Chandigarh

StateCommission

A/90/2023

M/s National Insurance Co. Ltd. - Complainant(s)

Versus

Neeru Bhatia - Opp.Party(s)

Gurpreet Singh Ahuluwalia Adv.

08 Sep 2023

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	90 of 2023
Date of Institution	:	09.05.2023
Date of Decision	:	08.09.2023

 

 

 

 

 

1]      M/s National Insurance Co. Ltd., 1^st Floor, SCO 38, Sector 29D, Chandigarh through its Manager.

2]      M/s Vipul Medcorp TPA Pvt. Ltd., 1^st Floor, SCO 98, Industrial Area, Phase 2, Chandigarh – 160022, through its Branch Manager.

….Appellants.

Versus

1]      Neeru Bhatia w/o Madhukar Malhotra, House No.2228, Sector 21C, Chandigarh – 160022.

2]      M/s Fortis Hospital, Sector 62, Phase VIII, Mohali – 160062 through its Medical Superintendent.

 

...Respondents.

 

BEFORE:   JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                        MR. RAJESH K. ARYA, MEMBER

ARGUED BY :-  

Sh. Gurpreet Singh Ahluwalia, Advocate for the appellants.

Sh. Pankaj Chandgothia, Advocate for respondent No.1/complainant.

Sh. Munish Kapila, Advocate for respondent No.2.

 

PER  RAJESH  K. ARYA, MEMBER

          This appeal has been filed by opposite parties No.1 & 2 i.e. M/s National Insurance Co. Ltd. and M/s Vipul Medcorp TPA Pvt. Ltd. (appellants herein) against order dated 14.03.2023 passed by District Consumer Disputes Redressal Commission-II, U.T., Chandigarh (in short ‘District Commission), vide which, consumer complaint No.159 of 2019 filed by the complainant – Neeru Bhatia (respondent No.1 herein) has been allowed against the appellants by directing them to pay an amount of Rs.2,47,411/- (hospital expenses + pre-hospital expenses) to respondent No.1 alongwith interest @10% p.a. from the date of discharge i.e. 2.3.2018 till its actual realization besides payment of Rs.15,000/- as compensation and Rs.10,000/- as costs of litigation. The order has been directed to be complied with within a period of 45 days from the date of receipt of its copy, failing which, the appellants have been made liable to pay additional compensatory cost of Rs.10,000/-. However, the District Commission dismissed the complaint against opposite party No.3 – M/s Fortis Hospital (respondent No.2 herein).

2]     Briefly stated the facts as narrated in the impugned order passed by the District Commission reads thus:-

“The case of the complainants precisely is that she obtained a mediclaim policy from OP in the year 2002 and got it renewed from time to time upto the period from 28.3.2017 to 27.3.2018 (Ann.C-1). The sum insured under the said policy was initially for Rs.2 lacs which increased with yearly renewal to the tune of Rs.4.5 lacs, apart from cumulative No claim Bonus accrued of Rs.2.25 lakhs making a total sum insured of Rs.6.75 lakhs.  It is stated that during the policy period, the complainant underwent some test which revealed unusual growth of fibroid in Uterus area and as such, underwent two procedures at Fortis Hospital Mohali of TLH (Total Laparoscopic Hysterectomy) and BSO (Bilateral Salpingo-Oophorectomy) on 28.2.2018 and discharged on 2.3.2018.  It is stated that while TLH is removal of Uterus and closure of vaginal cuff, BSO is an additional procedure involving the surgical removal of both ovaries and both fallopian tubes.  It is submitted that Fortis Hospital issued a Bill totaling Rs.2,08,741/- on various counts (Ann.C-3) and apart from this, the complainant incurred pre-hospitalization charges of Rs.38,670/- and postal hospitalization expenses of Rs.411/-.  The complainant lodged claim for said amount with OP Insurance Company (Ann.C-4) and the OP No.2 allowed only Rs.67,591/- and deducting Rs.1,90,231/- (Ann.C-5).  It is stated that the OPs ignored to allow any claim on account of BSO (Bilateral Salpingo-Oophorectomy) treatment  and also made deduction basing it PPN packing pricing and GIPSA package, which is not related to complainant. It is also stated that the OPs also disallowed various bills for pre-hospitalization period on the ground that these are 30 days before the hospitalization whereas these were necessary for conducting surgery/treatment taken by complainant. The complainant agitated the matter with OPs in respect of wrong deduction with request to reimburse the entire claim amount, but the OPs did not pay any heed. Hence, this compliant has been filed alleging the said act & conduct of the OPs as deficiency in service and unfair trade practice.

