DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. NO.358/2021

Date of Institution: 21.09.2021

Judgment Reserved on: 04.10.2023

Judgment Passed on: 13.10.2023

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms.Rashmi Bansal (Member)

Order by: Sh. Ravi Kumar (Member)

JUDGMENT

The Complainant has alleged deficiency in service on the part of OPs in not settling his medical claim in terms of the Health Insurance Policy (OP1 & OP2) he had taken and also for charging higher rates in his medical bill by the Hospital (OP3). 

1. It is the case of the Complainant that he was having Health Insurance Policy under ‘Diamond Plan’ covering himself and his wife from OP1 for the last 15 years and for the relevant period policy number was 272601/48/2021/1004 which was valid from 18.07.2020 to 17.07.2021 and the sum insured was Rs.12,00,000/-. 
2. The Complainant fell sick and was admitted in Max Smart Super Specialty Hospital, Saket (OP3) between 11.12.2020 and 18.12.2020 and at the time of admission he was diagnosed as a patient of COVID-19, Diabetes Mellitus, Hypertension, ARDS, Type – I Respiratory failure (Resolved). 
3. When he was admitted in Hospital he informed the TPA about the Health Insurance Policy he was holding and sought cashless facility however the same was not provided and after the treatment a bill of Rs.2,72,732/- was raised, out of which the approval of Rs.1,09,900/-,  including Hospital discount of Rs.10,530/- was given thus totaling Rs.99,370/- by stating that the same is as per the Government of NCT of Delhi guidelines of capping of Rs.10,000/- per day plus permitted expenses and Complainant was compelled to pay balance amount of Rs.1,78,832/- (as per payment details) at the time of Discharge from the Hospital on 18.12.2020, whereas OP3 Hospital should have recovered the balance amount of Rs.1,73,362/- as per payment details. 
4. Complainant has also alleged that OP3, which is the Hospital where he was admitted, overcharged the Bill in connivance with OP1 and OP2. 
5. Complainant has contended that OP1 and OP2 cannot put any cap of Rs.10,000/- per day or change the policy conditions unilaterally since OP1 while settling his claim of Rs.2,72,732/- had allowed only the payment of amount as per the DGHS directions dated 20.06.2020 whereas as per the IRDAI letter no.IRDAI/HTL/REG/CIR/054/03/2020 dated 04.03.2020 under Clause 1(ii) ‘ The cost of admissible medical expenses during the course of treatment including the treatment during quarantine period shall be settled in accordance to the applicable terms and conditions of policy contract and the extant regulatory framework’ and again as per IRDAI Circular No. IRDAI/HLT/REG/CIR/01/2021 dated 13.01.2021 under Clause 3, the health insurance claims shall be settled as per the Terms & Conditions of the policy contract and under Clause 4 Insurers were advised to issue suitable guidelines on this to all TPAs.
6. The Complainant wrote many e-mails and requested OP1 to settle the claim in terms of the Insurance Policy however the same was not done.  The Complainant issued Legal Notice dated 16.08.2021 which was not replied.

In his complaint, the Complainant has sought following reliefs:

1. To direct the Opposite Parties, jointly and severely to pay to the Complainant, a sum of Rs 1,78,832/- (Rupees One Lakh Seventy Eight Thousand Eight Hundred Thirty Two).
2. To direct the Opposite Parties, jointly and severely pay to the Complainant, a compensation amounting to Rs.2,00,000/- (Rupees Two Lakh) towards putting the life of the Complainant in danger, mental agony, harassment and sufferings.
3. To direct the Opposite Parties to pay pendente lite interest @ 12% per annum on the aforesaid amount from 18.12.2020 till its realization,
4. Impose Penalty on the Opposite Parties under the Consumer Protection Act, 2019 for the committing the Unfair Trade Practice.
5. Pass  further  order(s)  as  this  Commission  may  deem  fit

