BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.102 of 2015
Date of Instt. 12.03.2015
Date of Decision :30.11.2015
Surinder Gupta son of Late Sh.Sant Ram Gupta, R/o 464, Guru Teg Bahadur Nagar, Jalandhar.
..........Complainant Versus
1. Apollo Munich Health Insurance Company Limited, Branch Office, 1st Floor, Satnam Complex, BMC Chowk, Jalandhar through its Branch Manager.
2. Apollo Munich Health Insurance Company Limited (Claim Department), Plot No.277, Udyog Vihar, Phase-II, Gurgaon-122006.
.........Opposite parties.
Complaint Under Section 12 of the Consumer Protection Act.
Before: S. Jaspal Singh Bhatia (President)
Ms. Jyotsna Thatai (Member)
Sh.Parminder Sharma (Member)
Present: Sh.KC Malhotra Adv., counsel for complainant.
Sh.VK Gupta Adv., counsel for opposite parties.
Order
J.S.Bhatia (President)
1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that the law abiding citizen/complainant above named conscious to the need of health insurance allured by tempting benefits obtained Optima Restore Individual Health Insurance Policy, for himself and his spouse Mrs.Kanika Gupta. The health insurance policy was taken from opposite party No.1, through its authorized agent for the period stated in the policy schedule effective from 23.3.2014 to 22.3.2015. The policy schedule dated 27.3.2014 of health insurance policy was issued in the name of the complainant insured. The sum insured was Rs.5,00,000/- for each of the insured. Opposite party No.1, issued/delivered to the complainant policy schedule dated 27.3.2014 of the risk coverage under health insurance policy. The policy document was not ever issued/delivered to the complainant by opposite party No.1, during the whole period of the policy. The complainant insured with opposite party No.1, was diagnosed Labor Pneumonia, Consolidation Bilateral Right>Left by Kapil Hospital, Jalandhar after necessary investigations were done. The complainant was advised and admitted in the said hospital on 20.9.2014 and discharged on 29.9.2014 for treatment as in patient for the diseases/ailments suffered and diagnosed by Dr.Kapil Gupta M.D. Physician Cardiologist, Diabeologoist of Kapil Hospital, Jalandhar. After discharge from hospital, the complainant preferred a claim in the sum of Rs.1,11,938/- for medical treatment, clinical and laboratory test investigation and treatment expenses incurred for reimbursement of hospitalization to opposite parties. Duly complete prescribed claim form dated 15.10.2014, bills, receipts, discharge certificates alongwith clinical tests and investigations reports were submitted to opposite parties. All the formalities were completed and complied with for settlement of health insurance policy claim for an amount of Rs.1,11,938/-. The claim was registered vide claim ID 227218/1. Opposite party No.2 vide its letter dated 27.1.2015 rejected the claim on flimsy, strange and funny purported reasons as under:-
“As per submitted documents case has been reviewed but claim will remain rejected under following discrepancies found in your claim-1.Indication for long stay is not clear as per submitted documents:.2.Indication of broad spectrum antibiotic is not clear as per submitted document. 3. No pre-post hospitalization records available to review. 4.Medicines record was not available for review. 5. All indoor case papers has same handwriting on all days”.
2. Earlier to rejection letter dated 27.1.2015(supra), in response to claim status-rejected, the complainant submitted detailed reply from treating doctor Dr.Kapil Gupta to all queries point wise (four pages) to opposite party No.1, local branch office which in turn forwarded the same to opposite party No.2 on 7.11.2014. The perusal of rejection letter and claim status report-rejected revealed that opposite party No.2 except word reviewed repeated the same reason. There is no remotest indication or explanation of consideration of the reply to queries and clarification given by treating doctor in rejection letter dated 27.1.2015. The rejection of claim was arbitrary and malafide, unjust and oppressive, made otherwise than good faith by misapplication of independent mind on conjunctures and surmises and is not sustainable. Opposite party No.2 has not taken protection of exclusion clause of aforesaid health insurance policy, on lame excuses whims and fancy in mechanical and routine manner and wrongly assumed and presumed the illness and treatment fall in relem of rejection on speculation and merely on guess. The treatment undergone and medicines prescribed and administered are fully covered and admissible as no specific exclusion cause was invoked by opposite party No.2 for rejection of claim. On such like averments, the complainant has prayed for directing the opposite party insurance company to pay him the claim amount of Rs.1,11,938/- alongwith interest. He has also claimed compensation and litigation expenses.
