Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 02/03.01.2018
Satish Babu Rajput, r/o H. No. 16B/H. No. 389,
Laxmi Nagar, Delhi-110092 …Complainant
Versus
HDFC Ergo General Insurance Company Limited
[erstwhile name Apollo Munich Health Insurance Co Ltd]
Branch Office 1st Floor, 6 and 7 Ray Road, Delhi-110002 ...Opposite Party
Date of filing 03.01.2018
Date of Order: 01.10.2024
Coram:
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
ORDER
Inder Jeet Singh , President
[The case is scheduled today for order (item no.10)]
1.1. (Introduction to case of parties) - The complainant/Insured filed the complaint against Insurer/OP alleging unfair trade practice and deficiency of services declining of reimbursement of medical bills despite it were covered under Health Insurance Policy for the treatment of his wife Smt. Suneeta Rajput/insured. The complainant seeks reimbursement of that amount of medical bills of treatment, compensation of Rs.50,000/- in lieu of mental pain and agony and sufferings, besides other proper appropriate relief.
1.2. The OP denies allegations of unfair trade practice and of deficiency of services since claim was declined as per terms of policy as hospitalization was for evaluation purposes and she remained in the hospital for less than 24 hours, both are not covered under the policy and exclusion clauses are applicable.
1.3 During the pending of complaint, there was merger of initial OP (Apollo Munich Health Insurance Co. Ltd.) into HDFC Ergo Health Insurance Ltd. as well as there is change of name, accordingly the name of HDFC Ergo General Insurance Co. Ltd. was substiuted vide order dated 21.08.2023, especially the latter was already appearance.
2.1. (Case of complainant) –. The complainant purchased and OP issued health insurance, it was also renewed by the complainant vide policy no. 110100/11121/AA00507193 vide health card no. 1100 ID-10010868304 for period 16.01.2017 to 15.01.2018 for sum insured Rs. 2 lakh against premium of Rs.15,920/- on 27.11.2016.
2.2. On 10.09.2017 at 2:12 pm Complainant’s wife was admitted in Max Super Specialty Hospital, since she was ill and having certain complains. All necessary investigations were done and managed with I/V fluids, antibiotic and other supported medication. She was planned for hystrectoscopy but the complainant and his wife were not desirous for hystrectoscopy, that is why the complainant was discharged after medical treatment on 11.09.2017 at 17:50 hrs. The complainant had incurred medical expenses of Rs. 33,652/-for which reimbursement/claim was lodged with OP on 21.09.2017 by giving each and every of detail, however, the complainant received rejection letter dated 14.10.2017, the OP had refused the reimbursement on false, vague and flimsy grounds.
The complainant’s wife remained hospitalized for more than 24 hours, she was also advised for cure by medicine itself, that is why the complainant and his wife did not prefer for hystrectoscopy; it cannot be termed as evaluation or investigation of ailment, the grounds of rejection are false and vague. The complainant’s claim cannot be rejected on such false and vague grounds. In order to avoid the reimbursement of claim, the OP is making false, vexatious and vague grounds for not releasing the claim. The OP has adopted unfair trade practice and also deficiency of services besides causing immense mental pain and agony. The complainant also served legal notice dated 25.11.2017 to the OP to look into the matter and redress the grievances but neither there was any reply nor reimbursement of the claim. The complainant was not having other alternate but to file the complaint for reimbursement of the claim, compensation of Rs. 50,000/- and other relief.
2.3. The complainant is accompanied with copies of – OPD prescriptions dated 10.09.2017, discharged summary dated 11.09.2017, in-patient bill with detail dated 11.09.2017, claim form, rejection letter dated 14.10.2017, legal notice dated 25.11.2017 and letter dated 27.11.2016 issued by OP regarding optima restore policy.
3.1 (Case of OP)- The OP filed written statement with images of some record, it is composite of detailed preliminary objections, preliminary submission but brief reply on merits besides citation of case law .
