BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.344 of 2015

Date of Instt. 14.08.2015

Date of Decision : 08.07.2016

Pawan Gupta aged about 46 years son of Om Parkash R/o H.No.65, Shankar Garden Ward No.15, Jalandhar City.

..........Complainant

Versus

1.Apollo Munich Health Insurance Company Limited, Apollo Hospitals Complex, Jubilee Hills Hyderabad Andhra Pradesh, through its Managing Director/Director/Manager/Authorized Personnel.

2.Apollo Munich Health Insurance Company Limited, Satnam Complex, near BMC Chowk, Jalandhar City through its Branch Manager.
 

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Mrs. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Prince Tayal Adv., counsel for the complainant.

Sh.Vikas Gupta Adv., counsel for the OPs.

Order

Bhupinder Singh (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act against the opposite parties (herein called as OPs) on the averments that complainant got health insurance policy titled as “Your Easy Health Insurance Policy” vide policy bearing No.180200/11051/AA00092949 from the OPs for himself and his family members for the period from 14.6.2014 to 13.6.2015. Complainant suffered medical problems i.e. heavy weakness with problem in walking, left arm weakness, resulting in great pain disabling the complainant to move its left arm, lift weight, etc. The complainant consulted Metro Hospital and Maternity Home, Hoshiarpur Road, Jalandhar City where he was admitted on 9.7.2014 and was discharged/referred to Dayanand Medical Collage and Hospital, Ludhiana on 10.7.2014. Complainant spent total expenditure of Rs.15,167/-. Thereafter, complainant was admitted in Dayanand Medical Collage and Hospital, Ludhiana on 2.8.2014 and he was discharged on 8.8.2014 where he was medically treated and the complainant spent total amount of Rs.64,384/- on his treatment. Complainant lodged claim with the OP but the OP repudiated the claim of the complainant vide letter dated 20.2.2015 on the ground that complainant was admitted in hospital only for investigation and evaluation of disease. Complainant submitted that opposite parties has wrongly repudiated the claim of the complainant. On such averments, the complainant has prayed for directing the OPs to reimburse the amounts i.e. Rs.15,167/- and Rs.64,384/- spent by complainant on his treatment alongwith interest. He has also claimed compensation and litigation.

2. Upon notice, OPs appeared through counsel and filed written reply pleading that OP received the claim from the complainant alongwith relevant documents that he was hospitalized in Metro Hospital, Jalandhar from 9.7.2014 to 10.7.2014 for generalized weakness, inability to walk and was diagnosed as having Hypokalemic Periodic Paralysis and final claim amount spent at Metro Hospital, Jalandhar was submitted to the OP company was Rs.15,167/-. OP wrote a letter dated 26.8.2014 to the complainant for submission of certain documents/information but complainant did not submit any reply. Then another letter dated 15.9.2014 was again issued and then complainant submitted another set of documents on 7.10.2014. From the submitted documents, it was found that admission in the hospital was for investigation and evaluation of ailment. Only, therefore, the claim was rejected under section 6 (C) (vi) of the terms and conditions of the policy vide letter dated 5.11.2014. Thereafter, pre-authorization request was received from Dayanand Medical Collage and Hospital, Ludhiana that the complainant was admitted on 2.8.2014 with diagnosis of recurrent Hypokalemia with renal tubular acidosis. His pre-authorization request for cashless service was declined. Complainant was discharged from Dayanand Medical Collage and Hospital, Ludhiana on 8.8.2014. Then, he submitted reimbursement claim on 22.8.2014 alongwith its discharge summary and other relevant documents but the complainant failed to submit all the documents and investigation reports. So, letter dated 27.9.2014 was written to the complainant asking him to submit certain reports/information. Reply was received from complainant on 7.10.2014. From the submitted documents, it was noted that mostly medicines prescribed were oral medicine and outdoor patient treatment could have been taken in the same. As such, hospitalization of the patient was not necessary. So, claim of the complainant was rejected vide letter dated 27.10.2014 as per terms and conditions of the policy.

3. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C99 and closed his evidence.

4. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OP/A alongwith copies of documents Ex.OP-1 to Ex.OP-13 and closed evidence.

5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.

