DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA

C.C. No. 69 of 29-03-2019

Decided on: 31-08-2022

1. Dinesh Gupta S/o Ramesh Chander;

2. Nidhi Gupta W/o Dinesh Gupta;

Both R/o # 96, Urban Estate-II, Bathinda.

........Complainants

Versus

1. New India Assurance Company Limited, Rampura Branch, through its Branch Manager.

2. The New India Assurance Company Limited, Divisional Office, The Mall, Bathinda through its Divisional Manager, Bathinda.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Sh.Kanwar Sandeep Singh, President

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Anil Gupta, Advocate.

For opposite parties : Sh. Sunder Gupta, Advocate.

ORDER

Kanwar Sandeep Singh, President:-

1. The complainants Dinesh Gupta and another (here-in-after referred to as complainants) have filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against New India Assurance Company Limited and another (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainants is that complainant No. 1 purchased medi-claim policy bearing No. 36060434162700000001 from the opposite parties for his entire family, valid w.e.f. 27.07.2016 to 26.07.2017. The opposite parties supplied only the Insurance cover note and not supplied terms and conditions.

3. It is alleged that Nidhi Gupta, complainant No. 2 wife of complainant No. 1 suffered from Laparoscopic Hysterectomy with Bilateral Salpingectomy on 01.11.2016. She was got medically checked up from Dr. Rupinder Kaur Romana, and thereafter on 02.11.2016 from Max Health Care Hospital and other Hospitals as OPD, but later on, due to her serious conditions, she was got admitted in Adlakha Hospital, Amritsar on 22.12.2016 where she remained admitted up on 25.12.2016. Dr. Rakesh Sinha, Surgeon of Adlakha Hospital, Amritsar operated complainant for 3 D Total Laparoscopic Hysterectomy with Bilateral Salpingectomy on 23.12.2016. Nidhi Gupta, was discharged on 25.12.2016 after providing necessary treatment. She followed up the treatment since 22.12.2016 to 25.12.2016 as indoor patient and thereafter as O.P.D and had spent about Rs.1,30,000/- on her treatment.

4. It is also alleged that complainant No.1 applied for reimbursement of medical bills of his wife i.e. complainant No.2 with the opposite parties and complied with all the terms and conditions including submission of original bills. The opposite parties paid Rs. 61,302/- vide claim settlement voucher dated 30.03.2017 against the above said claim of Rs.1,30,000/- of complainants. The opposite parties wrongly and illegally paid Rs.18,072/- against Anaesthesia charges of Rs.25,000/-, surgeon fee of Rs.63,072/- has been denied totally whereas Rs.6,830/- has been paid as medication charges instead of Rs,7928/-. Total Rs.71,098/- has been illegally and arbitrarily denied by the opposite parties.

5. It is further alleged that against the above said illegal deductions made by the opposite parties, the complainant sent e-mails dated 06/04/2017 & 01/05/2017 for query and in response to said e-mails, the opposite parties replied that Rs.1500/- has been deducted as excess in Anesthesia charges and Rs.43,330/- have been deducted as excess surgeon fee as per reasonable and customary clause and Rs.1098/- has been deducted as consumable are not payable. The said reply is totally vague against the actual claim settlement voucher which is in possession of the opposite parties. Due to non payment of amount of Rs.72,098/-, the complainants suffered mental agony, pains, botheration as well as financial loss for which they claim compensation to the tune of Rs.50,000/-.

6. On this backdrop of facts, the complainants have prayed for directions to the opposite parties to pay medi-claim of Rs.71,098/- along with interest @ 18% per annum from the date of admission of the complainant No.2 till the date of its final payment in addition to Rs.50,000/- as compensation besides Rs.10,000/- as litigation expenses.

7. Upon notice, opposite parties appeared through counsel and filed joint written reply raising legal objections that complainant obtained New India Asha Kiran Policy from the opposite parties. As per record wife of complainant was admitted in Adhlakha Hospital, Amritsar for the period from 22.12.2016 to 25.12.2016 where she was diagnosed a case of Fibroid Uterus with Heavy Bleeding. She was operated upon in that hospital for Total Laparoscopic Hysterectomy and complainants have alleged that they have incurred Rs.1,30,000/- on her treatment and claim was lodged with the Raksha TPA, who after verifying the medical treatment record and medical bills submitted, allowed cashless claim under claim No.9051617521101 to the tune of Rs.61,302/- as per clause 2.35 of terms and conditions of aforesaid insurance policy. The remaining amount is not payable as per terms and conditions of the aforesaid policy.

   The detail of claim settled is as under:- CLAIM NO 9051617521101

It has been pleaded that lawful claim of the complainants has been fully paid as per terms and conditions of Insurance Policy and complainant is not entitled for any other amount.

9. Further legal objections are that the complainant is estopped by his own act and conduct to file the present claim. That the complainant has not come to this Commission with clean hands, rather has suppressed the true and material facts and documents. That the complainant has got no locus standi or cause of action to file the present complaint. That the amount of compensation claimed is highly excessive and exorbitant one. That the complaint is false, frivolous and vaxatious to the knowledge of the complainant.

10. On merits, the opposite parties have admitted that complainants obtained aforesaid Medi-claim policy bearing No.36060434162700000001 effective from 27.07.2016 to 26.07.2017. Terms and conditions of the Insurance Policy along with cover note was duly supplied to the complainant. It has also been admitted that complainant remained admitted in Adhlakha Hospital, Amritsar for the period from 22.12.2016 to 25.12.2016 where she was diagnosed a case of Fibroid Uterus with Heavy Bleeding ans as per record she was operated upon in that hospital for Total Laparoscopic Hysterectomy.

