Haryana

Ambala

CC/134/2022

Ved Parkash Kaushal - Complainant(s)

Versus

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

Ravinder Pal Singh

20 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	134 of 2022
Date of Institution	:	05.05.2022
Date of decision	:	20.09.2023

1. Ved Parkash Kaushal son of Sh. Samay Singh
2. Smt. Sunita Kaushal wife of Sh.Ved Parkash Kaushal

Both residents of House No.1236, Sector 10, HUDA, Ambala City.   

      

……. Complainants.

Versus.

 

1. MANIPALCIGNA Health Insurance Co. Ltd. SCO 149-150, Sector 9-C, Above Yes Bank, Chandigarh Through its Manager,
2. Charu Batra daughter of Sh. Ashok Dhalu Ram Batra, Resident of House No.186, Rupo Marja, Near Shiv Mandir, P.O. Dhurkara, District Ambala (Authorized Agent of MANIPALCIGNA Health Insurance Co. Ltd.)

 

….…. Opposite Parties.

 Before:          Smt. Neena Sandhu, President.

                                Smt. Ruby Sharma, Member,

             Shri Vinod Kumar Sharma, Member.           

 

Present:          Shri Ravinder Pal Singh, Advocate, counsel for the complainants.

                        Shri Sunil Sharma, Advocate, counsel for the OP No.1.

                       OP No.2 already given up.

 

Order:           Smt. Neena Sandhu, President.

 

1.                Complainants have 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.1,07,806/- spent for treatment of complainant No.2-Smt. Sunita Kaushal.
2. To pay compensation to the tune of Rs.3 Lacs for causing mental agony, harassment and financial loss to the complainants.
3. To pay Rs.55,000/- as litigation expenses.

OR

Grant any other relief which this Hon’ble Commission may deems fit. 

 

2.             Brief facts of this case are that the complainants have purchased the Heath policy bearing Policy No.100200000001/04/00 dated 17.5.2021 from the OP No.1, valid upto 16.5.2022. The said policy was purchased in the names of the complainants and their son namely Shivam.  Earlier, the complainants had taken the heath policy from United India Insurance Company since 2016 to June 2021 and when the said policy reached the expiry date, in the meanwhile, OP No.2 who is authorized agent of the OP No.1 approached to the complainants and assured that they will be benefited in the policy in question.  As per assurance and promises given by the OPs, the complainants purchased the policy in question from the OPs.  In the month of January 2022, complainant no.2 fell down from the stairs in her house and was taken to Sarwal Hospital, Ambala City. As per advice of doctors, MRI was conducted on 10.2.2022 from PKR Jain Health Care Institute, Village Nasirpur, Hissar Road, Ambala City, upon which, she was advised for surgery. As such, she was admitted in the said hospital on 15.2.2022, where her knee surgery was performed on 17.2.2022, for which she paid an amount of Rs.60,806/- vide Bill No.SH/019 dated 19.2.2022. After the said surgery, complainant no.2 remained admitted in the said hospital and during that period she paid an amount of Rs.47,000/- (Approximately) for medicine etc. Before admitting in the said hospital, the complainants gave intimation to the OPs, who assured the complainants that the entire payment of treatment will be reimbursed to them, when complainant no.2 will be discharged from the said hospital. When complainant no.2 was discharged from the said hospital, thereafter, she lodged claim with the OPs, yet, the same was repudiated by them vide email dated 30.3.2022.  Thereafter, on 6.4.2022 the complainants sent an email in the matter, but again the OPs vide letter dated 14.4.2022 refused to entertain her claim, without any reason. The complainants also served a legal notice dated 15.4.2022 to the OPs in the matter but to no avail. Hence, the present complaint.
3.           Upon notice OP No.1 appeared and filed written version wherein it raised preliminary objections to the effect that the complaint filed by the complainants is not maintainable and is liable to be dismissed as they attempted to misguide and mislead this Commission; the complainants have suppressed material facts etc. On merits, while admitting factual matrix of the case, regarding purchase of the policy in question; treatment taken by complainant no.2 in the said hospital and repudiation of her claim, 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 various discrepancies and misrepresentations were found during the investigation. 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.  OP No.1 received a Claim No.27693504 on 07.03.2022 whereby it was stated that insured Sunita Kaushal was hospitalized at Sarwal Hospital for Unspecified Tear of Unspecified Meniscus, current injury, unspecified knee, initial encounter. After thorough investigations and scrutiny of documents it was noted that the claim was not admissible due to Multiple Discrepancies. The said claim was repudiated with the reason, mentioned as under;

