District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.674/2021.
Date of Institution:29.12.2021.
Date of Order: 08.02.2024.
Mr. Vishawjeet S/o Sh. Subodh Mandal aged about 30 years R/o House No. DZ-960, Ward No. 31, Patel Nagar, Sector-4, Ballabgarh, Faridabad, Haryana. Mobile No. 8506952528.
…….Complainant……..
Versus
1. HDFC ERGO General Insurance Company Limited registered & Corporate office at:- 1st floor, DHFC House, 165/166, Backbay Reclaimation, H.T. Parekh Marg, Churchgate, Mumbai – 400 020.
2. HDFC ERGO General Insurance Company Limited, Customer Service Address:- D 301,3rd floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai – 400 078.
3. HDFC ERGO General Insurance Company Limited Branch Unit No. 502 , 504, 506, 5th floor, Mahatta Tower 54, Block B-1, Community Centre, west Delhi.
4. HDFC ERGO General Insurance Company Limited, 5th floor, Tower-1, Steller IT Park, C-25, Sector-62, Noida, Uttar Pradesh-201301.
…Opposite parties……
- M/s QRG Health City Plot No.1, Sector-16, Faridabad, Haryana – 121002.
- B.R.Memorial Hospital, FCA 103, Mukesh Colony, Ballabgarh, Faridabad, Haryana – 121004.
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. Vikas Kumar, counsel for the complainant.
Sh. D.D.Arya , counsel for opposite parties Nos.1 to 4.
Sh. Deepak Daima, proforma opposite party No.1
Dr. Manisha Gupta, AR on behalf of OP No.2(Performa).
ORDER:
The facts in brief of the complaint are that the complainant purchased an insurance policy from HDFC ERGO General Insurance Company Limited initially on 16.01.2020 bearing policy No. 2952 2032 3816 0200 001 and the same remained continued uninterruptedly till date. At the time of birth of baby Ishu, she was in a healthy condition and no disease was diagnosed at that time. Just to save his family for any unexpected illness of health. The complainant also included his daughter in the insurance policy and the all the particulars pertaining to the health of the child were duly communicated to the insurance company. Since the birth of the child till 05.09.2021, the child was living a healthy life apart from the minor tender age related and seasonal illnesses but she was never diagnosed or suffered any critical diseases. On 05.09.2021, the child was , due to stomach infection and vomiting, after that the after checkup the doctor had declared Hernia. After that the complainant asked his insurer for the treatment of Hernia as it disease had covered or not , then the opposite party refused that this disease was covered under the insurance policy. After that the complainant got his daughter treated with his own money. After some time the daughter of the complainant got suffering from another stomach problem. Then the complainant again admitted his daughterin B.R.Memorial Hospital, FCA 103, Mukesh Colony, Ballabgarh, Faridabad, Haryana (Proforma opposie party No.2) and doctor had declared that it was abdominal pain. Upon the same the aforesaid hospital was duly informed to the insurance company within the stipulated time and initially a part approval for Rs.6802/- was issued by the insurance company to the B.R.Memorial Hospital, Faridabad, to the opposite party for the approval the reimbursement claim. Upon the same the opposite party approved the same and released Rs.6802/- in the account of the aforesaid hospital. After that the opposite party refused the request of the complainant for payng the pending bill amount, when was paid by the complainant on his own Rs.7557/- to the proforma defendant No.2. As per the approval the complainant admitted her daughter in WRG Hospital, Faridabad (proforma opposite party No.1) for better treatment with the advised of the proforma opposite party No.2. Where the aforesaid hospital informed the insurance company for the approval of claim reimbursement for the treatment of the daughter of complainant. But it was shocking to the complainant the claim had been rejected by the insurance company. When the complainant asked about the same then the opposite party said that as per the terms & conditions of the policy his loan have been rejected. Moreover, the complainant asked them to previous loan approval for the same disease, then they said that the aforesaid disease was caused by, so the claim could not be assed. The complainant requested them to pay the hospital bill which was Rs.151857/-, but they refused the same. The complainant again paid the bill of her daughter’s treatment to hospital, which was a very big dent of on his pocket. The complainant again contacted to the doctor of QRG Hospital, Faridabad , to prescribed the matter with the insurance company, upon the same the doctor namely Mr. Lokesh Mahajam, M.D. HOD Department of Paediatrics & Neonatology, QRG Hospital, Faridabad, observed and described the disease and told that “Her admission cannot be tottery attributed to the condition of Heria/its surgery, this medical condition can also show in children without above medical condition (Hernia)”, but all efforts the complainant went in vain. The complainant approached the reimbursement department for the approval of his claim, but the same was rejected by the same department on 04.11.2021. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the claimed amount of Rs.1,84,414/- alongwith 24% interest P.a. till the disposal of this complaint
b) pay Rs.4,00,000/- as compensation for causing mental agony and harassment .
c) any other relief which the Hon’ble Commission deem fit and proper may also to be awarded to the complainant.
