Punjab

Ludhiana

CC/14/816

Rajnesh Kumar - Complainant(s)

Versus

Bajaj Allianz Gen.Ins.Co.Ltd - Opp.Party(s)

Sanjeev Kumar

14 Aug 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 816 of 28.11.2014

Date of Decision            :   14.08.2017

 

Rajnesh Kumar son of Shri Bant Lal, resident of House No.26, Sector 39, Chandigarh Road, Ludhiana.

….. Complainant

                                                            Versus

 

1.Bajaj Allianz General Insurance Company Limited, 2^nd Floor, Bajaj Finerv Building, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar, Pune-411014, through its General Manager.

2.Bajaj Allianz General Insurance Company, SCO 147, Feroze Gandhi Market, Ludhiana through its Manager.

…Opposite parties

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT                                        

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

 

For complainant               :         Sh.Sanjeev Kumar, Advocate

For OPs                           :         Sh.G.S.Kalyan, Advocate

 

PER G.K.DHIR, PRESIDENT

 

1.                 Complainant a reputed businessman of Ludhiana city obtained mediclaim insurance policy from OP1 through its branch office at Ludhiana namely OP2 through policy No.OG-13-1203-6009-00000372 with validity uptill 29.10.2015. Health of the complainant started deteriorating on 8.12.2013, because he was suffering from headache, vomiting, stomach pain etc. Due to this, complainant was shifted to Sachdeva Nursing Home, Ludhiana, where doctors started giving medical aid at once. Complainant remained admitted in that hospital until 16.12.2013 because of bodily sufferings. Facility of AC room at the rate of Rs.2500/- per day for five days was availed by the complainant. Complainant was shifted to ICU for three days. Later on medical tests suggested by the doctors to be got done by the complainant. An amount of Rs.81,835/- in all spent by the complainant during hospitalization and thereafter, complainant approached Ops for reimbursement of these expenses. However, OPs kept on procrastinating the matter. In one of the letter written by the employees of OPs, complainant is mentioned as dead and the said mistake cast a shadow in the mind of the complainant about working capability of the Ops. Despite sending emails to Ops with the request to satisfy his claim, Ops failed to give any reply to the same and as such, by pleading deficiency in service on the part of OPs, prayer made for directing Ops to reimburse the medical expenses of amount of                 Rs.81,835/- with interest@18% per annum. Compensation for mental pain and agony of Rs.1 lac more claimed.

2.                 In joint written statement filed by Ops, it is pleaded interalia as if complaint is not maintainable for want of cause of action; there is no deficiency in service on the part of OPs; complainant has not approached this Forum with clean hands because of suppression of material facts and that repudiation of claim done as per terms and conditions of insurance policy. Admittedly, the mediclaim health insurance policy was purchased by the complainant from Ops. All the terms and conditions of policy were duly explained to the complainant and he after understanding the same, filled the proposal form by claiming as if he has submitted the true and correct information. After believing the information supplied by the complainant to Ops through the proposal form, the policy was issued by supplying complete booklet. The policy was having validity period w.e.f.30.10.2012 to 29.10.2015. After receipt of the claim intimation, OPs appointed investigator for ascertaining genuineness of the claim and received report dated 17.2.2014. Through that report, it was pointed out that certain discrepancies and lapses found in the claim documents and that is why, Op company advised to take appropriate steps. After receipt of the documents and investigator report, Ops scrutinized those documents and declined the claim of complainant vide letter dated 20.2.2014 by finding that hospitalization of the complainant was for investigation and treatment of acute febrile illness with dengue fever only and in view of discrepancies and lapses in the claim documents, claim is not payable.

3.                 Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C6 and then his counsel closed the evidence.

4.                 On the other hand, counsel for OPs tendered in evidence affidavits Ex.RA and Ex.RB of Sh.Navjeet Singh, Assistant Manager Legal of OPs and of Dr.Kiran B along with documents Ex.R1 to Ex.R51 and then closed the evidence. By way of additional evidence, document Ex.R52 even tendered by counsel for OPs and thereafter, he closed the additional evidence.

5.                 Written arguments not submitted by any of the parties. Oral arguments alone addressed and those were heard. Records gone through minutely. 

