Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-235/22.08.2019
Yuvraj Sharma s/o Shri Ramashrey Sharma
r/o G-1401-2nd floor C.R. Park, New Delhi-110019 ...Complainant
Versus
OP1: Cigna TTK Health Insurance Limited through CEO,
401/402, Raheja Titanium, Western Express Highway
Goregaon (East), Mumbai-400063
OP2: Cigna TTK Health Insurance Ltd.
Branch Office at: 32-B 3rd floor,
Rajinder Nagar, Pusa Road,
near Pillar No. 122 of Metro Station
Karol Bagh, New Delhi-110005 ...Opposite Party
Order Reserved on: 04.01.2023
Date of Order: 25.02.2023
Coram: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1. The complainant alleges deficiency in services against the OPs/Insurer, since his paid medical bills were not reimbursed , despite currency of policy obtained from OPs; the complainant had gone to hospital for treatment because of emergent medical condition, he was admitted as indoor patient and given treatment there. There was no reason for the OPs to decline the reimbursement of the claim lodged to the OPs. Whereas, the OPs opposed the complaint that there is no deficiency in the services, the claim was rightly repudiated, since the claim was not covered vis-à-vis certain serious discrepancies were found in the record as well as in the treatment given.
2. The complainant obtained health policy no. PROHLR980148978 dated 10.09.2018 for sum insured of Rs. 5,50,000/- against payment of premium for Rs. 5,862.24/-, valid from 10.09.2018 to 09.09.2019 (policy is Annexure-C1 to the complaint). On 19.03.2019, the complainant suffered severe pain in his abdomen, he rushed to nearby hospital Ariston Multi-specialty Hospital at 1-1690, Chitranjan Park, New Delhi, where he was admitted and later he was discharged on 20.03.2019 at 10:30 AM (discharge summary is C-4). However, at the time of admission he had deposited Rs. 1,500/- for treatment as well as tests, since he was prescribed prescription along with multiple test (Annexure-C2). He had deposited all the dues of Rs. 16,300/- against receipt (Annexure-C3) at the time of discharge. However, complainant lodged his claim with TPA Medi-Assist TPA Pvt. Ltd. for reimbursement of Rs. 16,300/- (copy of claim form dated 17.04.2019 Annexure-C5) but his claim was repudiated and denied (Annexure-C6). Then, legal notice dated 30.05.2019 ( Annexure-C7 with postal receipt and track report) was served on the OPs to pay amount of valid claim but no result. OPs were also requested by email dated 03.07.2019 (Annexure –C9) to reinvestigate the claim and consider it but OPs sent email dated 16.07.2019 (Annexure-C10) and forwarded denial letter dated 05.05.2019 referring Clause VIII 24 of the policy that claim may be denied if it is found to be fraudulent and false declaration etc. the any benefit under the policy shall be void or may be forfeited, however, OP failed to demonstrate how any fraud has been committed, just bald allegations have been made. Hence, the complaint was filed for reimbursement of Rs. 16,300/-, along with interest at the rate of 18%, apart from compensation of Rs. 50,000/- on account of harassment and mental agony and litigation cost of Rs. 25,000/-.
3. The OPs do not dispute about the issue of policy, its tenure, payment of premium against policy, however, other allegations are opposed. The complainant was bound by terms and conditions of policy inclusive of condition of fraudulent claim- Clause VIII 24. The complainant was advised multiple test of CBC, LFT, KFT and BSR after his admission in the hospital but they are not covered under the policy. Para 9 of the reply enumerates that certain discrepancies discovered in the claim by its Investigator, which were furnished by its report, as the complainant could not be administered injection Rantac and injection Pantoprazole at the same time, the complainant was discharged at 10:30am on 20.03.2019 but nursing chart shows timings till 11am, there were also other over writing in the nurse note, apart from the complainant was hospitalized at 9:30am as per discharge summary but as per indoor case the injection Rantec was given at 8:50am, the doctor prescribed the injection at 4:30am on 19.03.2019 but it was recorded to be given at 8:50am (Annexure-R1/C) The claim was found fraudulent ,that is why it was repudiated by repudiation letter (Annexure-R1/D). The reply also mentions many case law, in nutshell when there is fraud and cheating involved, the complaint should be tried by the civil court. The OPs also refer policy document (Annxure-R1/A) and discharge summary (Annexure-R1/B) [ which were also the documents referred by the complainant]. The complaint deserves dismissal.
4. However, the complainant also opposed the reply of OPs by filing his rejoinder with explanations that as per investigation report dated 23.04.2019 (Annexure-R1/C), the OPs own Investigator reports that "Overall finding were verified- I verified hospital and patient collected I.C.P. and patient statement other documents, case to be genuine". The complainant/patient was given injection Rantac at 8:50am before his admission at 9:30am on 19.03.2019, injection Drotin was prescribed by the doctor in notes on 19.03.2019 at 4:20pm; it was given too prior to 8:30 am (i.e. prior to his admission in the hospital), as such there is no discrepancy but claim was repudiated without any ground, since prescription and administration of medicine was within hospital/medical domain, apart from the record was being maintained in the hospital, claimant had no role therein. It can be tried by the Consumer Forum being summary jurisdiction as no fraud was committed by the complainant. The complainant was prescribed multiple test during the course of treatment and the record relied upon by the OPs as well as by the complainant itself is clear that complainant was under the treatment & disposal of doctors and hospital administration. The complaint is correct.