2]      The OPs NO.1 & 2 have filed reply and while admitting the factual matrix of the case about the issuance of policy and treatment undergone by the complainant, stated that as per Discharge Summary, TLH+BSO was done on 28.2.2018 and it cannot be said that these are two procedures.  It is denied that BSO is an additional surgery and from Discharge Summary it is clear that on 28.2.2018 TLH+BSO was done (Ann.OP-1 & 2/2).  It is stated that as per Clause 3.24 of the Insurance Policy, the expenses incurred for 30 days prior to date of admission in the hospital are not payable, so the bills prior to 30.1.2018 are not payable to complainant. It is submitted that the OP Insurance Company has settled the claim for Rs.67,591/- as per terms & conditions of the policy and the rates as agreed by PPN Hospital. It is submitted that the complainant has not availed cashless facility nor the hospital explained to her about the package pricing for particular surgery.  It is also submitted that reimbursement claim was lodged and it was settled as per GIPSA package and Fortis Hospital Mohali being a Network PPN Hospital, Rs.60,000/- was payable for Lap Hysterectomy.  It is pleaded that TSH and BSO are not two procedures but only one procedure and therefore, the Fortis Hospital charged the amount under one head Hysterectomy.  It is also pleaded that OP No.2 has already paid the admissible amount as per GIPSA PPN Package rates and if OP No.3 has charged more from the complainant, the OP No.3 alone is liable and not OP No.2.  Denying all other allegations and pleading no deficiency in service, the OPs No.1 & 2 have prayed for dismissal of the complaint.

        The OP No.3-Fortis Hospital has also filed reply stating that the complainant admitted on 28.2.20218, underwent surgery of Total laparoscopic Hysterectomy and Bilateral Salpingo Oophrectomy (TLH+BSO) and discharged on 2.3.2018.  It is stated that the total bill of the complainant came to the tune of Rs.2,08,741/- out of which, Rs.1,12,500/- was charged towards package cost Total Laparoscopic Hysterectomy which includes stay in single room and Rs.35,000/- was charged towards the surgical procedure cost of Bilateral Salpingo Oophrectomy and OT Anaesthesia Charges (excluding package of TLH with Drugs and Consumables) which came to the tune of Rs.22,750/-, hence total cost of the procedure as shown in the bill came to Rs.1,70,250/- (Ann.R-3/1), apart from other expenses/bill.  It is pleaded that the complainant paid a total sum of Rs.2,08,741/- against Bill Ann.C-3.   It is also pleaded that TLH with BSO procedures are two separate procedures.  It is submitted that about the denial of medical reimbursement claim by Insurance Company is concerned, the same is between the complainant and OPs No.1 & 2 and answering OP has no role in the same.  It is also submitted that when the complainant was admitted as cash paying patient, the applicability of GIPSA rates do not apply and the Hospital would charge as per Hospital rates.  Pleading no deficiency in service, the OP NO.3 has prayed for dismissal of complaint qua it.” 

3]     After hearing the contesting parties and going through the material available on record, the District Commission allowed the complaint against the appellants, as stated above.

4]      In the present appeal, the appellants are seeking modification of the impugned order on three counts. Firstly, the District Commission while directing the appellants to pay to respondent No.1 an amount of Rs.2,47,411/- (hospital expenses + pre-hospital expenses), has failed to take into consideration the amount of Rs.67,591/- which the appellants had already paid to respondent No.1 towards claim and as such, this amount of Rs.67,591/- should have been deducted by the District Commission from the awarded amount. Secondly, that the District Commission has wrongly allowed the claim of respondent No.1 towards pre-hospitalization bills, which needs to be set aside in view of Clause 3.24 of the Insurance Policy, as per which, respondent No.1 was entitled to medical expenses incurred 30 days immediately before hospitalization and thirdly, that the interest awarded by the District Commission @10% p.a. is on the higher side and thus, calls for reasonable reduction.

5]      On the other hand, it has been submitted on behalf of respondent No.1 that the District Commission has rightly allowed the complaint on the basis of documentary evidence on record and while addressing arguments on the basis of averments made in the complaint, respondent No.1 prayed for dismissal of the appeal.

