitals, Chennai.  Information regarding the admission into the Hospital and surgery was informed timely to the TPA of the Insurance Company M/s.Heritage Health Insurance TPA Private Limited on 01.11.2022 and the total expenses incurred was Rs.1,83,020/-which was claimed from the opposite party.  However a paltry sum of Rs.82,585/- was only paid by the opposite party towards a total sum of Rs.1,83,020/-.  On approaching the Insurance Ombudsman a further amount of Rs.25,000/- was  paid by opposite party on allowing the complaint. Thus the present complaint was filed for the balance amount of Rs.75,435/- along with the compensation and cost of the complaint.

4. On the side of complainant proof affidavit was filed along with documents marked as Ex.A1 to Ex A11. Though one Advocate undertook to file vakalath for the opposite parties no vakalath and written version was filed within the mandatory period as per the statute and hence the opposite parties were set exparte on 05.04.2024 &12.04.2024 for non appearance and for non filing of written version.

Points for consideration:-

1) Whether the complaint allegation against the opposite party with respect to non reimbursement of the entire claim as made by the complainant but honouring only a partial sum of Rs. 1,07,585/- amounts to deficiency in service on the part of the opposite party and whether the same has been successfully proved by the complainant?

2) If so, to what reliefs the complainant is entitled?

Point No.1:-

5. The complainant/ party in person appeared and argued that it was not justifiable on the part of opposite party in only honouring/reimbursing a part of the claim.  It is his contention that when he had insured for himself and his wife for Rs.9,00,000/- it was unfair on the part of the opposite parties to reimburse only a part amount of the expenses made by him.  Thus he sought for the complaint to be allowed as prayed for.

6. On perusal of the entire pleadings and material evidences submitted by the complainant we hold that the complaint allegations has been proved for the following reasons;

1. The complainant had produced the Health Insurance Policy as Ex.A11 in proof of his holding the insurance policy and entitlement for reimbursement of the medical expenses;
2. The complainant has clearly established that the surgery undergone by his wife was covered under the policy and that the same was performed in a Net Work Hospital as found in the policy schedule;
3. Though the complainant had approached the Ombudsman, the Ombudsman allowed the complaint, however ordered only for payment of Rs.25,000/- by stating that the third party Administrator had arrived the rates applicable to similar hospitals in the same city was only around Rs.80,000/- and however the complainant had spent nearly Rs.1,83,000/-, however only an additional amount of Rs.25,000/-  was allowed.  The Ombudsman also failed to provide the ratio that on what basis the TPA had arrived at a finding that the expenses in and around Hospital in the same city would be only Rs.80,000/-
4. When the amount spent by the complainant for the Permitted Surgery in a Net Work Hospitals was fully covered under the sum assured and when the complainant had provided sufficient proof for the payment, there is no basis for the insurer to allow only a part of the claim.  Especially when it is not the case of the opposite party that the surgery done was in a non net work hospitals nor the surgery was covered under the policy;
5. When no fixed amount was provided under the policy for the specific surgery as undergone by the complainant’s wife the opposite party could not unilaterally fix a sum to be a reasonable amount spent towards the said surgery;
6. The opposite party did not come forward to explain what is “AS PER REASONABLE & CUSTOMARY MAXIMUM PAYABLE FOR PROCEDURE OF RS.79,200/- OF DURING HOSPITALIZATION.”
7. The opposite party did not come forward to file any affidavit by the TPA, by appearing before this commission to substantiate his decision in arriving the said amount.

7. Therefore, for the above reasons we hold that the opposite party in not paying the balance amount towards reimbursement of the medical insurance claim of the complainant amounts to clear deficiency in service and unfair trade practice when no admissible reason was cited by them except a bald defence that AS PER REASONABLE & CUSTOMARY MAXIMUM PAYABLE FOR PROCEDURE OF RS.79,200/- OF DURING HOSPITALIZATION. Further the opposite party did not appear before this commission to deny the complaint allegations and to establish that what amount reimbursed by them was the appropriate claim amount.  Thus we answer the point accordingly in favour of the complainant and as against the opposite party.

Point No.2:-

8. As we have held above that the opposite party had committed deficiency in service in not paying the entire claim of the complainant, we direct the opposite party to pay the balance amount of Rs.75,435/- along with reasonable compensation of Rs.25,000/- for the mental agony and sufferings undergone by the complainant by refusal of the opposite party to pay the amount in entirety.  We also award cost of Rs.5,000/- towards litigation expenses.

In the result, the complaint is partly allowed against the opposite parties 1 & 2 directing them

a) To pay the balance amount of Rs.75,435/- (Rupees seventy five thousand four hundred thirty five only) spent by the complainant towards medical expenses within six weeks from the date of receipt of copy of this order;

b) To pay a sum of Rs.25,000/- (Rupees twenty five thousand only) towards compensation for the mental agony and hardship caused to the complainant;

c) To pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant;

d) Amount in clause (a) if not paid within four weeks from the date of receipt of copy of this order, interest at the rate of 6% will be levied on the said amount from the date of complaint till realization.

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this 29^th day of April 2024.

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MEMBER-II                                    MEMBER-I                                                  PRESIDENT

List of document filed by the complainant:-

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MEMBER-II                                           MEMBER-I                                           PRESIDENT