Punjab

Ludhiana

CC/19/458

Jageshwar Prasad Sen - Complainant(s)

Versus

National Insurance Company Limited - Opp.Party(s)

M.S.Sethi Adv.

07 Dec 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 458 dated 25.09.2019.                                                        Date of decision: 07.12.2022.

 

Sh. Jageshwar Prasad Sen 59 years @ J.P. Sen. s/o. Late Mangal Sen, r/o.68, 4^th Floor, Swami Vivekanand Vihar, near DAV School, B.R.S. Nagar, Ludhiana-141004.                                                                                                                                                                                                    ..…Complainant

                                                Versus

1. National Insurance Company Ltd., Second Floor, SCO-38, Feroze Gandhi Market, Ludhiana-141001 through authorized signatory.
2. Dedicated Health Care Services TPA (India) Private Ltd., Khetan Bhawan, Office No.18, Second Floor, J. Tata Road, Chuchgale Mumbai-400040 through authorized signatory.                                                                                                                            …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. M.S. Sethi, Advocate.

For OP1                         :         Sh. D.R. Rampal, Advocate.

For OP2                         :         Complaint against OP2 not admitted vide order                                           dated 25.10.2019.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant is regularly taking medi-claim policy from the opposite party since 09/2015. The complainant again hired the services of opposite party No.1 for obtaining medi-claim policy for himself along with other three family members for a period effective from 09.30 hours on 20.09.2015 to the midnight on 19.09.2017. Opposite party No.1 charged a premium of Rs.36,074/- and thereafter, issued a cashless National Medi-claim Policy bearing No.404502/48/16/8500000694 (Ex. C1) consisting of four pages only. Opposite party No.1 further disclosed the name of opposite party No.2  being TPA at the second page of the policy. During the tenure of the said medi-claim policy, the complainant was admitted in SPS Apollo Hospital for a period 09.06 AM on 03.05.2017 to 04.05.2017 at 12.22 PM for operation of Laparoscopic cholecystetomy, discharge certificate is Ex. C2. However, the opposite parties refused to provide cashless facility without giving anything in writing and then under compelling circumstances and urgency of medical assistance, a sum of Rs.99,605/- was deposited with the hospital vide receipt Ex. C3. Thereafter, the claim was lodged with the opposite parties along with discharge certificate, payments receipts and medical bills and it was registered against claim No.14696302 of 2017. After lodging of claim, emails Ex. C5 to ex. C7 were exchanged between the parties hereto to process the claim. On 16.10.2017, the opposite parties intimated that they have to settle the claim according to GIPSA (General Insurance Public Sector Association)   package as the treating hospital as on GIPSA penal but the hospital has charged more than GIPSA rates. On 10.11.2017, vide email Ex. C9, the complainant requested the opposite parties to provide the package rates in writing and explanation of SPS Hospital, if any. The complainant also requested for supply of copy of insurance policy where it is so provided. The complainant also requested to review the matter. After a long delay, the opposite party finally offered Rs.41,426/- only out of the total lodged claim amount of Rs.99,605/-. On 11.04.2019 vide email Ex. C10, protest was lodged for short settlement of the claim amount but instead of making payment of remaining claim amount, the opposite parties vide email dated 27.06.2019 Ex. C12 after a lapse of two years, took a following new plea:-

“That PPN hospital have to charge according to PPN package set by GIPSA for the PPN hospital. Has you shown the card or policy to the hospital then they would have charged according to the package. We have confirmed from the hospital as well as from the TPA that you have not shown the policy or card i.e. why the hospital has charged other than PPN Package assuming that you are not covered by any health policy. Pl. find attached circular vide which it is clearly mentioned at sr. no.6 about/reimbursement of claim.”

On 27.06.2019 vide email Ex. C13, the complainant intimated the word GIPSA rate has not been mentioned in the policy. According to the complainant, the opposite parties took another plea vide email dated 28.06.2019 (Ex. C14) that the claim has been settled as per terms and conditions of 3.23 of the policy and the PPN package by the GIPSA in the PPN hospital. However, the opposite parties on 16.10.2017, made a payment after a lapse of six months and the remaining claim of Rs.58,179/- was denied on the basis of letter Ex. C15. Non approval and non-payment of Rs.58,179/- under following heads is arbitrary and illegal merely on the reason being settled on GIPSA rates:-

1. Opposite party denied hospital charges of Rs.6,000/- & Rs.500/- for investigation & Lab charges on the reason settled as per GIPSA package rate.
2. Opposite parties further allowed Rs.326/- only against the non-taxable pharmacy & medicine charges of Rs.16,124/-. The opposite party denied remaining amount of Rs.15,798/- on the reason of settled as per GIPSA package rate and no prescription.
3. Opposite party denied total amount of Rs.13,361/- under its head ‘Miscellaneous charges’ in the claim approval letter dt. 18.10.2017 and disclosed reason for non-payment on the ground of instrument charges payable & claim settled as per GIPSA package rate.
4. Opposite party denied total amount of Rs.12,500/- under its head ‘Surgery Charges’ in the claim approval letter dt 18.10.2017 and disclosed reason for non-payment on the ground of claim settled as per GIPS package rate.
5. Opposite party denied amount of Rs.9,970/- under its head ‘Consultant Charges’ in the claim approval letter dt. 18.10.2017 and disclosed reason for non-payment on the ground of claim settled as per GIPSA package rate.

