Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.141 /18.11.2022
Mrs. Rama Garg, w/o Sh. Rajendra Kumar Garg,
G-80, Ashok Kumar, Phase-1,
Delhi-110052 …Complainant
Versus
OP- ICICI Prudential Life Insurance Company Ltd.
ICICI Prulife Towers 1089, Apppasaheb Ma Prabhadevi,
Mumbai, Maharashtra-400025 ...Opposite Party
Senior citizen's Case
Date of filing: 18.11.2022
Coram: Date of Order: 09 12.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
FINAL ORDER
Inder Jeet Singh , President
It is scheduled today for order (item no.2)
1.1 (Introduction to dispute ) – The complainant has grievances that when she, being senior citizen, was hospitalized in day care in BLK Max Super Specialty Hospital and there was request to OP for cash-less facility since a health policy was purchased from OP. However despite request the medical bill was not cleared by the OP, that too after authorization and the complainant-patient was kept overstayed in hospital during Covid-19 wave for want of clearing of bill by OP. There is negligence and deficiency of services. That is why the present complaint for compensation/damages for Rs. 20,00,000/- in lieu of harassment, inconveniences and mental agony cost by OP, interest, costs and for other relief.
1.2. There was no defence version or evidence on the part of OP but the complaint was opposed that pre-authorization was valid for 03 day and subsequently there was another request by over-writing over previous pre-authorization instead fresh request for pre-authorization. The OP cannot be blamed by the complainant.
2.1. (Case of complainant) – The complainant had purchased a health policy No. 11062170 about 13 years back and since then the policy has been continuously renewing against regular payment of premium. The complainant was diagnosed with some medical issues, she was advised day care treatment by Dr. Keerti Khetan. On the advices of doctors, the complainant applied for preauthorization for cashless on 09.04.2022, it was approved by the OP on 11.04.2022. She was to be admitted in BLK Max Super Specialty Hospital, Delhi (in brief hospital) for scheduled date on 15.04.2022 for medical issue of post menopausal bleeding with endometrial hyperplasia. However, on further advice by the doctor, the complainant’s admission was rescheduled for 26.04.2022, therefore, complainant again applied to the OP for pre-authorization/ cashless facility on 23.04.2022. The complainant’s husband is also senior citizen, he was attending the medical need of the complainant for her proper treatment and care.
2.2. On 26.04.2022 at 9:49 am, the complainant was admitted under the treatment of Dr. Tripti Sharan and Dr. Keerti Khetan for day care treatment. The complainant was administered the scheduled treatment and she was discharged by the hospital on 26.04.2022 itself through final bill prepared by the hospital and sent to PPA at 8:49 pm on 26.04.2022 for final approval. However, despite receiving the discharge summary by email dated 26.04.2022 at 8:48 pm from the hospital, the OP did not take up any step to approve the bill for treatment met to the complainant and to release the amount. The complainant’s husband keep on calling the customer care of OP at 8:49 pm till entire night, besides call to concerned person/Executive of OP throughout the night 26/27.04.2022 but there was no response by the OP. The complainant with her senior citizen husband/attendant was compelled to stay in the hospital despite discharge of the complainant by the hospital but want of release of amount by the OP. The complainant and her husband were forced to stay in the hospital at a time when Covid 19 pandemic was in surge again, they being senior citizens were at higher risks of contacting the said disease.
2.3. The complainant had to stay for one extra day in the hospital because of absolute indifferent approach of OP, the hospital has to revise the bill which was yet again sent to OP on 27.04.2022 at 09:09 am. Moreover, the complainant’s husband was again started calling to the OP/its Executive by series of calls continuously until 12:57 pm on 27.04.2022 when final approval was granted by the OP. There is inexplicable delay on the part OP since there was preauthorization on 11.04.2022 but for want of admission on that occasion, there was another request for preauthorization on 23.04.2022, which was informed to the OP about the scheduled treatment for 26.04.2022 but OP failed to approve the preauthorization request made on 23.04.2022. It was well in advance but OP failed to process the discharge summary bill dated 26.04.2022 in time.
2.4. The complainant and her husband had undergone severe mental harassment and agony due insensitive, careless and negligent approach of OP, the said agony further exaggerated because both of them are senior citizen and Covid-19 cases were surging in the capital city vis-à-vis and complainant had undergone medical treatment and she was required complete physical and mental rest, but it was deprived because of negligence and deficiency of services of OP.
