Delhi

North

CC/39/2019

GAGANDEEP - Complainant(s)

Versus

HANS CHARITABLE HOSPITAL & ORS - Opp.Party(s)

02 Sep 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No.:39/2019

 

Ms. Gagandeep Kaur

W/o. Sh. Arvinder Singh,

H. No. 570, Parmanand Colony,

Delhi-110009.                                                                                                   ...                         Complainant No.1

 

Sh. Arvinder Singh

S/o Iqbal Singh,

H. No. 570, Parmanand Colony,

Delhi-110009.                                                                                                    …                          Complainant No.2

 

                                                                                         Vs

Hans Charitable Hospital

Through its Managing Director

2001-2, Baba Banda Bahadur Marg,

New Delhi-110009                                                                                             …                          Opposite Party No.1

 

Dr. Asha Hans,

2001-2, Baba Banda Bahadur Marg,

New Delhi-110009                                                                                              …                          Opposite Party No.2

 

M/s HDFC ERGO Health Insurance Ltd.

(Erstwhile M/s Apollo Munich Health Insurance Co. Ltd.)

5^th Floor, Tower-I, Stellar IT PARL C-25,

Sector-62, Noida, Uttar Pradesh.

 

Also at:

1^st Floor, HDFC House,

165-166, Backbay Reclamation,

H. T. Parekh Margh, Churchgate,

Mumbai-400020, Maharashtra.                                                                        …                             Opposite Party No.3

ORDER

02/09/2023

Ashwani Kumar Mehta, Member:

 

I.        The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the Complainant No.2- Arvinder Singh has taken a Mediclaim policy namely Optima Restore Floater Policy No.110100/11121/AA00579951-01 from OP-3 (M/s Apollo Munich Health Insurance Co. Ltd. which has now been merged with M/s HDFC Ergo Health Insurance Ltd) covering all the family members and the said policy was valid for the financial year of 2018-19. Under this policy, both Complainant No.1 and Complainant No.2, along with their baby were covered. The coverage given under the policy was Rs. 5,00,000/- with multiplier benefit of Rs.2,50,000/-. It has been alleged that after collecting the premium of Rs.14,247/32p, the OP-3 issued policy without any terms and conditions of the policy.

II.       It is further stated by the complainant on 02/07/18, the Complainant No.1 got admitted to Hans Hospital /OP-1 as she was undergoing labour pain under pregnancy. The Gynaecology Department in the hospital was under OP-2’s supervision. The OP-2, after carrying out internal examination, advised Complainant No.1 and Complainant No.2 that the Complainant No.1 might have to undergo Caesarean delivery as normal delivery was not possible and it may endanger Complainant No.1’s life. Complainant No.2 and other family members, keeping in mind the Complainant No.1’s health, gave consent for Caesarean delivery on OP-2’s advice and consent form was signed by the Complainant No.2. The total expenditure for the operation was Rs 55,000/-. The Complainant No.2 was directed to pay Rs. 20,000 as advance which Complainant No.2 deposited in cash. The OP-2 operated on Complainant No.1 at 4:00pm and Complainant No.2 was told by the staff that the operation was successful and a baby girl was born. When Complainant No.2 asked about the health condition of Complainant No.1, the staff told that due to caesarean surgery, Complainant No.1 was unconscious and she will regain consciousness. After Complainant No.1 regained consciousness, she felt pain in her abdomen post-surgery. When Complainant No.1 complained about the pain to the staff, they replied that this pain is normal that occur post-delivery and the pain will lessen over period of time. Around 9pm, OP-2 came for check-up where Complainant No.1 narrated her pain which she was suffering since delivery. After examining Complainant No.1, OP-2 disclosed that there has been a complication during the surgery and a nerve present in the vital part of the abdomen got punctured during the surgery. The Complainant No.2 was advised to shift Complainant No.1 to another speciality hospital for further medication as OP-1 wasn’t equipped with specialised equipment and technology. Upon hearing this, Complainant No.2 and the family members were shocked and surprised about the negligence caused by OP-2 during surgery. Without further delay, Complainant No.2 and family members shifted Complainant No.1 to Max Hospital for medication and surgery where Complainant No.1 was put on ventilator and necessary surgery for 2 days and Complainant No.2 was told by the doctors that the nerve inside the uterus wasn’t punctured; instead it was cut at the time of operation at OP-1 performed by OP-2 as a result of which excess blood spread around the uterus.

