Haryana

Ambala

CC/354/2021

Ritu Jain - Complainant(s)

Versus

Manipal Cigna Health Insurance Co Ltd - Opp.Party(s)

Rekha

25 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	354 of 2021
Date of Institution	:	17.11.2021
Date of decision	:	25.09.2023

Ritu Jain C/o Sh.Gian Chand Jain, Shop No.5688/3, Kabari Bazaar, Ambala Cantt. Haryana

……. Complainant.

Versus

1. MANIPAL CIGNA Health Insurance Company Ltd. Branch Office SCO 149-150, 1^st Floor, Sector 9-C, Madhya Marg Chandigarh, through its Branch Manager.
2. MANIPAL CIGNA Health Insurance Company Ltd. Registered Office 401/402, 4^th Floor, Raheja Titanium, Off Western Express Highway, Goregaon (East), Mumbai-400063.  

….…. Opposite Parties.

 Before:       Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Ashish Sareen, Advocate, counsel for the complainant

                    Shri Sunil Sharma, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay an amount of Rs.66,500/-.
2. To restore the policy with its original number.
3. To pay compensation to the tune of Rs.1 Lac for causing mental agony, harassment and financial loss to the complainant
4. To pay Rs.25,000/- as litigation expenses.
5. To pay interest @24% p.a. on the amount sought for.                                                                                                                                                                                           OR                                                                                                                                                 Grant any other relief which this Hon’ble Commission may deems fit.

 

2.             Brief facts of this case are that in the year 2016 the complainant and her family took insurance policy – ProHealth- Protect Insurance policy, bearing no PROHLR990003559, valid for the period from 27-08-2016 to 08-11-2021 from OP No.1. The said policy covered the risk of Smt. Ritu Jain, her minor son Priyanshu Jain, her daughter Urvashi Jain. Thereafter, the said policy was renewed next year on 28/07/2017 by paying premium and the period of insurance covered was 28-07-2017 to 27-08-2018. Again, it was renewed from 28-08-2018 to 27-08-2019 and now the risk covered under the policy in question was Rs.4,50,000/-. The daughter of the complainant was hospitalized in Shri Sai Hospital, Ambala Cantt for treatment of acute pancreatitis and when the complainant contacted the officials of OP No.1, seeking reimbursement of hospitalization expenses of her daughter under the above mentioned health insurance policy, they asked for  providing the details of actual expenses borne by her. Resultantly, claim to the tune of Rs.66,500/- paid by her against the treatment taken by her daughter for the period from 10-10-2019 to 20-10-2019 as indoor patient and also other expenses towards reports, medicines etc. was submitted with the OPs. However, the claim filed was   repudiated by the OPs on vague grounds. Number of requests made by the complainant to settle the claim filed by her did not yield any result. Hence, the present complaint.
3.           Upon notice, OPs appeared and filed written version wherein they  raised preliminary objections to the effect that the complaint filed by the complainant  is not maintainable and is liable to be dismissed as she attempted to misguide and mislead this Commission; the complainant has suppressed material facts; the complainant failed to cancel the policy in free look period; the complainant has not acted in good faith etc. On merits, while admitting factual matrix of the case, regarding purchase of the policy in question; treatment taken by the daughter of the complainant for acute pancreatitis in the said hospital and repudiation of the claim in question, it was stated that the company has acted strictly as per the policy terms and conditions. The claim in question was repudiated on the ground that it was not genuine and following Multiple discrepancies were found during the investigation:-  
   1. In ICPs nowhere patient complaints mentioned. No resolution in symptoms also found.
   2. TLC on dated 19/10/2019 noted as 19000 and patient was discharged the very next day.
   3. No serum amylase investigation conducted post 15/10/2019.
   4.  All the lab reports are verified by Lab technician and not authorized MD pathologist.
   5. No seen by notes of Dr Bedi noted in ICPs, along with his sign/stamp.
   6. No chest physician reference noted I/V/O left pleural Health infusion noted in CT Scan report conducted on 14/10
   7. Till 15/10 medication charting found. Post that not prepared.
   8. No clarification provided by hospital authorities I/VIO discrepancies noted

 

