Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 196/19.05.2016
Afzal Khan, son of Shri Akhtar Hussain
D-39, First Floor, Zakir Nagar (West),
Okhla, New Delhi-110025 …Complainant
Versus
OP -HDFC Ergo General Insurance Company Limited
[erstwhile - Apollo Munich Health Insurance Co. Ltd/
HDFC Ergo Health Insurance Limited]
208, 2nd floor, Sewa Corporation Park,
Mehrauli-Gurgaon Road, Gurugram,
Haryana - 122001 [see sub-paragraph 1.3 below] ...Opposite Party
Date of filing 19.05.2016
Date of Order: 14.10.2024
Coram:
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
FINAL ORDER
It is scheduled today for order (item no. 1)
Inder Jeet Singh , President
1.1. (Introduction to case of parties) - The complainant/Insured filed the complaint against Insurer/OP by alleging arbitrary action and deficiency of services because of declining him cashless facility for medical bills and other expenses during his hospitalisation and subsequently claim for reimbursement of medical bills was also declined despite all such expenses are covered under Easy Health Insurance Policy no.110100/11001/1000168918-15 issued by OP and lastly it was renewed w.e.f. 25.02.2015 to 24.02.2016 for sum insured of Rs.2,00,000/- (hereinafter referred as Policy or Insurance Policy].
The complainant seeks reimbursement of medical bills of Rs.53.162/- of his treatment and compensation of Rs.1,00,000/- [in lieu of harassment, mental agony and sufferings] with interest of 12%pa and other appropriate relief under the circumstances. The complainant round off the claimed amount as Rs.1,60,000/-.
1.2. The OP denies all allegations including of deficiency of services. There was request for pre-authorization of medical bill but it was rightly declined with reason. Later regular claim lodged was also declined by exclusion clause of VIC(viii)(b) and (c) in the terms and condition of policy, since the hospitalisation was for only for evaluation and investigation purposes, it was not covered under the policy. It cannot be treated as deficiency of services. The complainant is not entitled for any claimed amount.
1.3 During the pending of complaint, there was merger of erstwhile OP (Apollo Munich Health Insurance Co. Ltd.) into HDFC Ergo Health Insurance Ltd. as well as there is change of name consequent to certificate of incorporation pursuant to change of name.
The application of present OP was heard and it was allowed vide reasoned order dated 30.10.2023; the name of HDFC Ergo General Insurance Co. Ltd. is arrayed accordingly.
1.4 Further, the OP had moved an application,( when the case was at the stage of final hearing) that it had obtained expert opinion regarding nature of treatment etc, however, after hearing both the sides, that application was dismissed by detailed reasoned order 06.11.2023.
2.1. (Case of complainant) – The complainant has been regular policy holder of OP for the last more than six years. The subject policy was got renewed from time to time regularly and lastly it was with effect from 25.02.2015 to 24.02.2016. There was no claim ever since raised by the complainant.
2.2. It was month of January 2016 when complainant was having fever, pain in his neck besides breathlessness problem which referred to his right shoulder and chest pain, but complainant did not take seriously. However, after a few days, he started experiencing severe pain in his chest and neck, he was also having problem in respiration. He went to a private physician Dr. Nafis Sidhiqui on 12.01.2016, he was thoroughly checked and he was detected typhoid. He was given treatment by the said doctor but complainant's condition was deteriorating and he was advised to consult an expert in the field of cardiology, as the problem may increase to lead to serious issues.
On 09.02.2016, he went to Asian Institute of Medical Science, Badkal Flyover Road, Sec 21-A Faridabad, where Dr. Manav Manchanda, examined and advised him admission by looking at the condition of the complainant, since complainant was having “acute bronchitis with lower respiratory tract infection’ and also suffering from severe/unbearable pain in his neck which referred to right shoulder and for the said complaint an expert neurosurgeon was consulted who after check up advised for M.R.I. Cervical Spine, including, complainant of cough, fever and breathlessness and body-ache, and during the course of treatment he was given IV-Monocef, IV-Pan, Nebulisation with Duolin and Budscort and other supporting treatment. Since the complainant having pain in neck and breathlessness, he was also consulted by expert of Ortho, ENT and Gastro Consultation, for which treatment was also given" The complainant was examined and treated on 09.02.20216, 10.02.2016, 11.02.2016 12.02.2016 and 13.02.2016 he was discharged on 14.02.2016. The total bill prepared was of Rs. 53,162/- and complainant has also incurred more expenses on his treatment.
2.3 The said hospital through it pre-authorization ID 229633/I and insured ID 10001566342 processed the cash-less mediclaim since it was cashless policy, however, the OP declined the request vide letter dated 12.02.2016 on simple ground that patient was admitted primarily for investigation and evaluation but complainant may file the claim for reimbursement post treatment. However, the complainant’s claim was also repudiated vide letter dated 30.03.2016 by the OP by alleging/invoking section VIC of policy terms and conditions that as per document submitted, the admission in the hopitalisation was for investigation and evaluation only.
