Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 149
Instituted on : 02.03.2020
Decided on : 06.06.2024.
Dhiraj Kumar s/o Sh. Ram Prakash, age-29 years, resident of Village Makrauli Kalan, District – Rohtak.
..............Complainant.
Vs.
- Bajaj Allianze General Insurance Company Ltd. Block No.4, 7th Floor. DLF Tower, 15 Shivaji Marg, New Delhi-110015. (through its Manager (Legal).
- Bajaj Allianze General Insurance Company Ltd. Ground floor, Dalal Complex, Opp. Liberty Cinema, Delhi Road, Rohtak. (Through its Manager).
……….respondents/opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.S.S.Khatri, Advocate for the complainant.
Sh.Puneet Chahal, Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that the opposite party no. 1 had issued a cashless health Insurance policy in favour of the complainant. The complainant suffered with complaints of restrosternal pain, chest pain and backache for which he initially went to Criticare Hospital at Kamothe, Mumbai and thereafter was referred to B&J Superspeciality Hospital, Kamothe, Navi Mumbai which is an empanelled hospital of the opposite parties. On 23.09.2019 the doctors conducted surgery of the complainant for IHD- Acute Anterior wall MI Compromised LV systolic function EF-30% s/p Primary PCI to LAD(23/09/19) (3.5X28mm Promus Elite Stent) Hyperhomocysteinemia. The risk regarding the ailment of the complainant was covered in the policy under cashless treatment, but the doctors of the empanelled hospital of the opposite parties told that he was not entitled for cashless treatment as per policy issued by the opposite party no. 1, and showed him the letter regarding the denial of cashless facility issued by the opposite party no. 1 whereby no specific reason for denial of cashless facility was mentioned by the opposite party no. 1 in the denial letter. Under compelling circumstances, the complainant had no other option except to deposit an amount of Rs.2,67,841/-in cash regarding his treatment. The complainant immediately availed a loan on interest @ 18% p.a. from his relative and deposited the amount with the hospital. Opposite party no. 1 has wrongly denied to provide the cashless facility regarding the treatment of the complainant and put a vague & wrong question to the treating doctor regarding the previous history of ailment regarding the patient. The treating doctor had by mistake mentioned the another patient's history and on the report of the treating doctor the opposite party had refused to provide the cashless facility to the complainant. The treating doctor had later on intimated the opposite party that wrong information of another patient was provided by him by mistake and in this regard the doctor had sent e-mail to the opposite party, but the opposite party had intentionally repudiated the claim of the complaint by ignoring the intimation by the doctor. The act of opposite parties is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that respondents may kindly be directed to pay a sum of Rs.2,67,841/- alongwith bonus, interest and other benefits as per terms and conditions of the policy and a sum of Rs. 50,000/-as compensation on account of harassment, mental agony and Rs.15,000/- as litigation charges alongwith interest to the complainant.
2. After registration of complaint, notice was issued to the opposite parties. Opposite party in their reply has submitted that the policy holder Dhiraj purchased Policy bearing no.OG-19-1000-6021-00067529 valid from 11.10.2018 to 10.10.2019 which is subjected to terms and conditions of the policy. The complainant approached the respondent company for the cashless claim for the hospitalization of insured. The preauthorization request states that the patient is diagnosed of having Ischemic heart disease Anterior Wall Myocardial Infarction in newly diagnosed diabetes and hypertension. Medical expenses surgical expenses incurred on treatment of the said ailments are not covered in the first 2 years of the policy. Hence the claim of the claimant of the complainant has been denied vide letter dated 24.9.2019. Under exclusion clause C-2 of the terms and conditions of the insurance policy. Insurance company is not liable to pay the claim of claimant for Hypertension and Diabetes or its complications during first two years of the policy inception, therefore claim of the complainant has rightly been denied as per terms and conditions of the insurance policy. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.