6.                 Admittedly, the mediclaim insurance policy was purchased by the complainant for period from 30.10.2012 to 29.10.2015 as disclosed by policy schedule Ex.C2. Insurance card of identity Ex.C1 in this respect was also issued. As per claim of the complainant, he fell ill suddenly during this policy period on 8.12.2013 and that is why he had to remain admitted in Sachdeva Nursing Home, Ludhiana during period from 8.12.2013 to 16.12.2013.

7.                 USG whole abdomen reports of different dates during admission produced on record as Ex.C3; Ex.R8; Ex.R30; Ex.R49 and Ex.R50. Perusal of all these reports reveals that gall bladder in abdomen of complainant was seen distended, but urinary bladder was seen partially distended. However, normalcy with respect to organs of liver, pancreas, spleen, kidneys and prostate was seen in all these reports. Ex.C4=Ex.R3=Ex.R35 is the hospital bills of Sachdeva Nursing Home, Ludhiana dated 16.12.2013 showing as if Rs.40,950/- were charged from the complainant on account of ICU fees for four days, private room fees, doctor fees, nursing fees etc. Discharge card Ex.C5=Ex.R2 is also produced on record to establish that the complainant remained admitted in Sachdeva Nursing Home during period from 8.12.2013 to 16.12.2013, on being diagnosed as case of acute febrile illness with dengue fever and NIDDM+ARRS+B/I pleural effusion. Ex.C6 is the receipt showing payment of bill amount of Rs.40,950/- by the complainant. Despite bearing expenses on necessary treatment, the insurance claim has been repudiated and as such, it is contended that Ops provided deficient services, resulting in unnecessary harassment of the complainant, due to which, he is entitled for hefty amount of compensation for mental agony, sufferings and financial loss in business. That repudiation of claim has been done by issue of letter Ex.R52 dated 20.2.2014.

8.                 After going through repudiation letter Ex.R52, it is made out that on verification of certain claim documents, it was found as if hospitalization was for investigation and treatment of acute febrile illness with dengue fever only and as such, due to noticed discrepancies and lapses in claim documents, the claim is repudiated. Detail of noticed discrepancies and lapses in claim documents not disclosed in Ex.R52 at all and as such, virtually this repudiation done without giving due intimation of found discrepancies and lapses. That shows that repudiation has been done without following principles of natural justice because as and when repudiation of claim to be done, then the actual reason for such repudiation must be disclosed to the person affected by such repudiation and as such, that also is an act of deficiency in service on the part of OPs.

9.                 Even if the noticed discrepancies and lapses not disclosed in Ex.R52, despite that those are pointed out in affidavit Ex.RA of Sh.Navjeet Singh, Assistant Manager Legal of OPs. These discrepancies recorded in para no.3 of affidavit Ex.RA as under:-

“a.As per patient statement, he got admitted in Sachdeva Nursing Home on 08.12.2013 in the evening where he has not mentioned about any stay in ICU.

b.As per the Indoor case paper, patient got admitted on 08.12.2013 around 10.30-10.45 am the same has been noted on the treatment chart.

c.As per the treating doctor certificate, the patient was diagnosed as acute illness dengue fever with NIDDM(Non Insulin Dependent Diabetes Milletus) with B/I Pleural effusion, though hospital has charged in the hospital final bill.

d.Discrepancy noted in the medicine bills and the treatment chart. As per treatment chart, patient was administered inj. Albumin on 10.12.2013, 11.12.2013, 12.12.2013 and 13.12.2013. But the medicine are purchased on 11.11.2013 and 10.12.2013, where date of admission is 08.12.2013 and discharge is 16.12.2013.”

