State Consumer Disputes Redressal Commission
Manoj Gupta vs United India Insurance Co. Ltd. And ... on 23 October, 2023
ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No.473 of 2021
Date of Institution : 21.12.2021
Date of Reserve : 09.10.2023
Date of Decision : 23.10.2023
Manoj Gupta, aged about 46 years son of Sh.Tilak Raj Gupta,
resident of H.No.B-XIX-166, Col. Gurdial Singh Road, Near Mall
Road, Ludhaina.
....Appellant/Complainant
Versus
1. United India Insurance Co. Ltd., Bombay Cloth House,
Dhurkot Chowk, Ahmedgarh, Distt. Sangrur.
2. Raksha TPA Health Insurance (P) Ltd., S.C.O. No.122, 5th
Floor, Feroze Gandhi Market Ludhiana through its Branch
Manager.
3. Raksha TPA Health Insurance (P) Ltd., C/o Escorts
Corporate Centre, 15/5, Mathura Road, Faridabad, Haryana
through its Directors/Managing Director/Branch Incharge
Manager.
........Respondents/Opposite parties
First Appeal under Section 41 of the
Consumer Protection Act, 2019 against the
order dated 08.11.2021 of the District
Consumer Disputes Redressal Commission,
Ludhiana.
First Appeal No 473 of 2021 2
Quorum:-
Mr.Harinderpal Singh Mahal, Presiding Judicial Member
Present:-
For the appellant : Sh.Sahil Abhi, Advocate
For respondent No.1 : Sh.Vipan Kumar, Advocate for
Sh.V.M.Gupta, Advocate
For respondents No.2&3 : Ex-parte
HARINDERPAL SINGH MAHAL, PRESIDING JUDICIAL MEMBER This appeal has been preferred by the appellant/complainant-Manoj Gupta against the order dated 08.11.2021 passed by the District Consumer Disputes Redressal Commission, Ludhiana (in short 'District Commission'), whereby the complaint filed by the appellant/complainant under Section 12 of the Consumer Protection Act, 1986 (in short 'the Act') was dismissed.
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.
2. Briefly stated facts of the case are that the complainant- Manoj Gupta, obtained the Insurance Policy from opposite party No.1 through their agent i.e. opposite parties No.2 & 3 and got himself insured vide Policy No.2006022816P112000209 by paying the requisite premium. The complainant felt some problem in his chest and after medically examined he found that he had some heart problem and surgery was to be conducted. For that he got himself admitted in Fortis Hospital, Ludhiana on 08.05.2017 and after surgery the complainant discharged on 10.05.2017. Total First Appeal No 473 of 2021 3 expenditure occurred on the treatment comes to Rs.3,74,705/-, which was paid by the complainant himself. Thereafter, the claim was lodged with opposite parties No.1 to 3 for reimbursement but opposite party No.1 released only a sum of Rs.1,81,705/-. Later on, another sum of Rs.9,900/- was also given to the complainant by way of transfer to his account, however, remaining amount i.e. Rs.1,83,100/- was never paid despite submitting all the documents and completing all the formalities. The complainant also wrote number of letters to the opposite parties but of no use. This act and conduct of the opposite parties amounts to deficiency in service and unfair trade practice which compelled the complainant to file the complaint before the District Commission seeking following reliefs:
i) to reimburse Rs.1,83,100/- along with interest @24% per annum;
ii) to pay Rs.1,00,000/- as compensation; and
iii) to pay Rs.22,000/- as litigation expenses.
3. Upon notice, opposite parties appeared and filed their separate replies. The opposite party No.1 filed its reply taking preliminary objections that there is no deficiency in service and the complaint deserves to be dismissed. It is submitted that after receiving the claim and scrutinizing the documents as per the terms and conditions, the opposite party No.1 found that Rs.1,93,000/- was found to be non payable as per hospital package rates and accordingly Rs.1,81,705/- plus Rs.9,900/- was paid by the First Appeal No 473 of 2021 4 complainant towards the claim lodged by him. The complaint is not maintainable as the complainant is not a consumer as defined under the Act. On merits, he reiterated all his submissions as detailed in the preliminary objections and denied all the averments as averred by the complainant in his complaint.
4. On the other hand, opposite parties No.2 & 3 filed their joint reply stating therein that opposite parties No.2 & 3 are registered under the Companies' Act 1956 is licensed TPA under IRDA Act, 2001 to act as a facilitator for processing the claim. The insurance contract is between the complainant and opposite party No.1 and they are the third party administrators only. The claim of the complainant was processed as per the terms and conditions of policy for hospital package as laid by opposite party No.1 and cashless facility was extended for Rs.1,81,705/- and further amount of Rs.9,900/- was paid to the complainant. The complaint filed by the complainant against opposite parties No.2 & 3 is not maintainable and the names of opposite parties No.2 & 3 are liable to be deleted from the complaint.
