State Consumer Disputes Redressal Commission
The New India Ass.Co.Ltd vs Rajesh Dilsukhrai Dave on 29 April, 2023
Details DD MM YY
Date of Judgment 29 04 2023
Date of filing 03 03 2023
Duration 26 01 -
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION
GUJARAT STATE, AHMEDABAD.
Appeal No.356/2023
Court No. 1
1. The New India Assurance Co. Ltd.
1st Floor, 'Nobles',
Near Nehru Bridge,
Ashram Road, Ahmedabad-380009.
Through Deputy Manager,
Legal Cell, New India Assurance Co.Ltd,
4th floor, Popular House,
Ashram Road, Ahmedabad. ...Appellant
Vs
1. Rajesh Dilsukhrai Dave,
18-A, Sharda Society,
B/H, Bhumnath Mahadev,
Near Shreyas fly over,
Paldi, Ahmedabad.
2. Zydus Hospitals and Healthcare Research Pvt.Ltd.,
Zydus Hospital Road, S G Highway,
Thaltej, Ahmedabad-3800054. ...Respondents
Coram :Hon'ble Mr. Justice V. P. Patel, President
Hon'ble Ms.A.C.Raval, Member
APPERANCE :Mr.N.V.Joshi, advocate for the appellant Mr. Rajesh D. Dave present party in person Order by Hon'ble Ms. A.C.Raval, Memeber
1. The appellant has filed this appeal under section 15 of the consumer protection Act 1986, being aggrieved by and dissatisfied with the order dated 09.11.2022 passed by the Learned District Commission Ahmadabad City (Main) in consumer complaint No.630/2020.
2. Heard learned Advocate Mr. N.V.Joshi for the appellant.
2.1. The appellant is the original complainant and respondents are Original Opponents before the Ld. District Commission. Hereinafter the parties will be referred as per their original status.
3. Order under challenge:
D.I.Dabhi A-356-2023 Page 1 of 8 " The complaint is partly allowed.
The Opponent no.1 is directed to pay to the complainant a sum of
Rs.3,09,327/- (Rupees three lakhs thousand three hundred and twenty sever only) along with interest @ 8 % per annum from the date of deduction i.e.22-11-2019 till its payment by account payee cheque directly to the complainant within one month of this award, falling which the opponent company shall pay an additional interest of 1 % to the complainant.
The Opponent no.1 is further directed to pay to the complainant an amount of Rs.10,000/-(Rupees ten thousand only) towards mental agony and stress and additional Rs.3,000/- (Rupees three thousand only) towards expenses of this complaint.
The complaint against opponent no.2 is dismissed. Registry is directed to provide a copy of this order to all the parties."
4. Facts of the case: It is the case of the complainant that the Complainant had purchased mediclaim policy from the opponent Insurance Company for the period 23.12.2018 to 22.12.2019 for the sum insured Rs.5,00,000/-. During the currency of the policy, the complainant was diagnosed for 'Mixed echoic lesion involving mid and lower pole of the left kidney as described' and he was treated for the same vide 'Robotic Left Radical Nephrectomy' in opponent no.2 Hospital as the tumor was large in size. The complainant incurred total expenses of Rs.4,00,474/- towards hospitalization, surgery and treatment expenses. The opponent no.1 had pre-approved Rs.86,000/- cash less facility on request of planned surgery. After the treat, the complainant filed the claim, against which the pre and post expenses were paid but the opponent no.1 arbitrarily deducted Rs.3,14,474/- out of the claim of the complainant. Hence, the complaint preferred consumer case no.613 of 2020 before the Consumer Disputes Redressal Commission Ahmadabad City (Main) which was partly allowed by the Learned District Commission Vide letter dated 09.11.2022.
5. Argument of the appellant: Learned advocate appearing for the appellant argued that the Learned District Commission has directed the opponent Insurance Company to make payment of Rs.3,09,327/- along with 8 % interest, along with the compensations and cost is against the principle of natural justice, facts on the record and the law. The claim of the complainant was (supplied by the Insurance Company with pre and best hospitalization expenses relaying upon the terms and conditions of the policy and PPN agreement between TPA of Insurance Company and D.I.Dabhi A-356-2023 Page 2 of 8 zydus hospital. The Learned District Commission has erred as if any unfair trade practice that some by the opponent no.2 because the opponent no.2 has charged an extra amount within the package amount agreed within the TPA. The cashless payment of Rs.86,000/- is paid to the complainant as per the agreement between PPN and the opponent no.2 hospital. The Learned District Commission has instead by said vital facts wrongly produced of the appellant. Hands the order passed by the learned district Commission is required to be quashed and set aside and this appeal may be admitted and allowed.
