Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR ………………PRESIDENT
SMT. SUKHDEEP KAUR……………………….MEMBER.
Present: Sh. Ashish Singla, Advocate for complainants.
Sh. Madan Goyal, Advocate for opposite party.
ORDER
The complainants have filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to OP).
2. In brief, the case of complainants is that complainant no.1 being an account holder of Post Office Bank had purchased a group health insurance policy namely Family Health Care: Gold bearing No. OG-22-1207-8433-00000300 valid from 19.01.2022 to 18.01.2023 for sum insured amount of Rs.2,00,000/- covering both the complainants and paid premium of Rs.13,574/- to the op. That unfortunately complainant no.2 namely Smt. Mamta Soni suffered from fever CVRF & viral with bronchus and for treatment she was admitted at Lalgarhia Hospital, Sirsa on 15.05.2022. She was treated by Dr. Sanjay Garg and was discharged on 18.05.2022. The complainants have spent a total sum of Rs.21,147/- as hospital expenses and further a sum of Rs.10,000/- on medicines, follow up, special diet and attendant’s charges for above said treatment. It is further averred that complainants had applied to the op for reimbursement of said charges and submitted duly filled claim form and provided all the documents such as discharge summary, test reports and all kinds of bills and information which were demanded by op and they were assured by op about reimbursement of the claim within 4-5 days of submission of claim and it was told that all the documents are in order but surprisingly a repudiation letter dated 07.09.2022 issued by Health Administration Team was received by complainants vide which it was informed that medical claim of complainants has been repudiated on the ground of misrepresentation of facts which is wrong, false and baseless ground to reject the genuine and lawful claim of complainants. It is further averred that thereafter complainants got issued a legal notice dated 25.10.2022 to the op but to no effect and the act and conduct of op clearly amounts to deficiency in service due to which complainants have suffered unnecessary harassment. Hence, this complaint.
3. On notice, op appeared and filed written version raising certain preliminary objections regarding no deficiency of service and concealment of material facts. It is submitted that while the claim of the complainant was being processed, several discrepancies came to light, which are enumerated as under:-
A. As per the ICP the patient was discharged on 18.05.2022 at 9 p.m. However, medicines were administered till 10 p.m. The temperature was found to be normal and there was no need for hospitalization.
B. As per the insured the patient was admitted to room number 102 and remained there till discharge. However, as per ICP the patient was initially admitted to room number 101 and thereafter shifted to room number P-3 on 17.05.2022.
C. As per the medicine bills, the patient purchased 7 PCM injections whereas as per the treatment chart 10 PCM injections were transfused.
D. As per the Lab reports the patient underwent investigations on 15.05.2022 and 17.05.2022 whereas there is no entry to that effect in the lab entry.
4. It is further submitted that claim of complainant was repudiated on 07.09.2022 due to misrepresentation of facts. The answering op after receiving the claim of complainant registered the claim and appointed investigator to scrutinize the documents and to verify the genuineness of the claim. The investigator has submitted his report with following observation:
* Patient was admitted in the Lal Garhia Hospital on dated 15/05/2022 under the supervision of Dr. Sanjay Garg as suffered from fever, cough, cold and chest pain since 3 days.
* Patient underwent relevant investigations and diagnosed with viral fever with URL
* Treatment was done conservative with IV fluids.
* As per patient and insured statement, patient was admitted in the hospital on dated 15/05/2022 at 12.00 pm and discharged on dated 18/05/2022 at 6.00 pm but as per ICP, patient admitted in the hospital on dated 15/05/2022 at 02:30 pm and discharged on dated 18/05/2022 at 09:30 PM.
* As per Insured statement, patient was admitted in the room no 102 and no change in room during hospitalization but as per ICP, patient was admitted in the room no 101 and shifted to room no P3 on dated 17/05/2022.
* As per medicine bills, patient purchased only 7PCM injections but as per treatment chart, 10 PCM were transfused to the patient which is not possible as patient only purchased 7 injections.
* Visit to the hospital has been done to collect the documents of the patient. Hospital denied providing the investigations report of the patient as they said they gave all the reports to the patient.
* Visit to the insured has been done. We confront the patient to provide all the lab reports which was done during hospitalization but as patient said all the investigations reports were already submitted in the insurance company.