5. The parties led their evidences in support of their respective contentions before the District Commission and after hearing the parties, the complaint was dismissed, vide impugned order dated 08.11.2021.
6. Aggrieved by the said order, this appeal has been filed by the appellant/complainant for setting aside the impugned order dated 08.11.2021 and to allow his appeal.
First Appeal No 473 of 2021 5
7. Notice of this appeal was issued to the respondents through Registered Post. The respondent No.1/opposite party appeared through his counsel but respondents No.2 & 3 did not appear and were proceeded against ex-parte, vide order dated 11.02.2022.
8. I have heard the contentions of the appellant/complainant and respondent No.1/opposite party and have carefully gone through the record as well as written arguments filed by them. I have also given our thoughtful consideration to the same.
9. Uncontroverted facts of the case are that the appellant/ complainant obtained the Individual Health Policy, vide cover note bearing No.2006022816P112000209. As per the terms and conditions of the health policy, he is covered for indoor treatment in the specified hospitals as enlisted with respondent No.1/opposite party. It is also not denied by respondent No.1/opposite party that the complainant got the chest pain and he got admitted to the Fortis Hospital, Ludhiana on 08.05.2017, where he was found to be suffered from heart problem. Accordingly, the surgery was conducted in the said hospital and was discharged on 10.05.2017. The total bill of Rs.3,74,705/- was raised by the hospital. All these documents were submitted by the appellant/complainant to the respondents/opposite parties for reimbursement of the expenses incurred by him for his treatment. Out of which Rs.1,81,705/- and Rs.9,900/- was reimbursed against the claimed amount. Hence, the complainant preferred this complaint for recovery of the remaining amount of Rs.1,83,100/- along with compensation and litigation First Appeal No 473 of 2021 6 expenses. However, the District Commission dismissed the complaint by holding that it was under covered under the terms and conditions of the policy.
10. The only contention raised by learned counsel for the appellant/complainant that the documents/e-mails, Annexure E & F make it evidently clear that the package rates are not applicable when the cause of action initially arose i.e. when the patient was subject to hospitalization.
11. The plea has been controverted by respondent No.1/opposite party by contending that the appellant/complainant never informed the hospital that he has received the Insurance Policy from the respondent No.1/opposite party and due to that the hospital did not inform the appellant/complainant regarding the package rates and his entitlement as per the Insurance Policy. He also referred to Clause 3.25 of the terms and conditions of the policy, which enunciate that as per the package rates with the hospital, the appellant/complainant is only entitled to the reimbursement of the said rates and not beyond that and the payment has already been made to the appellant/complainant as per the package rates which were applicable qua that hospital. Clause 3.25 of the terms and conditions is reproduced hereunder:
"3.25 Network Provider Network Provider means the hospital/nursing home or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility. The list of Network Hospitals First Appeal No 473 of 2021 7 is maintained by and available with the TPA and the same is subject to amendment from time to time. Preferred Provider Network means a network of hospitals which have agreed to a cashless packaged pricing for certain procedures for the insured person. The list is available with the company/TPA and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing."
12. No doubt, as per the clause 3.25, it has been incorporated that in a cashless insurance, the reimbursement is to be made as per the package of the hospitals enlisted with the TPA and agreed to a cashless packaged pricing. It is the specific plea of the respondent No.1/opposite party that since the Fortis Hospital, Ludhiana is an enlisted hospital and it has been agreed between the hospital and Insurance Company that the rates of the treatment are to be paid as per the package fixed. The list of the package of Fortis Hospital is Ex.R-2.
13. No doubt, as per this document, Fortis Hospital, Ludhiana is also enlisted with the Insurance Company under the said scheme of the respondents/opposite parties. However, it is pertinent to mention here that in the appeal some documents or queries procured by the appellant/complainant from the Fortis Hospital, have been placed on the record as Annexure E. Taking a judicial note, I found that the document placed by the appellant/complainant with the appeal is quite genuine and is necessary for proper adjudication of the case. As per said First Appeal No 473 of 2021 8 annexure, a query was put by the appellant/complainant with the request to inform when this cashless tie up made by the respondent-Insurance Company with the Fortis Hospital, Ludhiana, to which, the hospital authorities replied through its email dated 17.12.2021 that Fortis Hospital, Ludhiana came into the tie up arrangement with GIPSA on 07.03.2019, whereas the Cashless Health Insurance was obtained by the complainant on 10.12.2016 and was valid upto 09.12.2017. The appellant/complainant remained under treatment in the Fortis Hospital, from 08.05.2017 to 10.05.2017 as per the Discharge Summary, Ex.C-5 i.e. when the policy was active and this period is much prior to the period when the tie up was made by the respondents/opposite parties with Fortis Hospital for cashless scheme as well as for packaged pricing.
