Date of filing: 19.07.2017
Date of Disposal: 20.05.2023
BEFORE THE III ADDITIONAL BANGALORE URBAN
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU – 560 027.
DATED THIS THE 20TH DAY OF MAY, 2023
CONSUMER COMPLAINT NO.2088/2017
PRESENT:
SRI.SHIVARAMA. K : PRESIDENT
SRI.RAJU K.S, : MEMBER
SMT.REKHA SAYANNAVAR, : MEMBER
Mr. Jailesh P Shah,
S/o. Pravin Chandra Shah,
Aged About 56 Years,
R/at: No.23, 2/3,
-
East Park Road,
Kumarapark East,
(Rep by Sri. M.R. Balakrishna, Advocate)
- V/s -
1) The Oriented Insurance Company
Limited, Oriental House,
A-25/27, Asaf Ali Road,
New Delhi-110002.
Represented by its Managing Director.
(Rep by Sri. Manoj Kumar M.R, Advocate)
2) The Vipul Medcorp TPA Private
Limited, 515, Udyog Vihar,
Phase V, Gurgaon,
Represented by its Managing Director.
3) The Branch Manager,
The Vipul Medcorp TPA Private
Limited, 17th D Main, No.154,
-
KHB Colony, 5th Block,
//JUDGEMENT//
BY SRI. SHIVARAMA K, PRESIDENT
01. The complainant has filed this complaint under section 12(1) of the Consumer Protection Act, 1986 seeking for a direction to the opposite parties to pay a sum of Rs.4,50,214/- with interest at the rate of 12% per annum and such other relief as this Commission deems fit in the circumstances of the case.
02. Opposite party No.1 & 2 are third party administrators who are licensed, governed and regulated under the insurance regulatory and development authority. Opposite party No.1 is the head office and opposite party No.2 is its branch.
03. It is not in dispute that, the complainant, his mother, his wife and two children have jointly taken the Shravak Arogyam Phase I Medi-claim health insurance and the coverage in the policy was for Rs.10,00,000/- for the period from 31.05.2016 to 30.05.2017. Further it is not in dispute that, complainant’s mother Smt. Jyotsna P Sha was admitted to Appolo Hospital in Bangalore on 10.03.2017 for treatment as she was suffering from lung infection and was discharged from the hospital on 23.03.2017 and again she was admitted to the same hospital on 28.03.2017 and discharged on 31.03.2017 and died on 24.05.2017. Further it is not in dispute that, the complainant had submitted medical bills to opposite party No.3 to the tune of Rs.4,86,177/- and opposite party had sanctioned a sum of Rs.3,11,730/- and did not reimburse a sum of Rs.1,77,447/-.
04. It is the further case of the complainant that, the complainant is entitled for pre and post hospitalization charges amounting to Rs.2,25,767/- as his mother was taking treatment for lung infection prior to her admission to the hospital and also she is entitled for post hospitalization charges. In-spite of several email correspondence been made and legal notice dated: 07.06.2017 been issued opposite party No.1 to 3 did not pay the balance amount. Further the complainant is entitled for a sum of Rs.4,00,214/- towards reimbursement of medical expenses and a sum of Rs.50,000/- towards mental agony. Hence the complaint came to be filed.
05. It is the further case of the opposite party that, as per terms and conditions of the policy 15% of the total amount is to be paid by the patient being Co-pay as per the terms. Further as per the terms and conditions of the policy the complainant is not entitled for Flowtron pump and syringe pump charge and private nursing home charge and towards mouth wash, gloves, under-pad, bandage, etc.,. Further the claim of the insured has been settled by the insurer in prompt and timely and expeditiously. Hence there is no deficiency of service on the part of opposite party thereby the complainant is not entitled for any amount towards mental agony and any claim. Hence, it is sought to dismiss the complaint.
06. To prove the case, the counsel for complainant has filed affidavit of the complainant in the form of his evidence in chief and has produced documents. Counsel for Opposite party No.1 has filed affidavit of the authorized signatory of opposite party No.1 in the form of its evidence in chief along with list of documents.