3. Ld. Counsel for the complainant in his evidence has tendered his affidavit Ex.PW1/A, documents Ex.P1 to Ex.P11 and closed his evidence on dated 08.03.2022. Ld. Counsel for the opposite parties has tendered affidavit Ex. Rw1/A, documents Ex.R1 to Ex.R6 and closed his evidence on 02.12.2022.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the insurance company vide letter dated 24.04.2019 which is placed on record as Ex.R4 on the ground that : “The preauthorization request states that the patient is diagnosed of having Ischemic heart disease Anterior Wall Myocardial Infarction in newly diagnosed diabetes and hypertension. Medical expenses surgical expenses incurred on treatment of the said ailments are not covered in the first 2 years of the policy, hence the cashless stands denied under exclusion clause C-2”. We have minutely perused the documents placed on record by the complainant. The complainant was admitted in B & J Super speciality hospital regarding the ailment, the date of admission is 23.09.2019 and date of discharge 27.09.2019. As per discharges summary he was suffering from IHD-Acute Interior wall MI Compromised LV systolic function EF-30% s/p CAG(23.09.2019)-Single vessel disease, s/p Primary PCI to LAD(23/09/19) (3.5 x 28mm Promus Elite Stent) Hyperhomocysteinemia. The patient was treated by Dr. Pritish.K.Bhagul. As per the complainant he was not suffering from hypertension and diabetes at the time of treatment. The hospital authorities wrote letters/clarifications on dated 24.09.2019, 25.09.2019 and 27.09.2019 and it has been clarified by Dr. Pritish K.Bhagol that: “Patient Dhiraj Kumar is non DM and non HTN and it was by mistake mentioned in the first query letter that patient is newly diagnosed as DM & HTN. There is no past of present history of the patient Mr. Dhiraj Kumar regarding DM & HTN, also there is no any investigation reports which is in favour of DM & HTN”. These letters were also handed over to the respondents by the complainant but the respondents have not considered the said letters. As per our opinion, the complainant was Non DM and non HTN but the opposite parties have wrongly rejected by the insurance company. If the pre authorisation has been rejected by the insurance company on dated 24.09.2019 in that situation it is the prime duty of the insurance company to consider the written request of the treating doctor that they have wrongly mentioned the patient as diabetes and hypertension in the initial history of the patient. It is crystal clear that treating doctor wrote several letters and clarification regarding the treatment history of the patient and repeatedly gave the reason that he has wrongly mentioned the above mentioned ailments in the treatment record. The insurance company should consider the claim on merit after receiving the clarifications but the insurance company failed to do so. Hence there is deficiency in service on the part of opposite parties and opposite parties are liable to pay the claim amount to the complainant. As per certificate Ex.P3, the cost of treatment told by the hospital is Rs.275000/- but as per complainant, he had spent an amount of Rs.267841/- on his treatment. As such he is entitled for an amount of Rs.267841/-. At the time of arguments, it has came to our notice that the complainant is a govt. employee and he might have claimed the re-imbursement of this amount from his department.
6. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the complainant to obtain a certificate from his department that he has not taken the reimbursement of the amount of Rs.267841/- on account of his surgery for IHD- Acute Anterior wall MI Compromised LV systolic function EF-30% s/p Primary PCI to LAD(23/09/19) (3.5X28mm Promus Elite Stent) Hyperhomocysteinemia on dated 23.09.2019 from B&J Superspeciality Hospital, Kamothe, Navi Mumbai and to submit the same with the opposite party within 15 days. Opposite parties are also at liberty to verify the alleged fact from his department at their own level. If the complainant had already got reimbursement of alleged amount from his department, in that case he is not entitled for any amount but if he has not received any amount from his department then opposite party is directed to pay Rs.267841/-(Rupees two lac sixty seven thousand eight hundred and forty one only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 02.03.2020 till its realisation and also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and 5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
06.06.2024
........................................................
Nagender Singh Kadian, President
..........................................
Tripti Pannu, Member.
……………………………….
Vijender Singh, Member