           "On scrutiny of the documents it has been observed that we have received claim documents for claimant Mrs. Sunita Kaushal admitted at Sarwal Hosptial from 15th February 2022 to 19th Feb 2022 with the complaints of Medial and Lateral Meniscus tear with Osteochondral defect knee joint. Claimant is covered under ManipalCigna Health Insurance Pro Health Group Insurance Policy Since 17th May 2021. On verification of the case and the hospitalization documents, multiple discrepancies are noted. Hence the claim stands repudiated under Clause Vii.25 of the policy in question’ As per the finding of the investigation team with the help of external investigator it was found that the claim was not genuine. The investigations revealed that following discrepancies and misrepresentations were found:-

1. Visit to Insured has been made and Statement has been collected and as per insured, Patient admitted in the hospital on dated 15-02-22 for c/o knee cyst, knee pain and could not able to move. Patient had h/o complaints of pain since Jan 2022. Patient had no h/o similar complaints. No h/o fall and accident is specified via insured.
2. Vicinity Check has been made and hospitalization is confirmed but no one knows about the patient past medical history.
3. Visit to Hospital has been made and IPD entry, ICP, doctor statement, lab reports and final bills has been collected and verified.
4. IPD Register has been checked as per Record DOA 15-02-22 DOD is 19-02-22
5. ICP has been collected as per ICP patient presented in the hospital with complaints of pain left knee joint and tenderness left knee. Patient was underwent CBC, RFT, LFT, CRP, X-ray, ECG and MRI and other relevant investigations. Patient had h/o HTN but no duration is specified in the ICP. No h/o fall or accident is specified in whole ICP. Patient was treated surgically. PAC and OT notes maintained. History of DM and HTN is specified in the ICP and then scribbled.
6. As per discharge summary, patient is diagnosed for medial meniscus tear lateral meniscus tear with osteochondral defects knee joint.
7. Lab Register has not been maintained by the hospital.
8. All Lab reports has been collected and verified. Patient was underwent MRI investigations and MRI is s/o cystic degenerative changes.
9. Doctor Statement has been collected as per doctor patient admitted in hospital for the c/o pain knee joint since 2 days. Patient had h/o fall. Patient underwent MRI investigation. Patient had no h/o chronic illness. Patient was diagnosed for medial meniscus tear.
10. Patient previously consulted on dated 08-02-22 at Sarwal hospital and as per OPD paper, patient consulted for c/o pain in knee and advised for MRI investigations. No h/o fall is specified in the OPD paper, ICP and insured statement.
11. In ICP, patient had h/o HTN but insured and doctor both refused for same.
12. No tariff list provided by the hospital Mumbai
13. As per insured, patient was admitted for the surgery of knee cyst and MRI investigation of revealed that patient is s/o cystic degenerative changes in left knee but in discharge summary, no cystic degenerative changes in left knee specified.

 

As the claim was not genuine, the company is not liable to pay any amount as per terms and conditions of the policy. Rest of the averments of the complainant were denied by OP No.1 and prayed for dismissal of the present complaint with exemplary costs.