14. By no stretch of imagination, it can be presumed that at the relevant time when the Insurance Policy was issued or when the appellant/complainant got admitted in the hospital and when the cause of action arose there was no cashless arrangement of the respondents/opposite parties with the Fortis Hospital then how they can take this plea that since the insured himself never informed the hospital about the Insurance Policy so he was not given the benefit by the hospital, which is totally irrelevant and baseless.
15. In this case, the respondent No.1/opposite party has already admitted that the claim was lodged by the appellant/ complainant for an amount of Rs.3,74,705/- before it but the First Appeal No 473 of 2021 9 respondent No.1/opposite party settled his claim to the tune of Rs.1,91,605/- and they paid him a sum of Rs.1,81,705/-, vide Ex.C- 31 and Rs.9,900/-, vide Ex.C-30, totaling Rs.1,91,605/-, however, the remaining amount of Rs.1,83,100/- has not been released, for which the appellant/complainant is agitating as he spent the same towards his treatment.
16. In this case, by wrongly interpreting the provisions of the policy, the respondents/opposite parties partially rejected the claim of the appellant/complainant. It is very clear that in any Health Insurance Policy, the Insurance Company has to reimburse all the medical expenses and they cannot decided themselves how much medical expenses the appellant/complainant is entitled to get and the Insurance Company cannot decide the hospital charges levied by the hospital. Reasonable medical charge means the expenses incurred for necessary treatment which cannot be treated as excessive expenses. The Insurance Companies by no means can decide that how much and what kind of expenses doctor can charge for treatment.
17. In the present case, as per the medical record of the Fortis Hospital, Ludhiana, the appellant/complainant remained under treatment from 08.05.2017 to 10.05.2017 and as per Discharge Summary, Ex.C-6, the following course was done in the hospital:
"Patient admitted with above mentioned complaint was immediately taken to cath lab in view of previous h/o PTCA, CAG done showed double vessel disease with critical RCA and LAD stenosis. PTCA and stenting to RCA and LAD First Appeal No 473 of 2021 10 done. Post procedure stay in hospital was uneventful, patient is now being discharged in stable condition on medical management."
18. As per the above said procedure, the stenting along with Angiography was also done and it was for the hospital to assess the cost of the procedure and treatment given to the appellant/ complainant and not for the respondent-Insurance Company that why these expenses were spent on the treatment.
19. As far as, pressing hard by the respondent No.1/opposite party upon clause 3.25 which relates to 'Preferred Provider Network' hospitals, is totally devoid of merits because, as discussed above, the policy was issued much prior to the adoption of the cashless claim and package of fixed pricing by the Fortis Hospital and at that relevant time when the policy was issued and the cause of action accrued to the appellant/complainant, the treatment does not cover under said clause of the policy. Moreover, the careful perusal of written reply filed by the respondents/ opposite parties before the District Commission reveals that no specific plea on this score was ever raised by the respondents/ opposite parties before the District Commission because, if any, issue is raised by a party they have to plead in the pleadings for giving the appropriate opportunity to the other party to rebut the same but no such specific plea was taken in the written statement and merely mentioning of the package rates does not substantiate their stand and this plea has been raised by the respondent/opposite party No.1 before this Commission, which has First Appeal No 473 of 2021 11 been properly rebutted by the appellant/complainant by placing on record an email, Annexure E, which is taken on record by this Commission being a material document. As per this document, the Fortis Hospital came into the tie up arrangement with GIPSA on 07.03.2019 i.e. much later than the cause of action accrued to the appellant/complainant or the policy was obtained by him and the treatment obtained from the Fortis Hospital.
20. So, taking into consideration the fact that the District Commission has decided this matter without having gone through the policy terms and conditions and medical record, therefore, this appeal needs indulgence of this Commission on this issue and in consequence of the same the impugned order dated 08.11.2021 of the District Commission is hereby set aside and the appeal of the appellant/complainant is allowed, resultantly the complaint is also allowed. The following directions are issued to the respondents/opposite parties:
i) to pay Rs.1,83,100/- i.e. the remaining amount of treatment spent by the appellant/complainant along with interest @6% per annum from the date of filing of the complaint till realization;
ii) to pay Rs.21,000/- as compensation on account of mental agony and harassment as well as litigation expenses.First Appeal No 473 of 2021 12
21. The respondents/opposite parties are directed to comply with the above said directions within a period of 30 days from the receipt of the certified copy of the order.
22. Since the main case is decided, the pending application, if any, is also disposed of.
23. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(HARINDERPAL SINGH MAHAL) PRESIDING JUDICIAL MEMBER October 23rd, 2023 parmod