PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

CONSUMER COMPLAINT NO.- 43/2022

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

Bikram Pattnaik,

S/o-Late Harihara Pattnaik

R/O-Tamalpada(Near Ranibagicha),

Po-Jharuapada, Ps-Town, Dist-Sambalpur-768001.               ...………..Complainant

Versus

1. The Branch Manager,

Star Health and Allied Insurance Company Ltd.

Sambalpur Branch.

2^nd Floor, Quality Mansion,

Nayapara, Sambalpur-768001.

2. The Branch Manager,

Star Health and Allied Insurance Company Ltd.

Annapurna Complex, Plot No. 263 (Adjacent to HDFC Bank)

VIVO Service Center Lane,

Balaji Nagar, Bhubaneswar-751009

3. Star Health and Allied Insurance Company Ltd.

Regd. Office at No. 15, Sri Balaji Complex, 1^St Floor,

Whites Lane, Royapettah, Chennai-600014.

4. Appollo Hospital, Bhubaneswar

Plot No. 251, Sainik School Road

Unit-15, Bhubaneswar-751005.                                    .…………...Opp.Parties

Counsels:-

1. For the Complainant           :-     Sri. D. Behera, Adv. & Associates
2. For the O.P.No. 1 to 3          :-    Sri. B.K.Purohit, Advocate
3. For the O.P. No.4                              :-    Ex-parte

Date of Filing:17.06.2022,  Date of Hearing :27.03.2023  Date of Judgement : 16.05.2023

Presented by Sri Sadananda Tripathy, Member.

1. The Brief fact of the Complainant is that the OP No. 1, 2 & 3 are the officers of Health Insurance Company and the OP No. 4 is the treating Hospital. The Complainant had entered into a health insurance policy from the OP No. 2 & 3 through OP No. 1, which was commencing from 10.09.2020 to 09.09.2021 for which the Complainant has paid a sum of Rs. 7,174/- towards the premium thereof for the renewal of the policy a sum assured of Rs. 5,00,000/- and thereafter the OP No. 2 issued the policy for a period of one year. On 07.05.2021 the Complainant suffered sever pain and fever. On 08.05.2021 the Complainant was treated as an outdoor patient under Dr. K.D Purohit and same day the Complainant came to know the Covid-19 report was positive and the condition was very critical and temperature was not controlled by the treating doctor. The treating doctor advised to refer to higher Covid center. On 09.05.2021 as when the Complainant condition was critical, the doctor along with family members decided to admit in Apollo Hospital, Bhubaneswar and in the evening hour the Complainant was shifted to Apollo Hospital, Bhubaneswar by way of Ambulance with ventilator. On 10.05.2021 early morning at about 3.30 A.M the Complainant was admitted at Apollo Hospital where the Complainant was treated as an indoor patient from 10.05.2021 to 14.05.2021. The Complainant was discharged on 14.05.2021 with an advise to take medicine etc. During the treatment at Sanjivani Hospital, Sambalpur, he spent a sum of Rs. 30,000/ and at Apollo Hospital, Bhubaneswar the Complainant paid a sum of Rs. 1,82,847/- total as bill of the Apollo Hospital and the Complainant spent a sum of Rs. 40,000/- towards the ambulance, convenience, diet etc for the attendants. After recovery the Complainant lodged his claim before the OP No.1 for payment of the expenditure towards the treatment, which the Complainant has incurred for his treatment as aforesaid. After lodging of the claim by the Complainant, the OPs sought some documents regarding the treatment of the Complainant and the Complainant submitted all the documents as required by the OP No. 1 & 2. After submission of documents the Complainant approached the OPs on several occasions to settle her claim and to pay the total amount but the OP No. 1, 2 & 3 not took any steps for settlement of claim of the Complainant. On 19.10.2021 the OP No. 1 send a letter to the Complainant and mentioned repudiation of claim and reply that “It is observed that from the submitted claim documents that insured patient’s vital signs are stable though out the period of hospitalization and investigation reports are within normal limit. Our medical team is of the opinion that the insured patient could have been managed under home isolation”. As the Complainant was severely ill by Covid-19 and the medicine specialist so also the renowned doctors of Sambalpur town and leading hospital of Sambalpur town advised the Complainant to admit in a higher center and the Complainant had no option to ignore the same for better treatment as the complainant had already taken high dose of antibiotics for a period of 3 to 4 days as the HRCT report did not show the infection was high. The OPs have taken a plea that it was normal condition which is not correct and so the Complainant will not get any claim and denied a claim. The OPs have acted with malafide by repudiating the claim and it amounts to failure in rendering service and so also unfair trade practice.
2. The written version of O.P No. 1 to 3 is that the Complainant took Young Star Insurance Policy covering himself for sum Insured of Rs. 5,00,000/- for the period 10.09.2020 to 09.09.2021. This Policy was issued with conditions, limitations, exclusions, which are the part of the Policy. As per the Exclusion Clause No. 36, it has been mentioned that “any hospitalisation, which are not medically necessary/does not warrant hospitalisation”. Will not be covered under the Policy. The Complainant was admitted at Apollo Hospitals Enterprises Ltd. with diagnosis of Covid-19 from 10.05.2021 to 14.05.2021. The Complainant initially submitted a claim for pre-authorisation cashless approval of hospitalisation expenses for an amount of Rs. 1,39,500/- vide pre-authorisation request form dtd. 10.05.2021. The Complainant further raised the query vide letter dtd 10.05.2021 and as per the documents submitted by the Complainant, it was observed that since 06.05.2021, the SPO2 level of the Complainant was more than 94% and his vitals were within normal limits. In fact, he was advised to be home quarantined as his treatment could be monitored from his home itself. Based on such documents of the Complainant, the claim was initially repudiated vide letter dtd. 11.05.2021 stating that, “It is observed from the submitted documents that the patient falls under CATEGORY-A of AIIMS COVID protocol and can be managed in home quarantine only. We are therefore unable to consider the approval for cashless treatment of the above diagnosed disease”. Subsequently, the Complainant submitted a claim for reimbursement of hospitalisation expenses for an amount of Rs. 1,82,847/- vide claim form. Thereafter, the Complainant submitted discharge summary, final bills and receipts on 09.10.2021 for processing his claim. After examining his claim based on the available documents, the claim was repudiated on dtd. 19.10.2021 stating that, “It is observed from the submitted claim documents that insured patient’s vital signs are stable throughout the period of hospitalization and investigation reports are within normal limit. Our medical team is of the opinion that the insured patient could have been managed under home isolation. As per the guidelines from All India Institute of Medical Science, New Delhi and Ministry of Health and Family Welfare, Government of India regarding the treatment of COVID 19 patients, this patient needs only home isolation and care. Instead the patient is hospitalized. Hence the claim is not payable as per the policy clause. We are therefore unable to settle your claim under the above Policy and we hereby repudiate your claim”.