* Meeting with the doctor has been done. Doctor visiting is there in the hospital on regular basis but denied to prove the photograph and ID proof of him.
* Hospital staff denied providing the medicine purchase invoice of the medicine.
* Visit to the Sirsa clinical laboratory has been done. They do not provide the copy of the lab reports of patient Mamta.
* Lab entry of the patient has been collected. As per lab entry, entry of patient Mamta has been mentioned in dated 15/05/2022 but lab bills were also collected of patient. As per lab bills, patient underwent investigations on dated 15/05/2022 and 17/05/2022. As per lab entry, there is no entry of dated 17/05/2022.
* Final bills are on hospital letter pad with no GST and invoice number.
* Whole ICP seems to be singled stretched.
* UHID numbers were scribbled mentioned in OPD paper.
* Scribbling was done in date mentioned in treatment chart. 18 were converted into 15.
* As per ICP, doctor statement and insured, patient has a complaint of fever but as per vital chart, temperature seems to be normal.
* As per ICP, patient has a complaint of chest pain and also diagnosed with respiratory infection but no X-ray and CT advised or done.
* Visit to the nearby area of the insured address to do the vicinity but patient strictly not allowed us to take the information about the patient.”
5. It is further submitted that hence the investigator has suggested to repudiate the claim on the above grounds. Therefore, complaint is liable to be dismissed on this ground. The answering op was well within its rights to repudiate the claim of complainant for misrepresentation of facts as per terms and conditions of the policy, more specifically covered under General Denial Clause 20 and Clause: Section B (1). On merits, the pleas of preliminary objections are reiterated, contents of complaint are denied to be wrong and prayer for dismissal of complaint made.
6. The complainants in evidence have tendered their affidavits Ex.C1, Ex.C2 and documents Ex.C3 to Ex.C34.
7. On the other hand, op has tendered affidavit of Sh. Saurav Khullar, authorized representative as Ex. R1/A and documents Ex.R1 to Ex.R6.
8. We have heard learned counsel for the parties and have gone through the case file. Written arguments on behalf of op also filed which have also been perused in which the above said grounds taken in its written version for repudiation of claim of complainants have been taken.
9. From the policy documents Ex.C3, it is evident that complainants were insured under health insurance policy in question of the op for the period 19.01.2022 to 18.01.2023 for the sum insured amount of Rs.two lacs. Further from the prescription slip of Lal Garia Hospital, Sirsa dated 15.05.2022 Ex.C4, it is evident that complainant no.2 Mamta i.e. insured was admitted in the said hospital on 15.05.2022 and discharge card Ex.C25 reveals that she was suffering from Fever CVRF & viral with bronchus and as such she was treated and was discharged on 18.05.2022. It is also evident from the record that her several tests were got conducted by the concerned doctor and in this regard test reports are also placed on file by complainants as Ex.C5 to Ex.C11. However, the claim submitted by complainants has been repudiated by op on 07.09.2022 on the ground of misrepresentation of facts but we are of the considered view that the claim of complainants for such a meager amount has been repudiated by op on such a lame excuses and false and baseless ground and same are mere technicalities for which insured persons cannot be blamed and they are not concerned with the fact that what has been done in the hospital record by the concerned doctor/ staff of the hospital and they were only concerned to take treatment. Even some of the demand of the op referred in its written version i.e. photograph and ID proof of the doctor, investigation reports and lab reports etc. are also irrelevant because all the investigation/ lab reports were already supplied by complainants alongwith the claim and photocopies of the same are also placed on record by complainants. So, it is proved on record that op has repudiated the claim of complainants on flimsy grounds only to escape from its legal liability i.e. to pay genuine claim of the complainants. It is also proved on record that complainants have spent an amount of Rs.21,147/- on the treatment of complainant no.2. As such complainants are entitled to claim amount of Rs.21,147/- from op as claimed by them vide claim form Ex.C14 and non payment of the same clearly amounts to deficiency in service and unfair trade practice on the part of op due to which complainants have suffered unnecessary harassment. However, complainants are not entitled to the amount which they might have spent on special diet and attendant’s charges.
10. In view of our above discussion, we partly allow the present complaint and direct the opposite party to make payment of claim amount of Rs.21,147/- to the complainants alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 22.12.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the op to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainants within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President
Dt. 11.10.2024. District Consumer Disputes
Redressal Commission, Sirsa.