07. Counsel for the complainant has filed written arguments. Counsel for opposite party No.1 has filed memo regarding production of document and particulars of the claim settlement.
08. Heard the arguments.
09. The points that would arise for consideration are as under:-
(1) Whether there is deficiency of service on the part of the opposite parties?
(2) Whether the complainant is entitle for the
relief sought ?
(3) What order ?
10. Our findings on the aforesaid points are as follows:-
POINT NO.1:- In affirmative.
POINT NO.2:- Partly in affirmative.
POINT NO.3:- As per the final order
for the following:
REASONS
11. POINT NO.1:- The complainant and authorized signatory of opposite party No.1 have reiterated the fact stated in their respective pleadings, in the affidavits filed in the form of their evidence in chief.
12. It is the contention of the learned counsel for the complainant as stated in para-4 of the written arguments that, the mother of the complainant after discharge from the hospital had submitted medical bills and other reports for having taken the treatment to the tune of Rs.4,86,177/- before opposite party No.3 and opposite parties have sanctioned a sum of Rs.3,11,730/- and the same was reimbursed by opposite party No.3, but the balance of Rs.1,77,447/- has not been reimbursed despite of submitted the medical documents on 27.03.2017. Further as per the policy cover the mother of the complainant is entitled for pre and post hospitalization charges amounting to Rs.2,25,767/- as the mother of the complainant has taken treatment for lung infection prior to her admission to the hospital.
13. It is the contention of the learned counsel for the opposite party that, the complainant has submitted claim No.18RB030IE0011 towards pre-post hospitalization bill for a sum of Rs.1,74,447/- and the same was settled to Rs.9,854/- on 02.08.2017. In the particulars filed it is stated that, non-payable items as per main claim for a sum of Rs.1,64,593/- has been deducted as not entitled. EX.R.10 is the claim settlement letter on the said claim. Further in the same bill for the hospitalization dated: 28.03.2017 to 01.04.2017 the claim amount was of Rs.1,20,057/- and a sum of Rs.22,561/- was deducted i.e., a sum of Rs.17,737/- towards co-pay 15% as per policy terms and conditions, Rs.1,230/- towards Pharmacy, Rs.3,018/- towards Pathology, Rs.576/- towards food and beverages. Further a sum of Rs.97,496/- was paid on 29.04.2017.
14. Further for the claim No.18RB030IE0195 (post hospitalisation) amount claimed was Rs.3,59,839/- and a sum of Rs.2,98,401/- was deducted and net amount of Rs.61,438/- was paid on 19.09.2017. The deduction was towards nursing charges a sum of Rs.1,52,200/- as private nursing charges not payable, consultation Rs.30/- as OPD service charges not payable, nursing charges of Rs.1,08,000/- as private nursing charges not payable, towards pharmacy a sum of Rs.2,571/- as mouth wash, gloves, under-pad, etc., are not payable, a sum of Rs.5000/- has also Excess.
15. Further for the claim No.17CB030IE0755 towards hospitalization from 10.03.2017 to 23.03.2017 the amount claimed was Rs.4,86,177/-, out of which a sum of Rs.1,19,667/- was deducted and net payable was Rs.3,66,510/- and a sum of Rs.3,11,730/- was settled on 02.05.2017 and paid and the short settlement by TPA of Rs.54,780/- was paid on 14.11.2017. The reason for the deduction was ICU + Nursing for a sum of Rs.19,200/- as per policy, ICU + Nursing charges limited is Rs.4,000/- per day. Hence total payable amount was Rs.48,800/-. Further a sum of Rs.1,152/- was deducted towards food and beverages, as the same was not payable as per the terms of the policy. Further a sum of Rs.350/- towards admission charges not payable and a sum of Rs.28,350/- towards medical equipment i.e., Flowtron Pump and Syringe pump charges not payable. Further a sum of Rs.325/- towards food and beverages as nutritional charges not payable. Further a sum of Rs.5,612/- towards Pharmacy non-payable items. Further a sum of Rs.64,678/- towards co-pay as 15% of co-pay as per policy terms and conditions the insured has to pay. Hence in total a sum of Rs.5,35,298/- was paid to the insured.