and proper in the facts and circumstances of the present case

7. Notice was issued and reply was filed by OP1 and OP3. No reply was filed by OP2 and OP2 was proceeded ex-parte on 26.04.2022. 
8. OP1 which is the Insurance Company, in its Reply has stated that the payable amount was Rs.99,730/- as against the claim and the Complainant is not entitled for more amount under the Terms & Conditions of the Policy.  The Complainant was covered under the Medical Policy in which sum insured was Rs.12,00,000/-.  He was Hospitalized at Max Hospital, Saket between 11.12.2020 and 18.12.2020 with diagnosis of COVID-19, Pneumonia with Diabetes Mellitus, Hypertension, ARDS, Type-I Respiratory Failure (Resolved).  Cashless was granted as per Circular of Govt. of National Capital Territory of Delhi dated 20.06.2020 according to which the maximum per day package for COVID-19 related treatment in Private Hospitals was Rs.10,000/- (including PPE Kit cost).  The Complainant was allowed Rs.70,000/-, Rs.32,400/- for injection Redyx and Rs.7500/- cost of IL-6.  The total payable amount was Rs.1,09,900/- as per the Policy and after giving discount of Rs.10,530/- by the Hospital the amount of Rs.99,370/- was paid by them. 
9. OP3 is the Hospital where the Complainant was admitted i.e. Max Smart Super Specialty Hospital, Saket in its Reply has stated that there is no allegation of medical negligence against them and the issue mainly pertains to OP1 and OP2 and they have been unnecessarily made a party in this case as the processing, disbursement and reimbursement of medical claim was the sole prerogative of OP1 being the Insurance Company.  It is a fact that on 11.12.2020 the Complainant was admitted in its Hospital for low grade fever with mild cough since one week and after preliminary investigation treatment of COVID-19, Pneumonia was given to him and the Complainant was discharged on 18.12.2020.
10. As per DGHS Order No.52/DGHS/PH-IV/COVID-19/2020/PRSECYHFW/14450/14649 dated 20.06.2020 the Hospital rates chargeable by the Private Hospital for the treatment of COVID-19 patients were capped subject to upper limit of 60% of total bed capacity of that Hospital.  In furtherance to the said order DGHS issued a Circular bearing No.F.23/Misc./COVID-19/DGHS/NHC/2020/Pt-VIII (A)/5732-5739 dated 20.06.2020 tabulating the percentage of total bed capacity for COVID related treatment which prescribed that maximum per day package rates would be applicable on 60% of COVID beds which made the Hospital to charge their ‘schedule rates’ under the balance 40% beds. 
11. OP3 has stated that Complainant was admitted in their Hospital on 11.12.2020 for the treatment for COVID-19 and on the said date their Hospital was running at total COVID-19 bed occupancy of 77.6% which was more than upper limit of 60% criteria.  The attendant of the Complainant was duly informed/counselled and was made aware about the same and he provided consent to get the Complainant admitted under 40% uncapped bed category and he gave Undertaking cum consent for payment of charges as per Hospital Tariff Form dated 11.12.2020.  He was also provided estimated cost of Hospitalization however the amount which was finally charged for the treatment was much less than the estimate. 
12. That TPA (OP2) has a team of qualified doctors and personnel who review the bills and the patient records which was done in this case and if it had been a case of overcharging, as alleged by the Complainant, then the respective TPA would have raised query regarding the billing or would have given the directive to them at the time of granting final approval that ‘No additional amount to be taken from the patient at the time of discharge’.  Whereas on the other hand TPA provided final approval of Rs.1,09,900/- without raising any query pertaining to the Bill and it was also mentioned that ‘Hospital must collect the excess amount over and above the authorization amount from the concerned member prior to discharge from the Hospital as per rules and regulations of the Hospital’.  OP3 has enclosed letter dated 18.12.2020 in this regard along with the reply.  The OP3 has also stated that they are a very reputed Hospital owned managed and controlled by Gujarmal Modi Hospital and Research Centre for Medical Sciences and there is no post of Managing Director in their Hospital.     
13. Complainant has filed Rejoinder to the Reply of OP1 wherein he has reiterated the contents of his complaint and has also stated that OP1 did not pay the Hospital Bill as per the Terms & Conditions of the Policy and in the alleged Circular of Government of NCT of Delhi dated 20.06.2020 there was no direction to the Insurance Company to reduce the entitlement of the insured’s policy mediclaim.  The Insurance Policy and its terms and conditions are the agreement between the parties and Insurance Company cannot change the same unilaterally. 
14. Complainant has also filed Rejoinder to the Reply of OP3 wherein he has reiterated the contents of his complaint and has stated that OP3 overcharged for room rent, facilities and consumables despite the Orders/Circulars of the Government of NCT of Delhi.  The OP3 has charged room rent more than Rs.10,000/-, Consultation charges many time in a day, inflated drug price, equipment and investigation charges and also separate PPE (basis 5-6 quantity per day) thus the OP3 has overcharged the Invoice/Hospital Bills and adopted Unfair Trade Practice.  The OP3 also got signed their pre-designed format for undertaking-cum-consent for payment of charges as per Hospital tariff vide Form dated 11.12.2020. 
15. Complainant has filed Evidence by way of Affidavit wherein he has marked the following documents as exhibits:

• Copy of the Electricity Bill and the copy of the Aadhar Card as Exhibit CW1/1 (Colly). 
• Copy of the Happy Family Floater – 2015 Health Insurance Policy as Exhibit CW1/2. 
• Terms and conditions of the policy as Exhibit CW 1/3.
• Copy of the Discharge Summary of the Complainant from the Hospital as Exhibit CW1/4. 
• Copy of the Hospital Bill of supply Inpatient bill (summary) along with the details bills as Exhibit CW 1/5.
• Copy of the receipts dated 11.12.2020 for the advance payment for the amount Rs.50,000/- paid by the Complainant to the Max Hospital towards Hospital Bill as Exhibit CW 1/6. 
• Copy of the Receipts dated 18.12.2020 for the balance payment for the amount Rs.1,28,832/- (Rupees One Lakh Twenty Eight Thousand Eight Hundred Thirty Two) paid by the Complainant to the Max Hospital towards Hospital Bill as Exhibit CW 1/7.
• Copy of the email dated 21.12 2020 issued by the Complainant as Exhibit CW 1 /8.
• Copy of the email dated 21.12.2020 issued by Mr. Anil Mehra Deputy manger of the Opposite Party to the Opposite Party no. 1 as Exhibit CW 1 19.
• Copy of the email reply dated 22 12 2020 issued by Rashika Chauhan, Grievance & Redressal Department to the Complainant as Exhibit CW 1 /10.
• Copy of the email dated 11.07 2021 issued by the Complainant as Exhibit CW 1/11.
• Copy of the Legal Notice dated 16 August 2021 issued by the Adhikan & Co., Advocates & Legal Consultants on behalf of the Complainant along with the postal receipts as Exhibit CW 1/12 and track report as Exhibit CW 1/13.
• Copy of the Circulars dated 04 March, 2020, 16:07 2020, 13 January 2021 and 29 April, 2021 issued by the Insurance Regulatory and Development Authority of the India (IRDAI) as Exhibit CW 1/14 (Colly).

16. OP1 has filed its Evidence by way of Affidavit wherein he has marked the following documents as exhibits:

• Terms & Conditions of the Policy as Exhibit RW 1/1. 
• Circular of GNCT of Delhi dated 20.06.2020 as Exhibit RW 1/2. 

17. OP3 has filed its Evidence by way of Affidavit wherein he has marked the following documents as exhibits:

• Power of Attorney of Dr. Gurpreet Singh as Exhibit OP3/1. 
• Order of Notification dated 20.06.2020 as Exhibit OP3/2. 
• Undertaking cum consent form as Exhibit OP3/3 (Colly). 
• List of patients admitted in the Hospital on 11.11.2020 as

              Exhibit OP3/4 (Colly). 