3. Upon notice, opposite parties appeared and filed their written replies. In its written reply opposite party No.1 took preliminary objections regarding the complaint being frivolous and vexatious, not approaching the Forum with clean hands and suppression of material facts. They further pleaded that the complainant has not disclosed the actual and true facts before this Forum and has concealed the actual and true facts, it is submitted that actual facts are that the complainant Surinder Gupta was admitted at Kapil Hospital on 20.9.2014 with complaints of fever for last three days, h/o of cough since last 3 days with chest pain Rt intramammary and intracapsular areas, associated with dyspnea on exertion since 1 day. The patient was investigated and diagnosed as a case of Lobar Pneumonia Consolidation Bilateral Rt>Lt. The patient was treated conservatively and discharged on 29.9.2014 with advice. The total hospital bill was of Rs.29,500/-. A claim was submitted to answering opposite party on 20.10.2014 for reimbursement. Post scrutiny few discrepancies were noted so to get the clarity on the claim a query was sent on 3.11.2014
1 | Attested copies of indoor case papers of hospitalization including admission notes and daily progress notes. |
2 | Break up bill of Lab investigation done as mentioned in hospital details. |
3 | Justify need to multiple antibiotics. |
4 | Justify need of prolong hospitalization. |
5 | Original cash paid receipt of the final bill. |
6 | Provide passport size photograph. |
7 | Provide X-ray films |
8 | Residence proof (recent telephone bill/electricity bill/ration card/valid rental agreement) showing policy main member name. |
4. On 13.11.2014, answering party have received a partial reply for the queries but the same was not found satisfactory to process the claim. To get the remaining documents again a query was sent on 29.11.2014. Meanwhile the claim was initiated for investigation. The report of investigation was received on 1.12.2014. The required documents were still awaited from the insured. So the claim was closed due to non-submission of the documents. The same was communicated to the complainant on 20.12.2014. Later on the case was reopened by Grievance Team, based out of the observation of submitted documents an expert opinion was also taken by Dr.Harish Tyagi MD(Med) Sir Ganga Ram Kolmet Hospital, New Delhi and after considering the medical records, investigation report and the opinion of Dr.Harish Tyagi MD (Med) Sir Ganga Ram Kolmet Hospital, New Delhi, and on the basis of available records and discrepancies, the case was rejected vide their letter dated 27.1.2015 and letter dated 23.2.2015. From the facts narrated above it is crystal clear that there is no deficiency in service on the part of the answering opposite party. Written reply filed by opposite party No.2 is also on the same lines.
5. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavits Ex.CA to Ex.CC alongwith copies of documents Ex.C1 to Ex.C24 and closed evidence.
6. On the other hand, learned counsel for the opposite parties has tendered affidavit Ex.OP-A alongwith documents Ex.OP1 to Ex.OP12 and closed evidence.