2. Opposite parties No.1 to 4 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 to 4 refuted claim of the complainant and submitted that the complainant applied for My: health Suraksha Insurance Policy and My: Health Suraksha health Insurance Policy No. 2952203238160200000 was issued to the complainant for a period with effect from 16.01.2020 17:34 hrs. to 15.01.2022, wherein complainant, his wife, and his two daughters was insured for the sum insured of Rs.3,00,000/-. As clear and evident from the policy wordings, certain diseases and their treatment was covered only after expiry of the waiting period as mentioned in waiting clause. Since the treatment of hernia received falls under the waiting period clause. The policy terms clearly speaks about the waiting period of 24 months with respect to the treatment of hernia and as such hernia was not covered within first two years (24 months) from the date of policy inception, whereas complainant was admitted in the QRG Health Hospital on 09.09.2020 and this period come with Ist year of the policy itself. The opposite party received a Cashless claim from B.R.Memorial Hospital for the complainant’s daughter Ishu which was registered vide cashless claim NO. RC-HS21-12603725 and insured was admitted in hospital and was diagnosed with acute gastritis. Post viewing case documents, initial approval of Rs.14000/- was given and later on final bill of Rs.7557/- was received in which Rs.6802/- was finally paid to hospital with deduction of Rs.755/- which was the discount offered by the hospital. On 09.09.2021 another cashless claim which was registered vide cashless claim NO. RC-HS21-12604908 was received for patient Ishu who got admitted in QRG Health City with date of admission as 09.09.2021 with case of pyrexia with subacute intestinal obstruction. As diagnosis was not clear, a query letter was sent by the opposite party to the hospital for “treating doctor’s certificate stating exact diagnosis” and reply was received from the hospital that exact diagnosis as confirmed by the treating doctor was Acute febrile illness with abdominal pain. The hospital shared discharge summary for taking final approval and from the discharge summary it was noted that diagnosis was “Post Herniotomy Sepsis with Intestinal Obstruction” and from the same it was clear that insured was admitted due to the complication due to post herniotomy and as treatment related to hernia comes under waiting period, the cashless claim was denied. The complainant submitted a reimbursement claim which was registered vide claim No. RR-HS21-12620199 for his daughter who was admitted on 09.09.2021 and date of discharge was 16.09.2021. Upon review of the discharge summary it was noted that insured was admitted due to the complication due to post herniotomy and as treatment related to hernia comes under waiting period, the claim was rejected.Opposite parties Nos.1 to 4 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Proforma Opposite party No.1 put in appearance through counsel and filed written statement wherein Proforma Opposite party No.1 refuted claim of the complainant and submitted that as per the present complaint, the complainant’s daughter was admitted on 09.09.2021 for complaint of fever, vomiting, pain abdomen and abdominal fullness for 5 days with history of post operated right inguinal herniotomy and was discharged on 16.09.2021. The complaint was discharge don 16.09.2021 being stable and was advised regular follow ups from the hospital post discharge. Proforma Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. Proforma Opposite party No.1 put in appearance through counsel and filed written statement wherein Proforma Opposite party No.1 refuted claim of the complainant and submitted that patient Ishu was admitted on 8.9.2021 with complaint of fever, vomiting abdominal pain since 2 days and she was managed conservatively but she did not get relieved so patient was referred to higher centre on 09.09.2021 she had history of operation for hernia on 5.9.2021 in some other hospital. During hospitalization patient utilized cashless facility under HDFC ERGO Health Insurance policy for which B.R.Memorial hospital received 6802 Rs. Against the billed amount of Rs.7557/- B.R.Memorial hospital did not claim any amount from the patient for hospitalization during this period. Proforma Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Vishawjeet, Ex.C1 – insurance policy,, Ex.C-2 – bill, Ex.C-3 – in patient bill, Ex.C-4 – Settlement letter without prejudice,, Ex.C-5 – Cashless authorization dealer, Ex.C-6 – final bill,, Ex.C7 & C8 – certificate of Dr. Lokesh Mahajan,, Ex.C-9 – claim repudiation letter.