6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got health insurance policy titled as “Your Easy Health Insurance Policy” vide policy bearing No.180200/11051/AA000 92949 from the OPs for himself and his family members for the period from 14.6.2014 to 13.6.2015. Complainant suffered medical problems i.e. heavy weakness with problem in walking, left arm weakness, resulting in great pain disabling the complainant to move its left arm, lift weight, etc. The complainant consulted Metro Hospital and Maternity Home, Hoshiarpur Road, Jalandhar City where he was admitted on 9.7.2014 and was discharged/referred to Dayanand Medical Collage and Hospital, Ludhiana on 10.7.2014. Complainant spent total expenditure of Rs.15,167/-. Thereafter, complainant was admitted in Dayanand Medical Collage and Hospital, Ludhiana on 2.8.2014 and he was discharged on 8.8.2014 where he was medically treated and the complainant spent total amount of Rs.64,384/- on his treatment. Complainant lodged claim with the OP but the OP repudiated the claim of the complainant vide letter dated 20.2.2015 on the ground that complainant was admitted in hospital only for investigation and evaluation of disease. Learned counsel for the complainant submitted that complainant was diagnosed as suffering from Hypokolemic Periodic Paralysis, it was managed with IV KCl Infusion and essential HTN with Recurrent Hypokalemia etc. In order to which he was medically treated at both hospitals i.e. Metro Hospital, Jalandhar and Dayanand Medical Collage and Hospital, Ludhiana but the OP has wrongly repudiated the claim of the complainant. All this amounts to deficiency in service on the part of the OPs qua the complainant.

7. Whereas the case of the OPs is that OP received the claim from the complainant alongwith relevant documents that he was hospitalized in Metro Hospital, Jalandhar from 9.7.2014 to 10.7.2014 for generalized weakness, inability to walk and was diagnosed as having Hypokalemia Periodic Paralysis and final claim amount spent at Metro Hospital, Jalandhar was submitted to the OP company was Rs.15,167/-. OP wrote a letter dated 26.8.2014 Ex.OP5 to the complainant for submission of certain documents/information but complainant did not submit any reply. Then another letter dated 15.9.2014 Ex.OP7 was again issued and then complainant submitted another set of documents on 7.10.2014. From the submitted documents, it was found that admission in the hospital was for investigation and evaluation of ailment. Only, therefore, the claim was rejected under section 6 (C) (vi) of the terms and conditions of the policy vide letter dated 5.11.2014 Ex.OP8. Thereafter, pre-authorization request was received from Dayanand Medical Collage and Hospital, Ludhiana that the complainant was admitted on 2.8.2014 with diagnosis of recurrent Hypokalemia with renal tubular acidosis. His pre-authorization request for cashless service was declined. Complainant was discharged from Dayanand Medical Collage and Hospital, Ludhiana on 8.8.2014. Then, he submitted reimbursement claim on 22.8.2014 alongwith its discharge summary and other relevant documents but the complainant failed to submit all the documents and investigation reports. So, letter dated 27.9.2014 Ex.OP11 was written to the complainant asking him to submit certain reports/information. Reply was received from complainant on 7.10.2014. From the submitted documents, it was noted that mostly medicines prescribed were oral medicine and outdoor patient treatment could have been taken in the same. As such, hospitalization of the patient was not necessary. So, claim of the complainant was rejected vide letter dated 27.10.2014 Ex.OP13 as per terms and conditions of the policy. Learned counsel for the OPs submitted that there is no deficiency in service on the part of the OPs qua the complainant.

8. From the entire above discussion, we have come to the conclusion that complainant got health insurance policy titled as “Your Easy Health Insurance Policy” Ex.OP2 from the OP for himself and his family members for the period from 14.6.2014 to 13.6.2015. Complainant suffered health problems and he was admitted in Metro Hospital and Maternity Home, Hoshiarpur Road, Jalandhar City on 9.7.2014 where he was medically treated and was discharged/referred to Dayanand Medical Collage and Hospital, Ludhiana on 10.7.2014 and complainant spent a sum of Rs.15,167/- on his medical treatment as is evident from discharge card of Metro Hospital, Jalandhar Ex.C80, where the complainant was diagnosed as having Hypokalemia Periodic Paralysis managed with intravenous KCl infusion. All this shows that patient was given intravenous KCl infusion for which admission of the patient is necessary because such infusion type treatment can not be given to the patient in OPD and complainant spent a sum of Rs.15,167/- for medical treatment at Metro Hospital, Jalandhar regarding which he produced bill Ex.C83 to Ex.C90 and the complainant submitted reimbursement claim with OP. OP rejected the claim of the complainant vide letter dated 5.11.2014 Ex.OP8 on the ground that the admission of the patient in the hospital is for investigation and evaluation of aliment only and as per section 6 (C) (vi) this claim is not payable. OPs without taking any report from the Metro Hospital, Jalandhar and without getting any expert opinion as to whether in this case hospitalization of the patient was necessary or not because the complainant has undergone medical treatment during hospitalization at Metro Hospital, Jalandhar as is evident from the medical treatment record of the patient i.e. discharge card Ex.C80 and investigation and treatment record Ex.C81 and Ex.C82 in which it has been clearly mentioned that the patient was diagnosed having Hypokalemia Periodic Paralysis managed with intravenous KCl infusion.

