District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 148/2021
Date of Institution:18.03.2021.
Date of Order:5.6.2023.
1. Mr. Mahavir Singh, S/o Shri Rajender Singh.
2. Smt. Anshu W/o Sh. Mahavir Singh
Both r/o H.No. 26, Adarsh Nagar, Malerna Road, Ballabagarh, District Faridabad.
…….Complainants……..
Versus
1. Fortis Escorts Hospital, Neelam Bata Road, Faridabad – 121001 through its Principal Officer.
2. Fortis Hospitals Limited, Regd. Office: Escorts Institute and Research Centre, Okhla road, New Delhi – 110 025 through its Principal Officer.
3. Dr. Kamal Gupta, Medical Officer of Fortis Escorts Hospital, Neelam Bata Road, Faridabad – 121001.
4. IFFCO Tokio General Insurance Company Limited, Regd. Office: IFFCP Sadan. C-1, District Centre, Saket, New Delhi – 110 017 through its Principal Officer/Manager.
Also at:
IFFCO Tower II, Plot No.3, Sector-29, Gurugram, Haryana – 122001.
…Opposite parties
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Vijay Sharma , counsel for the complainant.
Sh. Rajesh Khanna , counsel for opposite parties Nos.1 to 3.
Sh. O.P.Gaur, counsel for opposite party No.4.
ORDER:
The facts in brief of the complaint are that the complainant NO.2, Smt. Anshu was wife of the complainant No.1. The complaints were holder of policy No. H0157555, which was family mediclaim insurance policy and the complainant No.2 Smt. Anshu was covered in the same. The complainant No.2 Smt. Anshu was having pain in her left chest and was unable to breath smoothly. The complainant No.2 had been taken to opposite party No.1, where she was checked in emergency. In the emergency of the opposite party No.1 the doctor told to the complainant No.2 to get admit immediately in the hospital for further treatment and to look out the disease if any. The complainant No.2 was got admitted in the hospital and UID No. was given 2623066 and Episode No. 70457/20/1105. The opposite party No.1 did several tests and also did examination of the person of the complainant No.2 Smt. Anshu and kept her for 03 person of the complainant No.2 Smt. Anshu and kept her for 03 days. After 03 days the wife of the complainant was discharged. The treatment of the complainant NO.2 was done by the opposite party No.3. The complainant NO.2 initially deposited Rs.10,000/- with the opposite party No.1 and waited for the
insurance money, which was to reimburse by the opposite party No.3. On 08.07.2020 the complainant NO.2 smt. Anshu was discharged and the complainants were waiting for his insurance claim to be paid by the insurance. But in the eleven hour, the complainants were told by the account department of the opposite party No.1 that the insurance company i.e the opposite party No.3 had declined the claim and had refused to reimburse the amount of bill, which were total Rs. 48,301/-. Again the complainants sent the representation for reimbursement of the claim but the opposite party No.3 repudiate the claim on the ground as per the clause “31 and point “15” of SKP (W) Policy what was not covered vide letter dated 23.07.2020. As per the doctor’s report the patient’s ECG showed Sinus Tachycardia. All relevant investigation was done. Ardio Dopler was done, which revealed non obstructive plaque in left carotid bulb. 48 Hrs. Halter monitoring was done, whose report was waited in view of the susceptive crohn’s disease Gastro consultation was taken advise followed. Patient was managed with supportive and symptomatic treatment and the patient was discharged with the medicine in stable condition. In other words it was necessary to locae the disease and it could be done only by admitting the patient for 48 hrs. As per the insurance policy, the claim starts when the patient admitted atleast 24 hrs. In this case the doctor of opposite parties NO.1 & 2 remained admitted the patient Smt. Anshu for three days and discharged on 08.07.2020. Now the question arose “if there was no disease, why the hospital and doctor had remained the patient Smt. Anshu in their hospital for three days, just to extract the money from the complainant (opposite party No.3 was also in the conspiracy with opposite parties Nos.1 & 2 to get admit for three days and to extract the money, if there was no disease) or if there was any disease why the insurance had declined
the claim of the complainant No.2). The complainant sent legal notice dated 21.09.2020 to the opposite party through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) reimburse the bill amount of Rs.48,301/- to the complainant.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) Any other relief which this Hon’ble Commission deems fit and proper may also be awarded in favour of the complainants and against the opposite parties.