Whereas, it was an arbitrary, illegal and mala-fide of the OP in declining the legitimate claim. That is why, the present complaint for reimbursement of medical bills/expenses of Rs. 53,162/- , damages of Rs. 1,00,000/- in lieu of harassment and agony suffered by the complainant.
2.4. The complainant is accompanied with copies/record of – Mediclaim policy, medical checkup record, discharge summary, pre-authorization letter and its decline dated 12.02.2016, final bill dated 14.02.2016 query letter dated 27.02.2016 and claim repudiation letter dated 30.03.2016.
3.1 (Case of OP)- The OP filed detailed written statement, it is composite of preliminary objections, preliminary submissions and reply on merits. The complainant was issued insurance policy on furnishing of proposal form on 20.01.2011 and the policy was issued which was renewed lastly with effect from 25.02.2015 to 24.02.2016 and the annual premium of Rs. 9,180/- was payable for sum insured of Rs. 2,00,000/- for husband and wife and Rs 1,00,000/- for both children - sons and daughter.
3.2. The OP denies allegations of complainant on all counts that although the policy was issued to the complainant but his hospitalisation was only for investigation and evaluation, which is not covered under the terms of the policy especially section VI C (viii) (b) (c).
There was request for pre-authorization in respect of patient/complainant Afzal Khan admitted for complaint of cough, fever, breathlessness body-ache for 3 days and probable diagnosis was of “Pyrexia of unknown origin with lower respiratory tract infection” and the admission for 4 days against cost of Rs. 49,000/-. The OP had raised query about the admission notes, investigation report etc and the query was responded with medical document that admission was for the purposes of investigation and evaluation, consequently, the claim was not admissible, Accordingly it was declined that it would be decided after review of document and policy condition on lodging the claim of complainant.
3.3 Thence, the complainant lodged claim on 24.02.2016 for reimbursement of amount of Rs 53,162/- of his hospitalisation from 09.02.2016 to 14.02.2016 and on scrutiny of documents, it was found that the complainant was admitted for management of lower respiratory tract injection and he underwent medical management. A query was also raised by letter dated 27.02.2016 and its reply was received on 16.03.2016 from the complainant, the document furnished contains certificate from the doctor and it was replica of what was mentioned in the discharge summary. Since the admission was for investigation and evaluation of ailment only, the claim was not admissible and payable by virtue of exclusion clause VIC (viii) (c) and (b) of the policy and accordingly, the claim was repudiated by letter dated 30.03.2016. The complaint is without cause of action. There is no deficiency of service nor any arbitrary act, consequently no harassment or agony. The complaint is liable to be dismissed.
3.4 The reply is accompanied with copies of - authority letter in favour of Ms Deepti Rustogi, proposal form, policy schedule with terms and conditions of policy, pre-authorization form, copy of query letter dated 11.02.2016, further requisition letter dated 27.02.2016 and reminder dated 14.03.2016, rejection letter, claim form, reminders, complainant's reply with documents and repudiation letter dated 30.03.2016.
4. (Replication)- The complainant filed detailed replication and he opposed the written statement by reproducing contents of the complaint and the same is reaffirmed. The complainant denies applicability of section VI C(viii)(b)(c), since the complainant was admitted in the hospital, he was examined, tests were also done and he was given treatment as indoor patient.
5.1 (Evidence)- The complainant Shri Afzal Khan led his exclusive evidence by filing detailed affidavit with documents , which were filed with complaint. The evidence is on the lines of complaint.
5.2. Similarly, the other side/ OP also led its evidence by filing exclusive affidavit of Ms. Deepti Rustagi, Vice President-Legal and Chief Compliance Officer, Attorney of (Apollo Munich Health Insurance Co. Ltd), predecessor in interest of OP. The evidence is on lines of defense version.
6.1 (Final hearing)- Both the parties have filed their written arguments. At the stage of oral submissions, Ms Kashika Singla, Advocate for OP presented submissions but no submissions on behalf of the complainant for want of causing appearance at this stage. However, the written arguments and contentions of the complainant will be considered vis. a vis. case and contentions of OP.
6.2. Since the written submissions of the parties are blend of their pleadings and evidence, therefore, it does not require to re-writing them, as the case of parties have already been mentioned in paragraphs 2 and 3 above. Moreover, their rival contentions will be considered and appreciated appropriately while analyzing and weighing their evidence.
7.1 (Findings)- The contentions of the parties are considered keeping in view documentary and other evidence of parties besides provisions of law. It is apparent that relationship of the complainant and of the OP is of the Insured and the Insurer respectively by virtue of insurance policy contract. There is no dispute of facts of hospitalisation of complainant, tenure of hospitalisation, medical bills and expenditure incurred by him from his pocket.
