PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR
CONSUMER COMPLAINT NO. 83/2023
Present-Dr. Ramakanta Satapathy, President,
Sri. Sadananda Tripathy, Member,
Biswanath Pattnaik,
S/O-Harihara Pattnaik,
R/O-Tamalpada (Near Ranibagicha) PO-Jharuapada, Ps-Town,
Dist-Sambalpur, Odisha-768001
Mob-9937725019. .……….......Complainant.
Vrs.
- The Branch Head,
Star Health and Allied Insurance Company, Limited.
2nd Floor, Quality Mansion, Nayapara,
Sambalpur-768001.
- The Branch Manager,
Star Health and Allied Insurance Company, Limited.
Annapurna Complex, Plot No. 263(Adjacent to HDFC Bank) VIVO Service Centre lane, Balaji Nagar, Bhubaneswar-751009.
- Star Health and Allied Insurance Company, Limited.
Regd Office At No. 15, Sri. Balaji Complex, 1st Floor,
Whites Lane, Royapettah, Chennai-600014.
- Amri Hospital, Bhubaneswar,
Plot No. 1, Besides Satya Sai Enclave, Khandagiri,
Bhubaneswar-751030. ……...……….Opp. Parties
Counsels:-
- For the Complainant :- Sri. A.K. Sahoo & Associates
- For the O.P. No. 1 to 3 :- Sri. B.K. Purohit, Adv.
- For the O.P. No.5 :- Sri. P. Debta & Associates
Date of Filing:30.05.2023,Date of Hearing :12.12.2023,Date of Judgement : 02.04.2024
Presented by Dr. Ramakanta Satapathy, PRESIDENT
- The case of the Complainant is that the Complainant entered into a health policy Vide No. P/191214/01/2021/002517 with O.P. No.1 to 3 for the period 11.09.2020 to 10.09.2021 and paid Rs. 20,455/- premium with sum assured Rs. 10.00 lakhs.
On 01.05.2021 the Complainant suffered from severe pain and fever, on 02.05.2021 treated as an outdoor patient by Dr. K.D. Purohit and came to know about Covid +ve Doctor advised to stay in isolation till 06.05.2021. When the Complainant suffered from breathing problem Dr. K.D. Purohit advised to refer to higher Covid center. On 07.05.2021 the Complainant was shifted to O.P. No.4 AMRI Hospital, Bhubaneswar by Ambulance with ventilator and admitted on 07.05.2021 at about 8.00 AM. Where the Complainant was treated as indoor patient from 07.05.2021 to 12.05.2021.
The Complainant spent Rs. 20,000/- in Sanjivani Hospital and in O.P. No.4 Rs. 1,28,680/- and the Complainant spent Rs. 40,000/- to-wards ambulance, convenience, diet for attendants etc. After recovery the Complainant lodged the claim before O.P. no.1 along with documents, but the O.P. no.1 to 3 not took any steps. and at last denied the claim which amounts to unfair trade practice and deficiency in service.
- The O.P. no.1 to 3 in their version submitted that health policy is admitted. The Complainant was admitted in O.P. No.4 hospital on 07.5.2021 and discharged on 12.05.2021 for treatment of Covid-19. The insured raised Pre-authorisation request to avail cashless facility which was denied on the ground that “it is observed from the submitted documents that the insured patient’s clinical picture and vital chats indicate the patient falls under category A of AIIMS Covid protocol and the patient could have managed in home quarantine.”
As per HRCT investigation report from AAROGYAM HOSPITAL all vitals are stable. No evidence of ground glass apacity or consolidation in bilateral lungs. CORAD SCORE-I CT SEVERITY score-0/25. The viatals are within normal limit. Temperature of the patient was below 98F in room temperature throughout the period of hospitalization which falls under category A of AIIMS Covid protocol. The treatment of patient needs only home isolation and care. Instead the patient hospitalized. This is hence not payable as per medically necessary clause of the policy. Vide letter dated 29.10.2021 the claim was repudiated.
There was no any medical necessity for the Complainant. The Complainant is not entitled for any claim.
- The O.P. No.4, AMRI Hospital, Bhubaneswar submitted that the Complainant was having VHID No. AM 40215976, Bed No. 5050, dated of admission 07.05.2021 and date of discharge 12.05.2021, medical condition-Covid 19 +ve, complaints-fever since 4 days, cough since 4 days, generalized weakness, patient was conscious and oriented, discharge condition conscious with all vital stable. The hospital rendered the best treatment to its patients and the dispute is between complainant and the insurer. Against the O.P. No.4 no any relief has been claimed.
- Perused the documents filed by both the parties. It is the admitted case of both the parties that the Complainant was admitted in AMRI, Bhubaneswar for the period 07.05.2021 to 12.05.2021. The Complainant was under the supervision of Dr. Gargi Singh Thakur. The O.P. no.1 to 3 submitted that as per guidelines from All India Institute of Medical Sciences, New Delhi & Ministry of Health and Family welfare, Govt. of India regarding the treatment of Covid 19 patients need only home isolation and care. Instead the patient was hospitalized. Accordingly, the claim is not payable as per medical necessary clause of the policy.
The Complainant submitted that on 06.05.2021 the Complainant facing breathing problem and not controlled the temperature and body pain. The treating doctor K.D. Purohit advised to refer to higher Covid Centre taking into consideration the serious condition of patient and as he was feeling uneasy. By way with help of Ambulance the Complainant was shifted to AMRI Hospital.
The insurance Regulatory and Development Authority of India(IRDAI) during Covid-19 pandemic issued guidelines vide circular No. IRDAI/HLT/REG/CIR/163/06/2020 that the insurer shall cover cost of treatment of Covid insured by the insured person on availing treatment at home maximum upto 14 days per incident provided that the medical practitioner advices insured person to undergo treatment at home. In the present case the Medical practitioner advised for shifting to higher hospital for management of Covid-19. Patients acts as per advise of doctors and accordingly the patient was shifted at AMRI for better management. The O.P. can not impose such condition and repudiate the claim on the ground that the patient would have take home isolation. In the discharge slip of AMRI hospital the investigations details are narrated and the patient was shifted to Covid-19 ward for further management and evaluation. This facility might not be available in home isolation as O.P. pointed out. Accordingly, the decision of the O.P. repudiating the claim is not proper and without application of mind.
Taking into consideration the circumstances of the case following order is passed:
ORDER
The complaint is allowed on contest against the O.P. no.1 & 3 and dismissed against O.P. no.4. The O.P. No.1 to 3 insurer is directed to pay expenses incurred by Complainant Rs. 20,000/- in Sanjivani Hospital Sambalpur and Rs. 1,28,680/- in AMRI, Bhubaneswar along with ambulance conveyance expenses. The amount shall be paid on actual payment receipts submitted before the O.P. Payment should be made within one month of this order failing which it will carry 12% interest P.A. from date of filing of the case. No any other cost and compensation.
Order pronounced in the open court on this 2nd day of April 2024.
Supply free copies to the parties.