5. Then stage of evidence arrived. The complainant Yuvraj Sharma, filed his detailed affidavit, coupled with documentary record, which was annexed with the complaint. On the other side of OPs, Shri Jaswinder Singh Shekhawat, Manager, Legal filed his affidavit in detail as evidence, it is replica of reply with document.
6. Both the parties filed their respective written statements, however, at the stage of final hearing only complainant's Counsel made oral submissions. However, the case of both the parties are being considered, by taking into account their respective case and contentions.
The complainant as well as OPs have referred many case law to support and fortify their contentions. However, the case law referred by the complainant is on plea of principle of natural justice that Consumer Forum may consider the complaint under summary procedure and on the other side OPs contends that the issue of fraud can only be adjudicated by the civil court.
7.1. The contentions of both sides are considered, the majority of evidence is in the form of documentary record, the investigator's report and opinion. The OPs had appointed its Investigator Barqat Inc., who had furnished 'Investigation Report' (Annexure-R1/C), who found admission of complainant in that hospital and on overall finding during verification, the record was collected and case was found genuine (it is mentioned on page no. 4 of the report dated 23.04.2019). This report is in four pages, the page numbers are also mentioned at the bottom as page no. 1 of 4 to 4 of 4. After four pages of complete report, there are two more sheets under the heading 'investigation report'. Under what circumstances these further report was prepared is not explained by OPs. Moreover, this investigation report of two pages, it does not bear page numbers nor it shows to be in continuation of previous Report of four pages. In the four pages Report, the report formally begins & also ends formally with signature and name of Investigator, apart from date of report dated 23.04.2019; and stamp of Ariston Multispecialty Hospital, but all these elements [of page number, signature & name of investigator with formal beginning & end, date of report, stamp of Ariston Multispecialty Hospital] are missing in the two pages placed after Report of four pages. Consequently, OPs own documentary record of said two pages becomes suspicious and this two page report is the same record, for which objections are taken in the written statement by OPs that there are discrepancies in the record of administration of medicine & discharge summary. In fact, in the four page Report of same Investigator, it was verified and found the case complaint is genuine. There is no weight in the plea of OPs that there is any fraud or the matter is within the domain of Civil Court. This issue is decided against the OPs by holding that this Consumer Forum/ Commission has jurisdiction on the subject matter.
7.2: It is much clear from the case of complainant as well as investigation got done by OPs that it was a genuine case of complainant in respect of treatment of abdomen pain in the said hospital for which complainant incurred total medical expenses of Rs. 16,300/-. The OPs protested that four tests [CBC, LFT, KFT and BSA for which hospital charged Rs. 2,950/-] are not covered in the terms of policy, that being so, by reducing this amount of Rs. 2,950/- from total bill amount of Rs. 16,300/-, the remaining amount comes to Rs. 14,250/-, it is covered in the insurance policy and complainant is held entitled for refund of this amount Rs. 14,250/-. The OPs in its claim repudiation information, has simply mentioned ‘claim of Rs. 16,300/- is repudiated’ by endorsing denial reason in a general way of reproduction of clause VIII 24, without specifying the fraud done. Whether its Investigator had conducted direct information from Hospital, if there appears to be any discrepancy or so called fraud, if so, then there is no other record filed by OPs except the four page Report, which confirms the case of complainant is genuine. Thus, it would not help the OPs in view of the conclusion also drawn in para no. 7.1 above.
7.3: The claimant claims interest of 18% pa in the absence of any terms or agreed rate of interest, interest at the rate of 6% pa from the date of complaint till realization will justify both sides.
7.4: The complainant is a yoga instructor by his occupation, however, on account of harassment and mental agony, he seeks compensation of Rs. 50,000/-. By taking into account features of this case, inclusive of documentary record of parties discussed, it is appropriate to award compensation equivalent to the amount withheld by the OPs i.e. Rs. 14,250 /- in favour of complainant and against the OPs. Cost of litigation also quantified as Rs. 5,000/-.
8: Accordingly, the complaint is allowed in favour of complainant and against the OPs to pay Rs.14.250/- [amount of medical expenses bill] along-with simple interest @ 6%pa (from the date of complaint till realisation of amount), apart from Rs.14,250/- as damages & Rs.5,000/- as litigation cost, further directing OP to pay it within 30 days from the date of receipt of this order.
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per Regulations.
10: Announced on this 25nd day of February, 2023 [फागुन 6, साका 1944].
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