• Copy of letter dated 18.12.2020 of TPA as Exhibit OP3/5.
• Final Invoice raised by the Hospital as Exhibit OP3/6.

18. Written arguments have been filed by the Complainant and OP1         & OP3. 
19. This Commission has heard the arguments of both sides and    perused the record.
20. The issues involved in the case are limited to the question whether OP1 & OP2 were right in settling the claim of the Complainant upon his Hospitalization as per the Government of NCT of Delhi (DGHS) notification dated 20.06.2020 (Exhibit OP3/2) or they were under obligation to settle the same as per the Terms & Conditions of the Insurance Policy as per IRDA guidelines (Exhibit CW 1/14) and also whether OP3 overcharged the Complainant during his treatment in their Hospital. 
21. Firstly, this Commission would deal with the factual position about the COVID-19 patient treatment in the OP3 Hospital.  It is not disputed that the Government of NCT of Delhi vide notification no.52/DGHSPH-IV/COVID -19/2020/prsecyhfw/14450-14649 dated 20.06.2020 (Exhibit OP3/2) had fixed the rate of moderate sickness of Isolation beds of Rs.10,000/- (including cost of PPE) and further Circular was issued on the same day by DGHS bearing No.F.23/Misc./COVID-19/DGHS/NHC/2020/Pt-VIII (A)/5732-5739 dated 20.06.2020 whereby the Hospital of OP3 was directed to keep 80% as COVID-19 beds.
22. As per these guidelines/ instructions, the Hospital of OP3 was having total bed capacity of 250  and the number of beds identified as COVID-19 beds were 200, out of which 60% beds were to charge at ‘prescribed rates’ and remaining 40% were to charge ‘scheduled rates’.  Thus, out of 200 there were 120 beds which were to charge at ‘prescribe rates’ and 80 beds were to charge at ‘scheduled rates’.
23. OP3 has enclosed list of patients between the period 26.09.2020 to 10.12.2020 and the name of the Complainant is showing at serial number 173 and it has been submitted by OP3 that since the same was beyond 120 beds which were to charge ‘prescribed rates’ and therefore the attendants of the Complainant i.e. his son was informed that Hospital will be charging ‘scheduled rates’ to which he gave his consent and the Complainant was admitted thereafter in the OP3 Hospital. 
24. Medical treatment was given to the Complainant by OP3 Hospital for COVID-19, Diabetes Mellitus, Hypertension, ARDS, Type –I Respirator failure (Resolved) between 11.12.2020 to 18.12.2020 and upon discharge a bill of Rs.2,72,732/- was raised and the Complainant filed its claim papers before OP1 through OP2 (TPA) for cashless permission however OP1 allowed claim of Rs.1,09,900/- and after giving discount of Rs.10530/- a total amount Rs.99,371/- was paid and the net balance of Rs.1,78,832/- was paid by the Complainant at the time of his discharge whereas he should have paid Rs.1,73,362/-. This aspect has not been explained by the Complainant that why he paid extra amount whereas the final bill of the OP3 Hospital was of Rs.2,72,732/- 
25. It is not also in dispute that the Complainant was having Mediclaim Policy number 272601/48/2021/1004 which was issued by OP1 under ‘Diamond Plan’ valid for the period from 18.07.2020 to 17.07.2021 and the sum insured was Rs.12,00,000/- and Complainant was admitted for ailment in the OP3 Hospital where he was given medical treatment.  The dispute arose only with regard to the less sanctioning of the amount by OP1 & OP2 despite of Complainant having cover of Rs.12,00,000/- under the guidelines issued by the Government of NCT of Delhi wherein the capping of Rs.10,000/- per day was fixed. 