It was also found that there had been a deliberate attempt to defraud the OPs. Such serious issues required a proper trial by a civil/criminal court and evidence has to be taken which cannot be dealt with by this Commission.The OPs being insurance company pay the claim amount from the common pool of the policyholders and payment of one wrongful claim adversely affects thousands of other rightful Policyholders. Therefore, the OPs repudiated the claim of the complainant on the grounds that the claim filed by the complainant was not genuine and the hospitalization documents suppress/conceal/misrepresent material facts about the ailment as per the documentary evidence available. The said denial was conveyed to the complainant and the hospital. The repudiation of the claim of the complainant is just, proper, legal, valid and made on the grounds of non-disclosure of material facts. Rest of the averments of the complainant were denied by OPs and prayed for dismissal of the present complaint with exemplary costs.

4.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-38 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of Mr. Jaswinder Singh Shekhawat, Senior Manager-Legal and Authorized Representative of the OPs Company-Manipal Cigna Health Insurance Company Limited, having its corporate office at 4^th Floor, Raheja Titanium, Off Western Express Highway, Goregaon East, Mumbai-400 063 as Annexure RW1/A alongwith documents as Annexure R-1 to R-4 and closed the evidence on behalf of the OPs.
5.            We have heard the learned counsel for parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by repudiating the genuine claim filed by the complainant qua the treatment taken by her daughter in the said hospital, despite the fact that the OPs were legally bound to pay for the amount spent, as it was taken during existence of the policy in question, the OPs are deficient in providing service.
7.           On the contrary, the learned counsel for the OPs while reiterating the objections taken in the written reply submitted that the claim of complainant was rightly repudiated on the grounds of misrepresentation of facts and discrepancies found in the documents attached with the claim form. He further submitted that the OPs repudiated the claim of the complainant on the grounds that the claim filed by the complainant was not genuine and the hospitalization documents suppress/conceal/misrepresent material facts about the ailment as per the documentary evidence available. He further submitted that the said denial was conveyed to the complainant and the hospital.  
8.           The moot question which falls for consideration is, as to whether, the claim filed by the complainant qua treatment taken by her daughter, who was also covered under the policy in question, was rightly repudiated by the OPs or not. It may be stated here that we have gone through the written version filed by the OPs and also repudiation letter 28.11.2019, Annexure C-3/R-4. Relevant portion of said repudiation letter reproduced hereunder:-

“……On scrutiny of the documents it has been observed that We have received clam documents for, claimant Miss Urvashi Jain admitted at Shri Sai hospital from 10/10/2019 16 20/10/2015 with the complaints of Acute pancreatitis. Claimant is covered under ManipalCigna Health Insurance Prohealth Protect policy since 2007/2016. On verification of the case and the hospitalization documents, multiple discrepancies are noted. Hence the claim stands repudiated under Clause VII 24. We regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other ground's available to us subsequently

With regards to the same, we request you to read the policy document and refer to the clause mentioned below.

Denial ClauselD Description

Fraudulent Claims  If any claim is found to be fraudulent, or if any false declaration is made, or if any fraudulent devices are used by You or the insured Person or anyone acting on their behalf to obtain any benefit under this Policy then this Policy shall be void and at claims being processed shall be forfeited for all Insured Persons. All sums paid under this Policy shall be repaid to Us by You on behalf of all insured Persons who shall be jointly liable for such repayment.”

9.           First coming to the stand taken by the OPs in repudiation letter 28.11.2019, Annexure C-3/R-4 to the effect that the claim has been repudiated keeping in mind clause VIII of the policy in question with says that the company is not liable to pay the fraudulent claims.  It may be stated here that it is clearly coming out from the Investigation Report dated 14.10.2019, Annexure R-3 having been prepared by Medi Assist Insurance TPA Pvt. Ltd., who investigated the claim on the instruction of the OPs, wherein, in the conclusion part, it has been clearly concluded by the said company (Medi Assist Insurance TPA Pvt. Ltd.) that neither there is any fictitious admission found nor inflated bills, nor manipulation of documents etc. Relevant part of the concluded part is reproduced hereunder:-  

If Non Genuine Please specify reasons	Fictitious Admission
	Inflated Bills	No.
	Manipulation of Documents	No.
	Suppression of PED	No.
	Tampering of Genuine Bills	No.
	Conversion of Exclusion	No.
	Misrepresentation/suppressions of facts	No.
	Other (specify)	No.

