District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 583/21.
Date of Institution:16.11.2021.
Date of Order:29.05.2023.
Megh Raj Singh S/o Lt. Shri Nawal Singh, R/o G-232, Gali No. 1, SGM Nagar, Haryana – 121001.
…….Complainant……..
Versus
1. HDFC ERGO General Insurance Company Limited, ist floor, HDFC House, Backbay Reclaimation, H.T.Parekh Marg, Chgurchgate, Mumbai – 400 029.
2. Heera Hospital at Shalimar Road, Kosikalan, Mathura – 281403 through its Owner/Director/CMD/MD or proper channel.
…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. Ganesh Chand , counsel for the complainant.
Sh. D.K.Gosain, , counsel for opposite party No.1.
Opposite party No.2 ex-pare vide order 15.03.2023.
ORDER:
The facts in brief of the complaint are that the wife of the complainant late Smt. Suman Singh aged 59 years was diagnosed with Covid-19 after clinical test and consultation. The wife of the complainant late Smt. Suman Singh aged 59 years now deceased succumbed to Covid-19 on 18.05.2021. On 09.05.2021 the deceased was admitted in the Heera Hospital ICU managed by opposite party No.2. The wife of the complainant discharged from Heera Hospital opposite party No.2 on 18.05.2021 as her condition was not under control and she was advised to shift to Goyal Hospital Faridabad for further treatment. During shifting from Heera Hospital to other higher facility the patient lost his life in between inside ambulance itself. During treatment at opposite party No.2 Heera Hospital the complainant paid hospital bills in cash total for Rs.4,45,200/-. On 07.06.2021 the complainant submitted claim form to opposite party No.1 for reimbursement of the aforementioned bill as the deceased was covered under mediclaim policy with opposite party No.1 and he same had been acknowledged by opposite party No.1. On 16.06.2021 the complainant raised the query for the status of the claim and further on 21.06.2021 the complainant against asked for the update on which the executive of opposite party No.1 told the complainant to check his email but no email was received on 21.06.2-21. On 25.06.2021 the opposite party No.1 illegally and unlawfully repudiated the mediclaim vide letter NO. CCN:PR-HS21-12459551 by invoking section 8 of the policy terms and conditions. ON 08.07.2021 the opposite party No.1 sent an email to the complainant informing the investigation findings. On 26.07.2021, 27.07.2021 again opposite party No.1 vide a letter informed that the claim was denied for the representation. Despite repudiation of the claim and illegal cancellation of the mediclaim policy the opposite party No.1 debited gross premium of Rs.15865 and again issued the policy covering from 02.09.2021 to 01.09.2022 vide policy NO. 2811203793392401000. It was pertinent to mention that the auto debit of the
amount of the premium and issuance of the policy by opposite party No.1 vitiates his previous act of repudiation of claim and the opposite party No.1 was liable for reimbursement of the medical expenses incurred in the complete treatment of this deceased wife. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay Rs.9,95,200/- as explained in para 14 of the reimbursement, loss injury, harassment, humiliation, pain, agony and negligence.
b) any other order which this Hon’ble Court/Commission may deemed fit to in the interest of justice.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that as per the submitted documents misrepresentation of facts was noted in the claim documents submitted by the complainant. In the investigation done by the opposite party through an independent investigator it was noted that insured’s husband affirmed that her nebulization was done but as per medication chart it was not medication chart it was not done. Insured’s husband affirmed that blood transfusion was done nbut a sper ICP nowhere mentioned about the same and Rs.6250/- were charged for the same. Two IPD bills were prepared, one of Rs.4,45,200/- from 9th May 2021 to 18th May 2021 to 20th May 2021 and it was prepared on 11.6.2021. As per bills UHID numbers were same but IPD number was different.(Different charges were applied in both bills). Insured’s husband affirmed that she expired on 18th May 2021 on the way to Goyal Nursing Home but one bill of Heera Hospital was prepared till 20.05.2021. As per final bill Rs.1,65,000/- charged for Oxygen. Insured was admitted for 10 days if she was regularly on oxygen support the 24 x 10 (240 hours). As per which her bill was of Rs.1,20,000/-. Rs.45,000/- extra charged for the same. (As per which DOD was 20.05.2021). As per final bill dated 18.055.2021, Rs.50,000/- charged for ICU. Rs.5000/- extra charged for the same. As per IPD register date of admission and date of discharge not found in order. Patient who was admitted on 28.04.2021 her date of admission mentioned before the patient who admitted on 10.04.2021. As per ICP progress notes not prepared but as per bill dated 11.06.2021 Rs.10,000/- extra charged for doctor’s visit and as per bill of dated 18.05.2021 Rs.30,000/- extra charged for doctor’s visit. Medicine bills were not available and as per medication chart one dose tab fabiflu was given but as per bill Rs.3,375/- extra charged for same. As per final bill Rs.2,25,000/- charged for medicines and consumables but there were no medicine bill available. No bifurcation of consumables available. Bill was not prepared as per Government Covid-19 tariff. Prescription of 09.05.2021 of Heera Hospital was available where no admission was advised, medicine of 05 days was advised. As per death certificate place of death was his residential address. Thus, there was no deficiency in service on the part of the opposite party while rendering services to the insured nor were the opposite party indulged into any unfair trade practice while rejecting the claim.
