Delhi

North

CC/68/2021

SONIA GILL - Complainant(s)

Versus

HDFC ERGO HEALTH INSURANCE LTD. - Opp.Party(s)

S.K. SINGH & RAKESH TIWARI

31 Jul 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

CC NO.68/2021

In the matter of

Ms.Sonia Gill

W/o Shivendra Kumar Singh,

E-9, Indraprastha Apartment,

Sant Nagar, Burari,

Delhi-110084.

 

Presently R/o

L-25, 2^nd Floor,

P. N. B. Road, Shastri Nagar,

Delhi-110052                                                       …               Complainant

Versus

HDFC Ergo.         Health Insurance Ltd.

(Formerly Known as Apollo Munich)

Health Insurance Co. Ltd.

Through its Manager,

1^st Floor, 2E/25,

Jhandewalan, New Delhi-110055.                       

 

Regd. Office at:

101, First Floor, Inizio,

Cardinal Gracious Road,Chakala,

Opposite P&G Plaza,

Andheri (East)

Mumbai-400069, Maharashtra.                                       …                Opposite Party

 

ORDER
31/07/2023

Harpreet Kaur Charya, Member

The present complaint has been filed by Ms. Sonia Gill, the complainant against, HDFC Ergo Health Insurance Ltd. (formerly known as Apollo Munich Health Insurance Ltd.) with the allegations of deficiency in services and unfair trade practice.

