Punjab

Ludhiana

CC/21/425

Vineet Gagneja - Complainant(s)

Versus

Chola MandalamMS General Ins.Co.Ltd - Opp.Party(s)

Kamal Jatika

07 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  425 dated 15.09.2021.                                       Date of decision: 07.10.2024. 

 

Vineet Gagneja son of Mulakh Raj, R/o. House No.75, Professor Colony, Barewal Road, Rajguru Nagar, Ludhiana.                                                                                                                                               ..…Complainant

                                                Versus

1. Chola Mandalam MS General Insurance Co. Ltd. Hari Niwas Tower, Second Floor, Dare House, 2 NSC Bose Road, Chennai-600001 through its Manager/Authorized representative.
2. Chola Mandalam MS General Insurance co. Ltd., Branch SCO 2463-64, Second Floor, Sector 22-C, Chandigarh through its Manager/Authorized representative.                                                                                                                                                               …..Opposite parties 

Complaint U/s. 35 of The Consumer Protection Act, 1986 for holding the opposite party for deficiency in services and also compensating the complainant.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Kamal Jatika, Advocate

For OPs                          :         Sh. Vyom Bansal, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant took one health policy from the OPs vide policy No.2887/00000140/00000154/000/00 for sum insured of Rs.3,00,000/- by paying annual premium of Rs.5049/-. The OPs assured the complainant that the said health policy covers all the diseases of human body and complainant can claim anytime in case of hospitalization, emergency.  The complainant stated that he remained ill in the month of February 2020 and was admitted in Orison Super Specialty Hospital from where he was discharged on 29.02.2020. Thereafter, he was admitted in Dayanand Medical College and Hospital from 29.02.2020 to 05.03.2020 in emergency. The complainant was diagnosed from kidney problems and doctors advised the complainant to undergo dialysis procedure. The complainant further stated that he incurred Rs.80,989/- on his treatment and is also undergoing dialysis treatment after every 10 days of calendar month. The complainant contacted the representative of the OPs and asked him to submit his case for insurance claim but the OPs did not consider his genuine request and refused to pay anything. According to the complainant he has suffered mental and physical agony due to act and conduct of the OPs. Even the Ops received premium of Rs.5163/- on 23.11.2020 for next year policy. In the end, the complainant has prayed for issuing direction to the OPs to pay Rs.80,989/- along with compensation of Rs.1,00,000/- and litigation expenses of Rs.3100/-.

2.                Upon notice, the OPs appeared and filed written statement assailed by complaint by taking factual submission and objections on the grounds of maintainability; the complaint being premature in nature; lack of jurisdiction and cause of action; the complainant is not a consumer of the OPs; suppression of material facts etc. The OPs stated that the cashless claim of the complainant was denied with request to the complainant to lodge a reimbursement claim but the complainant never approached them for reimbursement of claim rather filed the present complaint. Further the cashless claim of the complainant was denied on the ground that the Insurance Company could not rule out the possibility of the ailment being pre-existing in nature. According to the OPs, the complainant was firstly insured vide policy No.2887/00000140/00000154/000/00 w.e.f. 26.11.2019 to 25.11.2020 under the Flexi Health Policy with them. A pre-authorization/cashless request was received for treatment of the complainant from Orison Super Specialty Hospital, Ludhiana for treatment with a provisional diagnosis of Acute kidney injury with hydrouretronephrosis and vide its letter dated 28.02.2020 the OPs sought "Need clear provisional diagnosis with detailed plan of treatment for further processing" and vide another letter dated 29.02.2020 the OPs sought "Need treating doctor certificate confirming the exact cause and duration of the present ailment. Need First consultation paper and all past consultation papers related to this case. All past treatment records related to insured regarding present ailment. KINDLY FURNISH THE DETAILS OF COMORBIDITIES, IF ANY? like DM/HTN/CAD.. Need current year policy copy with chola". Further from the documents submitted, it was noted that patient failed to submit the required documents for assessing the claim and therefore, the cashless facility of the complainant was denied by the OPs vide letter dated 29.02.2020 stating that "CASHLESS CANNOT BE EXTENDED IN THIS CASE AS PROBABILITY OF PRESENT AILMENT TO BE A COMPLICATION OF PRE EXISTING DISEASE CANNOT BE RULED OUT. HENCE CASHLESS FACILITY IS BEING DENIED. A denial of cashless access is NOT to be considered in any way as a denial of treatment.

The insured can send a request for consideration through reimbursement within 30 days from the date of discharge.”

The OPs further stated that instead of lodging a reimbursement claim along with documents, the complainant preferred the present complaint.

                   On merits, the OPs reiterated the crux of averments made in the factual submission and objections. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 to Ex. C55 and closed the evidence.