4.           The OP No.2 was given up vide order dated 14.09.2022.
5.           Learned counsel for the complainants tendered affidavit of the complainant No.1 as Annexure CA alongwith documents as Annexure C-1 to C-49 and closed the evidence on behalf of the complainants. On the other hand, learned counsel for the OP No.1 tendered affidavit of Jaswinder Singh Shekhawat, Senior Manager-Legal and Authorized Representative of the OP No.1 i.e 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-5 and closed the evidence on behalf of the OP No.1.
6.            We have heard the learned counsel for the complainants and learned counsel for the OP No.1 and have also carefully gone through the case file.
7.           Learned counsel for the complainants submitted that by repudiating the genuine claim of the complainant no.1, despite the fact that OP No.1 was legally bound to pay for the amount spent on treatment of complainant no.2, as it was taken during existence of the policy in question, OP No.1 is deficient in providing service and also adopted unfair trade practice.
8.           On the contrary, the learned counsel for the OP No.1, while reiterating the objections taken in the written version submitted that the claim of complainant no.2 was rightly repudiated on the grounds of misrepresentation of facts and discrepancies found in the documents attached with the claim form. 
9.           The moot question which falls for consideration is, as to whether, the claim filed by the complainants was rightly repudiated by OP No.1 or not. It may be stated here that we have gone through the repudiation letter 30.03.2022, Annexure C-31 and also the stand taken by OP No.1 in its written version, wherefrom it is evident that the claim of complainant no.1 has been rejected on following grounds:-
   1. Visit to Insured has been made and Statement has been collected and as per insured, Patient admitted in the hospital on dated 15-02-22 for c/o knee cyst, knee pain and could not able to move. Patient had h/o complaints of pain since Jan 2022. Patient had no h/o similar complaints. No h/o fall and accident is specified via insured.
   2. Vicinity Check has been made and hospitalization is confirmed but no one knows about the patient past medical history.
   3. Visit to Hospital has been made and IPD entry, ICP, doctor statement, lab reports and final bills has been collected and verified.
   4. IPD Register has been checked as per Record DOA 15-02-22 DOD is 19-02-22
   5. ICP has been collected as per ICP patient presented in the hospital with complaints of pain left knee joint and tenderness left knee. Patient was underwent CBC, RFT, LFT, CRP, X-ray, ECG and MRI and other relevant investigations. Patient had h/o HTN but no duration is specified in the ICP. No h/o fall or accident is specified in whole ICP. Patient was treated surgically. PAC and OT notes maintained. History of DM and HTN is specified in the ICP and then scribbled.
   6. As per discharge summary, patient is diagnosed for medial meniscus tear lateral meniscus tear with osteochondral defects knee joint.
   7. Lab Register has not been maintained by the hospital.
   8. All Lab reports has been collected and verified. Patient was underwent MRI investigations and MRI is s/o cystic degenerative changes.
   9. Doctor Statement has been collected as per doctor patient admitted in hospital for the c/o pain knee joint since 2 days. Patient had h/o fall. Patient underwent MRI investigation. Patient had no h/o chronic illness. Patient was diagnosed for medial meniscus tear.
   10. Patient previously consulted on dated 08-02-22 at Sarwal hospital and as per OPD paper, patient consulted for c/o pain in knee and advised for MRI investigations. No h/o fall is specified in the OPD paper, ICP and insured statement.
   11. In ICP, patient had h/o HTN but insured and doctor both refused for same.
   12. No tariff list provided by the hospital Mumbai
   13. As per insured, patient was admitted for the surgery of knee cyst and MRI investigation of revealed that patient is s/o cystic degenerative changes in left knee but in discharge summary, no cystic degenerative changes in left knee specified.
   14. As per insured and ICP, there is no h/o accident or fall specified. No h/o fall and accident is specified in the first consultation paper but doctor manipulate the statement and mentioned that patient had h/o fall to cover the insurance.

 

10.           A bare perusal of the contents of the repudiation letter and also the written version of OP No.1 reveals that the main grounds of repudiation are:-
    1. Vicinity Check has been made and hospitalization is confirmed but no one knows about the patient past medical history.
    2. Patient had h/o HTN but no duration is specified in the ICP. No h/o fall or accident is specified in whole ICP. Patient was treated surgically. PAC and OT notes maintained. History of DM and HTN is specified in the ICP and then scribbled.
    3. Lab Register has not been maintained by the hospital.
    4. No h/o fall is specified in the OPD paper, ICP and insured statement.
    5. In ICP, patient had h/o HTN but insured and doctor both refused for same.
    6. No tariff list provided by the hospital Mumbai
    7. As per insured, patient was admitted for the surgery of knee cyst and MRI investigation of revealed that patient is s/o cystic degenerative changes in left knee but in discharge summary, no cystic degenerative changes in left knee specified.

 