The complainant claimed the following reliefs in the complaint:-

1. Letter dated 18.10.2017 disallowing the remaining claim amount of Rs.58,179/- and thereafter, if any, for rejection of the claim may kindly be held illegal, arbitrary and be set aside in view of facts & documents on record and the opposite parties be also directed to settle and pay the claim of Rs.58,179/- along with interest @12% from the date of lodging claim till payment.
2. For causing mental tension, harassment as well as rendering deficient/negligent services to the complainant and for adopting unfair trade practice & for causing delay in deciding the fate of the claim and for not intimating the fate or status of the lodged claim in its true nature, the opposite parties be also penalized to Rs.50,000/- as compensation to the complainant along with litigation cost of Rs.11,000/-.  

2.                The complaint as against opposite party No.2 was not admitted vide order dated 25.10.2019.

3.                Upon notice to opposite party No.1, written statement has been filed by taking preliminary objections that the complaint is not maintainable and same is bad for non-joinder and mis-joinder of necessary parties.  It has been further alleged that the claim was scrutinized by competent doctors of opposite party No.2 and after observing the guidelines of terms and conditions of insurance policy, they worked out payable amount of Rs.41,426/- and the same was received by the complainant. The complainant is not entitled for amount of Rs.58,179/- from the opposite parties. The complainant is estopped from demanding any further amount. There is no deficiency of service on the part of the opposite parties. On merits, opposite party No.1 admitted the issuance of the policy, its validity and exchange of emails between the complainant and the opposite parties. The complainant further asserted that the policy along with condition and clause 3.23 was served. It was also asserted that the claim was rightly settled and there is no unfair trade practice and deficiency in service on their part. The settlement sheet dated 18.10.2017 was duly prepared by the doctors of the opposite parties. The treating hospital i.e. SPS Apollo Hospital is on the penal of opposite party No.2 and there is a memorandum of understanding between opposite party No.2 and SPS Apollo hospital with regard to the charging the specific amount for specific treatment and SPS Apollo Hospital is bound to provide the service and take reasonable rate/charges as per GIPSA package rate settled between them. The other averments made in the complaint have been denied being wrong and in the end, a prayer for dismissal of the complaint has been made.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C15 and closed the evidence.

5.                On the other hand, counsel for opposite party No.1 tendered affidavit Ex. RA of Sh. Vinod Kumar, Divisional Manager of opposite party No.1 along with document Ex. R1 i.e. claim approved letter and closed the evidence.  

6.                During the course of argument, it was found that the complete policy was not placed on record by either of the parties. The opposite parties were directed to place the copy of policy which was taken on record.

7.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

8.                Perusal of the claim approved letter dated 18.10.2017 Ex. C15 shows that the total amount of Rs.99,605/- was claimed and an amount of Rs.41,426/- was settled. The category breakup of total claim has been given as under:-

Category Break Up
Charge Type	Bill Amount	Payable Amount	Non Pay Amount	Non Payable Reason
Hospital Charges	6000	0	6000	17-18C804/04/05/2017: Claim settled as per GIPSA package rate
Investigation & Lab charges	6370	5820	550	3368:01/05/2017: No prescription attached: 17-18C804/04/05/2017: Claim settled as per GIPSA package rate
Non Taxable Pharmacy & Medicine Charges 16124	16124	326	15798	3369:01/05/2017:No prescription attached: 1179:04/05/2017: Gauze Pieces not payable, 17-18C804/04/05/2017: Claim settled as per GIPSA package rate, 2937:04/05/2017: No prescription attached: 1066:24/05/2017: No Prescription attached.
Miscellaneous charges	13361	0	13361	17-18C804/04/05/2017: Instrument charges not payable 17-18C804/04/05/2017:other charges not payable; 17-18C804/04/05/2017: Claim settled as per GIPSA package rate.
Surgery Charges	12500	0	12500	17-18C804/04/05/2017: Claim settled as per GIPSA package rate.
Consultant Charges	45250	35280	9970	17-18C804/04/05/2017: Claim settled as per GIPSA package rate. 17-18C804/04/05/2017: Claim settled as per GIPSA package rate.

The counsel for the complainant has drawn the attention of this Commission towards Retail Invoice Ex. C3 dated 04.05.2017 and contended that the same has been issued and supplied by the hospital itself and not by any private/medical store. There is no specific disclosure of all the six heads and its corresponding amounts in Ex. C3. However, the opposite parties never informed that the insurance policy is subject to GIPSA rates, either at the time of issuance of policy or thereafter even the receipt of emails dated 10.11.2017 (Ex. C9) and 27.06.2019 (Ex. C13). As such, deductions are unjustifiable and illegal. However, the counsel for the opposite parties has vehemently refuted the allegations of the complainants that it is the complainant who did not bring into the notice of the hospital which lead to the application of non GIPSA rate.

