| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No.210 of 11.09.2020 Decided on : 22-05-2024 Sukhmander Singh aged about 37 years S/o Darshan Singh R/o 638, Village Seman, Tehsil and District Bathinda. ........Complainant Versus ManipalCigna Health Insurance Co. Ltd., 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai-400063. .......Opposite party Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Smt. Priti Malhotra, President Smt. Sharda Attri, Member Present : For the complainant : None for the complainant. For opposite party : Sh.Vinod Garg, Advocate. ORDER Priti Malhotra, President The complainant Sukhmander Singh (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against ManipalCigna Health Insurance Co. Ltd. (here-in-after referred to as opposite party). Briefly stated, the case of the complainant is that he purchased one medical policy from opposite party. At that time, the company asssued that during the validity of the policy, the company will provide medical expenses immediately upto Rs.3,50,000/-. Opposite party also issued policy bearing No.PROHLR 980094816 valid from 18.7.2019 to 17.7.2020 for the cashless hospitalization upto Rs.3,50,000/-. It is alleged that on 10.1.2020, the complainant suffered from Dyspnea, cough and fever and became serious. He got admitted in Kalra Multi Specialty Hospital, Ajit Road, Bathinda and doctor concerned gave him treatment. The family of the complainant informed opposite party and requested it to pay the amount of treatment, but it lingered on the matter on one or the other pretext and it could not pay any heed to his requests. It is further alleged that at the time of discharge of the complainant from the hospital, he lodged the insurance claim of Rs.1,06,000/- for cashless treatment with opposite party in terms of insurance policy obtained by the complainant. Opposite party sanctioned cashless medical expenses to the tune of Rs.1,06,000/- and assured the complainant that the amount of claim shall be reimbursed after final bill of the hospital. As such, he deposited a sum of Rs.1,06,000/- with the hospital. At the time of discharge, the complainant requested opposite party to reimburse the insurance claim, but it refused to pay the medical expenses without assigning any reason. The policy ensure cashless for all indoor medical treatment, pre and post hospitalization specified as defined, day care procedures, (requires less than 24 hours hospitalization) and OPD medical expenses relating to chronic disease up to a sum of Rs.3.50 lakhs per year on floater basis. Medicines for disease is also available on cashless basis from designated stores and hospitals in every district and block. Also all pre existing diseases are covered. It is further alleged that the complainant is entitled for medical expenses up to a sum of Rs.3.50 lakhs during the policy period i.e. 18.7.2019 to 17.7.2020. He also sent e-mails for claim to opposite party, but it repudiated the claim. On this backdrop of facts, the complainant has prayed for directions to opposite party to honour his lawful claim and to make payment of the insurance claim of Rs.1,06,000/- alongwith upto date interest @18% p.a. w.e.f date of lodging of the claim till its realization and to pay Rs.3,50,000/- as compensation and Rs.11,000/- as litigation expenses. Upon notice, opposite party appeared through counsel and contested the complaint by filing written version and raising legal objections that the intricate and contentious questions of fact and law are involved in the complaint. They require extrinsic oral and voluminous documentary evidence. It cannot be decided by way of summary jurisdiction enacted before this Commission. The complainant has concealed real facts from this Forum. In fact, a claim for reimbursement of medical expenses was received by opposite party for admission of complainant in Kalra Hospital, Bathinda from 10.1.2020 to 19.1.2020 with complaints of chest infection as he was covered under ManipalCigna Health Insurance Prohealth (Protect) policy since 19.6.2018. On verification of the case and the hospitalization documents, multiple discrepancies were noted and documents were found to be manipulated during verification. Hence, claim was repudiated vide repudiation letter dated 20.3.2020 under Clause VIII.19. The discrepancies and manipulations found during processing of claim are as under: i) Date of discharge has been manipulated at multiple places: Scribbling has been noted over the date of discharge in ICP as well as Admission Register wherein Date of Discharge has been changed from 16.1.2020 to 19.1.2020. No justification in ICPS for extending length of stay. ii) On admission, no notation of symptoms done in ICPS. The complainant has been admitted to ICU, but no reason of corroborating symptoms noted on ICPS: though as per hospital final bill, patient was admitted for 8 days in ICU and for 2 days in private room, but no such notes of patient being admitted in ICU are available in ICP. No notes of patient’s room being changed is available in ICP. iii) No indication given as to why nebulization has been advised here. Patient is in ICU but monitoring has only been done once in a day. iv) No symptoms or complaints noted anywhere in the ICPS. No progression of symptoms noted either. Need for ICU admission