| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 280 of 16-10-2018 Decided on : 29-04-2022 Parkash Devi Wd/o Satpal @ Satpaul Goyal, aged about 68 years Sanjeev Goyal S/o Satpal @ Satpaul Goyal, aged about 47 years Ranjeev Kumar S/o Satpal @ Satpaul Goyal, aged about 45 years Munish Goyal S/o Satpal @ Satpaul Goyal, aged about 40 years - All are R/o # 67 Veer Colony, Bathinda.
........Complainants Versus Raksha TPA Private Limited C/o Escorts Corporate Centre, 15/5 Mathura Road, Faridabad, Haryana 121003, through its Manager/Incharge The Oriental Insurance Co. Ltd., Divisional Office, Bank Bazar, Bathinda, through its Divisional Manager
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member Smt. Paramjeet Kaur, Member Present For the complainant : Sh. Naresh Garg, Advocate. For opposite parties : OP No. 1 exparte Sh. M L Bansal, Advocate for OP No. 2. ORDER Kanwar Sandeep Singh, President The complainant Parkash Devi and others (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 Raksha TPA Private Ltd., and another (here-in-after referred to as opposite parties). Briefly stated the case of the complainants is that the complainants are the class I legal heirs of the deceased Satpaul Goyal who was duly insured with the opposite parties having saving account with Oriental Bank of Commerce, Bank Street, Bathinda. The opposite parties sold one Mediclaim Insurance Oriental Bank Mediclaim Policy Schedule and insured Satpaul Goyal and complainant No. 1 vide Policy No. 233200/48/2018/1871 w.e.f. 09.10.2017 to 08.10.2018 under cashless scheme with opposite party No. 2. It is alleged that in the said policy, complainant No. 1 and her husband were duly insured for Rs.5,00,000/-. This Insurance was sold by the opposite parties to the complainant and her family under their agency arrangement with the scheme to issue the OBC Bank Customers. It was also told to the complainant that the OBC Bank is strategic partner under special MOU with the OIC for selling this Medical Insurance Scheme and the same is only for the customers of the OBC Bank as such, the name of the scheme is Oriental Bank Mediclaim Policy. In this insurance, the total sum insured is Rs.5,00,000/- and any one can use the said amount from insured family. The said insurance is continuous insurance since 2015 and the said policy was issued by OBC Bank under their arrangement with opposite party No.1. It is alleged that Delhi Heart Institute & Multispecialty Hospital and DMC Hospital, Ludhiana are the network hospitals of the said insurance scheme with opposite parties. The Insurance is cashless Insurance and the opposite parties also assured the complainant that in case of any emergency the claim can be lodged anywhere in India with the nearest offices of the opposite parties and admitted in any hospital in India. It is alleged that Satpaul Goyal was treated for Myasthenia Gravis on 02.04.2018 and admitted in Delhi Heart Institute Multispecialty Hospital and was discharged on 07.04.2018. He was immediately referred to DMC Hospital, Ludhiana on the same day i.e. 07.04.2018 and was discharged from that hospital on 30.04.2018. The period of treatment was under above said insurance scheme. It is alleged that Delhi Heart Institute & Multispecialty Hospital prepared the total bill of Rs. 1,21,234/- and the opposite parties paid the part payment of Rs.73,690/-. The complainant paid Rs.47,544/- to the Hospital from his own pocket and submitted total bill and treatment papers to opposite parties under their scheme. It is also alleged that DMC Hospital, Ludhiana prepared the total bill of Rs.3,83,649/- and the opposite parties paid the part payment of Rs.3,42,649/- and Rs.28,302/-. The complainant paid Rs.12,698/- to the Hospital from his own pocket and submitted the total bill and treatment papers to the opposite parties under their scheme. It is further alleged that finally after treatment, the hospitals discharged Satpaul Goyal on 30.04.2018 and they illegally charged Rs.47,544/- + Rs.12,698/- = Rs.60,242/- from the complainant for the treatment of Satpaul Goyal and without payment of this amount, hospitals were not ready to discharge the patient on the ground and they received part payment from the opposite parties. It is also alleged that due to illegal act of the opposite parties, Satpaul Goyal insured came under mental stress and ultimately he died on 07.06.2018. The amount of Rs.60,242/- is still pending with the opposite parties. It is further alleged that complainant visited office of opposite party No.2 at Bathinda and handed over the photocopy of total medical treatment file alongwith photocopy of the bills and requested it to make payment of balance amount of Rs.60,242/-. The complainant also got issued legal notice in this regard, but to no effect. The opposite parties neither paid the balance claim of Rs.60,242/- nor supplied any clause for retaining this amount nor rejected the said claim. Due to non-payment of Rs. 60,242/- complainants suffered mental agony and pain for which they claim compensation to the tune of Rs.15,000/-. On this backdrop of facts, the complainants have prayed for directions to the opposite parties to pay claim amount of Rs. 60,242/- with interest @ 18% p.a. and pay Rs. 15,000/- as compensation besides Rs. 15,000/- as litigation expenses. Registered notice of complaint was sent to the opposite parties. None appeared on behalf of opposite party No. 1. As such, exparte proceedings were taken against opposite party No. 1. The opposite party No. 2 put an appearance through counsel and contested the complaint by filing written reply raising legal objections that the present complaint has been filed by the complainants only to injure the goodwill and reputation of the opposite parties. Even otherwise, complaint is false, frivolous and vexatious to the knowledge of the complainant. That intricate questions of law & facts are involved in the present complaint, which requires voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act'. That the complainant has concealed material facts and documents from this Commission. It has been pleaded that on receipt of cashless approval from the concerned hospitals regarding treatment of insured, payable claim amount out of bill of Rs.1,21,234/- has already been disbursed. However, the