DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.65/2020

Mohd Nasim

S/o Mohd Ghulam Rasool

R/o 11/419, First Floor, Lalita Park

Laxmi Nagar, Delhi-110092

….Complainant

Versus

IFFCO Tokio General Insurance Company Ltd.

Through its Director/Managing Director

Regd. Office: IFFCO Sadan, C-1,

District Centre, Saket

New Delhi-110017

       ….Opposite Party

 Date of Institution    :  03.03.2020     

 Date of Order            :  29.07.2024     

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Present: Adv. Manoj Kumar along with complainant.

               Adv. D.N Singal for OP.   

ORDER

Member: Ms. Kiran Kaushal

1.       Complainant approached this Commission for direction to Iffco Tokio General Insurance (OP) to reimburse the bill amount of Rs.45,439/- for medical charges during the treatment of the complainant and also award compensation of the Rs.5,00,000/- for harassment, mental agony and humiliation along with cost of litigation.

2.       It is stated that complainant had purchased an insurance policy from Iffco Tokio General Insurance Company Ltd, hereinafter referred to as OP. During the subsistence of the policy complainant on 26.11.2019 was taken to emergency at Max Super Speciality Hospital, Patparganj, Delhi with complaint of severe pain in his abdomen. Despite the initial treatment as the complainant was not getting any relief, he was advised by the doctor to get himself admitted in emergency for further treatment and administer certain tests required for the purpose of diagnosis.

3.       It is next stated that the complainant was treated and from the medical reports  dated 27.11.2019 Doctors found that there was stone in his right kidney. Accordingly, the complainant was treated by the doctors and got some relief from  acute abdominal pain after the treatment. As the complainant had some relief from the pain, the complainant was discharged on 27.11.2019 with certain advice and prescription. It is stated that despite having the insurance policy from OP, complainant was refused the cashless treatment and was left with no option except to pay the medical charges. Complainant again pursuaded for his claim but the claim was finally repudiated by OP vide letter dated 15.11.2019.

4.       Aggrieved, on the rightful claim being declined by OP, complainant approached this Commission for redressal of his grievance.

5.       OP filed its written version stating inter alia that the claim has been rightly repudiated as per the terms and conditions of the insurance policy. It is stated that OP company declined the cashless claim thereafter received the reimbursement claim from the complainant.

 6.      On scrutiny of the claim, it was noted that the complainant was admitted in Max Super Speciality Hospital, Patparganj with diagnosis of Right Ureteric Calculus with complaint of severe pain in right side of the abdomen for a period from 26.09.2024 to 27.09.2019. It is next stated that the complainant’s claim was repudiated vide letter dated 15.11.2019 wherein it is stated that the vitals at the time of admission were within normal limit. He did not necessitate hospitalization and the patient could have been treated on OPD basis. Also the patient had undergone various investigation and the admission is mainly for diagnosis purpose.  Therefore, OP declined the claim of the complainant referring to Clause No.11,12 and 14 of the policy.

7.       Reiterating the fact that the claim has been rightly repudiated as per the terms and conditions of the insurance policy, it is prayed that the complaint be dismissed with the exemplary cost being false, frivolous and vexatious in nature.

8.       Rejoinder is filed on behalf of the complainant reiterating the averments made in the complaint. Evidence and written arguments have been filed on behalf of both the parties. Arguments made by the Learned counsels are heard. Material placed on record is perused.

9.       Before, we proceeded with the merits of the case, it is important to go through the relevant portion of the discharge summary, which is reproduced as under-

Presenting Complaints:

 The patient presented to emergency department in Max Super Speciallity Hospital Patparganj, Delhi on 26.09.2019 with complaints of severe pain right side abdomen.

Course During Hospitalisation:

The patient presented to emergency and admitted with above mentioned complaints. He was evaluated, investigated and treatment started with IV antibiotics, IV fluids and other supportive medicine.

CT whole abdomen revealed- Right Ureteric Calculus measuring approx. 6 x 3 Academy (HU ~ 590)

Patient was managed by conservative treatment. Now pain  has improved and is being discharged with following advice.

10.     From the discharge summary above, it is clear that complainant was admitted to emergency ward due to acute pain . His pain could not be managed  with the help of the medicines therefore  complainant was  advised by the doctor to stay in the hospital for evaluation and investigations further. As and when the pain  improved and it was diagnosed that the complainant was suffering from Right Ureteric Calculus, the patient was discharged.

 11.    It is not the case of the complainant that he went to the hospital for investigations. It was deemed appropriate by the medical practitioner  that the complainant stays in the hospital till his pain subsides or till the problem is diagnosed. OP’s observation in the repudiation letter that the complainant’s vitals at the time of the admission were within the normal limit which does not necessitate hospitalization and the patient could have been treated OPD basis, cannot over rule the expert opinion of the Doctor in the emergency ward who took the call to evaluate and observe the patient  before discharging him.

12.     In light of the discussion above,  this Commission of the view that OP has wrongly repudiated the claim of the complainant, therefore, OP is directed to reimburse the bill amount of Rs.45,439/-  for medical charges with interest @6% p.a from the date of repudiation  i.e 15.11.2019 within 03 months from the date of order, failing which OP shall be liable to pay above stated amount with interest @8% till realization.

13.     Additionally OP is directed to pay Rs 10,000/- towards compensation for harassment and mental agony.

            Parties be provided copy of the judgment as per rules. File be consigned to the record room. Order be uploaded on the website.