PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                             CONSUMER COMPLAINT NO.158 /2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. SadanandaTripathy, Member,

Pathani Samanta Chandra Shekhar Sathua, aged about 48 years,

S/O-Late NabinSathua, R/O-Sunaripara, PO-Laida, Ps-Katarbaga,

Dist-Sambalpur-768214, Odisha.                                   ….…......Complainant.

                                    -Vrs.-  

1. Aditya Birla Health Insurance Co. Ltd.,

9^th Floor, Tower1, One Indiabulls Centre, Jupiter Mills Compound,

B41, SenapatiBapat Marg, Elphinstone Road, Mumbai-400031,

Maharashtra.

2. Apollo Hospital Enterprise Limited, 251, Sainik School Road, Bhubaneswar, Dist-Khurda-751005, Odisha.
3. Dr. ByomakeshDikshit Consultant Cardiologist,

Appollo Hospitals, Bhubaneswar,

Dist-Khurda-751005, Odisha.                     …………........Opp.Parties

Counsels:-

1. For the Complainant      :- Sri. S.S. Sarangi & Associates
2. For the O.P. No.1            :- Nitu Roy & Associates
3. For the O.P. No.2 & 3     :- Sri. S.S. Panda & Associates

Date of Filing:03.10.2023,  Date of Hearing :14.05.2024,  Date of Judgement :02.07.2024

Presented byDr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complainant is that the Complainant availed one Health Insurance policy from O.P. No.1 product Active Health and plan-name platinum. Enhanced bearing policy No. 21-19-0044752-01 w.e.f. 02.03.2022 to 01.03.2023 for a premium of Rs. 17,480/-. The sum assured was Rs. 10.00 lakhs only. During the subsistence of policy the Complainant when made medical check up in O.P. No.2 through Dr. Byomakesh Dikshit, O.P. No.3 certain tests were done. The O.P. NO.3 found ASD(OS)(14mm size), ASD DEVICE CLOSURE(18mm Size) and did surgery of coronary Angiogram, temporary maker and device disclosure of PDA, ASD and VSD on 16.11.2022. The Complainant admitted for the period 15.11.2022 to 19.11.2022 in O.P. No.2 hospital. Claim was assigning “non-discloure of his earlier diseases”. The Complainant came to know that O.P. no.2 sent a letter through e-ail showing detection of Hepatitis B +Ve earier which was neither signed by the treating doctor nor the same carried by date to the O.P. No.1 by uploading the same. When O.P. no.1 not paid the medical dues, the Complainant was compelled to pay the hospital dues and to get the medical documents. The Complainant knowing about hepatitis B +ve treatment rushed to O.P. no.2 and knew that by mistake the O.P. No.1 was informed through e-mail.

The O.P. no.3 when was contacted, he clarified that the Complainant has/had no such hepatitis B +ve disease and issued him a medical certificate in that regard.

Although having valid insurance policy due to wrong certification of O.P. No.2 & 3 the Complainant could not get his claim. Complaint was made before Ombudsman who advised to approach the O.P. No.1 for refund of amount paid. Request was made to O.P. no.1 for refund of medical claim but O.P. No.1 refused and repudiated the claim. Vide letter dated 24.11.2022 the O.P. No.1 cancelled the policy of insurance holding that the policy is lapsed due to disclosure of hepatitis B +ve since three years and refunded some premium amount.

Being aggrieved complaint was filed.

2. The O.P. No.1 insurer submitted that policy No. 11-19-0044752-00 was issued in favour of Complainant. In proposal from the Complainant not disclosed pre-existing disease and violated clause 19 and 2 of the policy. On 15.11.2022 pre-authorisation request No. 1112285082189 for cashless was received. The Complainant was a know case of Hepatitis B before inception of the policy and undergoing treatment for the same. The pre-authorisation request was denied on 18.11.2022 and informed to Complainant through email. The repudiation of the claim is proper.
3. The O.P. No.3 for O.P. no.2 & self. Submitted that there is no deficiency in service or medical negligence on the part of O.P. No.2 & 3. The Complainant was admitted in O.P. No.2 hospital under supervision of O.P. no.3 and diagnosed to be have SOB for two months for which ASD device closure was done. On 15.11.2022 admitted and discharged on 19.11.2022 bearing UHID No. ODB1.0000742854.

The Complainant was having medical insurance and accordingly all the documents and treatment record of the Complainant were sent to insurer. When the insurer refused the claim the Complainant cleared the medical dues and discharged.

The patient on the date of admission as per test result was not Hepatitis-B +ve. Subsequently, the patient was developed Hepatitis B +ve as per his medical report and it has been reflected in the report. ASD has no relation to Hepatitis B+ve in any was and the same was signed by O.P. No.3, hence no mistake has been done by O.P. No.2. There is no any fault in medical record submitted by O.P. No.2.

The Complainant did not have any prior HbsHg, which is not disputed by O.P. No.2. As per the progress sheet the Complainant was disgnosed to having Hepatitis B +ve on 16.11.2022. Quality Service has been provided to the Complainant and the Complaint is liable to be dismissed.