is not clear as the vitals are near normal everywhere. No name or stamp of attendant doctor or RMO anywhere, no evidence that who has seen and managed the patient. Though doctor visit charges for 20 visits have been charged in final bill, but doctor has entered notes only for one time per day. Same treatment has been given to the patient throughout the hospitalization despite the fact that the insured almost never had fever after first day of hospitalization. No mention of ICU stay even in discharge summary. No name or stamp of treating doctor on discharge summary. v) SPO 2 monitoring not done on vital chart. vi) On visit to pathology lab, no register was shown. As per Star Lab, it did not maintain any copy of lab reports and neither maintains any entry for same. Carbon copy of bills and tariff list was not provided by the hospital. As per doctor, path lab has been in-door but all the tests of patient during hospitalization were done in outdoor lab. No reference number or IPD number on pathology reports. Though tests conducted on 10th and 12th January were almost same and only 4 tests were conducted extra on 10th, but though, Rs.3030/- was charged on 10th January, but only Rs.750/- was charged on 12th January. No chest X-ray advised inspite of respiratory symptoms. vii) Hospital final bill and receipt have handwritten numbers. The relevant Clause No. VIII.19 reads as under: “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 under this policy shall be void and all 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 payment.” However, in the alternative, in case, this Commission comes to the conclusion that the complainant is entitled to any relief, only in that case, it opposite party reserves its right to decide the claim of the complainant as per policy terms and conditions as its admissibility and quantum. It is further pleaded that the complainant has not given any affidavit to the effect that he has not claimed the amount claimed in this case from any other person or individual or insurance company through any other FORA, PLA or MACT. He has no locus-standi or cause-of-action to file the complaint. The complainant does not fall within the definition of ‘consumer’ as laid down by 'Act'. He has violated the terms and conditions of policy and as such, no claim is payable to him. The complaint is bad for non-joinder of necessary parties. The complainant has not impleaded Kalra Hospital, Bathinda as party to the complaint from where he took treatment. As such, the complaint is liable to be dismissed on this ground. On merits, opposite party has reiterated its stand as taken in the legal objection as detailed above and controverted all other averments of the complainant and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 11.9.2020, (Ex.C4) and documents, (Ex. C1 to Ex. C3). In order to rebut the evidence of complainant, the opposite party has tendered into evidence affidavit of Akhil Kulhari dated 13.11.2020, (Ex.OP1/5) and documents, (Ex.OP1/1 to Ex.OP1/4 and Ex.OP1/6 to Ex.OP1/7). We have heard learned counsel for opposite party and gone through the file carefully. Learned counsel for opposite party has reiterated his stand as taken in the written version as detailed above. We have given careful consideration to these submissions. Perusal of file reveals that the complainant has availed insurance policy bearing No.PROHLR 980094816 valid from 18.7.2019 to 17.7.2020 for the cashless hospitalization upto Rs.3,50,000/-, (Ex.OP1/3). On 10.1.2020, the complainant suffered from Dyspnea, cough and fever. He got admitted in Kalra Multi Specialty Hospital, Ajit Road, Bathinda and remained admitted there from 10.1.2020 to 19.1.2020. Discharge summary, (Ex.C2) proves this fact. After discharge from the hospital, the complainant lodged the insurance claim of Rs.1,06,000/- with opposite party, but opposite party rejected his claim vide e-mail dated 20.3.2020 on the ground that 'on verification of the case and hospitalization documents, multiple discrepancies are noted', moreover a bare perusal of documents such as discharge summary, bills, (Ex.C2) and medical record, (Ex.OP1/4) reveal no discrepancies in the treatment given to the complainant and hospitalization of complainant and treatment given to him seems genuine. Thus, there is deficiency in services on the part of opposite party for rejecting the claim of the complainant. For the alleged discrepancies, opposite parties were free to investigate from the hospital from where the complainant took treatment and the burden to prove the claim is not genuine is on opposite parties which they failed to discharge. In view of what has been discussed above, present complaint is partly allowed with Rs.10,000/- as cost and compensation against opposite party. opposite party is directed to settle and pay the claim of the complainant as per its terms and conditions. The compliance of this order be made within 45 days from the date of receipt of copy of this order. In case of non-compliance of the order within the stipulated period, thereafter opposite party will be liable to pay additional cost of Rs.15,000/- to the complainant. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 22-05-2024 - (Priti Malhotra)
President (Sharda Attri) Member
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