On the other hand counsel for the opposite parties Nos.1 to 4 strongly agitated and opposed. As per the evidence of the opposite parties Nos.1 to 4 Ex.RW1/A – affidavit of Shri Shweta Pokhriyal, Senior Manager, HDFC ERGP General Insurance Company Ltd., 208,2nd floor, Sewa Corporate Park, Mehrauli – Gurgaon Rd. Gurugram, Haryana,, Ex.RW1/1 (colly) – insurance colly –insurance policy, Ex.RW/2 – settlement letter without prejudice,, Ex.RW-3 – Cashless Authorization letter, Ex.RW-4 – discharge summary ,Ex. RW-5 – claim repudiation letter without prejudice,
7. In this complaint, complaint was filed with the prayer to pay the claimed amount of Rs.1,84,414/- alongwith 24% interest P.a. till the disposal of this complaint. b) pay Rs.4,00,000/- as compensation for causing mental agony and harassment . c) any other relief which the Hon’ble Commission deem fit and proper may also to be awarded to the complainant..
8. As per the complaint, the patient was admitted earlier in hospital of proforma No.2- B.R.Memorial Hospital and cashless authorization letter dated 09.09.2021 was sanctioned by the insurance company. Bill was of Rs.7557/- & Rs. 6802/- was paid by the opposite parties. For the better treatment patient was referred to QRG and the patient was admitted for few days and the QRG hospital raised a bill of1,51,857/- which was denied by the opposite parties reason thereby this treatment belongs to exclusion clause i.e waiting period.
Exclusion clause:
a) Expenses related to the treatment of the listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us This exclusion shall not be applicable for claims arising due to an accident.
b) Surgical Procedures
Adenoidecatomy, tonsillectomy | Tempanoplasty, Mastold-ectomy |
Dilation and curettage (D&C) | Nasal concha resection |
Myomectomy for fibroids | Surgery of Genito urinary system |
Surgery on prostate | Cholecystectomy |
Hernia | Hydrocele/Rectocele |
Surgery for prolapsed inter vertebral disc. | Joint replacement surgeries |
Surgery for varicose veins and varicose ulcers | Surgery for Nasal septum deviation |
Surgery for Perianal abscesses | Fissurectomy, Haemorrholdectomy, Fistulectomy, ENT surgeries. |
and the claim of the complainant was repudiated on this ground.
On the other hand, complainant also tendered certificate of Dr. Lokesh Mahajan, MD of dated 05.11.2021 vide Ex.C7 and Certificate of Dr. Lokesh Mahajan, MD of dated 16.09.2021 in which it has been mentioned that “Her admission cannot be tottery attributed to the condition of Heria/its surgery, this medical condition can also show in children without above medical condition (Hernia)”. As per discharge summary vide Ex.RW-4 the diagnosis is:
“Post Herniotomy Sepsis with Intestinal Obstruction
Presenting Symptoms:
Child brought to hospital, by parents, with the history of post operated Right inguinal herniotomy , admitted with complaints of fever, vomiting, pain abdomen and abdominal fullness for 5 days. “
9. After going through the evidence led by the parties, as per Ex.C7 & C8 the certificate given to the insurance company as well as the complainant also of the same doctor create doubts about the treatment of the patient whether the treatment was of the Hernia or not? The benefits of doubts goes in favour of the complainant. The complainant had paid the huge amount of the premium to the opposite party.
On the other hand, counsel for the opposite parties agitated and also stated at Bar that this claim is not covered of waiting period i,e 24 months. The date of the policy was 16.1.2020 to 15.01.2022 and the patient was admitted in the hospital on 09.09.2021 which is less than 24 months as per the Terms & conditions of the policy but opposite parties has not placed on record terms and conditions of the policy. Benefit of issues goes in favour of the complainant. Hence, the complaint is partly allowed.
10. Opposite parties Nos.1 to 4, jointly & severally are directed to pay 50% of the billed amount of QRG Hospital because they have already given the amount to the proforma opposite party No.2 i.e. B.R.Memorial Hospital. There are no order as to costs. Compliance of this order be made within 30 days from the date of receipt of copy of order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 08.02.2024. (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.