6]      On behalf of respondent No.2 – M/s Fortis Hospital, it has been argued that since the District Commission has already dismissed the complaint against it and as such, no case or claim is made out against respondent No.2.

7]      It may be stated here that during the course of arguments before us, counsel for the appellants had submitted that no claim has been passed against respondent No.2 – M/s Fortis Hospital by the District Commission and complaint qua it has been dismissed and further that the appellants also did not claim anything from respondent No.2.

8]      After hearing the Counsel for the contesting parties and going through the documentary evidence/material available on record, the impugned order and the written arguments of the parties, we are of the considered view that the appeal is liable to be accepted for the reasons to be recorded hereinafter.

9]      So far as the first contention of the appellants that the District Commission while allowing the complaint and directing the appellants to pay an amount of Rs.2,47,411/- (hospital expenses + pre-hospital expenses), has failed to deduct an amount of Rs.67,591/- which the appellants had already paid to respondent No.1 towards claim, is concerned, we find sufficient merit in the same as respondent No.1 has already received the said amount of Rs.67,591/-, which fact was conceded by their Counsel during the course of arguments. Therefore, the amount of Rs.67,591/-, which respondent No.1 has already received from the appellants, is liable to be deducted from the amount awarded by the District Commission and to this extent the impugned order needs to be modified.

10]    Now coming to the next contention of the appellants that the District Commission has wrongly allowed the claim of respondent No.1 towards pre-hospitalization bills, which needs to be set aside in view of Clause 3.24 of the Insurance Policy as per which, respondent No.1 was entitled to medical expenses incurred 30 days immediately before hospitalization, it may be stated here that it is not Clause 3.24 but actually, it is Clause 3.21 in the Insurance Policy, which defined ‘Pre hospitalisation’. The said Clause 3.21, being relevant, reads thus:-

“3.21 Pre hospitalization means medical expenses incurred 30 days immediately before the insured person is hospitalized provided that:

1. such medical  expenses are incurred for the same condition for which the insured person’s hospitalisation was required, and
2. the in-patient hospitalisation claim for such hospitalisation is admissible by the insurance company.”

11]    Bare perusal of Clause 3.21 makes is abundantly clear that only the medical expenses incurred for the same condition, 30 days immediately before the insured person was hospitalized, were payable by the insurance company. In our considered opinion, the District Commission has erred in awarding pre-hospitalization charges as claimed by respondent No.1 and as such, the impugned order needs to be set aside to the extent of awarding pre-hospitalization charges of Rs.31,490/- by the District Commission.

12]    Now coming to the third and final issue with regard to awarding of interest @10% p.a. on the awarded amount, it may be stated here that the same seems to be on the higher aside for the simple reason that the District Commission has also awarded compensation of Rs.15,000/- and litigation cost of Rs.10,000/- separately vide the impugned order and in favour to comply the same, an additional compensatory cost of Rs.10,000/-. In our considered view, award of interest @9% p.a. would be adequate to meets the ends of justice and as such, the impugned order also needs to be modified to this extent.

13]    For the reasons recorded above, the appeal is accepted and while modifying the impugned order, we now direct the appellants/opposite parties No.1 & 2 as under:-

[i]       to pay an amount of Rs.1,09,660/- to respondent No.1/complainant i.e. (Rs.2,08,741.00 minus Rs.67,591.00 already paid by the appellants minus Rs.31,490.00 awarded towards pre-hospitalization bills/charges) alongwith interest @9% p.a. from the date of discharge i.e. 02.03.2018 till actual realization.

[ii]      to pay an amount of Rs.15,000/- as compensation to respondent No.1/complainant.

[iii]     to pay an amount of Rs.10,000/- as litigation cost to respondent No.1/complainant.

[iv]     This order shall be complied with by the appellants/opposite parties No.1 & 2 within a period of 45 days from the date of receipt of its certified copy, failing which they shall be liable to pay additional compensatory cost of Rs.10,000/- apart from above relief.

14]    The appeal against respondent No.2 – M/s Fortis Hospital stands dismissed with no orders as to costs.

15]    Certified copy of this order be sent to the parties free of charge.

16]    File be consigned to the Record Room after completion.

Pronounced.

08.09.2023.

(RAJ SHEKHAR ATTRI)

PRESIDENT

 

 

 

(RAJESH K. ARYA)

MEMBER

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