3.2. The OP denies allegations of deficiency of service and it is not liable on any count towards the complainant. The complaint is without merits and there is no cause of action in his favour and against the OP. The paragraph 2 of the preliminary objection is just compiling of averments, without corroborative facts, that the present Commission lacks the jurisdiction, the complaint suffers from non-joinder and mis-joinder of necessary party, the complaint is gross abuse of process of law, the complainant has suppressed the material fact and so on. The complaint is barred u/s 3 of the Consumer Protection Act 1986 since the matter needs recording of elaborate evidence – oral, documentary and medical – by civil court, which is not possible by summary procedure.
3.3. The complainant had furnished application/proposal form dated 23.11.2016, the subject insurance policy was issued on the basis of information furnished in the proposal form. The complainant was provided insurance policy kit. The parties are bound by the terms and conditions of policy and as per terms and conditions of the policy (clause section V-C(XII)(f) in respect of medical exclusions; section VII/Def25 and other important terms), the exclusions are applicable, which do not cover diagnostic and evaluation purposes only as well as hospitalization is to be for minimum period of 24 consecutive hours.
The OP had received request for cashless facility on 11.09.2017 from Max Super Specialty Hospital, Ghaziabad, UP in respect of admission of patient on 10.09.2017 of complains of abnormal uterine bleeding x 32 months with an estimate amount of treatment of Rs.64,930/-. On scrutiny of document the complainant was asked certain papers, enumerated in paragraph 8 [of the brief submissions of written statement]. Later the OP received claim for reimbursement of expenses of Rs. 33,652/-, in the claim form the date/time of admission was mentioned as 10.09.2017/2:12 pm and date/time of discharge was mentioned as 11.09.2017/01:24pm, she was diagnosed of abnormal uterine bleeding, menorrhagia. The written statement reflects images of discharge summary and claim form..
As per discharge summary, the duration of hospitalization was less than 24 hours and single drug/Inj. trenaxa was used during whole hospitalization. The complainant’s wife was admitted primarily for investigation, evaluation, her hospitalization was for less than 24 hours, that is why the claim was rejected by letter dated 14.11.2017 while invoking exclusion clauses of section VII/def. 25 and other section V (C) (xii) (f) of the policy. The parties are bound by the terms and conditions of the policy, which is a contract between the parties [while relying upon (a) Yeshashwini Yojna Vs Mumtaz Begum-RP1173/2007; (b) General Assurance Society Ltd. Vs Chandumull Jain and anr (1996) 3 SCR 55; (c) Oriental Insurance Co. Ltd. Vs. Sony Cheriyam AIR 1999 SC 3252; (d) United India Insurance Co. Ltd. Vs Harchand Rai Chandan Lal Appeal no. 3277/2004 dod 24.09.2004].
3.4. Neither there is any unfair trade practice nor deficiency of services on the part of OP nor any other misleading acts. The OP acts as custodian of funds of the public, in order to protect the policy holder it has to be vigilant in ensuring that only admissible claim under the policy are to be paid. The OP adopts best trade practice that too in the interest of its policy holders. But the complaint is frivolous, it is liable to be dismissed u/s 26 of the Consumer Protection Act and complainant should be imposed cost of Rs.10,000/- payable to the OP.
3.5 The reply is accompanied with copies of - authority letter/ POA, application/ proposal form, policy schedule with policy wording, pre-authorization form, its query and letter of information, claim forms and rejection of claim.
4. (Rejoinder) - The complainant filed rejoinder/replication in detail, by denying the allegations of the written statement either of general grounds like non-joinder or mis-joinder of parties or of without cause of action or the complaint is barred u/s 3 of the Act 1986 or it needs adjudication by way of detailed examination in civil court or it cannot be tried summarily. The complainant reaffirms the complaint that his wife remained hospitalized for more than 24 hours, she was treated there and her admission was not just for evaluation or management vis-à-vis the exclusions clauses are not applicable. The complainant reaffirms the complaint as correct.