The complainant also sent legal notice dated 11.05.2022 through her counsel, it was served upon the OP by email but there was frivolous reply and instead of making apology and to address the grievances, the OP gave unsatisfactory and evasive explanation by blaming the complainant.
2.5. The complaint is accompanied with documents/copies of – covering letter for benefit of insurance policy including claim process, policy document, claim form, cashless authorization letter dated 11.04.2022 and another cashless authorization letter dated 27.04.2022, revised bill with enhance claim, legal notice with postal record.
2.6. The OP could not file the written statement in time and written statement was proposed with an application to condone the delay of 46 days, the application was dismissed by detailed reason order dated 20.03.2023 and the written statement proposed was not taken on record.
Thence, the case was put for evidence of the complainant.
3. (Evidence)- In order to prove the complaint, the complainant Ms. Rama Garg, led her evidence by filing detailed affidavit of evidence with the support of documents filed with the complaint.
4.1. (Final hearing)- At this stage, the complainant and the OP filed their respective written arguments followed by oral submissions by Shri Amit Kumar Singh, Advocate for complainant and Shri Rahul Lal Akharya, Advocate for OP.
4.2. The arguments of complainant are blend of pleadings and evidence and it is further supplemented that there is a circular No. IRDA/HLT/MISC/CIR/95/4/2020 dated 18.04.2020, which mandates that decision of authorization for cashless treatment shall be communicated to the hospital within two hours from the time of receipt of authorization request and last necessary requirement from the hospital either to the insurer or to the TPA whichever is applicable [it was revision in Regulation no.27 about preauthorization which was for 24 hours basis for settlement of the claim]. Then, there were directions for reducing the period of two hours to one hour in the W.P/(C) 5026/2021 and consequently another circular Ref. IRDA/HLT/MISC/CIR/113/04/221 dt. 29.04.2021 was issued to this effect. Thus, the cashless approval to the concerned hospital is to be within minimum time of 30 to 60 minutes so that they shall not be any delay in discharge of the patient and hospital beds do not remain unoccupied.
4.3. However, the OP opposed the complaint, on the basis of material of the complainant (because there is no defence version or evidence) that initially preauthorization letter dated 11.04.2022 was valid till 17.04.2022 being for 03 days treatment and not thereafter. The complainant had not undergone surgery on 15.04.2022 and it was not intimated to the OP. It was on 23.04.2022 when OP was informed through the hospital that complainant had taken another date for surgery on 26.04.2022. As per terms and conditions of policy the previous preauthorization letter meant for 15.04.2022 was not valid after three days from the proposed admission. The new preauthorization request should have been initiated and new/fresh request form should have been submitted by the complainant, but it was not done and instead thereof the hospital intimated the OP on 23.04.2022 by just overwriting on the preauthorization letter dated 11.04.2022.
However, the surgery was performed on 26.04.2022. The OP had processed the request the after clarifications, the OP received revised discharge summary on 27.04.2022 at 9:09 am. The OP raised query to the hospital at 10:51 am and the clarification received at 12:44 pm and then claim was approved at 12:57 pm. The OP requests for dismissal of the complaint.
5.1 (Findings)- The case complainant is considered, analyzed and assessed keeping in view the material on record, in form of documentary record, the counter contentions of OP, the provisions of Consumer Protection Act, the circulars and the directions mentioned the Writ Petition (placed on record). By taking into account the stock of all such materials, the following conclusions are drawn :
(i) There is no dispute of hospitalization/day care for the treatment of complainant in the BLK Max Super Specialty Hospital, inclusive of admission and her discharge. The enire bill was paid by the OP.
However, the dispute is in respect of over stay of the complainant that she could have been discharged on 26.04.2022 after discharge summary issued by the hospital but she was discharged on 27.04.2022 after 12:57 pm besides the other issues of manner of second request for preauthorization.
(ii) During the course of arguments, Ld. Counsel for OP has pointed out that the timing of discharge is 3:12pm on 27.04.2022 (as per revised bill at page No. 61) but the complainant has counter plea that in the reply dated 25.05.2022 to the legal notice, the OP mentions timing of 12;57 pm when the claim was approved and thereafter the complainant was discharged.