16. It is the further contention of the learned counsel for the opposite party that, the deductions were made as per the terms of the policy vide EX.R.3, in this regard he has brought to our notice to the exception clause as per 4.5 in EX.R.3, policy in which it is stated that, “Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period.” The learned counsel for the complainant did not produce any document to prove that, private nursing home charges claimed for a sum of Rs.1,52,200/- was for the active treatment obtained. Further the counsel has brought to our notice serial No.6 in clause 4.5 in EX.R.3 conditions of the policy. In which it is stated that, the insured for external and non-medical equipment of any kind used for diagnosis and for treatment and any medical equipment which is subsequently used at home is not entitled. Further it is also stated in the conditions of the policy that, vitamins and tonics are not entitled and expenses incurred towards naturopathy treatment and all medical expenses including personal comfort and convenience and similar incidental expenses or services. Further any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist and out-patient diagnostic. Further expenses incurred towards treatment which is continued before hospitalization and continued even after discharge for an ailment different from the one for which the hospitalization was necessary. We feel the opposite party has rightly deducted the claim for which the expenses incurred is not entitled.
17. According to the complainant as stated in the affidavit dated: 12.06.2018 filed in the form of his evidence-in-chief that the complainant is entitled for a sum of Rs.2,00,000/- for domiciliary hospitalization which covers up to 20% of the sum assured in the policy of Rs.10,00,000/- and opposite party is wrong in deducting a sum of Rs.1,52,200/-. No such point has been pointed out by the learned counsel for the complainant in the terms and conditions of the policy. Hence there is no merit in the said contention.
18. It is further contended in the written arguments filed by the complainant that, after filing the complaint the opposite parties have paid a sum of Rs.9,854/- on 02.08.2017 as per EX.R.10 and a sum of Rs.61,438/- on 19.09.2017 as per EX.R.11 and further it is contended that, opposite party No.1 produced EX.R.9 and has stated that, a sum of Rs.2,74,089/- has been paid through NEFT on 02.05.2017 to the complainant, but the complainant did not receive the said amount.
19. As per the documents produced by the complainant it appears in EX.R.9 that, a sum of Rs.2,74,089/- has been remitted through NEFT on 02.05.2017 as per EX.R.10 settlement letter it appears that a sum of Rs.9,845/- has been remitted to the complainant through NEFT on 02.08.2017 and EX.R.11 letter reflects that, a sum of Rs.61,438/- has been remitted to the complainant. On perusal of the statement produced by the complainant it is not forthcoming with regard to the remittance of the amount stated in EX.R.9, for a sum of Rs.2,74,089/-. It is the case of the complainant that, out of the claim of Rs.4,86,177/- a sum of Rs.3,11,730/- has been sanctioned and it was reimbursed in favour of opposite party No.3 and the balance amount of Rs.1,77,447/- was not reimbursed. Even in the affidavit filed by the complainant in the form of his evidence in chief it is stated that, Rs.3,11,730/- was reimbursed. Further for the non-reimbursement of Rs.1,77,447/- opposite party had stated the reasons as to why the complainant was not entitled for certain amount. It is only stated in the written argument filed that, the amount mentioned in EX.R.9 of Rs.2,74,089/- has not been paid even though it is stated by the complainant that, the said amount was paid through NEFT on 02.05.2017. The claim of the complainant is with regard to medical documents submitted on 27.03.2017. Since it is admitted that, opposite party No.3 has reimbursed a sum of Rs.3,11,730/- and only balance was of Rs.1,77,447/- we feel it cannot be said that, an amount of Rs.2,74,089/- is still due.