 

III.      It is further alleged that during the Complainant No.1’s treatment at Max Hospital, OP-3 failed to provide cashless facility for the treatment which was within the limit the coverage for cashless treatment of Complainant No.1. After denying cashless facility under the policy, the complainants were forced to pay Rs 2,68,400/- the dues at time of discharge of Complainant No.1  from Max Hospital, for which Complainant had filed a claim alongwith all the documents with OP-3 for reimbursement of the entire payment but OP-3 failed to do so. The OP-3 denied to make the payment on the ground that this is a maternity concern which was not covered under the policy. The complainants tried to explain the OP-3 that because of the negligent acts of OP-1 and OP-2, Complainant No.1 had to suffer and therefore, had to get operated at Max Hospital which was covered under the policy. The complainants have further alleged that the OP-3 had made deficiency of service as well as unfair trade practice and thereby the OP-3 is liable to pay compensation. It is further stated that after the incident, the complainant has also written letters to the :-

 

1. SHO, PS Mukherjee Nagar on 04/08/18

2. Delhi Medical Council on 14/08/18

3. CMO, Grievance Cell, Directorate of Health Service on 10/09/18

 

IV.      The complainant has sent a legal notice on 17/10/18 to all the OPs in this case which was replied by OP-1 and OP-2 only whereas OP-3 didn’t reply. Therefore, the Complainant has been filed this complaint praying for directions to:-

1. the OPs-1 & 2 to return the amount of Rs.20,000/- to Complainants which was got deposited for the maternity operation in OP-1 hospital.
2. all the OPs to pay as sum of Rs.2,68,640/- which was paid to MAX hospital at the time of discharge of Max hospital jointly or individually.
3. the OPs-1 & 2 to pay all charges including Special diet, conveyance and attendant charges which were paid by Complainants after the negligent act done by the OP-2 for which Complainants restrict to claim on above heads to Rs.1,00,000/-.
4. all OPs to pay compensation of Rs.2,00,000/- each for negligence act, unfair trade practice and deficiency of services made by all the OPs to the Complainants.
5. all the OPs to pay the cost of the complainant and Rs.21,000/- towards pleaders’s fee; and
6. Any other or further relief which this Honb’le Court deem fit and proper in the facts and circumstances of case, may also be passed in favour of Complainant and against the OPs, in the interest of justice.

 

V.       In support of the allegations levelled in this complaint, the Complainants have also filed copy of the policy No. 110100/11121/AA00579951-01 dated 20.03.2018, copy of the discharge summary and medical bills of treatment at Max Hospital with the complaint. The complainant also filed the copies of the letters sent to (1) SHO, PS Mukherjee Nagar, (2) Delhi Medical Council (3) CMO, Directorate of Health Services (4) copies of its reply (5) copies of the legal notices sent to the OPs and (6) the replies to the notice received from OP-1and OP-2.

VI.      Accordingly, notices were issued to the OPs and in response, the OPs have filed its reply which are discussed below:-

VI-A.             Reply of OPs-1 & 2

          The OP-1 and OP-2 have filed joint reply stating that the complaint submitted by the complainant is not maintainable as the same complaint is also filed before the Delhi Medical Council which is a competent authority to deal with cases of the acts of negligence on the part of medical practitioners. The present complaint was examined by the Executive Committee under the Council where it was opined that there was no medical negligence on the part of OP-1 and OP-2 in providing medical treatment to the complainant in any manner. The OPs have further stated that the complainant was provided medical care under competent and experienced team of doctors and staff of OP-1 Hospital. The OPs have further contended that the complainants don’t fall under the definition of Consumer because they haven’t paid the entire amount to the hospital; only part payment was made and as per the Consumer Protection Act the word “consumer” refers to one who had made the payment OR purchased any item. The OP-1 contends that complainant’s complaint is not maintainable because OP-1 is duly insured with United India Insurance and if there is any liability on them, then it is the duty of the insurance company to deal with the issue. It is further contended by the OPs that the present complaint is a gross misuse and abuse of the process of law resorted to by the complainant in order to blackmail them and extort money and the allegation raised by the complainant regarding deficiency of services on the part of OPs is false and frivolous.

