Chandigarh

DF-I

CC/269/2022

Tushar Bhardwaj - Complainant(s)

Versus

ManipalCigna Health Insurance Co. Ltd. - Opp.Party(s)

Deepak Aggarwal

02 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                                     

Consumer Complaint No.	:	CC/269/2022
Date of Institution	:	04/03/2022
Date of Decision	:	02/08/2024

 

Tushar Bhardwaj son of Sh. Tejasvi Kumar, aged 40 years, House No.3447, First Floor, Sector 27-D, Chandigarh-160019.

… Complainant

V E R S U S

1.     ManipalCigna Health Insurance Company Limited, Registered Office at 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai 400063. through its Directors/Authorized Signatories.

2.     ManipalCigna Health Insurance Company Limited, Corporate Office at 1st Floor SCO 149/150 Sector 9-C, next to Yes Bank, Chandigarh 160009 through its Directors/ Authorized Signatories.

3.     Narottam Puri, Director, ManipalCigna Health Insurance Company Limited 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai 400063.

4.     Jason Dominic Sadler, Director, ManipalCigna Health Insurance Company Limited, 1st Floor SCO 149/150 Sector 9-C, next to Yes Bank, Chandigarh 160009.

… Opposite Parties

5.     Fortis Hospital, Sector 62, Phase - VIII, Mohali, Punjab, India, Pincode-160062 through its Authorized Signatory.

…. Proforma party/OP

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Sh. Deepak Aggarwal, Advocate for complainant
	:	Sh.Vikramjeet Singh, Adv. Proxy for Sh.Inderjeet Singh, Adv. for OPs 1 to 4 (defence struck off vide order dated 10.4.2024
	:	Sh.Munish Kapila, Adv. or OP-5 (defence struck off vide order dated 10.4.2024)

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Tushar Bhardwaj, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that on 27.10.2015, complainant had obtained an insurance policy namely “ProHealth - Protect Family Floater” from OPs 1 to 4 (hereinafter referred to “insurer”) for himself and his wife Smt.Neena Bhardwaj valid w.e.f. 27.10.2015 to 26.10.2016 and got the same renewed from time to time and the last policy was valid w.e.f 15.12.2019 to 14.12.2020 (Ex.C-1) (hereinafter referred to as “subject policy”) with sum insured of ₹2,50,000/-. On 24.2.2020, complainant met with an accidental gunshot injury, as a result of which he was taken to OP-5 hospital (hereinafter referred to as “treating hospital”) where he was asked to make payment upon which the complainant asked to raise claim with the insurer as he was having the subject policy.   However, to the utter shock of the complainant, insurer denied the cashless facility to the complainant without disclosing any valid reason. After treatment, complainant was discharged from the treating hospital on 4.3.2020 upon making the entire payment from his own pocket.  The treating hospital handed over letter dated 6.3.2020 (Ex.C-2) to the complainant, received from the insurer through which it was informed that the liability of the insurance company cannot be determined at that juncture.  Thereafter the complainant was again admitted in the treating hospital on 15.3.2020 and again the insurer denied the claim of cashless facility by conveying that the liability of the insurance company cannot be determined.  Even after that, when the claim of the complainant was not settled by the insurer till November 2020, he started communication with the insurer and only then he was informed that his claim has been denied/rejected on the ground that there was delay on his part to submit the claim.   However, due to lockdown in the country w.e.f.22.3.2020 and also due to fracture in femur bone of his leg, he was advised bed rest with zero mobility, the complainant could not submit the claim with the insurer.  In this manner, the aforesaid act of the OPs 1 to 4/insurer in wrongly rejecting/denying the claim of the complainant amounts to deficiency in service and unfair trade practice on their part. OPs 1 to 4 were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. Since the OPs had filed their separate written versions after the prescribed period, therefore, their defence was struck off and their written versions were taken off the record vide order dated 10.4.2024 of this Commission.