4. The Complainant filed following documents:

1. Aadhar of the Complainant.
2. Copy of Insurance policy.
3. Policy Certificate No. 21-19-0044752-01
4. Test reports dated 16.11.2022.
5. The discharge summary dated 19.11.2022.
6. Certificate issued by O.P. No.3.
7. Receipt No. 7220744 dated 19.11.2022 for Rs. 2,09,444.00 issued by O.P. no.2.
8. Certificate issued by O.P. no.3 dated 16.11.2022.
9. Complaint of Complainant before insurance Ombudsman.
10. Cancellation letter of policy dated 24.11.2022.

The O.P. No.1 insurer filed the following documents:

1. Policy details of Health Insurance.

The O.P. no.2 & 3 submitted.

2. Discharge Summary dated 19.11.2022.
3. Progress report of the patient.

5. After perusal of the contentions and documents filed by the parties it is admitted that the Complainant is having health insurance policy No. 21-19-0044752-01 valid for the period 02.03.2022 to 01.03.2023. The Complainant was admitted in O.P. No.2 hospital on 15.11.2022 and discharged on 19.11.2022 bearing UHID NO. ODB1.0000742854. ASD device closure of the Complainant was son with 18mm device under TPI support by O.P. no.3 and the Complainant being hemodynamically stable was advised for discharge and on 19.11.2022 discharged. As the Complainant is insured with O.P. No.1 all the documents and treatment record of the Complainant were sent to the insurer for approval . The insurer repudiated the claim of the ground of “non disclosure of earlier diseases”. The Complainant paid all the hospital dues of O.P. No.2 and discharged. Being aggrieved on repudiation complaint has been filed.

Taking into consideration the pleadings and documents following issues are framed:

ISSUES

1. Whether the Complainant was having any pre-existing disease and not disclosed the insurer?
2. Whether repudiation of the claim is proper?
3. Whether the O.Ps are deficient in their service?
4. What relief the Complainant is entitled to get?

Issue No.1:- Whether the Complainant was having any pre-existing disease and not disclosed the insurer?

From Ext.6 filed by the Complainant is reveals that the O.P. No.3 has issued a certificate that “…..Investigation of routine test pt. was detected, he was pepatatus B +ve, but no sign and symptom of hbAg +ve. ASD was related to HB Ag +ve in any way.

From discharge summary it reveals that there is no any remarks of O.P. no.3 regarding Hepatitis B_+Ve nor in the progress report submitted by O.P. No.2 & 3 any reflection has been made regarding the disease. Here question arises in the medical history is there is no any reflection of the disease found place then how the O.P. No.3 issued a certificate dated nil to O.P. No.1 (Exhibit 6) that the Complainant is a know case of hepatitis B+ve.

The second point of consideration is that in Annexure-6 of the Complaint(Ext.6) it has no where been mentioned that the Complainant has prior Hepatitis-B and the said certificate was also produced by the treating doctor of the Complainant i.e. O.P. No.3. The O.P. No.2 has provided the records available with him and has not violated any provisions of the consumer law as per statement of O.P. No.3.

The O.P. No.3 in his statement saying that the Complainant is a known case of Hepatitis B +ve where as no where in the history of the patient it is disclosed that the Complainant is a earlier case of hepatitis B+ve from annexure 8 it is clear that the O.P. No.3 at his sweet will issuing certificates to the insurer and vide Ext.8 ( Annexure-8) to the Complainant.

The Complainant has no any prior disease of Hepatitis B +ve as reflected in Ex.6 and it is discarded.

The issue is answered in favour of the Complainant.

ISSUE NO.2 Whether repudiation of the claim is proper?

When there is no any pre-existing disease exists or suppressed by the Complainant findings of the insurer while considering the claim is not proper. Accordingly repudiation of claim of Complainant is not proper.

The issue is answered accordingly.

ISSUE NO.3 Whether the O.Ps are deficient in their service?

It is admitted by O.P.No.2 & 3 that the O.P. No.3is that attending doctor in O.P. No.2 hospital for treatment of the Complainant. It is the general practice that while any treatment is made to a patient past history required to be noted in the prescription. Neither in the discharge slips nor in the treatment details previous history have been reflected. Further in exhibit 6 no any date has been reflected it speaks that on the request of the insurer certificate has been issued. It proves the conspiracy between the O.P. No.1 and O.P. No.2 & 3. Non reflection of past history of a patient, issue of a forged certificate against a patient is against the medical ethics. Accordingly, the O.Ps are deficient in their service and it is an unfair trade practice.

Issue is answered accordingly.

ISSUE NO.4 What relief the Complainant is entitled to get?

From the supra discussion it is clear that the Complainant is entitled for relief as claimed and accordingly it is ordered:

ORDER

The complaint is allowed on contest against the O.Ps. The O.P. No.1 is directed to pay Rs. 2,09,444/- treatment cost to the Complainant within one month of this order. In case of non-payment the amount will carry 7% interest per annum from date of discharge i.e. 19.11.2022 till realisation.

The O.P. No.2 & 3 are liable to pay compensation of Rs. 1,00,000/- each for harassment and unfair trade practice. The O.Ps are liable to pay litigation expenses of Rs. 10,000/- each to the Complainant.

Order pronounced on open court on 2^nd July, 2024.

Supply free copies to the parties.