VI-B.             Reply of OP-3

          The OP-3 has stated that the complaint is not maintainable because the ailment for which the cashless facility/ claim was raised falls under the exception clause of the policy. Therefore, no benefit is available to the complainant. It is further contended that the complainant was admitted for treatment of post LSCS (Lower Segment Caesarean Section) which comes under the Medical Exclusion Clause category and denial of the claim is justified as per Section V- C (xii) (r) of the policy. The relevant exclusion clause has been reproduced below:

“Section V -C (xii) (r):  Exclusion

     “Medical Exclusions”

     xii) Types of treatment, defined illness/ conditions/ supplies:

1. ….
2. …..
3. ….

To

q.         ….

r. Any expense attributable directly or indirectly to pregnancy (including voluntary termination), miscarriage (except as a result of an accident or illness), maternity or child birth (including caesarean section), except in case of ectopic pregnancy in relation to a claim under 1a) for in-patient treatment only.”

 

     It is further stated that the OP-3 has acted as per the terms and conditions of the policy, therefore, there is no deficiency of service on part of the OP-3.

VII.     Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the complainant & OPs and it has been observed that:-

1. The Complainant has stated in Para 5 of the complaint that he was holding a Mediclaim policy (Optima Restore Floater policy covering Complainant No.1) issued by the OP-3 vide policy No.110100/11121/AA00579951-01 dated 20.03.2018 valid from 31.03.2018 till 30.03.2019 and this policy was issued without any terms and conditions. It is stated in the complaint that the copy of the policy annexed as Annexure A but no Annexure-A has been found Annexed/enclosed with the entire complaint. Moreover, in the index of the complaint filed also, List of documents does not indicate any details of documents enclosed as Annexure A to Annexure J as mentioned from Para 5 to Para 21 of the complaint.   However, in the index list of documents alongwith documents have been mentioned as from pages 12 to 118 and at pages 13 to pages 18 (6 pages) have been found enclosed with the complaint as letter of renewal of policy No.110100/11121/AA00579951-01 dated 20.03.2018 for the period from 31.03.2018 to 31.03.2019 in the name of Mr. Arvinder Singh/ Complainant No.2. On the basis of these documents only, the Complainant has contended that the policy has been issued to him without any terms and conditions. In this regard, the OP-3, while rebutting this allegation of the Complainant, has furnished a copy of complete set of the Optima Restore Insurance Policy No.110100/11121/AA00579951 issued on 26.03.2017 in the name of Mr. Arvinder Singh/ Complainant No.2 as first policy which mentions that the policy kit sent to the insured/ Complainants contained following documents:-
   1. The Policy Schedule along with income tax (80 D) certificate (wherever applicable)
   2. Customer Information Sheet and Policy wording
   3. Member cashless card/s
   4. Network Hospital List, and
   5. Copy of Proposal form

 

Therefore, the Complainant’s allegation of non-supply of the terms and conditions document alongwith the policy is false and non-maintainable.

2. The OP-3 in its reply has also denied the allegations of the Complainant about deficiency of service for non- reimbursement of claim and has stated that that the complainant was admitted for treatment of post LSCS (Lower Segment Caesarean Section) which comes under the Medical Exclusion Clause category and denial of the claim is justified as per Section V- C (xii) (r) of the policy. The relevant exclusion clause has been reproduced below:-

“Section V -C (xii) (r):  Exclusion

              “Medical Exclusions”

              xii) Types of treatment, defined illness/ conditions/ supplies:

1. …..
2. ……
3. …..

To

q.  …….

r. Any expense attributable directly or indirectly to pregnancy (including voluntary termination), miscarriage (except as a result of an accident or illness), maternity or child birth (including caesarean section), except in case of ectopic pregnancy in relation to a claim under 1a) for in-patient treatment only.”

 

As such, the OP-3 has acted as per the terms and conditions of the policy taken by the complainants for which the terms & conditions were also supplied to them.

 

3. The Delhi Medical Council has also examined the complaint filed by the complainant against OP-1 & 2 and found that proper medical care was provided in this case.

IX.      In view of the above observations, we are of the considered view that there is no deficiency in service on the part of OP-1, OP-2 & OP-3. Therefore, the complaint is dismissed being non-maintainable.

X.       Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

                                          ASHWANI KUMAR MEHTA                                         DIVYA JYOTI JAIPURIAR  

                                       Member                                                                                    President       

                               DCDRC-1 (North)                                                                  DCDRC-1 (North)