State Consumer Disputes Redressal Commission
The Oriental Insurance Company Limited vs Vinod Kumar Anand on 31 August, 2017
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION UT CHANDIGARH First Appeal No. A/215/2017 (Arisen out of Order Dated 20/06/2017 in Case No. Complaint Case No. CC/811/2016 of District DF-I) 1. The Oriental Insurance Company Limited chd ...........Appellant(s) Versus 1. Vinod Kumar Anand chd ...........Respondent(s) BEFORE: HON'BLE MR. JUSTICE Jasbir Singh PRESIDENT DEV RAJ MEMBER PADMA PANDEY MEMBER For the Appellant: For the Respondent: Dated : 31 Aug 2017 Final Order / Judgement STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH Appeal No. : 215 of 2017 Date of Institution : 29.08.2017 Date of Decision : 31.08.2017 The Oriental Insurance Company Limited, Regional Office, Batra Building, SCO 109-110-111, Sector 17, Chandigarh, through its Chief Regional Manager, through its authorized signatory, Shri B.S.Ahuja, Deputy Manager, Oriental Insurance Company Limited, Regional Office, Surendra Building, SCO 109-110-111, Sector 17-D, Chandigarh . ......Appellant V e r s u s 1. Vinod Kumar Anand r/o # No.1079, Sector 27-B, Chandigarh. 2. Medi Assist India TPA Private Limited, SCO 521, 2nd floor, Sector 70, Mohali (Punjab) - 160071, through its Chief Executive Officer. .......Respondents Appeal under Section 15 of the Consumer Protection Act, 1986 against order dated 20.06.2017 passed by District Consumer Disputes Redressal Forum-I, U.T. Chandigarh in Consumer Complaint No. 811/2016. BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT. MR. DEV RAJ, MEMBER.
MRS. PADMA PANDEY, MEMBER Argued by: Mr.Satpal Dhamija, advocate for the appellant.
PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT Appellant/Opposite Party No.1 has filed this appeal against order dated 20.6.2017, passed by the District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (in short the Forum only), vide which a complaint filed by respondent No.1/complainant was allowed giving him the following relief ;
(i) To make payment of balance amount of Rs.1,46,000/- to the complainant. (ii) To make payment of an amount of Rs.15,000/- to the complainant as compensation for harassment on account of deficiency in service. (iii) To pay Rs.10,000/- as litigation expenses to the complainant.
2. The complainant purchased PNB-Oriental Royal Mediclaim Policy through Punjab National Bank on 11.8.2010. It was renewed from time to time and last renewed policy was valid between 11.8.2015 to 10.8.2016. The complainant is a senior citizen. He developed some eyesight problem, for which he went to M/s Grewal Eye Institute at Chandigarh on 10.6.2016 for medical check-up. He was diagnosed as a case of cataract in his right eye and was advised Robolazr Toric IOL to cure the disease. Before taking any further treatment, the complainant intimated OP No.1 on 13.6.2016 giving the detail of diagnosis and the procedure to be taken up to correct the eyesight. After about 10 days, on 25.6.2016, surgery was carried out and he was discharged on the same day. In the said process, the complainant spent an amount of Rs.1,75,504/-. He submitted his claim for re-imbursement on 28.6.2016, however, without any justification, his claim amount was reduced to Rs.29,504/-. Without his consent, the above amount was transferred to his bank account. He sent a protest letter on 18.7.2016, but without yielding any result. Legal notice sent on 12.8.2016 also met the same fate. Compelled under the above circumstances, he filed a consumer complaint before the Forum.
3. Upon notice, a joint reply was filed by the OPs i.e. appellant and respondent No.2. The factual matrix of the case was not controverted. It was stated that it was for the complainant to get cashless treatment facility from Grewal Eye institute as the said institute was an approved institute of Medi Assist India TPA Pvt. Ltd.. It was further stated that reasonable amount, as per Policy, was reimbursed. Pleading that there was no deficiency in providing service, a prayer was made for dismissal of the complaint.
4. Complainant by filing rejoinder, reiterated the averments made in the complaint and further contended that provisions of the Policy were wrongly interpreted to unjustifiably deny his claim.
Both the parties led evidence. The Forum, on analysis of pleadings, documents on record, and hearing arguments, allowed the complaint by observing as under ;
"We have carefully considered the rival contentions. At the outset, it would be fruitful to reproduce the provisions of clause 1.2 of the medical insurance policy (Annexure R-1) as under :-
"1.2 COVERAGE UNDER THE POLICY The following reasonable and necessary expenses (subject to limits) are payable under the policy for various benefits ;
HOSPITALISATION BENEFITS BENEFIT Liability under Policy Room, boarding and Nursing expenses as provided by the Hospital/Nursing Home.
Not exceeding 1% of the Sum Insured per day.
Intensive Care (IC) Unit Expenses as provided by the Hospital/Nursing Home.