9. Not only this, Metro Hospital, Jalandhar authority referred the patient to Dayanand Medical Collage and Hospital, Ludhiana for further evaluation. The OP has, therefore, wrongly repudiated the claim of the complainant vide letter dated 5.11.2014 Ex.OP8. Not only this, complainant further was admitted in Dayanand Medical Collage and Hospital, Ludhiana on 2.8.2014 where he remained under diagnosis/investigation and medical treatment upto 8.8.2014 as is evident from Dayanand Medical Collage and Hospital, Ludhiana record i.e. discharge summary and treatment record Ex.C27 to Ex.C79 as well as the record produced by the OP Ex.OP9 and Ex.OP10 and the complainant spent a sum of Rs.67,384/- for his medical treatment at Dayanand Medical Collage and Hospital, Ludhiana, the bills of which have been duly produced by the complainant alongwith claim form Ex.C9 i.e. details of the bill Ex.C10 and bills Ex.C11 to Ex.C25 but the OP again repudiated the claim of the complainant vide letter dated 27.10.2014 Ex.OP13 on the same ground that the admission of the complainant in Dayanand Medical Collage and Hospital, Ludhiana was mainly for investigation and evaluation of the disease and as per terms and conditions of the policy, expenses during admission for investigation and evaluation alone are not payable. The record of Dayanand Medical Collage and Hospital, Ludhiana Ex.C27 to Ex.C79 fully proved that complainant was diagnosed as Essential Hypertension with Recurrent Hypokalemia and Etiology and the patient remained under treatment at Dayanand Medical Collage and Hospital, Ludhiana from 2.8.2014 to 8.8.2014. The condition of the patient was so serious that even the Dayanand Medical Collage and Hospital, Ludhiana authorities were not in a position to discharge the complainant though the condition of the patient improved during hospital course. Even, they recommended that the patient need further stay in hospital for further evaluation but the patient was discharged on his request as is evident from the summary of the hospital report attached with the discharge summary Ex.C27. Even, Dayanand Medical Collage and Hospital, Ludhiana authorities have given certificate dated 23.9.2014 produced by OP itself with detail bills Ex.OP12 fully proved that the admission of the patient was necessary as the patient complained of weakness of left arm and left leg back alongwith history of weakness of all four limbs since October 2013 and the patient was diagnosed as the case of hypertension essential HTN with Recurrent Hypokalemia, etc. The patient was suffering from Hypokalemia Periodic Paralysis for which admission in the hospital was necessary for the evaluation as well as treatment purposes. OP did not get any certificate from any doctor of Dayanand Medical Collage and Hospital, Ludhiana or any medical expert opinion to prove that under such circumstances and medical problems suffered by complainant, admission of the patient in the hospital was not required. Dayanand Medical Collage and Hospital, Ludhiana which is a reputed Medical Institute does not keep the patient admitted in their hospital for 6/7 days only for diagnosis purposes but the patient was medically treated for the aforesaid sufferings/diseases being suffered by complainant. Consequently, we hold that OP has wrongly repudiated the claim of the complainant vide letter dated 27.10.2014 Ex.OP13. Consequently, we hold that OP is liable to be pay/reimburse the amount, the complainant has spent on his medical treatment at Metro Hospital, Jalandhar i.e. Rs.15,167/- as well as the amount spent by complainant at Dayanand Medical Collage and Hospital, Ludhiana i.e. Rs.64,384/-.

10. Resultantly, we allow the complaint with cost and the OPs are directed to pay the aforesaid amounts i.e. Rs.15,167 + Rs.64,384 = Rs.79,551/- to the complainant within one month from the date of receipt of copy of this order, failing which OPs shall be liable to pay interest @ Rs.9/- % per annum from the date of filing of the complaint till the payment is made to the complainant. OPs are also directed to pay the cost of litigation to the complainant to the tune of Rs.3000/-. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Bhupinder Singh

08.07.2016 Member Member President