9.                GIPSA stands for General Insurance Public Sector Association. It is a group of four general insurance companies consisting of The New India Assurance Company Ltd., The National Insurance Co. Ltd., The United India Insurance Company Ltd. and The Oriental Insurance Company Ltd. This group of insurance companies has a particular price band with limited cashless services with limited hospitals which accept these companies’ price band and join their own PPN (Preferred Provider Network). The opposite parties were required to make complainant/policy holder aware that he can avail cashless medical services in the PPN approved by GIPSA only and if any of the hospital overcharges, the policy holder can raise a grievance with the insurance company. The insurance company is liable to reimburse the claim of the policy holder done in non PPN hospital but in the present case, the complainant had been asserting that opposite partyNo.1 supplied four pages of the insurance policy consisting of policy schedule, premium certificate and Ombudsman centre and they did not supply the complete and comprehensive policy containing terms and conditions. During the course of settlement of the claim, the complainant sent email Ex. C9 asking the opposite parties to provide the details of GIPSA package.  Again on 27.06.2019, the complainant sent an email Ex. C13 asking the opposite parties to disclose about the GIPSA package and how it is the part of the policy but the opposite parties did not respond. Rather in the written statement, they continued to shift their stand and took about more than two years in settling the entire claim As such, there is a deficiency on the part of the opposite parties.

10.              Perusal of the policy Ex. C1 shows that it has not been specifically mentioned that in the event of raising a claim by the complainant, the claim would be governed by the rates as applicable by GIPSA package. There appears to be an ambiguity in this regard aspect more so when the complainant has specifically asserted that he has not been supplied with complete copy of insurance policy. It is settled law that the words are to be construed, resulting in two alternative interpretations then, the interpretation which is against the person using or drafting the words or expressions which have given rise to the difficulty in construction, applies. This Rule is often invoked while interpreting standard form contracts. When such standard form contracts ordinarily contain exception clauses, which are invariably construed contra proferentem rule against the person who has drafted this. Sum of the judgments which has considered the Contra Proferentem Rule are referred as under:-

a)       In General Assurance Society Ltd. Vs Chandmull Jain AIR 1966 (SC) 1644 whereby it has been held by the Hon’ble Supreme Court of India that where there is an ambiguity in the contract of insurance or doubt, it has to be construed contra proferentem against the Insurance Company.

b)      In Delhi Development Authroity Vs Durga Chand Kaushish AIR 1973 (SC) 2609 it has been held by the Hon’ble Supreme Court of India that in construing a document one must have regard, not to the presumed intention of the parties, but to the meaning of the words they have used. If two interpretations of the document are possible, the one which would give effect and meaning to all its parts should be adopted and for the purpose, the words creating uncertainty in the document can be ignored.

c)       In Central Bank of India Vs Hartford Fire Insurance Co. Ltd. AIR 1965 (SC) 1288 it has been held by the Hon’ble Supreme Court of India that what is called the contra proferentem rule should be applied and as the policy was in a standard form contract prepared by the insurer alone, it should be interpreted in a way that would be favourable to the assured.

d)      Further in Md. Kamgarh Shah Vs Jagdish Chandra AIR 1960 (SC) 953 wherein it has been held by the Hon’ble Supreme Court of India that where there is an ambiguity it is the duty of the court to look at all the parts of the document to ascertain what was really intended by the parties. But even here the rule has to be borne in mind that the document being the grantor’s document it has to be interpreted strictly against him and in favour of the grantee.

11.              Applying the ratio of the aforesaid Rule and judgments, the deduction made by opposite party No.1 are not justifiable and the complainant is entitled to the remaining claim of Rs.58,179/- along with interest @8% per annum from 04.05.2017 till actual payment along with composite compensation of Rs.5,000/-.

12.              As a result of above discussion, the complaint is allowed with direction to opposite party No.1 to  pay the remaining clam amount of Rs.58,179/- to the complainant along with interest @8% per annum from 04.05.2017 till actual payment within 30 days from the date of receipt of copy of the order. Opposite party No.1 shall also pay a composite compensation of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made  within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

Announced in Open Commission.

Dated:07.12.2022.

Gobind Ram.

Jageshwar Prasad Vs Oriental Insurance Co. Ltd.                      CC/19/458

Present:       Sh. M.S. Sethi, Advocate for complainant.

                   Sh. D.R. Rampal, Advocate for OP1.

                   Complaint against OP2 not admitted vide order dated 25.10.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with direction to opposite party No.1 to  pay the remaining clam amount of Rs.58,179/- to the complainant along with interest @8% per annum from 04.05.2017 till actual payment within 30 days from the date of receipt of copy of the order. Opposite party No.1 shall also pay a composite compensation of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made  within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:07.12.2022.

Gobind Ram.