10.               Bill of purchase of medicines dated 11.11.2013 is produced on record as Ex.R44. This bill is pertaining to purchase of medicines of worth of Rs.8100/- on 11.11.2013. However, the treatment of the complainant in Sachdeva Nursing Home, Ludhiana was for period from 8.12.2013 to 16.12.2013 and as such, certainly amount of this bill Ex.R44 liable to be excluded from consideration, particularly when it is not claimed by the complainant that date 11.11.2013 recorded on bill Ex.R44 due to inadvertent or clerical mistake. Even if amount of Rs.8100/- of bill Ex.R44 to be excluded from consideration, despite that amounts of other bills of purchase of medicines cannot be excluded from consideration because they pertains to the amounts spent on purchase of medicines from the concerned chemists during period from 8.12.2013 to 16.12.2013. Reference to bills Ex.R39 to Ex.R43 and Ex.R45 and Ex.R46 in this respect can specifically be made. As these bills Ex.R39 to Ex.R43 and Ex.R45 and Ex.R46 pertains to purchase of medicines by the complainant during the hospitalization with Sachdeva Nursing Home, Ludhiana and Ops unable to show the in-genuineness of these bills and as such, the amounts of these bills liable to be taken into consideration in respect of reimbursement of amount. However, reimbursement declined in toto in view of discrepancies in statement of complainant recorded by the investigator and hospital record or like reasons. However, these pointed out discrepancies virtually do not exist, more so when hospital record to be taken as correct being prepared by the agency of independent doctor or hospital. If the treating doctor or the hospital was to connive with the complainant for      enabling him to get amount in excess of actual expenses borne on treatment, then the inflated bill could have been prepared. However, that is not done and as such record of bills Ex.C4=Ex.R3=Ex.R35 of Sachdeva Nursing Home virtually is a correct record. Only amount of Rs.40,950/- charged on account of nursing charges,    fee of doctor, hospital rent and laboratory charges for period of 8 days treatment.  Keeping in view the number of days for which the complainant retained in       ICU and the reports of different tests, it has to be held that charges of Rs.40,950/- are not excessive or inflated at all.

11.               Ex.R1 is the claim form submitted by the complainant for getting reimbursement of medical claim regarding his treatment with Sachdeva Nursing Home, Ludhiana for period from 8.12.2013 to 16.12.2013. Ex.C9=Ex.R4=Ex.39 is the receipt of payment of Rs.40,950/- to Sachdeva Nursing Home, Ludhiana, whereas Ex.R5 to Ex.R7 are the copies of bills regarding purchase of medicines for period from 8.12.2013 to 16.12.2013. These bills are in addition of the bills of purchase of medicines referred above. The amounts of these bills of purchase of medicines are also genuine, when looked into the light of medicines purchased there through.

12.               Repudiation letter Ex.R52 has been produced on record by Ops. Perusal of same reveals that on verification of claim documents, it was found as if complainant hospitalized for investigation and treatment of acute febrile illness with dengue fever, but there are discrepancies and lapses in the claim documents on the basis of which, the claim is repudiated. The discrepancies and lapses though alleged in the repudiation letter Ex.R52, but those are not detailed/disclosed therein. Details of those discrepancies are given in para no.3 of affidavit Ex.RA of Sh.Navjeet Singh, Assistant Manager Legal of OPs only      and those discrepancies even not pointed out in detail in affidavit Ex.RB of Dr.Kiran B. In affidavit Ex.RB, the discrepancies pointed out regarding the medicine bills, treatment charge qua administration of injection Albumin or its purchase only. Bill Ex.R44 of date 11.11.2013 had already been ordered to be excluded from consideration because complainant was not under treatment for the ailment in question on that date at all. Just mentioning of existence of many discrepancies in medical documents in affidavit Ex.RB is not sufficient because those discrepancies must have been pointed out, which is not done and as such, contents of affidavit Ex.RB, being vague and general regarding allegations of many discrepancies liable to be excluded from consideration. It is so because as and when certain facts to be proved on the basis of tendered affidavit, then those facts must be given in detail with reason for those details. Those are altogether missing in Ex.RB regarding the alleged many discrepancies and as such just on strength of Ex.RB, it cannot be held that actually there are many discrepancies in the medical record or in the statement of complainant as recorded by the investigator.