5.1 (Evidence)- The complainant led his exclusive evidence by detailed affidavit Similarly the OP also led evidence by filing affidavit of Ms Deepti Rustagi, Vice President (Legal and Chief Compliance Officer, of predecessor of OP)
5.2 (Final hearing)- Both the parties have filed their written arguments. At the stage of final submissions, Sh. Ashok Kumar, Advocate for complainant and Sh. Pankaj Aggarwal, Advocate for OP presented their submissions.
(Findings)
6.1 - The contentions of the parties are considered keeping in view documentary and other evidence of parties, case law referred and relied upon. The cases of parties and documents proved have already been referred, therefore, it does not need to reproduce them again, however, their rival contentions will be appreciated while analyzing and weighing the evidence.
6.2. It is apparent from plain reading of case of parties in pleading, evidence or otherwise, that the relationship of the complainant and of the OP are of the Insured and the Insurer respectively, the complainant, his wife and their daughter is also covered under the policy risks. There is also no dispute of previous policy issued or the subject policy or of its tenure and premium paid. It is also not disputed that the complainant's wife Smt. Suneeta Rajput was hospitalized in Max Super-specialty Hospital, pre-authorization was not approved as well as the complainant had paid the entire medical bills to Hospital since cash-less facility was not extended by OP.
7.1. There are rival plea of the parties on the point of scope for summary trial of the complaint. According to OP the matter involves adjudication by the civil court by recording detailed examination of the parties inclusive of weighing the medical record, which is opposed by the complainant vehemently that nowhere either in the pleadings or evidence of OP it is suggested of iota of fact that it needs adjudication by the civil court.
7.2 The record is considered. The medical record of discharge summary as well as of the medical bills issued by Max Super Specialty Hospital are not disputed vis-à-vis its part images has been made in the written statement by the OP. While taking objection under this heading, the OP has also mentioned that medical aspect is to be considered but nothing has been shown as to what medical aspect needs assessment by the civil court. Therefore, it is held that the present DCDR Commission is competent to adjudicate the issue under summary procedure. There is no scope for adjudication by the civil court.
8.1 However, the consumer dispute is "whether or not the complainant is entitled for insurance claim and other reliefs”? vis a vis “whether or not exclusion clauses of section VII/def. 25 and other section V (C) (xii) (f) of the policy apply"? It needs to access and analyze the evidence of parties to determine the consumer dispute involved. The following are culled out from the proved record :-
(i) The complainant has proved discharge summary dated 11.09.2017, its part image is also exhibited in the written statement but written statement is not supported with such document.
(ii) The OP has proved claim form (its image is also reflected in the written statement that the complainant has mentioned date/time of admission was mentioned as 10.09.2017/2:12 pm and date/time of discharge was mentioned as 11.09.2017/01:24pm.
(iii) The complainant has proved in-patient bill dated 11.09.2017 showing that the patient was admitted on 10.09.2017/14:12, bill date/time of 11.09.2017/17: 50 and discharge date and time is 11.09.2017/17:50.
(iv) On plain reading of sub-clauses (i) to (iii), it manifests that the OP is computing the time of admission from the claim form and from the discharge summary which mentions 10.09.2017/2:12 pm and date/time of discharge was mentioned as 11.09.2017/01:24pm. But on the other side the complainant is relying upon such medical record as well as final in-patient bill, which clearly mentions as that the patient was admitted on 10.09.2017/14:12, bill date/time 11.09.2017/17:50 and discharge date/ time as 11.09.2017/17:50.
The record cannot be read in isolation but it is to be read completely to the situation. The in-patient bill not only mentions the detail of bill, services rendered and charges but also the date and time of admission, date and time of bill as well as date and time of discharge. The discharge summary is prepared by the doctor and then subsequent steps are followed like payment of bills and clearance, then patient is physically relieved/ discharged. First, it is decided by the doctors to discharge the patient and then subsequent protocol is followed. The circumstances are envisaging that physical discharge of the patient was after deposit of the Inpatient bill on 11.09.2017/17:50 and by computing undisputed date of admission/time of 10.09.2017/14:12, the complainant’s wife remained hospitalized for more than 24 hours. Therefore, this establishes that clause VII/Def 25 does not apply to the situation in hand.