1. Facts as per complaint are that, the complainant had purchased Health Insurance policy bearing No.110800/11108/1000284077-03 for a period from 13/03/2018 to 22/03/2020 by paying a premium of Rs. 10,477/-.  The sum insured was Rs.2,00,000/-.
2. On 02/04/2019, as the complainant was not responding to any question, the husband of the complainant in apprehension that the complainant had consumed naphthalene balls got her hospitalized at St. Stephen Hospital, Delhi. It has been stated that the complainant was under acute stress as her mother-in-law was in coma .The complainant was discharged on 03/04/2019 as LAMA. 
3. Again, on 04/04/2019, the complainant visited St. Stephen’s Hospital, where Dr. Atmesh Kumar (Psychiatric Deptt.) recommended for hospitalisation. The complainant was hospitalized from 04/04/2019 to 20/04/2019, at the             St. Stephen Hospital. OP was informed, however, the cashless claim was denied on 12/04/2019 on the grounds of exclusion clause that treatment related to suicide attempt was not covered under the policy terms and condition.  As per the complaint, claim for reimbursement of Rs.74,164/-was lodged but till date the complainant has not received hard copy of the rejection letter.  The complainant has stated that in the year 2018, claim was reimbursed by OP, when the complainant was hospitalized for similar issues.
4. The complainant has alleged that OP failed to follow the guidelines of IRDA, hence, the present complaint with the relief for reimbursement of Rs.74,164/- along with interest @18% p.a. from the date of denial of cashless service i.e. 12/04/2019 till realization; pay compensation of Rs.3,00,000/- on account of deficiency in services/unfair trade practices; cost of litigation of Rs.25,000/- and any other order which the commission deemed fit in the interest of justice.
5. The complainant has annexed the copy of the health insurance policy for the period 13/03/2018 to 12/03/2020 as Annexure-C-1(Colly); denial of cashless service dated 12/04/2019 and an email dated 27/06/2019 titled as “claim rejection for claim ID 1054464” as Annexure C-2; duplicate discharge bill for 02/04/2019 to 03/04/2019 and discharge bills for 04/04/2019 to 20/04/2019, an undated letter to the Manager, Apollo Munich Health Insurance  and Renewal of the Health Individual Standard two years insurance policy for the period 24/03/2020 to 23/03/2022 as  Annexure C-3
6. Notice of the present complaint was issued to OP. Thereafter, written statement was filed on their behalf.
7. In their written statement the issuance of Easy Health Individual Standard Policy is admitted.  It has been submitted that cashless claim was lodged by St. Stephen Hospital on 11/04/2019 claiming that the complainant was admitted on 04/04/2019 with the complaint of low mood, guilt, suicide attempt by cutting wrist and consuming Naphthalene was etc., due to which the cashless hospitalization was rejected as per Clause VI (C) (iii) of Standard Exclusion Policy terms and conditions. It has been denied that the complainant had filed/submitted the discharge summary for her treatment from 02/04/2019 to 03/04/2019 and thereafter from 04/04/2019 to 20/04/2019.  Thus, no cause of action arose in the favour of the complainant and there is no deficiency in services on part of OP.  It has been denied that on 02/04/2019, the complainant was admitted in St. Stephen Hospital due to acute stress.  It has been submitted that the complainant had made a suicide attempt on 02/04/2019 after cutting her wrist and consuming Naphthalene balls.
8. Rejection of cashless authorisation on 12/04/2019 has been admitted.  It has been submitted that the claim for reimbursement was rejected by email dated 27/06/2019 due to the reason that the claim for management of an ailment which is complication of intentional self injury, which is not payable as per Clause VI (C) (iii) of policy terms and conditions. Rest of the contents of the complaint have been denied.
9. They have annexed the cashless authorisation dated 11/04/2019, Letter dated 11/04/2019 explaining the reason for  delay in intimation to TPA, copy of the card, Aadhar card, PAN card, copy of the discharge summary (illegible) , denial of cashless service (illegible) , renewal of health Insurance policy for the period 13/03/2016 to 12/03/2018 along with schedule with copy of membership card, policy document along with schedule for the period 13/03/2014 to 12/03/2016, denial of cashless service (illegible ) and policy terms and conditions along with their written statement.
10. Rejoinder on behalf of the complainant to the Written Statement of OP was filed.  It has been denied that the complainant had made a suicide attempt.  Rest of the contents of the written statement have been denied and those of the complaint have been reaffirmed.
11. Evidence by way of affidavit was filed on behalf of the parties.  The complainant has reaffirmed the contents of the complaint and has relied on the documents annexed with it. The copy of the insurance policy and certificate have been exhibited as Ex.CW-1/1; copy of letter dated 12/04/2019 of denial of cashless service as Ex.CW-1/2 and copy of discharge bills, payment receipt and proof of payment  as Ex.CW-1/3.
12.  OP has got examined Sh. Aviraaj Singh, Assistant Manager –Legal on their behalf.  He has also deposed on oath the contents of their written statement.  He has got exhibited the copy of the policy along with terms and conditions as Ex.RW1/1, copy of discharge summary dated 02/04/2019 to 03/04/2019 as Ex.RW1/2 and copy of repudiation letter as Ex.RW1/3.
13. We have heard the rival contentions on behalf of both the parties and perused material placed on record.  Existence of Health insurance for the period from 13/03/2018 to 12/03/2020 for a sum of Rs.2,00,000/- is not in dispute.  The complainant is aggrieved by non-reimbursement of her claim of Rs.74,164/- on account of hospitalization for 02/04/2019 to 03/04/2019 and 04/04/2019 to 20/04/2019 by the OP.  The said claim has been repudiated on the ground of General Exclusion under Section VI clause (iii) which reads:-

We will not pay for any claim, which is caused by, arising from or in any way attributable to:

Non Medical Exclusion

 

                     i).................................

                    ii).................................

iii) Intentional self injury or attempted suicide by sane or       insane.

 

14.  A look is to be made at the discharge summary dated 20/04/2019 for the period of hospitalization from 04/04/2019 to 20/04/2019 (Ex.RW1/3).Under the head:

COMPLAINT & HISTORY: 

Low mood

Fearfulness 

Self blame with guilt

Hearing voices unheard by others for 4 -5 days

Sleep disturbances

Decreased interest in daily activities

Above symptom present for 1 year, exaggerated over 03 weeks.