13.               Statement Ex.R47 of complainant was recorded by the investigator through which, he disclosed that  owing to suffering from headache, vomiting, stomach pain and stomach blockage for the last two days,he got treatment from Dr.Atul Sachdeva in Sachdeva Nursing Home, Ludhiana during period from 8.12.2013 to 16.12.2013. Through this statement, it is mentioned that complainant after conduct of blood test, vidal test, dengue test, USG X-ray  of Chest as well as CT scan etc, came to know as if he is suffering from dengue. So, if the complainant has not disclosed in Ex.R47 regarding sufferance from dengue fever, then it is owing to the fact that he was not sure of his suffering from dengue fever initially or at the time of admission in the hospital. Rather, the complainant got knowledge of his suffering from dengue fever only after conduct of dengue test and Vidal test etc., and as such, discrepancy pointed out in this                      respect in para no.3 of affidavit Ex.RA is of making of mind of deponent of Ex.RA only.

14.               Certainly in statement Ex.R47, the complainant disclosed to the investigator as if he was admitted in private room with facility like of AC, TV, washroom with single bed and no mention regarding admission of complainant in ICU of said hospital is made, but ICU fee of Rs.14,000/- claimed in hospital bill Ex.R3 and as such, discrepancy in this respect is existing. Even if such discrepancy may be existing, despite that record of hospital or of discharge summary cannot be ignored because doctor has no motive to prepare the false discharge summary or reports.

15.               In para no.3 of affidavit Ex.RA, it is mentioned that certificate of treating doctor shows as if complainant was diagnosed as a case of acute febrile illness with dengue fever with NIDDM(Non Insulin Dependent Diabetes Miletus) with B/I Pleural effusion, but for confirmation of dengue B/I Pleural, X-ray chest report not obtained and that is a discrepancy. These findings recorded in para no.3 of affidavit Ex.RA absolutely are incorrect because x-ray of chest not required to be   got conducted for ascertaining as to whether the complainant was suffering from pleural effusion because there are other modern tests for such diagnosis. As per medical study put on the internet of Google website, the pleural fluid analysis can diagnose the cause of accumulation of fluid in the chest cavity(pleural effusion). As per that medical study put on internet, there are two main reasons for fluid accumulation and an initial set of tests, including fluid protein, albumin or LD level, cell count and appearance is used to differentiate between the two types of fluid that may be produced, transudate or excudate. Related tests are:- pericardial fluid analysis;  peritoneal fluid analysis, gram stain, susceptibility testing, total protein, albumin, glucose tests, LD, CEA, Fungal tests, AFB testing, adenosine deaminase. Even as per this medical study, pleural fluid analysis may be ordered when a health care practitioner suspects that a person has a condition or disease that is causing pleuritis and/or pleural effusion. Such analysis may even be ordered on finding the following signs or symptoms:-

a)Chest pain that worsen with deep breathing.

b)coughing

c)Fever, chills

d)Fatigue

e)difficulty in breathing, shortness of breath.

When such modern tests are available for finding pleural effusion, then           there was no necessity of conduct of x-ray chest alone.

16.               In this case, USG of whole abdomen got conducted, regarding which reports Ex.C3; Ex.R8, Ex.R49, Ex.R30 and Ex.R50 are already produced on record and besides report of Haemogram report by Cell Coulter along with Haemogram report by blood cell counter were obtained by the treating doctor as disclosed by contents of Ex.R9 and Ex.R15. The medical study referred above itself shows that initial set of tests including the cell count etc., enough for finding as to whether case of the complainant is a case of pleural effusion or not. So reports Ex.R9, Ex.R15, Ex.R17, Ex.R19, Ex.R21. Ex.R24, Ex.R25A, Ex.R26 and Ex.R28 were sufficient. After going through these reports, it is made out that on Haemogram report by Cell Coulter, it was found as if Thrombocytes PLT were *30 on 8.12.2013(See Ex.R9); but they were *31 on 9.12.2013(see Ex.R12);  but *33 on 10.12.2013(see Ex.R15); *38 on 12.12.2013(see Ex.R17); *44 on 12.12.2013(see Ex.R19); *59 on 13.12.2013(see Ex.R21); *68 on 14.12.2013(see Ex.R24); *80 on 15.12.2013(see Ex.R25A=Ex.R28) and *100 on 16.12.2013(see Ex.R26). This level of Thrombocytes PLT was found on above referred tests, despite the fact that normal level should be between 150-450 m/mm3. As the plate count through blood cells counter was adopted as a test for finding B/I pleural effusion and as such, diagnosis of B/I pleural effusion is done in this case as per modern technology by not adopting the traditional method of x-ray test.