But, the narrow issue is “whether the complainant's claim is covered within the policy or does it fall in exclusion clauses invoked by OP”. By answering this issue, it will determine the consumer dispute.
7.2. After taking stock of all the material, the following conclusions are drawn:-
(i). The documents filed and proved either by the complainant or the OP are not disputed. There is same discharge summary referred by the complainant as well as by the OP but its interpretation by the parties is according to their own case, which has already been detailed in paragraph 2 and 3 above.
(ii). The OP has proved the terms and conditions of the policy and its exclusion clause VIC read with clause (viii)(b) which reads “ condition of which treatment could have been done on an OPD basis without hospitalisation” and (viii)(c) “experimental, investigational or unproven treatment devices and pharmacological regimens” do not liable the insurance company to pay any claim/amount.
(iii). The complainant has referred the contents of discharge summary in the complaint and in his evidence (it substance is also mentioned in sub-paragraph of paragraph 2.2 above). On plain reading thereof, the complainant was given injection IV-Monocef (which is given for bacterial infection of lung etc.) and Nebulization with Duolin and Budecort (which is given for treatment and prevention of bronchitis or treatment of obstructive pulmonary disease) besides other supporting treatment. In addition, he was also given treatment for Ortho consultation, ENT and Gastro consultation. His admission was because of, as diagnosed, acute bronchitis with lower respiratory tract infection.
(iv). The complainant has also proved letter dated 12.02.2016 issued by Asian Hospital, [this document is also proved by the OP and it is also in its paper-book] that the complainant was admitted for treatment in the hospital due want of relief by oral treatment. It is also certified that complainant was not admitted exclusively for examination or investigations because the patient had already examinations/investigations outside as an OPD.
(v). The complainant has also proved final bill issued with detail of charges heading-wise, comprising nebulisation charges, consultation, images, medicines and the bills component also mentions the IV- injection given and other medicines administrated. The complainant was put to IV cannula in order to administrated the injection, medicine, fluids intra-veins since oral medicines were not being administrated as oral medicine had not worked.
(vi). By reading the conclusion drawn in sub-clauses (iii) to (v) above, they clearly demonstrate that the complainant was not given treatment by administrating the medicine orally but by intra-veins by inserting cannula in the body; which is not done/feasible for OPD patients. The admission was for the purposes of treatment which consists of examining, investigation, evaluation and management for the ailments suffered by the complainant. The undisputed discharge summary clearly mentions about the treatment given besides other examination, investigation etc.
However, as appears the OP is construing the clauses VIC (viii)(b)(c) of the insurance policy to give a color as if the admission was exclusively for the purpose of investigation and evaluation and nothing else; but the documents are establishing that the complainant has undergone treatment, which also includes investigation etc. The admission was not exclusively for investigation and evaluation but for treatment.
Therefore, it is held the exclusion clause invoked by OP does not apply to decline the claim to the set of facts proved by documents and circumstances of the complainant. The claim of complainant was valid claim within the terms and conditions of the policy and sum insured. The issue is answered that complainant's claim is covered within the policy terms and conditions and limit of sum insured vis a vis the exclusion clause invoked does not apply to this situation. The denial of medical claim is short-coming and deficiency in the services on the part of OP.
8.1 Consequent to aforementioned conclusions, the complainant is held entitled for reimbursement of medical/ hospitalisation expenses in respect of his treatment at Asian Institute of Medical Sciences [a unit of Blue Sapphire Healthcare Private Limited]. The complaint is allowed for Rs. 53,162/- in favour of complainant and against the OP.
8.2. The complainant has also sought damages of Rs.1,00,000/- towards agony for want of reimbursement of medical expenses and trauma faced by him. On the basis of circumstances that complainant suffered inconvenience and harassment, the compensation is quantified as Rs.14,000/- in favour of the complainant and against the OP.
8.3 The complainant has claimed interest of 12%pa. Since complainant had paid the entire medical bill dated 12.02.2016 at the time of his discharge, the complainant has parted with the money in payment of bill and had he not parted with money, he would have at-least earned interest on such amount. It is appropriate to allow interest at reasonable rate, which appears to be 5%pa from the date of payment of 12.02.2016 till realisation of amount.
So far, complainant's other request is concerned, what could be appropriate relief and whether complainant is entitled thereof. Since complainant was constraint to file the complainant, for want of settlement of claim in his favour, therefore, cost of Rs.10,000/- is also determined and allowed in favour and against the OP.
9. Thus, the complaint is allowed in favour of complainant and against the OP while directing OP to pay/reimburse medical amount of Rs.53,162/- alongwith simple interest at the rate of 5%pa from the date of payment of bill of 12.02.2016 till realistion of this amount to the complainant, besides compensation of Rs.l4,000/- 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 OP will be liable to pay interest at higher rate of 7% per annum on that amount of Rs.53,162/-.
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 14th day of October, 2024 [अश्विन 15, 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
[ijs125]