6. Argument of the Respondent: The respondent Mr.Dave appeared as party in person and argued that the complainant has proceeded for pre- approval by his claim and admitted in the hospital for the robotic surgery. The complainant under gone operation of the left robotic partial nephrectomy . The complainant lodged his claim of total expenditure of Rs.4,00,474/- that the opponent Insurance Company along with the original bills and documents indeed for processing the claim. The sum insured of the policy was Rs.5,00,000/- the compliment had lodged he is claim within the limit of sum insured the Insurance Company has relaying upon the agreement between TPA and zydus hospital settle the claim of the complainant for Rs.86,000/- for cashless payment + Rs.56,084/- treats pre and best hospitalizations expenses for total= Rs.1,42,084/-. Settle the claim and rest of the case was rejected on the ground of the agreement between TPA and the zydus hospital. While taking the insurance the compliment entitled to contract that the Insurance Company has nothing to do with the internal argument with the Insurance Company and third party. The claim of the compliment was approved for Rs.3,09,5327/- and the amount deducted as per PPA Rs.3,013,27/- and hospital payable amount was shown as Rs 86,000/-.
Merit of the case:
6. For deciding the facts undisputed that the complainant with his wife at jointly taken medicalim policy no.21010034189500006822 From opponent no.1 Insurance Company for the period 23.12.2018 to 22.12.2019 with sum insured Rs.5,00,000/-. The said policy was further renewed for 1 more year. In 3rd August 2019 complainant filed chest and back pain etc. Concerned the doctor the complainant under gone certain D.I.Dabhi A-356-2023 Page 3 of 8 laboratory and medical test in of abdomen in Zydus Hospital. On 29.08.2019 complainant consulted Dr.Kamlesh Patelat Zydus Hospital and suggested to under gone operation of left robotic patchily nephrectomy. The surgery was fixed on 13.09.2019. In advanced, on 30.08.2019. The complainant submitted to Zydus Hospital is 3 year medical insurance policy issued by opponent no.1 and all other documents required for pre-approval for cashless treatment. On 02.09.2019 the complainant was admitted in Zydus Hospital at Ahmadabad has the approval from the opponent no.1 for cashless treatment was not received the complainant deposited Rs.3,10,000/-
that the Zydus Hospital. The complainant was operated on 03.09.2019 with robotic surgery method. The complainant was discharged from hospital on 06.09.2019. He paid Rs.4474/- an additional amount with the Zydus Hospital he paid total Rs.3,40,474/- with the Zydus Hospital during his hospitalization from 02.09.2019 to 06.09.2019 in addition to Rs.86,000/- approved by the opponent no.1 has cashless amount. Hence, the total hospital bill of Rs.4,00,474/- was incurred has a hospital expenditure. The treating doctor had given certificate about the operation and the treatment given to the complainant. The Insurance Company approved only Rs.86,000/- has a payable amount relaying upon the agreement between TPA and Zydus Hospital.
7. Copy of the Insurance policy is produced at page no.26. the sum insured shown as Rs.5,00,000/-. The cashless authorities letter dated 02.09.2019 is produced at page no.140 with the amount of Rs.86,000/- is authorized has cashless facility and in the colum of status it is mentioned initial so at the initial stage on 02.09.2019 Rs.86,000/- authorized by the company for the cashless facility on next page no.141. The particulars of bill amount with deduction and payable amount is mentioned. After certain deduction the payable amount is mentioned Rs.2,04,400/- and none payable robotic as per PPN form Rs.1,08,400/- and under hospital payment amount was shown Rs.86,000/- at page no.142 the final cashless authorized letter is produced that at 06.09.2019. Whether Rs.86,000/- is shown as a authorized payable amount for cashless facility at the status filed authorization along with the same at page no.143 after deducting certain amount to payable amount is shown as Rs.3,95,327/- and as per PPN Rs.3,09,327/- is D.I.Dabhi A-356-2023 Page 4 of 8 deducted and hospital payable amount is shown as Rs.86,000/-. This approval of 06.09.2019 which was reject to the complainant after operation was carried out and after the complainant paid the bill amount to the hospital. Here though the amount of Rs.3,95,327/- shown as payable amount deducted relaying upon the PPA and only Rs.86,000/- is approved.
