Haryana

Kaithal

CC/66/2022

Mohan Lal - Complainant(s)

Versus

HDFC Ergo ID ER - Opp.Party(s)

Sh.P.L Bhardwaj

07 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL

 

                                                               Complaint Case No. 66 of 2022.

                                                               Date of institution:      25.03.2022.

                                                               Date of decision:       07.05.2024.

 

Mohan Lal s/o Shri Subhash Chand, r/o H.No.559, Village and Post Office Teontha, Tehsil Pundri, District Kaithal.

                                                                                      …Complainant.

                                                    Versus

 

1. HDFC Ergo ID ER 2010918905-01 ECCN No.RC-HS00-11379927 Steallar (T Park), Andheri (Kurla Road, Andheri East), Mumbai-400059 (Maharastra), through its Branch Manager.
2. The Managing Director, HDFC Ergo ID ER 2010918905-01 ECCN No.RC-HS00-11379927 Steallar (T Park), Andheri (Kurla Road, Andheri East), Mumbai-400059 (Maharastra).

...Opposite Parties.

 

          Complaint under Section 35 of the Consumer Protection Act

 

CORAM:   SMT. NEELAM KASHYAP, PRESIDENT.

                   SMT. SUMAN RANA, MEMBER.

                   SHRI SUNIL MOHAN TRIKHA, MEMBER.

                  

Present:       Shri P.L. Bhardwaj, Advocate for the complainant.   

                   Shri Sudeep Malik, Advocate for the Opposite Parties.

                  

ORDER  -  NEELAM KASHYAP, PRESIDENT

          Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019, against the OPs.

2.                In the complaint, complainant alleged that he insured himself with cashless benefit from OPs No.2952202246411401-2825. That he suffered from breathlessness generalized weakness, body ache, non-productive cough, which was diagnosed started J12.9 optical phenomena by the doctor after diagnosis conducted by Shah Multispeciality Hospital, Kaithal. That as per advise of doctors of Shah Multispeciality Hospital, Kaithal, he was admitted on 12.10.2020 and discharged on 17.10.2020 and thereafter, he remained under treatment as an outdoor patient. That he applied for claim against the said policy after fulfilling all the formalities and claim form Part-B which was to be filled by the hospital on 17.10.2020. That after submitting the claim documents, his health became worst condition and became necessary to remain hospitalize and therefore, he again admitted in Shah Multispeciality Hospital, Kaithal and treated there while indoor patient. That the OPs had wrongly repudiated his claim, which amounts to deficiency in service, on the part of OPs, due to which, he suffered huge physical harassment, mental agony as well as financial loss, constraining him, to file the present complaint, against the OPs, before this Commission.

3.             Upon notice of complaint, OPs appeared before this Commission and filed written statement, stating therein that cashless request was received on 12.10.2020 from Shah Hospital with respect to complainant with date of admission 12.10.2020 for post Covid (13/09/2020) LRTI with complaints of breathlessness, fever and cough. That post receipt of said documents claim was sent for investigation and during patient hospitalization, investigator visited hospital and noted that insured was in HDU but no any sick look found, insured was behaving as a normal healthy person and he was symptomatic and all the vitals were normal in ICPS, hence admission in HDU is not justified. That it was further noted that antigen test report was given by hospital and insured found normal and asymptomatic but he was in HDU and there is no any indication for HDU admission, hence, cashless request was rejected vide letter dated 14.10.2020 as per policy terms and conditions. Hence, there is no deficiency in service, on the part of OPs and prayed for dismissal the present complaint.

4.                To prove the case, complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C36.

5.                On the other hand, OPs tendered into evidence affidavit Ex.RW1/A and documents Annexure R-1 to R-4.

6.                We have heard the learned counsel for the parties and perused the record carefully.

7.                Learned counsel for the complainant has argued that the complainant insured himself with cashless benefit from OPs. He further argued that the complainant suffered from breathlessness generalized weakness, body ache, non-productive cough, which was diagnosed started J12.9 optical phenomena by the doctor of Shah Hospital, Kaithal and as per their advise, the complainant was admitted on 12.10.2020 and discharged on 17.10.2020 and thereafter, remained under treatment as an outdoor patient. He further argued that the complainant applied for claim against the said policy after fulfilling all the formalities. He further argued that after submitting the claim documents, health of complainant became worst condition and became necessary to remain hospitalize and therefore, he again admitted in Shah Hospital and treated there while indoor patient, but the OPs had wrongly repudiated his claim, which amounts to deficiency in service, on the part of OPs.

8.                On the other hand, learned counsel for the OPs has argued that cashless request was received on 12.10.2020 from Shah Hospital with respect to complainant with date of admission 12.10.2020 for post Covid (13/09/2020) LRTI with complaints of breathlessness, fever and cough. He further argued that post receipt of said documents claim was sent for investigation and during patient hospitalization, investigator visited hospital and noted that insured was in HDU but no any sick look found, insured was behaving as a normal healthy person and he was symptomatic and all the vitals were normal in ICPS, hence admission in HDU is not justified. He further argued that it was further noted that antigen test report was given by hospital and insured found normal and asymptomatic but he was in HDU and there is no any indication for HDU admission, hence, cashless request was rejected vide letter dated 14.10.2020 as per policy terms and conditions. Hence, there is no deficiency in service, on the part of OPs and prayed for dismissal the present complaint.

9.                There is no dispute between the parties that the complainant along with his wife and son was having a Health Suraksha Policy Silver, valid from 31.05.2020 to 30.05.2022, with Basic Sum Insured of Rs.3,00,000/-, as is evident from policy document Annexure R-2.