remaining alleged claim amount was/is not payable as per the terms conditions of the policy, so the same has rightly been declined by the opposite parties viz. out of doctors fee, an amount of Rs.4,000/-, out of lab charges, an amount of Rs.13,800/- out of Hospital services, an amount of Rs.17,000/-, out of medication charges, an amount of Rs.9,244/-, out of admission charges, an amount of Rs.3500/-, totaling to Rs. 47,544/- were/are not payable as it related to DM, HTN, COPD, Heart Disease and claim was settled for treatment related to Myasthenia Gravis only. It has been further pleaded that similarly, payable claim amount out of bill of Rs.3,83,649/- has already been disbursed. The remaining alleged claim amount was/is not payable as per the terms & conditions of the policy, so the same has rightly been declined by the opposite parties viz. an amount of Rs.1,170/- on account of Hospital Services, an amount of Rs.11,228/- on account of Medication Charges, and Rs.300/- on account of Registration fees, totaling to Rs.12,698/- were/are not payable as per terms & conditions of the policy. Further legal objections are that the complainants have no locus standi or cause of action and that the complainants are not consumers. On merits, the opposite party No. 2 admitted that deceased Satpaul Goyal was insured with the opposite party No. 1. It has been pleaded that policy has been issued strictly as per terms and conditions thereof and the claim, if any, is payable only as per terms & conditions of the policy and the detailed terms & conditions were duly supplied to the insured. No amount much less Rs.60,242/- is pending against opposite party No. 1. The payable amount has already been disbursed and now nothing is due and payable by the opposite parties as per terms & conditions of the policy. In further reply, the opposite party No. 1 has reiterated its version as pleaded in legal objections and detailed above. In support of their complaint, the complainants have tendered into evidence affidavits of Parkash Devi, Sanjeev Goyal, Ranjeev Kumar and Munish Goyal all dated 16-10-2018 (Ex. C-1 to Ex. C-4), photocopy of policies (Ex. C-5 to Ex. C-7), photocopy of medical file (Ex. C-8), photocopy of bill (Ex. C-9), photocopy of medical file (Ex. C-10), photocopy of bill (Ex. C-11), photocopy of death certificate (Ex. C-12) and photocopy of legal notice (Ex. C-13). In order to rebut the evidence of complainants, the opposite party No. 1 tendered into evidence affidavit dated 13-12-2018 of Ashwani Kumar (Ex. OP-2/1), photocopy of claim note sheet (Ex. OP-2/2), photocopy of opinion (Ex. OP-2/3), photocopy of letter (Ex. OP-2/4), photocopy of policies (Ex. OP-2/5 to Ex. OP-2/7), photocopy of bill (Ex. OP-2/8), photocopy of letter (Ex. OP-2/9), photocopy of claim form (Ex. OP-2/10), photocopy of letter (Ex. OP-2/11) and photocopy of opinion (Ex. OP-2/12) . We have heard learned counsel for the parties and gone through the record. The learned counsel for the parties reiterated their stand as taken in their respective pleadings. These are admitted facts of the parties that Satpaul Goyal and complainant No. 1 were insured with the opposite parties vide Insurance Policy Ex. C-7. As per said insurance, the insured were entitled to cashless treatment. Satpaul Goyal took treatment for Myasthenia Gravis and remained admitted in Delhi Heart Insitute & Multispeciality Hospital from 7-4-18 to 30-4-18. The said hospital prepared total bills of Rs. 1,21,234/- out which opposite parties paid Rs. 73,690/- and remaining amount of Rs. 47,544/- was paid by complainants. Thereafter Satpaul Goyal was referred to DMC Hospital, Ludhiana, wherein he remained admitted from 7-4-18 to 30-4-18. The hospital prepared bill of Rs. 3,83,649/- out of which opposite parties paid Rs.3,42,649/- and Rs.28,302/- and remaining amount of Rs. 12,698/- was paid by complainants. The submission of learned counsel for opposite party No. 2 regarding deduction of Rs. 47,544/- is that these expenses are not payable as it relates to DM, HTN, COPD, Heart Disease and further opposite parties have deducted Rs. 12,698/- from total bill amount of Rs.3,83,649/- of DMC, Hospital, Ludhiana, on account of hospital services medication charges, registration fee, on the ground that these charges are not payable as per terms and conditions of the policy. This Commission observed that the opposite parties have not placed on file any terms and conditions of the insurance policy in question according to which expenses incurred on the treatment of DM, HTN, COPD, Heart Disease are not payable. No document is produced on file by the opposite parties to show the formula/basis of deduction or any term and condition of the policy on the basis of which deduction can be made in the claim of complainants qua hospital services, medication charges and registration fee etc., In such circumstances, complainants are entitled to the amount as detailed above i.e. Rs. 60,242/- incurred on the treatment of deceased Satpaul Goyal. Hon'ble Punjab & Haryana High Court in the case titled New India assurance Co. Ltd., Vs. Usha Yadav 2008(3) RCR Civil 111 has observed that : “Cash rich Insurance Company indulging in luxury litigation to repudiate claim of the insured – It seems that the Insurance companies are only interested in earning the premiums and find ways and means to decline the claim. Therefore, in the absence of any terms and conditions, the above said deductions made by the opposite parties from the total medical expenses of the complainants, are not justified and it amounts to deficiency in service on the part of the opposite parties. In the result, this complaint is partly allowed with Rs.10,000/- as cost and compensation against the opposite parties. The opposite parties are directed to pay Rs. 60,242/- to complainants in equal share, with interest @8.% p.a. from the date of payment to respective hospitals, till realization. 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. The complaint could not be decided within the statutory period due to covid pandemic and heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.
Announced : 29-4-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member
(Paramjeet Kaur) Member
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