2. In order to prove his case, complainant has tendered/proved evidence by way of affidavit and supporting documents.
3. We have heard the learned counsel for the contesting parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that complainant had obtained the subject policy (Ex.C-1) from OPs 1 to 4/insurer valid w.e.f. 15.12.2019 to 14.12.2020 with sum insured of ₹2,50,000/- and the complainant had suffered gunshot injury on 24.2.2020 for which he had taken treatment from the treating hospital where he remained admitted w.e.f. 24.2.2020 to 4.3.2020 and 6.3.2020 to 15.3.2020, as is also evident from the discharge summary (annexed with Ex.C-4 colly.at page 111) and email (Ex.C-5 colly. at page 166), and also that the request made by OP-5 on behalf complainant to the insurer for approval of cashless treatment was denied by the insurer on the ground that adequate queries have not been replied by the treating hospital, as is also evident from Ex.C-2 and C-5 (colly.), the case is reduced to a narrow compass as it is to be determined if the OPs/insurer are unjustified in denying/rejecting the approval for cashless treatment of the complainant and complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant or if the OPs have rightly denied/ rejected the approval for cashless treatment of the complainant and the consumer complaint of the complainant, being false and frivolous, is liable to be rejected, as is the defence of the OPs. 
   2. Perusal of the medical record (Ex.C-4 colly.) pertaining to the treatment of the complainant clearly indicates that he was firstly admitted in the treating hospital on 24.2.2020 and was discharged on 4.3.2020 where he was treated for gunshot injury and was again admitted in the treating hospital w.e.f. 6.3.2020 to 15.3.2020.  It is further clear from Ex.C-2 & Ex.C-5 that the request for cashless approval was denied to the complainant by the insurer on the ground that specific queries have not been replied by the treating hospital or by the complainant.
   3. Detail of the alleged injury suffered by the complainant, as mentioned in the discharge summary, is reproduced below for ready reference:-

       “PRESENT ILLNESS

Patient presented to FHM with the chief complaints of pain and bleeding from left knee=3 hours. Patient had an alleged history of Gunshot injury (forearm injury) DOI-24/2/2020, TOI=7:35 PM, DOA-24/2/2020, TOA11:00PM. Patient had alleged history of physical assault with gunshot injury took place on 24/2/2020 at around 7:35 pm at phase 11 from where patient was taken to GMC-32 got primary treatment there and then brought to FHM Emergency for further management."

4. Perusal of the remarks given by the insurer, while denying the cashless facility to the complainant, shows that it was mentioned that the claim cannot be considered and the liability of the insured cannot be determined at that juncture as further evaluation is required.

    "We have received a cashless request for Grade 3 Open fracture distal femur left with fracture patella. Claimant covered under policy since 27 Oct 2015. Even after raising repeated queries for mode if Injury and MLC we have not received adequate query replies, Hence liability of the Insured cannot be determined at this Juncture. Please file for reimbursement with all documents. Need further evaluation and verification for history of the ailment. We regret our inability to admit this liability."

5. However, it is clear from the letter dated 6.3.2020 that, in fact, OPs 1 to 4/insurer have denied the cashless facility to the complainant in a very casual and technical manner, without making evaluation or verification of the history of the ailment, which otherwise was the bounden duty of the insurer to do the same after receiving intimation about the treatment taken by the complainant from the treating hospital and also that the treating hospital had twice made request to them for the approval of cashless facility to the insured/complainant.
6. Not only this, it has not been coming from any documents adduced on record that OPs/insurer ever made any attempt or effort to verify the history of the ailment of the complainant through their independent agency despite of the fact that the complainant had submitted all the medical record with respect to his treatment taken from the treating hospital and the treating hospital has also admitted that the complainant was treated in its hospital for gunshot injury where he remained admitted.  Hence, it is safe to hold that the act of OPs 1 to 4/insurer in denial of cashless facility and closure of the complainant’s claim, certainly amounts to deficiency in service and the present consumer complaint deserves to succeed.
7. Now coming to the quantum of amount to be granted in the present case, no doubt the complainant has produced medical bills to the tune of ₹4,28,470/-, but, since the sum insured under the subject policy is ₹2,50,000/- only and the complainant has also claimed the said amount, it is safe to hold that OPs 1 to 4/insurer are liable to pay the sum insured of ₹2,50,000/- to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1 to 4 are directed as under :-

1. to pay ₹2,50,000/- to the complainant alongwith interest @ 9% per annum (simple) from the date of making payment by the complainant i.e. 9.3.2020 onwards.
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OPs 1 to 4 within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Since OP-5 is merely a proforma party and no relief has been claimed against it, the consumer complaint against OP-5 stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

02/08/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member