8. Learned advocate appearing for the appellant submitted that the TPA of the Insurance Company entered into an agreement that the Zydus Hospital were the complainant had taken treatment and it is agreed between the party that is TPA and Zydus Cradila Hospital that for nephrectomy/nephrotomy/pyelolithotomy Rs.86,000/- minimum is fixed for the treatment therefore the Insurance Company is liable to pay as per the agreement entered TPA and the Zydus Cradila Hospital. The contract of insurance is between the insured in the insurer any agreement between the third party agency and the treating hospital is not binding to the complainant and there is no contract between the complainant and third party agency or the complainant and the treating hospital.
9. The relay is also made on the IRDAI guidelines dated 27 September 2019 which was made effective from 1 October 2020 onwards. As per the IRDAI guideline no.3.19 is coverage or modern treatment or procedure mentioned guideline no.3.19.7 is reads as under page no.303;
"3.19.7 Robotic surgeries, upto 50 % of sum insured subject to Maximum of Rs.5 lakh."
9.1. The limit policy period that the treatment and procedure in robotic surgery is mentioned at 3.19.7. The limit mentioned is upto 50 % on sum insured subject to maximum of Rs. 5 lakh. It is pertinent to not that the complainant was operated on 06.09.2019 and this guidelines came into force from 1 October 2020. Therefore, it is after the because of action arose for payment. Hence, these guidelines cannot be applicable in the case of the complainant.
10. The appellant has produced the letter dated 11.07.2022 issued to all TPA's and all ROIC health managers regarding clarifications under modern treatment in health policy (refers page no.307). In the colum of Procedure/treatment the robotic surgery is included the detail of the procedure and treatment is mentioned and the stand of the company is D.I.Dabhi A-356-2023 Page 5 of 8 clarified. Where it is mentioned that the limit is for robotic component of the surgery and other charges as per policy terms and conditions. This letter is also issued on 11.07.2022 which is produced for refers and calculation of charges, which is policy under applicable in the case of complainant as is the complainant was operated which prior to issuance of this clarification letter.
11. The claim of the complainant is decided and approved by the TPA. By relaying upon the judgment of State Consumer Dispute Redressal Commission Punjab in F.A.No.99 of 2017 dated 13.02.2013 for the matter between New India Insurance Company Vs. Vikram Gohel.When the powers of TPA have been discussed paragraph no.14,15 and 16 of the said judgment reads as under:
"14.Health Services to be provided by the TPA have been specified in IRDAI (THIRD PARTY ADMINISTRATORS-HEALTH SERVICES) REGULATIONS, 2016, issued vide Notification F No IRDAI/REG/5/117/2016, Dated 143.2016 and the same read as under:
"Health services by TPA
3. (0) A TPA may render the following services to an insurer under an agreement in connection with health insurance business:
a. servicing of claims under health insurance policies by way of pre- authorization of cashless treatment or settlement of claims other than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the guidelines issued by the insurers for settlement of claims.
b. servicing of claims for Hospitalization cover, if any, under Personal Accident Policyand domestic travel policy. e. facilitating carrying out of pre- insurance medicalexaminations in connection with underwriting of health insurance policies:
Provided that a TPA can extend this service for life insurance policies also d. health services matters of foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalization outside India e. servicing of health services matters of foreign travel policies issued by foreign insurers forpolicyholders who are travelling to India:
Provided that such services shall be restricted to the health services required to beattended to during the course of the visit or the stay of the policyholders in India. f.servicing of non-insurance healthcare schemes as mentioned in Regulation 22 (3) of these Regulations g, any other services as may be mentioned by the Authority. (2) While performing the services as indicated at Regulation 3 (1) of these regulations, a TPA shall nota. Directly make payment in respect of claims b. Reject or repudiate any of the claims directly c.D.I.Dabhi A-356-2023 Page 6 of 8
Handle or service claims other than hospitalization cover under a personal accident policy d. Procure or solicit insurance business directly or indirectly e. Offer any service directly to the policyholder or insured or to any other person unless such service is in accordance with the terms and conditions of the policy contract and the agreement entered into in terms of these regulations. (3) A TPA can provide health services to more than one insurer. Similarly an insurer may engage more than one TPA for providing health services to its policyholders or claimants."