11. It has been pleaded that opposite parties paid Rs.61,302/- to the complainants as per terms and conditions of Insurance Policy and remaining amount was not payable. In further reply, the opposite parties reiterated their version as pleaded in legal objections and detailed above. After controverting all other averments of the complainants, the opposite parties prayed for dismissal of complaint.

8. In support of his complaint, the complainants have tendered into evidence affidavit dated 29.03.2019 of complainant No. 1 (Ex.C-27), and the documents (Ex.C-1 to C-26).

9. To rebut the claim of the complainants, opposite parties have tendered into evidence affidavit of Ashish Pal dated 18.09.2019, (Ex.OP-1/3) and documents (Ex.OP-1/1 to Ex.OP-1/2)

10. We have heard learned counsel for parties and gone through the file carefully.

11. Learned counsel for parties have reiterated their stand as taken in their respective pleadings and detailed above.

12. In the case in hand, there is no dispute between the parties regarding medi-claim insurance of complainants; treatment of complainant No. 2 and expenses incurred by the complainants on the treatment to the tune of Rs. 1,30,000/- and payment of claim made by the opposite parties to the complainants amounting to Rs. 61,302/- after deducting Rs. 71,098/-.

13. The opposite parties have pleaded that remaining amount is not payable to the complainants as per clause 2.35 of terms and conditions of the policy.

14. Clause 2.35 of the policy (Ex. OP-1/3) reads as under :-

    Clause 2.35 Reasonable and Customary Charges:- mean the charges for reasonable expenses of treatment and supplies, which are the standard charges for the service provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved

15. Section 1 of the said policy reveals :-

    What We Cover : Section -1

    If during the Period of Insurance, you or any Insured Person incurs Hospitalization Expenses which are Reasonable and Customary and Medically Necessary for treatment of any Illness or injury sustained in Accident, We will reimburse such expenses incurred by you.

16. The opposite parties have approved and allowed cashless claim to complainant No. 2 to the extent of Rs.61,302/- and complainant No. 2 got treatment from the approved/panelled hospital of the opposite parties.

17. As detailed above, Section 2.35 of the policy provides benefit/charges under the policy, mean the charges for reasonable expenses of treatment and supplies, which are the standard charges for the service provider and Section 1 of the policy provides - If during the Period of Insurance, any Insured Person incurs Hospitalization Expenses which are Reasonable and Customary and Medically Necessary for treatment of any Illness, the opposite parties will reimburse those expenses. Thus, in such circumstances, when the complainant got treatment from the hospital approved by the opposite parties and her claim was allowed, then deduction of charges on account of Anaesthesia, surgeon fee and operation theatre charges are not justified as these expenses cannot be said to be not reasonable and medically necessary. Moreover, Opposite parties failed to bring on file any document to prove charges for reasonable expenses of treatment and supplies, which are the standard charges for the service provider and the consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved.

18. Further Ex. C-24 is settlement voucher vide which claim was settled fee Rs.61,302/- against Billed amount of Rs.1,30,000/-. Anaesthesia charges are shown as Rs.25,000/- after deduction of Rs.6,928/- approved amount is of Rs.18,072/-, Surgeon fee Billed amount Rs.63,072 and approved amount Rs. Zero, Operation theatre charges Rs.25,000/- and approved amount is Rs.25,000/- but as per reply as well as affidavit opposite parties in evidence (Ex. OP-1/1) Anesthesia charges are mentioned as Rs.25,000/-, after deduction of Rs.15,000/- payable amount shown as Rs.10,000/-, Surgeon charges Rs.63,072/-, Deduction of Rs. 40,000/- and amount payable is mentioned as Rs.23,072/-, Operation theatre charges Rs.25,000/- deduction Rs.15,000/- and amount payable is mentioned as Rs.10,000/-. Surprisingly claim of settlement voucher and pleading of evidence of opposite parties is not in consonance with each other and evidence produced by opposite parties is also beyond pleadings.

19. Insurance Regulatory and Development Authority (IRDA) vide circular “ Ref No. IRDA/HLTH/MISC/CIR/216/09/2011 Dated 20-09-2011 directed All life insurers and non-life insurers :

    “The Insurers' decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.”

20. Thus, this Commission is of the considered opinion that there is deficiency in service on the part of the opposite parties in making the deductions from genuine treatment expenses of the complainant which she actually incurred, without any solid reason.

21. Ex. C-23 is the receipt of payment which reveals that an amount of Rs. 1,30,000/- has been paid to Adlakha Hospital, Amritsar by complainant No. 2 through RTGS.

22. In view of what has been discussed, this complaint is partly allowed with Rs.10,000/- as cost and compensation. The opposite parties are directed to pay Rs. 70,000/- (Remaining charges Rs. 15000/- for anaesthesia + Rs. 40,000/- surgeon charges + Rs. 15,000/- operation theatre charges) with interest @ 8% p.a. from the date of payment of previous claim amount of Rs. 61,302/- till realization.

23. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order.

24. The complaint could not be decided within statutory period due to Covid pandemic and heavy pendency of cases.

25. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.

    Announced:-

    31-08-2022

 (Kanwar Sandeep Singh)

President

(Paramjeet Kaur)

Member