Alleged intake of Naphthalene balls (4-5) on 02/04/2019

Past H/o similar psychiatric illness in March 2018 (treated as IP and OP in Psychiatric Department)  

CLINICAL FINDINGS:

PR-84 BPM

BP-100/80 Hg

CVS-S1 S2 heard, no murmurs

RS-normal vesicular breath sounds no added sounds

P/A-soft, non tender, bowel sounds

CNS-no sensorimotor deficit

Multiple hesitation cut marks on both forearms

MSE 04/04/2019:- Conscious, cooperative, guarded, PMA decreased, rapport could not be established, Speech-rate/tone/volume-decrease, reaction time increased, depressed mood and affect.  Thought-Guild++suicidal ideation++, poverty of thought present, Auditory Hallucinations could be elicited, insight-1/6, judgment-impaired MSE-20/04/2019:- Conscious, Cooperative, Rapport could be established, Speech-rate/tone/volume-normal, reaction, time-normal, Thought-denies suicidal ideation, euthymic mood and appropriate affect insight-4/6, judgment-partially intact

 

Thus as per exhibit CW-1/3 & RW1/3 the complainant was diagnosed with “F 33.3”which is recurrent depressive disorder, current episode, severe with psychotic symptoms; a disorder characterised by repeated episodes of depression, the current episode being severe with psychotic symptom, as in F 32.3 and with no previous episode of mania. 

Endogenous depression with psychotic symptoms

Manic-depressive psychosis, depressed type with psychotic symptom

Recurrent severe episode of:

• Major depression with psychotic symptom
• Psychogenic depressive psychosis
• Psychotic depression
• Reactive depressive psychosis

Wherein F 32.3 is severe depressive episode with psychotic symptom

An episode of depression as described in F.32.3 but with the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activity are impossible; there  may be danger to life from suicide, dehydration, or starvation.  The hallucinations and delusions may or may not be mood-congruent. 

Single episode of:

• Major depression with psychotic symptom
• Psychogenic depressive psychosis
• Psychotic depression
• Reactive depressive psychosis (source icd.who.int)

The course in the hospital was;

Patient was admitted with above complaints through emergency.

Medicines were optimised according to the symptom.  BPRS improve from 84 at the time of admission to 55 at the time of discharge.  SARS improved from 58 at the time of admission to 40 at the time of discharge.  HAM-D improved from 58 at the time of admission to 31 at the time of discharge.  Psychodiagnostics was done.  Counselling sessions were held with the patient.  Family was psychoeducated about the illness.  Rheumatology consult was sorted for arthritis; endocrinology consult was sorted for hypothyroidism and advice followed.  Patient was receptive for therapy and started showing improvement.  Patient showed improvement, however, family requested for discharge and hence is being discharged on request.

 

  (The Brief Psychiatric Rating Scales (BPRS) is a tool used to measure psychiatric symptoms such as anxiety, depression and psychosis. HAM-D is a rating scale for depression and as evident in the case of the complainant it improved from 58 at the time of admission to 31 at the time of discharge.)

15. Thus, it is clear that the complainant was treated for depression during her stay in the hospital from 04/04/2019 to 20/04/2019. It is pertinent to note that the complainant attempted suicide because of episode of depression. Even in the past, the complainant was treated for depression in 2018 as mentioned in para 5 of the complaint and the claim was settled by OP.  Therefore, the rejection on the ground that the claim was not payable as the complainant tried to commit suicide for which she was hospitalized is not justified. The complainant has not filed the discharge summary for hospitalisation from 02/04/2019 to 03/04/2019, and the copies filed by OP are illegible. Therefore, in absence of which we are unable to ascertain the reason for hospitalisation.

16. Hence, in the facts and circumstances of the present complaint, we direct OP to:

1. Reimburse Rs. 54,910/- on account of medical expenses incurred by the complainant for hospitalisation for the period from 04/04/2019 to 20/04/2019.
2. Pay interest at the rate of 7 % p.a. on the amount mentioned in clause (i.) from the date of payment to the hospital 20/04/2019 till realisation.
3. Pay compensation of Rs. 15,000/- on account of mental agony and harassment, inclusive of litigation expenses.

    Office is directed to supply the copy of this order to the parties as per rules.  Order also be uploaded on the website.  Thereafter, file be consigned to the record room.

 

 

(Harpreet Kaur Charya) Member

(Divya Jyoti Jaipuriar) President