7. We have carefully gone through the record and also heard the learned counsels for the parties.
8. The complainant took mediclaim policy from opposite party insurance company and during the validity of the said policy, the complainant fell ill and was admitted in hospital on 20.9.2014 and discharged on 29.9.2014. After discharge from the hospital, the complainant preferred a claim for Rs.1,11,938/- for medical treatment, clinical and laboratory test investigation and treatment expenses incurred by him. However, opposite party No.2 vide letter dated 27.1.2015 rejected the claim. Later on the case was reopened by Grievance Team but the claim was again rejected by opposite party insurance company vide letter dated 23.2.2015. Counsel for the complainant contended that the claim of the complainant has been rejected on surmises and conjunctures and not on any valid ground. He further contended that complainant has submitted the required clarification from the treating doctor vide letter Ex.C4 but the opposite party insurance company again rejected the claim after obtaining opinion Ex.OP6 from Dr.Harish Tyagi. He further contended that infact the opposite party insurance company assumed Ex.OP6 to be opinion given by Dr.Harish Tyagi and whereas he has not given any opinion that the claim lodged by the complainant was wrong. On the other hand, it has been contended by learned counsel for the opposite party insurance company that the claim has rightly been rejected firstly vide letter dated 27.1.2015 Ex.OP7 and then vide letter dated 23.2.2015 Ex.OP8. We have carefully considered the contentions advanced by learned counsels for both the parties. In the letter Ex.OP8 it is mentioned that they have carefully reviewed his claim based on the documents submitted and they regret to inform him that his claim is not payable under the policy. In the rejection letter dated 27.1.2015 Ex.OP7 the reasons for rejection are mentioned as under:-
“Reasons:-
As per submitted documents case has been reviewed but claim will remain rejected under following discrepancy found in your claim-1. Indication for long stay in not clear as per submitted document. 2. Indication of broad spectrum antibiotic is not clear as per submitted document. 3. No pre-post hospitalization records available to review. 4. Medicine record was not available for review. 5. All indoor case papers has same handwriting on all days”.
9. The reasons given in the above said letter are not sufficient to reject the claim of the complainant. The opinion Ex.OP6 obtained by opposite party insurance company from Dr.Harish Tyagi can not be termed as opinion. In the concluded portion of the letter Ex.OP6 the above said doctor has written that no further comments are possible in view of the deficient record. So no definite opinion was given by Dr.Harish Tyagi vide letter Ex.OP6. On the other hand, the treating doctor gave justification for multiple antibiotic given to the complainant, need of prolonged hospitalization etc. Ex.C7 is CT Scan Report of the patient given by Dr.Vinay's Scanning Centre wherein he has given the impression that patient was suffering from Large Lobar Pneumonia Right Lung. Ex.C8 is X-ray Chest Report of the patient. Ex.C10 is Discharge Card of the patient wherein biochemistry profile of the patient is mentioned. Ex.C13 is bill of Kapil Hospital where the patient was admitted. Ex.C14 are bills of Kapil Pharmacy. Ex.C15 is payment receipt of X-ray, Ex.C16 is payment receipt of X-ray. Similar Ex.C17 to Ex.C19 are payment receipts. Ex.C20 is copy of cash receipt given by above said scanning centre. Ex.C22 is hospital bill details, it is for Rs.1,11,938/-. Ex.C23 is Pharmacy Bill Details. The patient was treated for Pneumonia and even as per CT Scan Report Ex.C7 the patient was suffering from the same. The opposite party has not lead any medical evidence to falsify the justification Ex.C4 given by the treating doctor regarding giving of multiple antibiotic and prolong hospitalization of the patient. Vide Ex.C4 the treating doctor also gave attested copies of indoor hospitalization paper, breake-up bill of lab. He has also mentioned in his reply regarding lab response and radiological response. There are no reasons to believe that the patient was not suffering from Pneumonia and was not rightly treated in Kapil Hospital. It is for the treating doctor to decide the course of treatment and need for the period of hospitalization. So in the above circumstances, we feel that the insurance company was not justified in repudiating the genuine claim of the complainant.
10. In view of above discussion, the present complaint is accepted and opposite parties are directed to pay Rs.1,11,938/- to the complainant alongwith interest @9% per annum from the date of repudiation of his claim till the date of payment. It is clarified that interest amount is being granted by way of compensation. The complainant is also awarded Rs.3000/- on account of litigation expenses. 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 Jaspal Singh Bhatia
30.11.2015 Member Member President