15. A perusal of Regulation 3(2)(b) of the above health services to be provided by TPA specifically reveals that while performing the services as indicated at Regulation 3(1)(b) of these Regulations, a TPA shall not reject or repudiate any of the claims directly. In the present case the claim has been repudiated by opposite party No.2- TPA, vide letter dated 7.12.2015, Ex.OP-1/6, which is in violation of the above said Regulations of the IRDAI. The duties and responsibilities of the Insurance Companies and TPA were also discussed by the Hon'ble Bombay High Court, in Public Interest Litigation No.12 of 2011 (Gaurang Dinesh Damani vs. Union of India &Ors.) in orders dated 5.3.2015 and 13.8.2015. It is a common practice that the TPA gives daily targets to its staff for approving claims, where they sanction total money in a day for and all the claims should not exceed particular limit. The hospital bill cannot be settled on the basis of targets fixed by the Insurance Companies. Otherwise, the TPAs have no authority to reject the claim. Such power lies, exclusively with the Insurance Companies. The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same.
16. Thus, I am of the opinion that the claim of the complainant was illegally and arbitrarily rejected by the TPA, against the aforesaid instructions of the IRDA. Since the Insurance Companies use the PPN or hospitals empanelled by the TPA and, resultantly, TPA ask the hospital to give commission on every claim, if they want to be enrolled in PPN. This has been observed by the regulators. Resultantly, the patients/consumers are over-charged by the hospitals, since they have to pay some commissions to TPAs to use the power on behalf of the Insurance Companies. They have no right to solicit business, like agents for the Insurance Companies. Their only job is to serve and process the claims. Accepting and rejecting the claims at their own by the TPAs is illegal, arbitrary, null & void and is not sustainable in the eyes of law. Hence the answer to question no.(ii) posed above is given in the negative."
12. Thus after 2016 as per the IRDAI regulations 2016 the TPA given accepted or rejected the claim of the insured the TPA can only process the claim and forward the same of the Insurance Company and the competent author of Insurance Company is to decide above the same accepting or rejecting the claim at their own by the TPA's is illegal, arbitrary and it is not sustainable in the eye of law. Hence any agreement between TPA and the treating hospital are not binding either to the Insurance Company or to the insured.
D.I.Dabhi A-356-2023 Page 7 of 813. We have considered the grounds stated in memo of appeal, reasons stated in impugned Judgment and order, documentary evidence produced on record, argument advanced by the learned advocate by the parties, ratio laid down in the above referred citation and fact and circumstances of the case. We have satisfied that the order passed by the Learned District Commission is legal,proper and correct in Eye of law. Therefore it does not required interference as a result the appeal is required to be dismissed. Hence in the interest of justice following order is passed.
ORDER A. The Appeal No. 356/2023 is dismissed at the admission stage. B. The order dated 09.11.2022 passed by the Consumer Disputed Redressal Commission; Ahmadabad City (Main) in Consumer Complaint No. 630/2020 is hereby confirmed.
C. No order as to cost.
D. Office is directed to verify the amount deposited by the appellant in appeal No. 356/2023 and if found deposited, refund the same with interest, if any, accrued on the deposit to the appellant by RTGS after following due procedure and verification. For this purpose the appellant has to file an application with details to the account branch of this commission.
E. Registry is directed to send certified copy of this judgment to the parties free of cost. Registry is further directed to send copy of this judgment to the District Commission Ahmadabad City (Main) through E-mail in PDF format for taking necessary action.
Pronounce in open court today on 29.04.2023.
[Ms. A. C. Raval ] [Hon'ble Justice V.P. Patel]
Member President
D.I.Dabhi A-356-2023 Page 8 of 8