4.                On the other hand, the counsel for the OPs tendered affidavit Ex. RA of Ms. Vidhi Passi, Legal-Claims of the OPs along with documents Ex. R1 to Ex. R5 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statement, affidavit and documents produced on record by the parties.

6.                Undisputably, the complainant remained hospitalized at Orison Super Specialty Hospital Infertility & Trauma Centre, Ludhiana from 28.02.2020 to 29.02.2020 where he was diagnosed of Acute Renal Failure with Hydroureteronephrosis vide invoice/LAMA Summary Ex. C40. The complainant submitted cashless claim with the OPs, upon which the OPs sent letter dated 28.02.2020 Ex. R3 as well as letter dated 29.02.2020 Ex. R4 to the hospital, vide which the OPs sought certain additional information from the complainant. The operative part of Ex. R3 is reproduced as under:-

“We refer to your Pre-Authorization request for the above customer. We request you to submit the below information from the treating doctor on hospital letter head/Documents within 24 hours or before discharge, whichever is earlier else we will not be able to process the cashless request.

Need clear provisional diagnosis with detailed plan of treatment for further processing.

Chola MS can pre-authorize cashless approval subject to the terms and conditions of the policy based on the adequate, relevant medical information. However, the patient is advised to continue/follow his/her treatment as advised by the treating doctor and not to discontinue the same pending the processing of preauthorization request.”

Operative part of letter dated 29.02.2020 Ex. R4 is reproduced as under:-

“We refer to your Pre-Authorization request for the above customer. We request you to submit the below information from the treating doctor on hospital letter head/Documents within 24 hours or before discharge, whichever is earlier else we will not be able to process the cashless request.

Need treating doctor certificate confirming the exact cause and duration of the present ailment. Need First consultation paper and all past consultation papers related to this case. All past treatment records related to insured regarding present ailment.. KINDLY FURNISH THE DETAILS OF COMORBIDITIES, IF ANY? like DM/HTN/CAD.. Need current year policy copy with chola..

Chola MS can pre-authorize cashless approval subject to the terms and conditions of the policy based on the adequate, relevant medical information. However, the patient is advised to continue/follow his/her treatment as advised by the treating doctor and not to discontinue the same pending the processing of preauthorization request.”

As the requisite information was not provided by the hospital authorities to the OPs as such, the OPs vide letter dated 29.02.2020 Ex. R5, denied the cashless claim of the complainant. The operative part of letter Ex. R5 is reproduced as under:-

“We refer to your Pre-Authorization request for the above customer. We regret to inform you that we cannot issue a Authorization letter for the hospitalization letter for the above customer due to the reasons mentioned below:

CASHLESS CANNOT BE EXTENDED INTHIS CASE AS PROBABILITY OF PRESENT AILMENT TO BE A COMPLICATION OF PRE EXISTIGN DISEASE CANNOT BE RULED OUT. HENCE CASHLESS FACILITY IS BEING DENIED.

A denial of cashless access is NOT to be considered in any way as a denial of treatment. The insured can send a request for consideration through reimbursement with in 30 days from the date of discharge.”

Thereafter, the complainant got treatment from Dayanand Medical College and Hospital, Ludhiana from 18.03.2020 to 18.03.2020 vide discharge summary (Part of claim form Ex. C37) and has been getting dialysis on regular basis  from Guru Nanak Charitable Dialysis Centre and has produced receipts Ex. C4 to Ex. C36 in this regard.

7.                 However, the complainant did not lodge any regular claim with the OPs for reimbursement of his medical expenses. This fact has been admitted by the OPs in their written statement that the complainant instead of lodging a reimbursement claim along with documents, preferred the present complaint. Even as per letter Ex. R5, the OPs informed the complainant that he can wend a request for consideration through reimbursement within 30 days from the date of discharge. As such, it is clear that it is the complainant who himself has not lodged any regular claim with the OPs with regard to his above said hospitalizations and further treatment through dialysis. In the given set of circumstances, it would be just and appropriate if the complainant is directed to lodge a regular claim with the OPs along with documents/information required as per letters dated 28.02.2020 as well as 29.02.2020 Ex. R3 and Ex. R4 respectively, available with him, if any, with the OPs within 15 days from the date of receipt of copy of order and thereafter, the OPs shall settle and pay claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

9.                As a result of above discussion, the complaint is partly allowed with direction to the complainant to lodge a regular claim with the OPs along with documents/information required as per letters dated 28.02.2020 as well as 29.02.2020 Ex. R3 and Ex. R4 respectively, available with him, if any, with the OPs within 15 days from the date of receipt of copy of order and thereafter, the OPs shall settle and pay claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant, failing which the complainant shall be held entitled to interest @8% per annum on the settled amount from the date of order till its actual payment However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.     

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:07.10.2024.

Gobind Ram.