Delhi

East Delhi

CC/8/2019

SAMPAT RAJ TATIA - Complainant(s)

Versus

N.I.C. - Opp.Party(s)

17 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No.08/2019

 

	Sampat Raj Tatiya R/o 43, Vardhan Apartments, 64, IP Extension, East Delhi	….Complainant
Versus
	National Insurance Company Scope Minar, Core-2, 11th Floor, North Tower, District Centre, Laxmi Nagar, Delhi.	……OP

Date of Institution: 11.01.2019

Judgment Reserved on: 16.02.2023

Judgment Passed on: 17.03.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

 

Order By: Shri Ravi Kumar (Member)

 

 

JUDGEMENT

1. By this order this Commission shall dispose of the complaint filed by the Complainant against OP alleging deficiency in service in not settling his claim despite of having valid Mediclaim Policy.
2. Complainant had initially made 2 OPs i.e. National Insurance Company and M/s. Raksha TPA Pvt. Ltd. However, later on 08.11.2019, OP2 was deleted and Complainant filed amended memo of party keeping National Insurance Co. only as OP and therefore the title of the case reflects only National Insurance Co. as OP.
3. The Complainant, a Senior Citizen and in his complaint has contended that he is holder of Mediclaim Policy from the OP bearing No.36170150170003610 (which was specially designed for BOI employees/ex-employees) valid from 12.09.2017 to 11.09.2018. The Complainant was diagnosed with Bilateral Cataract in his right eye and Complainant informed this fact M/s. Raksha TPA Pvt. Ltd. about it alongwith Doctor’s advice in writing for approval of expenses. The expenses estimated for his Cataract operation were Rs.49000/-. On 31.03.2018 the Complainant underwent the Cataract Surgery at Eye Care Centre, A-102/103, Santa Cruz Mansion, 1^st Floor, Santa Cruz, East Mumbai and he was discharged on same day and expenses of Rs.45900/- were incurred which he paid. He made claim before the OP for Rs.45900/- and submitted the Prescription, Invoice, Certificate issued by the Doctor and the Discharge Card before the TPA on 18.04.2018. However, against the claim amount of Rs.45900/- he was paid only Rs.24900/-. After receiving the above approved amount he asked OP for the details of the same and also the details of rejected amount alongwith reason for rejection but OP quoted the Rules and Guidelines of the Policy and deprived the Complainant of his genuine claim.

 

 

 Complainant has made the following prayers in his complaint:

• To direct OP to pay in full the Rs.45900/-, the sum spent on the cataract Surgery to the complanant.
• To direct the OP to compensate the complanant to the tune of Rs.1,00,000/- for causing harrassment and suffering of pain and agony to the complainant.
• To award litigation expences of Rs.11000/- in favour of the complainant;

Pass any other relief as deemed fit and proper in the facts and circumstances of the case, in the interest of justice.