20. It is not in dispute that, after the complaint been filed opposite party had paid a sum of Rs.1,26,072/- on 25.07.2017 and 07.11.2017. Further it appears in the statement produced by the counsel for opposite party No.1 along with memo dated: 29.12.2022 it is mentioned that, after the complaint been filed a sum of Rs.54,780/- was paid on 14.11.2017, a sum of Rs.61,438/- was paid on 19.09.2017 and a sum of Rs.9,854/- was paid on 02.08.2017. Hence it cannot be said that the opposite party was prompt and settled the claim expeditiously as contended. Therefore there is deficiency of service on the part of opposite party No.1 to 3 as contemplated under section 2(1)(g) of the Consumer Protection Act, 1986. Accordingly we answer this point in affirmative.
21. POINT NO.2:- In view of the discussion made above, the complainant is not entitled for a direction to the opposite party to pay a sum of Rs.4,50,214/-. Since the claim has not been settled on time the complainant has sustained mental agony and hardship. For that, the complainant is entitled for a sum of Rs.10,000/-. Further the act of opposite party made the complainant to get issued legal notice dated: 07.06.2017 and to approach this Commission. Hence the complainant is entitled for a sum of Rs.10,000/- towards litigation expenses. Accordingly we answer this point party in affirmative.
22. POINT NO.3:- In view of the discussion made above, we proceed to pass the following:-
ORDER
The complaint is allowed in part.
The opposite party No.1 to 3 are jointly and severally liable to pay a sum of Rs.20,000/- to the complainant with interest at the rate of 9% per annum from today till realization.
The opposite party No.1 to 3 shall comply the order within 30 days.
Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.
Applications pending, if any, stands disposed-off in terms of the aforesaid judgment.
(Dictated to the Stenographer, typed by him, the transcript corrected, revised and then pronounced in the open Commission on 20th Day of MAY 2023)
- REKHA SAYANNAVAR) (RAJU K.S) (SHIVARAMA. K)
MEMBER MEMBER PRESIDENT
//ANNEXURE//
Witness examined for the complainant side:
Sri. Jailesh P Sha, the complainant has filed affidavit in the form of his evidence in chief.
Documents produced for complainant side:
- Copy of the policy dt.09.03.2015.
- Copy of acknowledgment for having received the claim by OP on 27.03.2017.
- Copy of the acknowledgment for having received the claim by OP on 17.05.2017.
- Copy of the email dt.15.05.2017 addressed by the complainant to OP.
- Copy of the email dt.02.06.2017 addressed by the complainant to OP.
- Copy of the letter dt.15.05.2017 addressed by the complainant to OP.
- Copy of the legal notice dt.07.06.2017.
- Copy of the postal acknowledgment for having received by OP No.1 and 3.
- Certified copy of bank statements of State Bank of India, Madhavanagar Branch and ICICI Bank, Kumara Park Branch, Bangalore.
Witness examined for the opposite party No.1 side:
Sri. R.S.Arasu, Authorized Signatory, of opposite party No.1 has filed affidavit in the form of his evidence in chief.
Documents produced for Opposite Parties side:
1. Schedule-Group Health Policy – Ex.R.1.
2. View Inclusion exclusion – EX.R.2.
3. Group Health Insurance Policy terms and conditions – EX.R.3.
4. Request for cashless hospitalization for medical insurance – EX.R.4.
5. Voter’s ID –Ex.R.5.
6. Copy of E-Card issued by OP – EX.R.6.
7. Copy of Approval letter – EX.R.7.
8. In-patient Bill – Ex.R.8.
9. Claim settlement letter dt.11.09.2017 for Rs.2,74,089/- - EX.R.9.
9. Claim settlement letter dt.11.09.2017 for Rs.9,854/- - EX.R.10.
10. Claim settlement letter dt.11.09.2017 for Rs.61,438/- - Ex.R.11.
11. Chart in regard to amount claimed, amount approved and amount disallowed as per OP No.2 & 3 claim settling agent – EX.R.12.
- REKHA SAYANNAVAR) (RAJU K.S) (SHIVARAMA. K)
MEMBER MEMBER PRESIDENT