It is well known that patient is discharged after clearance of billing, therefore, when the bills were approved at 12;57 pm on 27.04.2022, it means she was physically discharged after that period of 12:57 pm not earlier. In addition, the written arguments also reiterate that discharge at `12:57pm on 27.04.2014.
(iii) The complainant has proved cashless authorization letter dated 11.04.2022 and it clearly mentions this preauthorization was on basis of request dated 09.04.2022 (page No. 55 of the paper book). The complainant has also proved second cashless authorization letter dated 27.04.2022 issued by OP and it clearly mentions this preauthorization was on basis of request dated 23.04.2022 (page No. 57 of the paper book).
It means the OP had received request on 23.04.2022. Moreover, the OP had also filed a similar letter dated 27.04.2022 (page No. 5 of its paper book; although the OP cannot lead defence but for the purposes of its submission, OP’s own document is being considered), in which the hospital made an endorsement that the date of discharge stand changed to 27.04.2022 and consequently room rent of three beds is to be charged vis-à-vis the date of discharge of 26.04.2022 was corrected with date 27.04.2022. This is inter-se arrangement between the hospital and OP of communication. It also reflects that this letter with endorsement was subsequent to discharge time of 26.4.2022 since the patient/complainant was not discharged on 26.04.2022 and request for revised date with room rent was made lateron.
Another aspect is also emerging, if there was a requirement that there ought to be a particular form of request for re-authorisation, when the OP had received request on 23.04.2022 and it was not as per the norms, the OP could have so written to the hospital. The OP cannot blame the complainant in this regard.
The circumstances are showing that OP has frivolous plea.
(iv) The OP is bound by the circulars and other directions issued in the Writ Petition, proved by the complainant and on the face of it and complainant, a senior citizen being attending by her husband, also a senior citizen, had forced stay in the hospital after their discharge on 26.04.2022 but they were not physically relieved for want of receipt of preauthorization payment from OP and the patient was discharged on 27.04.2022 after much delay. The OP had released the amount on 27.04.2022, which also shows that whatever revised bills were prepared nu hospital, the OP had consented for such enhanced revised bill.
The complainant and her attendant/husband were forced to remain in the hospital physically that too at their peril and risks of health during the surge of Covid 19. In addition , in Devesh Singh Chauhan vs State and ors. MANU/DE/1348/2017, it was held that merely because the dues of the hospital treating the patient are outstanding, that certainly cannot be a reason to withhold the release of the patient..
(v) The circumstances discussed and concluded in sub-clauses (i) to (iv) above are crystal clear that the complainant has suffered harassment, inconvenience, agony, discomfort, uncertainty and other psychological fear while remaining under forced admission in the hospital because of want of release of the medical expenses to the hospital. The complainant has proved the complaint on the basis of documents with the support of notification and directions of Writ Petition.
5.2. In view of sub-paragraph 5.1 above, the complainant is held entitled for compensation. The complainants have also sought damages of Rs.2,00,000/- towards harassment, inconvenience and mental agony for want of timely release of bill amount to hospital in violation of circulars and judgment of Hon'ble High Court of Delhi that too during pandemic Covid-19. On the basis of circumstances that complainant being senior citizen and her attendant-husband, also senior citizen, suffered harassment, inconvenience un-certainty, harassment, confinement surrounding by other patients , the compensation of Rs.1,00,000/- in favour of the complainant and against the OP is being considered appropriate, accordingly it is allowed in favour of complainant and against OP.
5.3. The complainant has also sought other appropriate relief of interest and costs. Since, the complainant has also exhausted last resort by writing legal notice but for want of its resolution, the complainant had to file the complaint. Thus, complainant is also entitled for costs, which is quantified as Rs.10,000/- in favour of the complainant and against the OP.
6. So, the complaint is allowed in favour of complainant and against the OP while directing OP to compensation of Rs.l,00,000/- and costs of Rs.10,000/-. The OP is directed to pay the amount within 45 days from the date of this order. In case amount is not paid within 45 days from today, then OP will be liable to pay interest [on that compensation amount] at rate of 4% per annum from that date of complaint till realization of amount.
The OP is at liberty to deposit the payable amount with the Registry of this Commission by way of valid instrument in the name of the complainant.
7. Announced on this 9th day of December 2024 [अग्रहायण 18, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
[Rashmi Bansal]
Member (Female)
[Inder Jeet Singh]
President
[ijs152]
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