Chandigarh

DF-I

CC/361/2020

Navdeep Singh Rana - Complainant(s)

Versus

Aditya Birla Health Insurance Co. Ltd. - Opp.Party(s)

Rahul Bedi & Kirti Kumar Googna

29 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/361/2020
Date of Institution	:	10.9.2020
Date of Decision	:	29/03/2023

 

Navdeep Singh Rana R/o House No.3218, 2^nd floor, Sector 40-D, Near Sharda Sarvhitkari School, Chandigarh 160036.

.

… Complainant

V E R S U S

1. Aditya Birla Health Insurance Co. Ltd. SCO No. 2473-2474, Sector 22-C, Chandigarh 160017 through its authorized representative or its Manager.
2. Aditya Birla Health Insurance Co. Ltd. 10^th floor R-Tech Park, Nirlon Compound, Next to HUB Mall, off Western Express, Highway Goregaon, East Mumbai-400063 through its authorized representative  or its Manager.

 .  … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY		Sh. Rahul Bedi counsel for complainant Ms. Nidhika Luthra vice counsel for Sh. Nitin Thatai, counsel for OPs

Per SURESH KUMAR SARDANA, Member

     Briefly stated the complainant purchased a health Insurance policy from the Opposite Parties (hereinafter referred to as OPs) by paying premium of Rs.3777/- on 18.3.2019.  The term of the policy was for one year covering a sum of Rs.3.00 lakh. The policy covered life threatening diseases.  On 3.1.2020 the complainant due to high fever admitted in Lifeline Super Specialty Hospital, Zirakpur, Mohali  and due information in this regard was given to the insurance company and the TPA of the OPs received the relevant documents from the complainant and the hospital. The complainant discharged on 3.2.2020 from the hospital and total expenditure incurred by him to the tune of Rs.37,523/-. On 13.2.2020 the complainant visited the OP No.1 office and submitted hard copies of all the relevant documents but despite approaching the OPs several times they harassed the complainant by claiming unnecessary documents from him though all the documents were submitted.  On 7.7.2020 the complainant sent a legal notice to OPs through but to no avail.  It is alleged that the OPs intentionally without any reason delayed the claim of the complainant. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed

1. The Opposite Parties in their reply while admitting the factual matrix of the case stated that on 22.2.2020 the OPs received the claim intimation form in which it was mentioned that the complainant was admitted to Life Line Super Specialty Hospital, Zirakpur from 31.1.2020 to 3.2.2020 as he was suffering from Acute gastroenteritis with high fever with urinary tract infection. On scrutiny the OP found certain discrepancy in the documents provided. It is averred that most of the ICP is written in single stretch i.e. Vitals and treatment. As per ICP doctor notes and vitals does not match with each other.  As per ICP and doctor statement patient diagnosed with acute gastritis and as per discharge summary diagnosed with acute gastroenteritis. Thus the claim was repudiated as per policy terms and conditions and the same was intimated vide repudiation letter dated 31.3.2020. All other allegations made in the complaint has been  denied being wrong.
2. Rejoinder was filed and averments made in the consumer complaint were reiterated
3. Contesting parties led evidence by way of affidavits and documents.
4. We have heard the learned counsel for the contesting parties and gone through the record of the case.
5. The only ground for repudiation of the claim of the complainant is that certain discrepancy were found in the documents provided. It is alleged by OP that as per ICP and doctor statement patient diagnosed with acute gastritis and as per discharge summary diagnosed with acute gastroenteritis, which do not match with each other. Hence the claim was rejected.
6. We have perused Annexure OP-3 at page 93 wherein  the Chief complaints are mentioned as below:-

“patient presents with fever with rigors and chills with sweat for 1-2 days assisted with headache, nausea, vomits for 1 days, loose motion for 1 day. Patient developed marked lethargy, listlessness and disorientation. Episode of vomiting with pain abdomen 2-3 per 6 hours.”

And provisional diagnosis is recorded as under:

     “Acute Gastritis with High Fever, Urine Infection.”

7. On perusal of page 94 which is a discharge summary the history of patient illness is given as below:-

     “patient presents with High Grade fever with rigors and chills with sweat for 1-2 days assisted with headache, Burning Micturation, nausea. Vomits & loose stool for 1 day. Patient came in emergency basis on examination febrile 102.6f, Dehydrated tenderness present. Patient started with Antibiotic and I/V fluids, fever continuous till day 3 of admission. Loose motions & vomiting subside after second day. At discharge patient is afebrile. General condition of patient table”

     Further the final diagnosis mentioned as under:

     “Acute gastroentritis with high fever with urine infection.”

 

8. After thoroughly examining the afore-extracted material on record it is observed that there is no major discrepancies noticed in the aforesaid two reports. We are of the concerted view that the OPs with an intention to frustrate the genuine claim of the complainant took the ground of mismatch of report and repudiated the claim of the complainant, which amounts to deficiency in rendering service and unfair trade practice on the part of OPs and they are liable to compensate the complainant for the same.   
9. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

1. to pay claim amount of Rs.37,777/- to the complainant with interest @9% P.A. from the date of filing of complaint till realization
2. to pay Rs.10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.7000/- to the complainant as costs of litigation.

10.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr. No.(iii) above
11.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member Sd/-
			[Suresh Kumar Sardana]
mp			Member