26. OP3 has demonstrated that when the Complainant was admitted in their Hospital then 120 COVID-19 beds were to be charged at ‘prescribed rates’ i.e. Rs.10,000/- per day and since all 120 beds for this purpose were full and the Complainant when he got admitted he was patient at S.No.173 as was required to pay at ‘scheduled rates’ out of total 200 beds marked for COVID-19 patients. However the question in hand is not whether the Complainant was entitled to have treatment under ‘prescribed rates’ or ‘scheduled rates’ but the controversy is that whether OP1 & OP2 should have settled the final Bill of the OP3 Hospital as per the Terms & Conditions of the Policy in terms of IRDAI guidelines or as per guidelines of Govt. of NCT of Delhi dated 20.06.2020.   
27. If both these guidelines i.e. DGHS Order No.52/DGHS/PH-IV/COVID-19/2020/PRSECYHFW/14450/14649 dated 20.06.2020 and further circular issued on the same day bearing No.F.23/Misc./COVID-19/DGHS/NHC/2020/Pt-VIII (A)/5732-5739 dated 20.06.2020 are to be are read together then it is clear that the government had set guidelines for the Hospitals to charge at ‘prescribed rates’ at 60% beds and for remaining 40% the ‘scheduled rates’ was to be charged.  However nowhere Government of NCT of Delhi had given liberty to the Insurance Company to settle the claim as per the capping done of Rs.10,000/- per day and in fact as per IRDAI guidelines (Exhibit CW 1/14) the Insurance Company was under obligation to settle the claims as per Terms & Conditions of the Policy.
28. OP3 Hospital has correctly charged ‘scheduled rates’ and not ‘prescribed rates’ and it was the duty casted upon the Insurance Company (OP1) by IRDAI (Exhibit CW1/14) to abide by the Terms & Conditions of the Insurance Policy while settling the claim of the Complainant which they failed to do. 
29. Any person who takes insurance policy covering medical expenses always bears in mind that at the time of his Hospitalization due care will be taken by the Insurance Company to settle the Bill as per Terms & Conditions of the Policy and he does not expect any kind of harassment or mental agony to be faced by him even when he is in the Hospital and fighting for his life / health. In the present case despite of valid Mediclaim Policy covering his Hospitalization expenses available to him, at the time of his Discharge from the Hospital Complainant was made to pay from his own sources substantial amount depriving him from the benefit of the Mediclaim Policy and the same was also in gross violation of IRDAI guidelines which were binding on OP1 & OP2.
30. Since DGHS Order No.52/DGHS/PH-IV/COVID-19/2020/PRSECYHFW/14450/14649 dated 20.06.2020 and further Circular issued on the same day by DGHS bearing No.F.23/Misc./COVID-19/DGHS/NHC/2020/Pt-VIII (A)/5732-5739 dated 20.06.2020 were not to be applied in the case where a person is well covered under his Mediclaim Policy, OP1 has without any basis invoked the same in the case of the Complainant and caused financial and mental stress to the Complainant which amounts to deficiency in service.
31. OP1 has also not disputed the bills raised by the OP3 Hospital about any overcharging and has basically accepted the same. In view of the same there is no deficiency in service on the part of OP3 Hospital.
32. OP2 which is the TPA has not filed its Reply and was proceeded ex-parte and in view of the same, the deficiency in service alleged by the Complainant goes un-rebutted against OP2. 
33. For the reasons stated supra OP1 & OP2 are jointly and severally held liable for deficiency in service and this Commission orders as follows:

• OP1 and OP2 to pay, jointly and severally Rs.1,73,362/- to the Complainant along with interest @ 9% p.a. with effect from 18.12.2020 within 30 days from the date of this Order. 
• OP1 and OP2 to pay jointly and severally Rs.25,000/- to the Complainant towards mental agony and harassment. 

Complaint against OP3 is dismissed. 

This order shall be complied within 30 days from the date of the Order failing which OP1 and OP2 shall pay, jointly and severally interest @11% p.a. to the Complainant on all the above amounts alongwith the amount till the date of realization.   

Copy of the Order be supplied/sent to the Parties free of cost as per Rules.

File be consigned to Record Room.

Announced on 13.10.2023