Failure to disclose the Insurance amount approved by TPA: Delhi Hospital directed Compensation

New Delhi: The District Consumer Disputes Redressal Commission-II, New Delhi recently held Mool Chand Khairatiram Hospital and Ayurvedic Research Institute liable for failure to disclose the amount approved by a third-party insurance administrator.

In its order, the commission has directed the hospital to pay Rs 5000 to the complainant's heir towards the cost of litigation, harassment and mental agony.

With this observation, the Commission directed New India Assurance Co. Ltd. to pay Rs. 24,329 to the complainant. This Rs 24,329 is the difference between the sanctioned amount and the actual amount claimed.

The matter goes back to 2015 when the complainant was admitted to Mool Chand Khairatiram Hospital and Ayurvedic Research Institute. He got admitted on January 20 and was discharged on January 27. For the treatment, the complainant initially deposited Rs 10,000 at the time of admission and later paid Rs 49,988 to the hospital.

Since the complainant was covered under the Mediclaim cashless policy of New India Assurance Company Ltd., a copy of the policy document was presented to the Hospital to avail the policy benefit.

However, the complainant was informed that Rs 49,988 was computed as the balance amount after getting the same sanctioned from TPA Suraksha, a third-party administrator connecting the insured, insurer, and provider.

Further, the complainant was informed that the claim amount would be directly communicated to the insurance company and would be received directly by the hospital.

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Following this, in order to cross-check the claim made by the hospital, the complainant decided to inquire from the office of TPA Suraksha and he was informed that the hospital made a total claim of Rs 1,27,188 and the third-party sanctioned Rs 84,329. 

Therefore, the complainant could not understand that when the amount sanctioned by TPA Suraksha was much higher than what constrained the hospital from providing the appropriate credit to the complainant. 

Apart from this, the complainant also argued that he is entitled to know on what basis TPA Suraksha sanctioned Rs 84,329 when the policy cover was of Rs 1 lakh. The complainant also pointed out that the hospital only informed that the amount sanctioned by TPA was Rs 60,083 including TDS without even mentioning breakup of gross amount and the TDS amount.

Meanwhile, New India Assurance company informed the Commission that it had issued a new Mediclaim 2012 policy for a period of Rs 28.01.2014 to 27.01.2015 with the sum insured of Rs 1 lakh and Rs 10,000 had been added as bonus.

The complainant claimed Rs 1,26,992 when the insured sum was Rs 1 lakh. As per the policy conditions, the total amount that was passed by the TPA was Rs 60,084 less 10% tax i.e. Rs 54,075. 

Referring to this, the Insurance Company submitted that the claim of the complainant had been settled as per the calculations that were made as per the terms and conditions of the policy. 

While considering the matter, the consumer court noted that at the time of discharge, the hospital raised an invoice for Rs 1,27,188 against the medical services provided to the complainant. Subsequently, TPA Suraksha sent an approval Rs 84,329 including the non-admissible items of Rs 17,129.

Taking note of the fact that the hospital chose not to appear before the Commission, the consumer court held that "...hence the averments made qua Op-1 have remained uncontroverted and unchallenged therefore there is no reason to disbelieve the version of the complainant."

With this observation, the consumer court held the Mool Chand hospital liable for failing to disclose the amount sanctioned by TPA Suraksha and noted,

"OP-1 (the hospital) is found to be deficient in service only to the extent of not informing the complainant about the amount sanctioned by OP-3."

The consumer court also took note of the fact that during the final arguments, the counsel for the OP-4 offered to settle the matter at Rs 84,329, out of which an amount of Rs 60,084 had been duly paid to the complainant therefore OP-4 expressed its willingness to pay Rs 24,329 towards full and final payment.

It was noted by the Commission that even though the OPs resisted the complaint on merit yet the Insurance Company has off and on been offering to settle.

"Hence we hold OP-4 to be indulging in unfair trade practice for withholding the amount to which complainant was entitled since beginning. OP-4 is this liable to pay the offered amount. Offer of OP-4 at this stage after six years entitled the complainant for the cost of litigation and the harassment caused," observed the Commission.

Therefore, the consumer court directed the New India Assurance Company to pay Rs 24,329 @6% interest per annum from the date of the filing of the complaint till realization. Additionally, the Commission also directed the Insurance Company to pay Rs 10,000 and the Hospital Rs 5,000 towards the cost of litigation, harassment, and mental agony.

"It is noticed that complainant passed away during the pendency of the complaint and his brother was permitted to be substituted. Photocopy of the Will dated 18.12.2010 purpOrtedly executed by the deceased complainant has been brought on record however the same is neither registered nor probated. Will is also silent as regard the amount claimed in present complaint, therefore we leave it for the OPs to pay the above stated amount to the LRs of teh complainant," observed the Commission.

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/delhi-consumer-court-224618.pdf

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