The complainant had submitted a proposal form for proposing to take an Group Assurance Health Plan policy for the sum insured of rs.10 lacs. It was very relevant to mention that complainant who was the policyholder was aware of all the terms and conditions of the policy. The policy was issued basis the details filled in the proposal form. Believing the above said declaration, information and details provided including the declarations of the medical history by the proposer in the proposal form to be true, correct and complete in all respect, giving the credence to the under writing norms of company, Group Assurance Health plan policy bearing No. 28112037933924000001 from 02.09.2020 to 01.09.2021 was issued to the complainant for sum assured opted as per proposal form. Answering opposite party always sent the policy document alongiwth copies of all the supporting documents to the policyhyoler to enable him to go through the details in entirely once again. In the present case as well, in accordance with Clause 6(2) of the Insurance Regulatory and Development Authority Regulations 2002 the answering opposite party had dispatched the policy documents alongwith the copy of the proposal form and the declaration to the policyholder. The said policy document alongwith the copy of the proposal form was duly received by him. The insured never approached the answering opposite party alleging any discrepancy in the proposal form or any grievance relating to the policy or its terms and conditions during freelook period, implying that the policyholder had agreed to the content sin the application form, policy and their terms and conditions were in order. The answering opposite party n 07.06.2021 received a reimbursement clam which was registered vide claim NO. RR-HS21-12459551 for patient Sushma Kumari who got admitted in Heera Hospital with date of admission as 09.05.2021 and date of discharge as 18.05.2021 for the diagnosis of Covid-19 with claimed amount as Rs.4,68,900/-. Complainant submitted some of the documents. The claim was sent for investigation and from the investigation misrepresentation was noted. The following the discrepancies noted by the opposite party company:
i) Insured’s husband affirmed that her nebulization was done but as per medication chart it was not done.
ii) Insured’s husband affirmed that blood transfusion was done but as per ICP nowhere mentioned about the same and Rs.6250/- were charged for the same.
iii) Two IPD bills were prepared, one of Rs.445,200/ from 9May 2021 to 18.5.2021 and pepared on 18.05.2021. Second bill was of Rs.4,00,200 from 09.05.2021 to 20.05.2021 and it was prepared on 11.6.2021. As per the bills UHID numbers were same but IPD number was different.
iv) Insured’s husband affirmed that she expired on 18.05.2021 on the way to Goyal Nursing Home but one bill of Heera hospital was prepared till 20.5.2021.
v) As per final bill Rs.1,65,000/- charged for Oxygen. Insured was admitted for 10 days if she was regularly on oxygen support the 24 x 10 (240 hours). As per which her bill was of Rs.1,20,000. Rs.45,000/- extra charged for the same. ( As per which DOD was 20.5.2021).
vi) As per final bill dated 18.05.2021, Rs.50,000/- charged for ICU, Rs.5000/- extra charged for the same.
vii) As per IPD register date of admission and date of discharge not found in order. Patient who was admitted on 28.04.2021 her date of admission mentioned before the patient who admitted on 10.4.2021.
viii) As per ICP progress notes not prepared but as per bill dated 11.6.2021 Rs.10,000/- extra charged for doctor’s visit and a per bill of dated 18.05.2021 rs.30,000/- extra charged for doctor’s visit.
ix) Medicine bills were not available and as per medication chart one dose tab fabiflu was given but as per bill rs.3,375/- extra charged for the same.
x) As per final bill Rs.2,25,000/- charged for medicines and consumables but there were no medicine bill available. No bifurcation of consumables available.
xi) Bill was not prepared as per Government Covid 19 tariff.
xii) Prescription of 09 May 2021 of Heera Hospital was available where no admission was advised, medicine of 05 days was advised.
xiii) As per death certificate place of death was his residential address.
Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the complainant had not come with clean hands before this Hon’ble Forum and she had suppressed the actual and material facts from this Hon’ble Forum. As a matter of fact Smt. Suman Singh aged about 59 years old female patient was admitted in the opposite party No.2 hospital with chief complaint and history of pertaining illness breathlessness dry cough and fever since last 10 days admission, temperature 98 ft. B.P. 120/170 PR 82/min., SPO2 67% on room air, so immediately put oxygen but not improvement in her condition so put on bipap immediately. Her condition was deteriorated further and she was intubated and put on mechanical ventilator support, thereafter, condition of the patient was not improved so her attendant wants to shift to other hospital, hence she was referred to another hospital vide discharge card dated 18.5.2021. It was further submitted that the patient namely Smt. Suma Singh was referred alive hence there was no fault on the part of the opposite party No.2. Opposite party No. 2 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–HDFC ERGO General Insurance with the prayer to: a) pay Rs.9,95,200/- as explained in para 14 of the reimbursement, loss injury, harassment, humiliation, pain, agony and negligence. b) any other order which this Hon’ble Court/Commission may deemed fit to in the interest of justice.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Megh Raj Singh, Ex.C-1 – Annexure C-1 - Status report,, Ex.C-2 – death certificate, Ex.C-3 – prescription,Ex.C-4 – Discharge card,, Ex.C-5 – IPD Running Bill detail,, Ex.C-6 - email, Ex.C-7 – Clam repudiation letter, Ex.C-8 – email dated July 08,2021, Ex.C-9 – letter, Ex.C-10 - policy.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit Vivek Yadav, Senior Manager, Corporate Legal- M/s.m/s. HDFC ERGO General Insurance Company Limited, Office NO. 208, 2nd floor, Sewa Corporate Park, Mehrauli – Gurgaon, Ex.R-1(colly) – policy, Ex.R-2 (colly)– Claim form, Ex.R-3(colly) – investigation report (reimbursement), Ex..R-4 claim repudiation letter dated 25.06.2021.
7. Case called several times since morning but none has appeared on behalf of opposite party No.2. Hence, opposite party No.2 was proceeded against ex-parte vide order dated 15.3.2023
8. In this complaint, the complaint was filed by the complainant with the prayer to pay Rs.9,95,200/- as explained in para 14 of the reimbursement, loss injury, harassment, humiliation, pain, agony and negligence.
9. In this case, Suman Singh age 58 years female expired on 18.05.2021. As per investigation report vide Ex.R-3(colly) bill dated 18.05.2021 for Rs. 4,45,200/- in which the date of admission is 09.05.2021 and there is another bill of dated 11.6.2021 for Rs.4,00,200/- in which the date of admission is 09.05.2021 and date of discharge is 20.05.2021 and the patient is expired on 18.5.2021.
10. After going through the record submitted by the opposite party No. 1 from Ex.R1 to R4 it shows that the opposite party No.2 i.e Heera Hospital is fabricating the false bill even after the expiry of the patient which shows the malafidy as well as deficiency of opposite party. Despite availing several opportunities, none has appeared on behalf of opposite party No.2. Therefore, opposite party No.2 was proceeded against ex-parte vide order dated 15.3.2023. The opposite party No.2 is avoiding their process of the law intentionally and fabricating the false bill after the death of the patient. It is a public money we can not blindly disburse the money.
11. Keeping in view of the above submissions, the Commission is of the opinion that opposite party No.2 will liable to pay an amount of Rs.4,45,200/- to the complainant as per Ex.C5. Hence, the complaint is allowed, Opposite party No.2 is directed to pay Rs.4,45,200/- alongwith interest @ 9% p.a. from the date of filing of complaint till its realization. Opposite party No.2 is also directed to pay Rs.50,000/- to opposite party No.1 as a cost for making the false medical bill. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room
Announced on: 29.05.2023 (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.