1. Is the Complainant a Consumer of the O.Ps?
2. Is there any deficiency in service/unfair Trade practice in part of O.Ps?
3. Whether the Complainant is entitled for getting any relief from the OPs?

Issue No. 1 Is the Complainant a consumer of the O.Ps?

The Complainant had entered into a health insurance policy from the OP No. 2 & 3 through OP No. 1, which was commencing from 10.09.2020 to 09.09.2021 for which the Complainant has paid a sum of Rs. 7,174/- towards the premium thereof for the renewal of the policy a sum assured of Rs. 5,00,000/-

Issue No. 2 Is there any deficiency in service/unfair Trade practice in part of O.Ps?

On 08.05.2021 the Complainant was treated as an outdoor patient under Dr. K.D Purohit at Sanjivani Hospital Sambalpur and On 09.05.2021 when the Complainant’s condition was critical, the doctor along with family members decided to admit in Apollo Hospital, Bhubaneswar and in the evening hour the Complainant was shifted to Apollo Hospital, Bhubaneswar by way of Ambulance with ventilator. On 10.05.2021 early morning at about 3.30 A.M the Complainant was admitted at Apollo Hospital where the Complainant was treated as an indoor patient from 10.05.2021 to 14.05.2021. As per the advice of Dr. K.D Purohit at Sanjivani Hospital Sambalpur, the Complainant was shifted to Apollo Hospital, Bhubaneswar by way of Ambulance with ventilator. But the OPs repudiated his claim on the ground that “insured patient’s vital signs are stable throughout the period of hospitalization and investigation reports are within normal limit. Our medical team is of the opinion that the insured patient could have been managed under home isolation. As per the guidelines from All India Institute of Medical Science, New Delhi and Ministry of Health and Family Welfare, Government of India regarding the treatment of COVID 19 patients, this patient needs only home isolation and care. Instead the patient was hospitalized. Hence the claim is not payable as per the medically necessary clause of the Policy. We are therefore unable to se`ttle your claim under the above Policy and we here by repudiate your claim”. It is found on the discussion, examination of documents and reports of the both the parties the counter allegation made by the OP No. 1 to 3 are not correct. The said OPs also not produced/submitted in the Commission of any report of Medical teams regarding the necessity of the admission of the Complainant in the said Hospital.   So deficiency in service/unfair Trade practice in part established against the O.P No. 1 to 3.

Issue No. 3 Whether the Complainant is entitled for getting any relief from the OPs?

From all the facts of the parties, the Complainant is entitled for getting reliefs what he claims in his complaint petition from the the O.P No. 1 to 3.

                             ORDER

The complaint is allowed partly against the O.P No. 1 to 3 and are jointly and severally liable to pay Rs. 2,52,847/- with interest @ 6% P.A. from the date of claim till realization toward cost of the medical expenses, Rs. 30,000/- towards suffering and mental agony as compensation and Rs. 10,000/- towards cost of the petition to the Complainant within 30 days from the date of order,failing which all the amount will further carry with 9% interest per annum till realization to the complainant.

Order pronounced in the open Court today on 16^th day of May, 2023.

Free copies of this order to the parties are supplied.