10.              The complainant fell ill and admitted as Indoor patient in Shah Multispeciality Hospital, Kaithal on 12.10.2020 and discharged on 17.10.2020 and spent total Rs.82,600/- vide IPD Bill Details Annexure C-9 and C-10. The said hospital sent Pre-Authorization Request to the OPs regarding the complainant, which was denied, by the OPs, vide its letter Annexure C-5.

11.              Learned counsel for the complainant has submitted that the complainant suffered from breathlessness generalized weakness, body ache, non-productive cough and was admitted in Shah Multispeciality Hospital, Kaithal on 12.10.2020 and discharged on 17.10.2020, but the OPs wrongly and illegally rejected his claim, which amounts to deficiency in service, on the part of OPs.

12.              Contrary to it, learned counsel for the OPs has submitted that after receipt of claim of complainant, during investigation by the investigator, it was found that the insured was in HDU but no any sick look found, as insured was behaving as a normal healthy person and was symptomatic and all the vitals were normal in ICPS, hence admission in HDU is not justified. Accordingly, cashless request was rejected vide letter dated 14.10.2020 as per policy terms and conditions. But it is pertinent to mention here that the OPs have failed to produce any documentary evidence, on the case file, vide which, it can be gathered that on which ground the said Investigator has come to the conclusion that admission insured (complainant) in HDU is not justified. Furthermore, the OPs contended that “no any sick look found, as insured was behaving as a normal healthy person and was symptomatic and all the vitals were normal in ICPS”, but again the OPs have also failed to produce any photograph or documents, to prove their above contentions, due to which, the above contentions of the OPs is not believable.

13.              Contrary to it, the complainant Medical Certificate issued by Shah Hospital, Kaithal (wherein the complainant was admitted from 12.10.2020 to 17.10.2020) as Annexure C-4, wherein, it is certified that the complainant was diagnosed a case of “A typical viral Pneumonia”.

14.              Complainant produced his Discharge Summary as Annexure C-7, wherein, in the column “CHIEF COMPLAINTS & REASON FOR ADMISSION”, there is mentioned “Breathlessness, Generalised Weakness, Body ache, Non Productive Cough since 10-15 days”.

15.              The complainant further produced OPD Slip of dated 12.10.2020 of Shah Hospital, Kaithal as Annexure C-24, wherein, it is mentioned that the complainant was having Post Covid symptom on 13.09.2020 and his Covid Rapid Antigen report came Negative on 03.10.2020. However, the doctor concerned has further advised for “Admission in HDU”, as such, the complainant might have admitted in that hospital on the same day i.e. on 12.10.2020 and discharged on 17.10.2020. In that report Annexure C-24, there is mentioned that complainant is suffering from breathlessness and cough. However, it is pertinent to mention here that as per Annexure C-24, the complainant was suffering from breathlessness, cough etc. in October 2020 and  during that period, the pandemic of Covid-19 in India was on peak, which remained for next two years. However, at that time, the primary symptom of pandemic Covid-19 was breathlessness and cough, as is the case of complainant, and due to that, the doctor concerned might have advised the complainant to take admission in HDU immediately and the complainant does the same. Furthermore, the complainant also produced his various tests reports, on the case file i.e. Annexure C-13, C-15, C17, C-20, C-21, C22 are Hematology Reports, Annexure C-14, C-16, C-19 are Biochemistry Reports, Annexure C-18 is Miscellaneous Tests Report and Annexure C-23 is NCCT+HRCT Scan of Chest.

16.              So, keeping in view the above medical record i.e. test reports, Doctor Prescription Slip of doctor concerned of complainant, problems of complainant, facing at that time in October 2020 i.e. breathlessness and cough (which are/were the primary symptom of Covid-19 at that time), we are of the considered view that there was urgent need of indoor admission of complainant in HDU and the complainant does the same by remained admitted as indoor patient of Shah Hospital, Kaithal from 12.10.2020 to 17.10.2020. In this way, the OPs insurance company has wrongly denied the claim of complainant on the false grounds that there was not required hospitalization for the complainant as he could have been managed as OPD patient. Thus, the above act and conduct of OPs amounts to gross deficiency in services, on their part. Hence, the OPs are liable to reimburse the amount, which was spent by the complainant, on his treatment, as per policy in question.

17.              Now the question which arises for consideration is what should be the quantum of indemnification? In Para No.10 of the complaint, complainant demanded Rs.82,600/- + Rs.10,367/-. However, the complainant has produced IPD Bill Details, issued by Shah Hospital, Kaithal of Rs.82,600/- as Annexure C-9 and C-10 respectively, on the case file. But the complainant has failed to produce any bill/receipt regarding the amount of Rs.10367/-, on the case file. From the policy document Annexure R-2, it is evident that the Basic Sum Insured under the policy in question was Rs.3 lacs. So, in this way, the OPs insurance company is liable to pay Rs.82,600/- along with compensation amount + litigation expenses, to the complainant.

18.              In view of our above discussion, we accept the present complaint and direct the OPs to pay the claim amount of Rs.82,600/- along with compensation amount of Rs.10,000/- + litigation expenses of Rs.5,000/-, to the complainant. The OPs are further directed to make the compliance of this order, within a period of 45 days, from the date of preparation of certified copy of this order, failing which, the total award amount shall carry interest @6% simple per annum, from the date of filing the present complaint, till its actual realization.

19.              In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019, as non-compliance of Court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the records, after due compliance.       

Announced in open Commission:

Dt.:07.05.2024.

                                                                                      (Neelam Kashyap)

                                                                                      President.

 

(Sunil Mohan Trikha).             (Suman Rana).              

Member.                                  Member.

 

 

 

Typed by: Sham Kalra, SSS.