Not exceeding 2% of the Sum Insured per day.
Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees As per the limits of the sum insured.
Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and similar expenses As per the limits of the sum insured.
Ambulance services charges For the entire policy period Actual or 1% of the sum insured or Rs.1000/- whichever less.
Hospital Cash Reimbursement of incidental expenses during the period of hospitalization of the proposer i.e. the PNB Account Holder only - actual subject to a maximum of Rs.1000 during the entire policy period.
Reimbursement of Funeral Expenses In the event of death of the insured person due to an insured peril covered under the scope of the policy, the company shall reimburse actual funeral expenses subject to maximum of Rs.1000 during the policy period.
DOMICILIARY HOSPITALIZATION (AS DEFINED HEREINAFTER) Surgeon, Medical Practitioner, Consultants, Specialists Fees, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Diagnostic Material and Dialysis, Chemotherapy, Nursing expenses.
10% of Sum Insured. Maximum Rs.25000/- during policy period.
A perusal of the above clause itself shows that for room, boarding and nursing expenses, liability under the policy is not exceeding 1% of the sum insured per day. For intensive care unit expenses, the liability of company/OPs is not exceeding 2% of the sum insured per day. For surgeon, medical practitioner, consultants, specialists fees etc. under domiciliary hospitalization, the liability of the company/OPs is 10% of the sum insured and maximum of Rs.25,000/- during the policy period. However, a perusal of clause 1.2 reveals that in respect of Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees, Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Material and X-Ray etc., the liability of the company under the policy is as per the limits of the sum insured. In the instant case, the limit of the sum insured is Rs.5,00,000/-. The copy of the letter dated 13.6.2016 (Annexure C-6) sent by the complainant to the Regional Manager of the OPs shows that he intimated the OPs that he was to be operated from Grewal Eye Institute by the Robo-Lazr IOL Implant Right Eye. The copy of the Claim Settlement Advice dated 16.7.2016 (Annexure R-4) shows that the TPA, after taking into consideration that the bill amount of the expenses of the complainant was Rs.1,75,504/-, reduced the payable amount to Rs.29,504/-. There is absolutely no explanation in the letter as to why the surgery charges and medicine and drug expenses etc. were reduced, though as per clause 1.2, the OPs were required to pay as per the limit of the sum insured. The OPs have not detailed any reasons as to how they considered the amount of Rs.29,504/- only to be reasonable amount. We are of the view that once the complainant had intimated the Regional Manager of the OPs that he was to be operated by the Robo-Lazr IOL Implant Right Eye, we feel that the OPs could not have endorsed the same there were any qualms/objections. It has rightly been contended by the OPs that the basic concept of insurance is that the insured should treat himself as uninsured. Had there been no insurance policy, would the insured still have incurred so much expenses on treatment of cataract without consulting other institutes? We are of the opinion that an amount of Rs.1,75,504/- asked for by the complainant is within allowable limit. The report of the TPA is not in accordance with the provisions of clause 1.2 of the policy. If there is any vagueness in the said terms, benefit would go in favour of the insured. In this context, attention can be had to Life Insurance Corporation of India Vs. Avdesh Chandra Upadhayaya-2006 (3) CLT 602(NC). We are of the view that the TPA arbitrarily reduced the claim of the complainant to Rs.29,504/- without assigning any cogent reasons."
5. By noting as above, it was said that TPA of the appellant was guilty of wrongly interpreting clause 1.2 of the insurance policy. The said clause which talks about payable insurance claim was discussed in detail. It was noted that for many procedures/treatments, no clear indication has been given. It was further said that disbursement of claim was wrongly declined to respondent No.1/complainant. It is on record that before undergoing the procedure, on 13.6.2016, the complainant sent complete detail of medical examination and procedure to be undertaken to correct his eyesight. If that was so, on receipt of the above intimation it was bounden duty of the concerned officer to intimate the hospital/institute to provide cashless medical facility to the complainant. It was not so done.
6. It is contention of Counsel for the appellant that on account of the complainant having not disclosed that he was covered under the mediclaim insurance policy, more amount was charged by the institute. The said dispute is to be settled by the appellant and the institute. Otherwise also, there is nothing on record that any authorized person in the institute ever asked the complainant qua above fact and even then it was not supplied. It is on record that prior thereto complainant's wife had also undergone similar surgery which was provided cashless. Under similar circumstances, qua medi-claim of the complainant, he might have disclosed it to the doctor in the institute. In view of the above, we find no case made out to interfere in the order, under challenge.
7. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Forum is upheld.
8. Certified copies of this order, be sent to the parties, free of charge.
9. The file be consigned to Record Room, after completion.
Pronounced.
31.08.2017 [HON'BLE MR. JUSTICE Jasbir Singh] PRESIDENT [ DEV RAJ] MEMBER [ PADMA PANDEY] MEMBER