2. Opposite parties Nos.1 to 3 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 to 3 refuted claim of the complainant and submitted that the complainants were even otherwise stopped by their own act and conduct from filing the present complaint impleading therein the answering opposite parties for their own admission in the pleading itself. As a matter of facts, proper care, medication and examination of the patient was done by answering opposite parties at the time of admission of the patient in the state of acute emergency with the complaint of sudden onset of chest heaviness radiating to left arm alongwith sweating and transient loss of consciousness, in such scenario the prime object the foremost duty of attending doctors was to stabilize her in place of thinking of her mediclaim benefits. The complainant No.2 Smt. Anshu was admitted in opposite party No.1 hospital in the acute state of emergency on 05.07.2020 and remained admitted in the hospital till 08.07.2020 vide UHID No. 2623066. The attending doctors considering the medical condition of the patient conducted several tests including ECG, 2D Echo, Carotid Doppler, Holter Monitoring (24 Hours) and other blood investigations apart from obtaining the
vitals of the patient as the heart beats of the patient was fast, blood pressure reading was elevated and ECG report had also shown changes (Sinus Tachycardia T Inverted III.VI. Lowe voltage Complexes in Limb Leads) therefore, the constant medical observations of the patient was necessary and the patient was advised admission in the hospital for further treatment, conducting various tests and examination which were not possible in the OPD considering the situation of the patient. Even otherwise the patient had past history of Gastritis and Crohn’s diseases (suspected) and provisional diagnosis was of acute coronary syndrome was entertained. The echocardiogram of the patient was conducted which showed normal cardiac chamber dimensions with no LV RWMA, LVEF -55 -60% alongwith Mild MR, Trival AR, Mild TR (PASP-40mmHHg. All the other mentioned detailed investigations were not possible without admitting the patient as indoor patient and the treatment of the patient was done as per standard medical practice. Apart from above Carotid Doppler Ultra-sound of the patient was conducted using a Lineara Transducer (10 mhz). Both the common Carotid Visualized Cervcal internal, external carotid and vertebral arteries were scanned. However, mixed echogenic now flow limiting plaque was seen in the left carotid bulb measuring 1.3mm in maximum thickness. Rest of the lumen caliber was normal. The velocities recorded were normal in intensity and wave form, visualized bilateral certvical vertebral arteries revealed normal blood flow and spectural wave form. Apart from above various laboratory investigations of the patient and X-ray were conducted. The patient was diagnosed with acute coronary syndrome with transient loss of consciousness. All relevant investigation were done. Carotid Doppler was done which revealed non obstructive plaque in left carotid bulb, 48 hours Holter Monitoring of the patient was done. In view of the suspected Crohn’s disease Gastro consultation of the patient was taken and after
proper medical examination and tests of the patient was manager and stabilized with supportive and symptomatic treatment and the patient was later discharged with prescribed medication in a stable condition. The patient was further advised to obtain urgent care in case of chest pain, breathlessness and loss of consciousness ghabrahat and palpitation, decreases or increased in blood pressure signs or symptoms of headache dizziness and blurring of vision. All the above mentioned medical examination and treatment extended to the patient clearly reveals that proper care of the patient was done with regard to the sudden onset symptoms with which patient present in the casualty and abnormal finding observed in the emergency by the attending doctor thus the patient was advised treatment as indoor patient by the answering opposite parties. The complainants had never made any complaint with regard to treatment and medical examination by the answering opposite parties but had deliberately shifted the burden of the denial of reimbursement by opposite party No.4 for medical bills of the patient by terming the admission and treatment apart from medical examination as unnecessary.. But as a matter of fact the same was mandatory considering the medical conditions of the patients at the time of admission in the hospital. Opposite parties Nos. 1 to 3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No. 4 put in appearance through counsel and filed written statement wherein Opposite party No.4 refuted claim of the complainant and submitted that It was submitted that Mr. Mahavir Singh purchased a Family Health Policy bearing No. 52854252 from Iffico Tokio General Insurance company Limited wherein he alongwith his wife Mrs. Anshu Singh, his daughter Miss Sonia and his two son Mr. Mamal and Mr. Deepak was insured. Thereafter policy was renewed every year. The present policy in which dispute regarding
claim had arisen was purchased by Mr. Mahavir Singh bearing policy NO. H0157555 from IFFCO Tokio General Insurance company Limited wherein he alognwith his wife Mrs. Anshu Singh, his daughter Miss. Sonia and his two son Mr. Kamal and Mr. Deepak was insured for a sum amount of Rs.3,00,000/-. The said policy was valid form 08.10.2019 to 07.10.2020. Any claim benefits pertaining to this policy was to be granted as per the terms and conditions of the policy. It was submitted that the insurance company received a cashless claim of Mrs. Anshu Singh who was admitted at Fortis Escorts Hospital, at Faridabad for the period from 05.07.20 to 08.07.2020 with diagnosis of Gastritis, Atpical Chest Pain, Iron Deficiency Anemia, LVEF -55 -60%. It was further submitted that thereafter, responding insurance company received a reimbursement claim from Mrs. Anshu Singh. On scrutiny of the submitted documents responding insurance company repudiated the claim via letter dated 24.07.2020. Opposite party No.4 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–Fortis Escorts Hospital with the prayer to: a) reimburse the bill amount of Rs.48,301/- to the complainant. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) Any other relief which this Hon’ble Commission deems fit and proper may also be awarded in favour of the complainants and against the opposite parties.
To establish his case the complainant has led in his evidence,
Ex.C/A – affidavit of Mahavir Singh, Ex.C1 page to 66 – Echo Cardiogram,,Ex.C-2 page 67 to 70 – legal notice,, Ex.C-3 – postal receipt, Ex.C-3 page 72 to 73 – reply to legal notice,
Shri Rajesh Khanna, counsel for opposite parties Nos.1 to 3 has made a statement that written version filed by opposite parties Nos.1 to 3 may be read as such evidence of opposite party Nos.1 to 3 and closed the evidence on behalf of opposite parties Nos.1 to 3 vide order dated 14.03.2023.
As per evidence of opposite party No.4 Ex.RW3/A – affidavit of Mridul Ranjan, S/o Shri M.L.Das, Working as General Manager of IFFCO Tokio General Insurance Co. Ltd.
,at Corporate office Iffco Tower II, Plot NO.3, Sector-29, Gurugram. Photocopy of Insurance policy alongwith terms and conditions, Discharge summary, Cashless denial letter dated 08.07.2020, repudiation letter dated 24.07.2020.
7. In this case, the complaint was filed by the complainant with the prayer to reimburse the bill amount of Rs.48,301/- to the complainant.
8. After going through the evidence led by the opposite parties , it is not possible that the patient can deny for the admission when it is advised by the Doctor. As per discharge summary, the patient has the chest pain and the doctor has advised for the admission. As per discharge summary, the patient admitted in the Fortis hospital from 05.07.2020 to 08.07.2020. Opposite party has repudiated the claim of the complainant on
this ground only. There is no need for the repudiation which is not justified.
9. Keeping in view of the above submission, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 05.06.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
