State Consumer Disputes Redressal Commission
Deepak Lamba vs United India Insu. Co. Ltd. on 24 July, 2019
Daily Order IN THE STATE COMMISSION: DELHI (Constituted under Section 9 of the Consumer Protection Act, 1986) Date of Decision:24.07.2019 First Appeal No.579/2016 (Arising out of the order dated 29.09.2016 passed in Complaint Case No. 164/2015 by the District Consumer Disputes Redressal Forum (Central), Kashmere Gate, Delhi) Mr. Deepak Lamba, S/o Mr. Baldev Raj Lamba, 1196, Dr. Mukherjee Nagar, Delhi -110009. .....Appellant Versus United India Insurance Co. Ltd., 10203, 3rd Floor, Jamna House, Padam Singh Road, Karol Bagh, New Delhi -110005. ....Respondent CORAM Ms. Salma Noor, Presiding Member
Whether reporters of local newspaper be allowed to see the judgment?
To be referred to the reporter or not?
Ms. Salma Noor, Presiding Member This is an appeal under Section 15 of the Consumer Protection Act, 1986 (in short, the "Act") against order dated 29.09.2016 passed by the Consumer Disputes Redressal Forum (Central) Delhi (in short, the "District Forum") in Complaint Case No.165/2015 whereby the aforesaid complaint has been dismissed.
Briefly facts relevant for the disposal of the present appeal are that a complaint under Section 12 of the Act was filed by the appellant herein i.e. the complainant before the District Forum stating therein that appellant/complainant had taken a mediclaim insurance policy from respondent/OP No.1 for himself and his family members, namely, Mrs. Mala Lamba (Wife), Mrs. Muskan Lamba (Daughter) and Mr. Anmol Krishna (son).
The sum assured under the policy was Rs.5,00,000/-. It is stated that the policy was a cashless policy. It was stated that as per advice of medical consultant wife of the appellant/complainant Mrs. Mala Lamba was performed with two surgeries at Bhatia Global Hospital & Endosurgery Institute on 11.12.2014. The appellant/complainant informed the hospital that he was covered under a valid cashless medical insurance policy with the OP, therefore, medical bills for all expenses be issued to OP insurance company, however, the appellant/complainant was insisted upon to pay Rs.20,000/- as advance which was duly paid on 10.12.2014. It is stated that the hospital further directed the appellant/complainant to deposit further payment as respondent No.1/OP No.1 denied cashless payment to them. It is stated that appellant/complainant deposited Rs.58,000/- on 12.12.2014 and Rs.51,700/- on 13.12.2014 in full settlement of hospital bill of Rs.157,400/-. It is stated that despite aforesaid payment, the patient was not released due to the reason that respondent/OP No.1 did not confirm the payment to the hospital and the patient was released after the sanction of Rs.27,700/- only by the TPA of respondent/OP No.1 Medsave Health Care Ltd. against the mediclaim insurance policy of Rs.5,00,000/-. It is stated that respondent /OP No.1 denied to pay medical expenses to hospital against the cashless medical policy. It is stated that thereafter appellant/complainant submitted all the documents consisting of Claim Form, Medical Expenses bills etc. to respondent/OP No.1 on 18.12.2014 for settlement of his claim, however, the claim was not settled. It is stated that appellant/complainant got issued a legal notice dated 03.01.2015 calling upon the respondent /OP No.1, however, respondent/OP No.1 neither settled the claim nor gave any response. Finding deficiency in service on the part of respondents /Ops, appellant/complainant filed a complaint before the District Forum seeking the total value of claim i.e. Rs.1,44,643/- alongwith interest @18%, Rs.10,00,000/- towards compensation and Rs.31,000/- towards litigation costs.
Complaint was opposed by the respondent /OP No.1 by filing written statement, wherein the issuance of mediclaim policy in favour of the appellant/complainant, policy being cashless and sum assured therein was admitted. It was stated that the policy was issued subject to its terms and conditions. It was stated that the claim was treated as No Claim as the appellant/complainant did not submit the required papers. It was stated cashless facilities are approved by the TPA as per terms and condition of the policy on the basis of details of illness and proposed treatment as provided and approved by the hospital and as per terms and conditions of the policy an amount of Rs.27,700/- was passed by the TPA. Respondent No.1/OP No.1 had prayed for dismissal of the complaint.