11.           First coming to the objection taken by OP No.1 that vicinity Check has been made and hospitalization is confirmed, but no one knows about the patient past medical history, it may be stated here that in the Nurses Notes dated 15.02.2022 to 17.2.2022,   prepared by the Multispecialty Hospital, where the complainant no.2 was treated, it has been clearly mentioned that “No any past surgical and Medical Treatment”. It is further evident from the discharge summary of complainant no.2 (placed on record by OP No.1 itself alongwith claim form annexed along with Annexure R.3), wherein it has been clearly written by the doctors concerned that there is no such past history of patient, except mild hypertension. Under these circumstances, the stand taken by OP No.1 that no one knew the past medical history of the patient being devoid of merit stands rejected.
12.           Coming to the objection taken by OP No.1 that patient had h/o HTN, but no duration is specified in the ICP; No h/o fall or accident is specified in whole ICP; History of DM and HTN is specified in the ICP and then scribbled, it may be stated here that in the Questioner for Doctor obtained by OP No.1, which is a part of the discharge summary attached by OP No.1 itself, it has been clearly mentioned by the doctors concerned of Sarwal Hospital that complainant no.2 was suffering from pain in knee joint for the last 2 days.  At the same time it is also coming out from the document Annexure C-34 issued by Dr.Ashok Sarwal, treating doctor of complainant no.2 that he has clearly certified that complainant no.2 suffered injury of knee joint, due to history of fall from stairs. In this document, it has been clearly mentioned by the said doctor that she has no significant past history except recent history. As far as history of DM and HTN is concerned, it is further coming out from the Bed Head Ticket dated 15.02.20222, Annexure C-12 and also Doctors Notes dated 15.02.2022, Annexure C-13  that the BP of complainant no.2 was 119/79 and   125/89 respectively from which it cannot be said that he was a patient of sugar and hypertension. Mild increase of BP at the time of surgery is often seen in the patients. Under these circumstances, objection taken by OP No.1 in this regard also being devoid of merit stands rejected.
13.           Coming to the objection taken by OP No.1 that Lab Register has not been maintained by the hospital, it may be stated here that OP No.1 has failed to place on record any evidence to prove this objection. Even otherwise, OP No.1 being an insurance company cannot be said to be an expert to opine as to how that lab register should be maintained by the hospital. Mere bald objection taken in this regard cannot be considered. Under these circumstances, objection taken by OP No.1 in this regard also being devoid of merit stands rejected.
14.           Coming to the objection taken by OP No.1 that no h/o fall is specified in the OPD paper, ICP and insured statement, it may be stated here that this issue has already been discussed above and it is reiterated that from the document Annexure C-34 issued by Dr.Ashok Sarwal, treating doctor of complainant no.2, it is clearly coming out that the said doctor has certified that complainant no.2 suffered injury of knee joint due to history of fall from stairs. Under these circumstances, objection taken by OP No.1 in this regard also being devoid of merit stands rejected.
15.           Coming to the objection taken by OP No.1 that in ICP, patient had h/o HTN but insured and doctor both refused for same, it is reiterated that it is clearly coming out from the Bed Head Ticket, Annexure C-12 and also Doctors Notes Annexure C-13 that the BP of complainant no.2 was 119/79 and   125/89 respectively, from which it cannot be said that he was a patient of sugar and hypertension. Under these circumstances, objection taken by OP No.1 in this regard also being devoid of merit stands rejected.
16.           Coming to the objection taken by OP No.1 that no tariff list was provided by the hospital concerned, it may be stated here that it has not been justified by OP No.1 that if the said hospital has not provided the tariff list, then how complainants are responsible for that. The hospital concerned might be on the panel of OP No.1 and it could have easily wrote a letter to the said hospital to provide them the tariff list. However, instead of doing that, the complainants have been made scapegoat by OP No.1. Under these circumstances, objection taken by OP No.1 in this regard also being devoid of merit stands rejected.
17.           Coming to the objection taken by OP No.1 that as per insured, patient was admitted for the surgery of knee cyst and MRI investigation of revealed that patient is s/o cystic degenerative changes in left knee but in discharge summary, no cystic degenerative changes in left knee specified, it may be stated here that in the  from the document Annexure C-34 issued by Dr.Ashok Sarwal, treating doctor of complainant no.2 and also other medical record, it is clearly coming out that complainant no.2 suffered medial meniscus tear lateral meniscus tear with osteochondral defect knee joint on account of fall from stairs. Thus, it has been proved on record that the complainant had taken treatment for the said injury and also the doctor concerned has confirmed the same, as such, in this view of the matter, objection taken by OP No.1 in this regard also being devoid of merit stands rejected.
18.           In the peculiar facts and circumstances of this case, it can easily be said that all the grounds taken by OP No.1 to repudiate the claim of complainants are based on presumptions and assumptions only and are vague. Nothing has been placed on record to prove that the complainant no.2 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 on her treatment, under the currency of the policy in question.  Thus, by repudiating the genuine claim of complainants, the OP No.1 is deficient in providing service and also adopted unfair trade practice.  The complainants are therefore held entitled to get the entire amount spent on the treatment of the complainant No.2. From the bills/invoice Annexure C-1, C-3 to C-5 and Annexure C-18 to C-19, it is evident that the complainants have spent Rs.97,242/- on the treatment of the complainant No.2. As such, the OP No.1 is liable to pay/reimburse the said amount to the complainants and not Rs.1,07,806/-, as claimed by them. The OP No.1 is also liable to pay interest on the said amount of Rs.97,242/- and also compensation for the mental agony and physical harassment suffered by them alongwith litigation expenses.
19.           In view of the aforesaid discussion, we hereby dismiss the present complaint against OP No.2 (being given up) and partly allow the same against OP No.1 and direct it, in the following manner:-  
    1. To pay/reimburse the amount of Rs.97,242/-, (as per bills attached) to the complainants alongwith interest @6% p.a. from the respective dates of payment, till realization.  
    2. To pay Rs.3,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.2,000/- as litigation expenses.

 

The OP No.1 is 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 OP No.1 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:- 20.09.2023.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President.