17.               Dengue serology NS1 antigen was got done as disclosed by dengue serology report Ex.R11 dated 8.12.2013. The dengue serology NS1 antigen was found reactivate through Ex.R11, but the dengue serology antibody(IgG)         were found non-reactive through Ex.R11. So, from this report Ex.R11, it is    made out that diagnosis of dengue was done by treating doctor after obtaining due report on the date of admission of complainant itself namely 8.12.2013. So, there is nothing wrong in case complainant got knowledge of his suffering from dengue fever only after his admission as claimed through statement Ex.R47. Various other tests like that of lipid profile, liver functioning test; blood sugar(random) and urine examination even were got conducted by the treating doctor as revealed by reports Ex.R14 to Ex.R29 and Ex.R25/A. Blood sugar(Random) of complainant was found as 205 level on 15.12.2013 as disclosed by Ex.R29 and as such, it is obvious that owing to complications from sufferance of blood sugar as well as of dengue fever, complainant had to get treatment by way of admission in hospital. Blood sugar report level was found at 210 on 12.12.2013 as per report Ex.R20. So, present is not a case in which treatment got by the complainant for evaluation or investigation purpose only, more so when level of blood sugar was found at 200 on 14.12.2013 as revealed by Ex.R25, despite the fact that this level       should have been between 70-140 mg/dl. A person suffering from dengue has a risk of life and the same requires continuous monitoring for seeing improvement of signs and symptoms of patient for due care and as such,if the complainant had to remain admitted in Sachdeva Nursing Home, Ludhiana for 8 days for treatment of dengue fever along with the other complaints of complications of vomiting, headache and stomach pain, then the same was essential for having due treatment and not for evaluation of health condition only. So, repudiation of claim on ground that hospitalization was for investigation and treatment of acute febrile illness with dengue fever is quite unjustified. Rather the denial of insurance claim is on flimsy and non existing grounds and as such certainly complainant had been made to suffer mentally and physically owing to altogether improper repudiation of insurance claim.

18.               As per law laid down in case titled as Sunil Sharma vs. National Insurance Co.Ltd-II(2015)Consumer Protection Judgments-46(Delhi State Commission), an otherwise genuine claim of insurance should not be rejected on flimsy and technical grounds because in case it is so done, then confidence of people in insurance company would be deeply eroded. Further, as per ratio of this case, Consumer Forums are not expected to go in technicalities of the Civil or Criminal jurisprudence because consumer disputes are to be decided on yardsticks of reasonableness, probability and by applying with full force the principles of natural justice. In this case before us also, the discrepancies pointed out by the deponent of Ex.RA actually do not exist or they are very ordinary in nature and bound  to exist when a version travels from one mouth to other and as such, repudiation of claim ordered in this case is on flimsy and technical grounds alone. Being so, complainant entitled to somewhat hefty amount of compensation for mental harassment and agony along with litigation expenses, so that such like genuine claim of insurer may not be rejected by unscrupulous or harsh insurer.

19.               As a sequel of the above discussion, complaint allowed in terms that OPs will reconsider the claim of complainant, settle the same and pay the due amount within 40 days from the date of receipt of copy of the order. Amount of bill Ex.R44 dated 11.11.2013 may be excluded from the payable amount. In case payment not made within 40 days as referred above, then complainant will be entitled to the due found amount by Ops with interest @7% per annum from the date of complaint namely 28.11.2014 till payment. Compensation for mental harassment and agony of Rs.25,000/- (Rupees Twenty Five Thousand only) and litigation expenses of Rs.5,000/- (Rupees Five Thousand only) more allowed in favour of complainant and against OPs. Payment of these amounts be also made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules.

20.                         File be indexed and consigned to record room.

 

         

          (Param Jit Singh Bewli)                        (G.K. Dhir)

                              Member                                                  President

Announced in Open Forum                                                                  Dated:14.08.2017 

Gurpreet Sharma.