(v) Since the discharge summary is undisputed, it mentions about procedure/treatment and course during hospitalization viz. “patient was admitted with above mentioned complaints. All necessary investigations were done and enclose patient was managed with I/V fluids, antibiotics and other supportive medications. She was planned for hystrectoscopy but attendants want to discharge, so now patient is being discharged in stable condition with advises”.
It is apparent from such record in the discharge summary that patient was not just admitted for evaluation or management. In fact, she was admitted because of complaint of bleeding and she was diagnosed of menorrhagia, after following the procedure/treatment, the patient was advised hystrectoscopy. This clearly spells out that the plea of OP of exclusion clause section V/C (xii) (f) does not apply to the situation in hand.
(vi) The complainant has also proved in-patient bill of Rs. 33652/-, which is undisputed but the dispute was regarding entitlement of the complainant, which has already determined. The OP claims that only the name of single Injection was used but the procedure followed and inpatient bills names other injections used and medicine administered, beside PAC.
(vii) It would not be out of context that the OP has vehemently demonstrated images of discharge summary and claim form showing the timings of admission and discharge but despite receipt of in-patient bill with the claim form from the complainant, which also shows actual date/timing of admission as well as actual date/timing of discharge; the OP has withheld that vital information. Therefore, it is not fair on the part of OP to say that the complainant has suppressed the material facts.
In addition, the complainant had also sent legal notice dated 25.11.2017 and paragraph 4 thereof mentions the dates and timings of admission and discharge, for which record was available with the OP and despite it the OP has not mentioned any fact in the letter dated 27.11.2016. There is deficiency of services on the part of OP to reimburse valid medical claim of Rs. 33,652/-.
In view of above conclusions, the complainant is held entitled for reimbursement of medical/ hospitalisation expenses in respect of his wife Smt. Suneeta Rajput. The complaint is allowed for Rs. 33,652/- in favour of complainant and against the OP.
8.2. The complainant has also sought damages of Rs.50,000/- towards agony for want of reimbursement of medical expenses. On the basis of circumstances that complainant suffered inconvenience and harassment, the compensation is quantified as Rs.10,000/- in favour of the complainant and against the OP.
8.3 The complainant has also sought other appropriate relief. What could be the relief and whether complainant is entitled thereof. Since complainant had paid the entire amount of medical expenses against bill dated 11.09.2017, the complainant has parted with the money in payment of bill. It is appropriate to allow interest at reasonable rate, which appears to be 5%pa from the date of payment of 11.09.2017 till realisation of amount. The complainant has also exhausted last resort by writing legal notice dated 25.11.2017 but for want of settlement of claim, the complainant had to file the complaint. Thus, complainant is also entitled for costs, which is quantified as Rs.10,000/- in favour of the complainant and against the OP.
9. So, the complaint is allowed in favour of complainant and against the OP while directing OP to pay/reimburse amount of Rs.33,652/- along-with simple interest at the rate of 5%pa from the date of payment of bill of 11.09.2017 till realistion of this amount to the complainant, besides compensation of Rs.l0,000/- and costs of Rs.10,000/-. OP is also directed to pay the amount within 45 days from the date of this order. In case amount is not paid within 45 days from today, then OPs will be liable to pay interest on that amount and rate of interest will be 7% per annum from that date till realization of amount.
The OP may deposit the amount with the Registry of this Commission by way of valid instrument in the name of the complainant.
10. Announced on this Ist day of October, 2024 [अश्विन 9, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Rashmi Bansal]
Member (Female)
[Inder Jeet Singh]
President
[ijs121]