Rejoinder was filed by the appellant/complainant wherein appellant/complainant had denied the allegation of respondent No.1/OP No.1 and reiterated the averments made in the complaint.
Perusal of the records shows that during the pendency of the complaint, appellant/complainant filed an application stating that he has received a settlement memo dated 28.01.2016 and an amount of Rs.88,413/- was paid to him against his claim of Rs.1,41,015/- out of which an amount of Rs.51,842/- was to be paid by the hospital on account of over and above of GIPSA PPN PKG charges, therefore, appellant/complainant prayed for compensation for mental agony and cost of litigation.
Respondent No.1/OP No.1 in reply to the said application stated that claim of appellant/complainant had already been settled on 28.01.2016 and the permissible amount under the policy was duly paid to him on receipt of documents. On 30.06.2016, amount of Rs.51,842/- was refunded by hospital against full and final settlement which was received on behalf of Mrs. Mala Lamba, wife of appellant/complainant.
After hearing the parties and considering the aforesaid, Ld. District Forum held that there was no deficiency on the part of respondent /OP No.1 and that appellant/complainant is not entitled for any compensation for mental agony and litigation and dismissed the complaint as settled.
Aggrieved with the aforesaid order present appeal is filed seeking compensation for mental agony and litigation costs.
Ld. counsel for appellant/complainant has submitted that the Ld. District Forum has failed to appreciated the fact that respondent/OP No.1 denied the cashless facilities for the treatment of his wife without giving any reasons at the time when she was in critical conditions. It is contended that ld. District Forum has failed to consider the fact that payment under cashless policy is to be made by the insurer to the hospital and insured has no role to play in it because TPA's basic role is to act as an intermediary between the insurer and insured and to facilitate the cashless service to policy holder.
As no one is appearing on behalf of the respondent/OP No.1 for the last two dates and even at the time of arguments on 16.07.2019 no one had appeared on behalf of the respondent/OP No.1 to assist this Commission, I have heard the arguments of ld. Counsel for appellant/complainant and perused the material on record.
In my considered view, the Ld. District Forum failed to consider the fact that cashless facilities were denied by the TPA of respondent/OP No.1 to appellant/complainant without giving any reason, which itself amount to deficiency in service. Further, respondent/OP No.1 in its written statement filed before the District Forum has failed to give any explanation as to why the cashless facilities were not provided to the appellant/complainant due to which the patient was not released and why an amount of Rs.27,700/- only was sanctioned by the TPA of respondent/OP No.1 Medsave Health Care Ltd. against the mediclaim insurance policy of Rs.5,00,000/-. Ld. District Forum also failed to consider the fact that the amount was settled only during the pendency of the complaint before District Forum.
In my considered view to decide the issue whether respondent/OP No.1 was deficient in service or not, it is necessary to determine, whether TPA is competent to deny the cashless facilities or repudiate the claim of the appellant/complainant or treat the same as No Claim?
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 14.3.2016 and the same read as under:-
"Health services by TPA
3.(1) 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 Policy and domestic travel policy. c. facilitating carrying out of pre-insurance medical examinations 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 for policyholders who are travelling to India:
Provided that such services shall be restricted to the health services required to be attended 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 not a. Directly make payment in respect of claims b. Reject or repudiate any of the claims directly c. 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."
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 though the claim was repudiated, however, the cashless service was denied by TPA, email dated 13.02.2014 (Annexure CW -1/22-23), which is in violation of the above said Regulations of the IRDAI and amounts to deficiency in service. 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 titled Gaurang Dinesh Damani vs. Union of India & Ors. in orders dated 5.3.2015 and 13.8.2015.
In view of the above, it is clear that TPAs have no authority to deny the cashless facilities or 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, which fact Ld. District Forum has failed to consider.
In view of the above, I accept the appeal and award compensation of Rs.20,000/- to the appellant/complainant towards mental agony and harassment suffered at the hands of respondent/OP No.1.
Appeal stands disposed of.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum for information. The record of the District Forum be also sent forthwith.
Thereafter, the file be consigned to record room.
(Salma Noor) Member