 

Thus, when the TPA appointed by the OPs itself has specifically concluded that neither there was any Fictitious Admission nor Inflated Bills nor Manipulation of Documents nor Suppression of PED nor Tampering of Genuine Bills nor Conversion of Exclusion nor Misrepresentation/suppressions of facts or any other fraudulent act on the part of the complainant qua the treatment taken by her in the said hospital, it has not been clarified by the OPs as to how they have repudiated the claim of the complainant on the ground of alleged fraudulent claim or that there was concealment of any facts on the part of the complainant.

10.           Now coming to the stand taken by the OPs in their written version to the effect that the following alleged discrepancies were found by them during investigation of the claim:-
    1. In ICPs nowhere patient complaints mentioned. No resolution in symptoms also found.
    2. TLC on dated 19/10/2019 noted as 19000 and patient was discharged the very next day.
    3. No serum amylase investigation conducted post 15/10/2019.
    4.  All the lab reports are verified by Lab technician and not authorized MD pathologist.
    5. No seen by notes of Dr Bedi noted in ICPs, along with his sign/stamp.
    6. No chest physician reference noted I/V/O left pleural Health infusion noted in CT Scan report conducted on 14/10
    7. Till 15/10 medication charting found. Post that not prepared.
    8. No clarification provided by hospital authorities I/VIO discrepancies noted

 

It is significant to mention here that it has been noted that though all the abovealleged discrepancies mentioned by the OPs are against the hospital concerned, yet, the OPs have failed to place on record any expert/medical report of any doctor especially Laparoscopic Surgeon to prove that the treatment carried out by the Hospital concerned was not in line, especially, when Dr.Dinesh Bedi, MBBS, MS, FMAS, Laproscopic Surgeon i.e. treating doctor has clearly certified by putting his signatures on claim form/document Index Sheet Annexure R-2 and in the Section F “Declaration by the Hospital”, it is categorically stated that We hereby declare that the information furnished in this claim form is true and correct to the best of our knowledge and belief”............ It is settled law that only doctor and not the insurance company can decide the line of the treatment to be given to patient. Thus, to challenge the said declaration of the doctor concerned, the OPs were legally bound to place on record some cogent and convincing report having been prepared by the medical expert/Doctor alongwith evidence which they miserably failed to do so. Even otherwise, if those alleged discrepancies were allegedly found by the Ops on the part of the Hospital concerned, then it has not been convinced by the OPs as to how the complainant was liable for the same, especially, when the treatment taken by her daughter for the said illness/disease has not been disputed by the OPs. 

11.           In the peculiar facts and circumstances of this case, it can easily be said that all the grounds taken by the OPs to repudiate the claim of the complainant are based on fictions, presumptions and assumptions only and are vague. Nothing has been placed on record to prove that the daughter of the complainant was suffering from any pre-existing disease or that there was any misrepresentation or fraud on her part, while filing the claim for reimbursement of the amount spent by her for her treatment aforesaid, under the currency of the policy in question.  Thus, by repudiating the genuine claim of the complainant despite the fact that her daughter took treatment during currency of the policy in question, the OPs are deficient in providing service. 
12.           It may be stated here that in the Investigation Report dated 14.10.2019, Annexure R-3 it has been clearly mentioned by the Medi Assist Insurance TPA Pvt. Ltd. under the heading Hospital Verification that the Hospital Final Bill Amount is in Rs.68867/-. It has further been mentioned by Medi Assist Insurance TPA Pvt. Ltd. in the said report under the heading “Conclusion” that the bills are not inflated. In this view of the matter, the complainant is therefore held entitled to get the amount of Rs.66,500/-, spent on the treatment of her daughter, as sought for by her in relief clause.
13.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-  
    1. To reimburse/pay Rs.66,500/-,to the complainant alongwith interest @6% p.a. from the date of making payment by her to the hospital concerned, for the treatment of her daughter.
    2. To restore the policy with its original number. 
    3. To pay Rs.5,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    4. To pay Rs.3,000/- as litigation expenses.  

The OPs are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

          Announced:- 25.09.2023