4. Alongwith his complaint the Complainant has filed copy of National Swasth Bima Policy, copy of letter dated 05.09.2018 of OP, copy of e-mails from the date 28.03.2018 to 12.07.2018, copy of letter 18.04.2018 addressed to TPA alongwith the enclosures, copy of National Insurance BOI National Swastha Bima General Insurance Plans.
5. OP has filed its reply wherein it has contended that the Complainant has not come with clean hands. There is no deficiency in service on the part of OP as the claim in question was rightly settled for Rs.24900/- which is as per ‘Reasonable and Customary Clause’ in the Policy terms. The claim pertains to Cataract Surgery (Phaco Lens) which is restricted to Rs.24000/-. However, they have settled the claim for Rs.24900/- based on documentary evidence and terms and conditions of Policy. OP has stated that insurance policy is a contract between insured and insurer and the terms and conditions thereof are strictly adhered to by both the sides and the complaint is not maintainable.
6. Rejoinder was filed by the Complainant to the reply of the OP wherein he has denied all the contentions as raised and has reiterated the contents of the complaint. He has stated that intimation of proposed Surgery was given to the TPA of the OP on 28.03.2018 and he had informed estimated cost of Surgery as  Rs.50,000/- and approval was sought. TPA however, vaguely replied vide their mail dated 03.04.2018 and gave approval of Rs.24900/- citing ‘Reasonable and Customary Clause’ in the Policy. Had this customary clause been in existence then OP should have approved specific amount as per the customary clause but they chose to give vague reply with malafide intention to not to pay the claim in full. Whereas OP was fully aware of the estimated cost communicated to them. OP has not submitted any documentary evidence on the basis of which they had arrived at Rs.24000/-. As per the policy conditions insurance company is bound to pay full amount of the claim. There does not exist any such ‘Customary and Reasonable Clause’ in the policy issued by the OP and even if there is any such clause it is very vague and arbitrary. Further OP had terminated its policy with BOI and therefore Complainant had to port the policy with Reliance General Insurance Co. and in the said new policy it is specifically mentioned the amount of claim for Cataract Surgery for one eye is Rs.40000/-.
7. Complainant filed his Evidence by way of affidavit and OP has also filed its evidence by way of affidavit.
8. This Commission has heard the argument of both the sides and perused the records.
9. Facts regarding issuing of Medi-claim Policy No. 36170150170003610, payment of premium and Complainant undergoing Cataract Surgery on 31.03.2018 are not in dispute. The controversy revolves around the issue as to how OP gave approval of Rs.24,900/- as against Rs.49,900/- and whether the same was in accordance with the Terms and Conditions of the Policy issued to the Complainant by the OP. It is also pertinent to mentioned that this Policy was tailor made for Bank of India Employees/Ex-employee by the National Insurance Co. and was given the name ‘National Swastha Bima’. The minimum and maximum assured amount was Rs.50,000/- and Rs.5,00,000/- respectively. The Complainant had paid the premium and opted for the insurance cover for Rs.5,00,000/-.
10. Upon Complainant suffering from Bilateral Cataract, he was advised cataract Surgery (Phacomulsification with foldable  PCIOL LA) by Dr. Bipin R. Shah vide his letter dated 26.03.2018 and Cataract Surgery was scheduled for 31.03.2018. As per the treating Doctor the approximate cost of the Cataract Surgery was Rs.45000/-. On 28.03.2018 the Complainant wrote e-mail to the TPA informing the same alongwith the details and stated that approximate cost  of the Surgery would be around Rs.50000/- and sought necessary approval as the Surgery was scheduled on 31.03.2018. This was replied by the TPA on 30.03.2018 by e-mail informing him that claim intimation has been registered with reference No. 58221718476116 and it also stated that they (TPA) is enclosing the claim form and list of document to be submitted while with lodging the claim.
11. To this e-mail Complainant again replied on the same day i.e. 30.03.2018 and sought approval of the amount and also informed since approval has not been provided it is assumed that TPA has given the approval of Rs.45,000/- to him.
12. The Complainant thereafter underwent Bilateral Cataract Surgery (Phacomulsification with foldable  PCIOL LA) on 31.03.2018 at Eye Care Centre, Mumbai and spent Rs.45000/- there. As evidence receipt No.2192 dated 31.03.2018 of Dr. Vipin Shah has been enclosed with the complaint.
13. After the Surgery was done on 31.03.2018, the Complainant received e-mail dated 03.04.2018 with the remark ‘we would like to inform you that the amount will be rectified after the submission of claim document’ and thereafter further e-mails were exchanged and on 14.05.2018 Complainant received e-mail from OP with the remark ‘we would like to apprise that the captioned claim pertains cataracts Surgery (Phaco Lens) and as per Reasonable and Customary Clause cataracts Surgery for ‘Phaco Lens' is restricted to 24000/- which has been reimbursement alongwith Rs.900/- towards pre-hospitalization charges’.
14. This was strongly protested by the Complainant and upon review the OP vide their letter dated 05.09.2018 confirmed that they agree with decision given by TPA.
15. The Complainant was identified as case of suffering from ‘Bilateral Cataract’ and as per his doctors advice he was operated on 31.03.2018 and he had spent Rs.45000/- for the said treatment as per the bill No.2192 dated 31.03.2018 of Dr. Bipin Shah (treating doctor). In the Discharge Card the Surgery has been mentioned as ‘(RE) Cat extn by phacomulsification with foldable PCIOL LA’. The stand of the OP that for this procedure which is also known ‘Phaco Lens’ the reasonable expenses approved for Rs.24,900/- was as per the Terms & Conditions of the Policy. The Complainant had already informed the TPA that the expenses of this procedure was around Rs.45,000/- which is supported by the letter dated 31.03.2018 of the treating doctor. This communication was sent to the TPA on 28.03.2018 and approval was sought and since upto 30.03.2018 upto 7.35 p.m. the TPA had not provided the approval nor denied it and the Complainant had informed that it will be no reply of the TPA is received, it will be assumed as approval for 50,000/- vide his e-mail dated 30.03.2018 to the TPA. The ‘Cataract Operation Procedure’ was done on 31.03.2018 and Complainant received communication from the TPA on 03.04.2018 at 12:42 p.m. stating that the ‘amount will be rectified’ after the submission of claim document. This terminology of the word ‘rectified’ is not clear as what the TPA wanted to convey, however, primarily it means that the expenses incurred for the medical treatment will be rectified/approved. However, this was not done and on 14.05.2018 at 4.43 p.m. the TPA informed that the claim pertains to Cataract Surgery (Phaco Lens) and as per the Reasonable and Customary Clause the amount is restricted to 24,000/- and alongwith pre-hospitalization charges of Rs.900/-, the total amount of Rs.24,900/- has been approved. Upon representation of the Complainant this stand of the TPA was further apprised vide letter dated 05.09.2018 of the OP.
16. The stand of the OP in sanctioning the reduced amount of Rs.24,900/- as against 45000/- is unreasonable and if that was the case then when Complainant had written e-mail dated 28.03.2018 then he should have been informed about it so that he could have taken his decision accordingly. This was not done and the Complainant also informed OP on 30.03.2018 that if he does not receive approval he he will presume that amount sought for Cataract Surgery to be performed next day i.e. 31.-3.2018 was approved which amounts to deficiency in service on the part of OP. Furthermore after the Surgery was done on 31.03.2018 and Bill/claim was sent for approval then OP relied upon non-specific and vague clause with the terminology ‘Reasonable and Customary Clause’ in the Policy and approved only Rs.24000/- towards Cataract Surgery which mounts to Unfair Trade Practice also.
17. Insurance Policy is an Agreement which requires utmost good faith and transparency by both sides where OP has failed and has incorporated a vague clause to rely upon while declining full claim to the Complainant which cannot be appreciated.
18. In view of the above reasons come this Commission order as follows:

• OP to pay Rs.21,000/- alongwith interest alongwith interest @7% p.a. from 31.08.2018 with a period of 30 days from the date of this order.
• OP to pay Rs.7,500/- toward mental harassment and agony to the Complainant.

This Order is to be complied within 30 days from the date of receipt of this order. Failing which the OP shall pay interest @9%  p.a. on the above amounts till the date of realization.

Copy of the order be supplied/send to parties free of cost as per rules.

File be consigned to Record Room.

Announced on 17^th day of March, 2023.