Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 195/2019
Harmeet Singh,
r/o 3257 Ground Floor, Ranjeet Nagar,
South Patel Nagar, New Delhi-110008 …Complainant
Versus
Max Bupa Health Insurance Company Ltd.
39, 3rd Floor, Samyak Towers, Pusa Road,
WEA Karol Bagh, New Delhi-110005 ...Opposite Party
Date of filing: 24.06.2023
Date of Order: 20.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Inder Jeet Singh
ORDER
1.1. (Introduction to case of parties) – The complainant has grievances of deficiency of services as he was denied medical reimbursement claim of Rs. 71,459/- under the policy no. 30517862201802. This medical claim pertains to post hospitalization of first episode (in which date of admission was 20.01.2019 to 24.01.2019 and also post hospitalization of second episode (date of admission 10.02.2019 to 14.02.2019) from Kailash Nursing Home. In continuation of the series of diagnosis and treatment, the complainant had undergone various evaluation, treatment and day care at Ganga Ram Hospital from 21.02.2019 to 21.02.2019), where further medical expenses were incurred, the OP declined the reimbursement by invoking exclusiion clause no. 8.16 of terms and conditions of policy that the expenses are not covered under that clause being permanent exclusions. In fact, as per insurance policy cover, there is specific covenant that ‘permanent exclusions are not applicable’.
1.2. The OP has opposed the claim by twin aspects of reply, firstly the hospitalization in the first episode and in the second episode vis-à-vis pre-authorisation of claim are matter of record, they are not disputed. So far post hospitalization medical claim, after the first episode and the second episode as well as the other medical expenses incurred in Ganga Ram Hospital, which are claimed to be Rs. 71,459/- are falling in the permanent exclusion clause no. 8.16 of the policy and the repudiation was in terms of contract of insurance policy. It was rightly declined.
1.3. It is relevant to mention that the record of pleadings and documents of the parties are voluminous. The complainant has narrated the facts in detail in a chronological way from the inception and similarly the OP has filed the reply. Moreover, the documents have also been filed as per narration given in the pleadings.
However, it does not require to load this final order with such minute detail of cases of the parties, however, the material and relevant facts and documents will be mentioned so that facts in the issue may be determined.
2.1. (Case of complainant)–The complainant had purchased medi-claim insurance policy no. 30517862201803 for sum insured of Rs. 37,00,000/- from OP for period having expiry date of 29.03.2019 for himself and his family members, he paid huge premium of Rs.45,949/- against receipt dated 27.03.2019. The paragraph nos. 3 to 5 mention about first episode of his admission in Kailash Nursing Home, where he remained as indoor patient from 20.01.2019 to 24.01.2019, he was discharged with certain medical advices (discharge summary is at page 70-71). There was request for cashless facility of Rs. 48,692/- and it was authorized and sanctioned for Rs.42,324/-. After his discharge, he had also gone for medication etc. for which he had purchased pharmacy. Further, The paragraph nos. 6 and 7 mentions about second episode of his admission in Kailash Nursing Home, where he remained as indoor patient from 10.02.2019 to 14.02.2019, he was discharged with certain medical advices inclusive of preventive (discharge summary is at page 84-85). There was request for cashless facility of Rs.46,281/- and it was authorized and sanctioned for Rs.39,771/- by OP. In the discharge summary he was specifically recommended preventive advice of plenty of fluids, soft diet and advice of ante-grade enteroscopy in follow-up. After his discharge, he had also gone for medication. Moreover, the complainant was in his young age of 30 years and because of severe and highly painful illness that too the previous episode had reoccurred, that is why, he was to be readmitted in the hospital, it was a tremendous amount of concern to the complainant and his entire family to overcome with the worst case scenario, the complainant had also lost 15 kgs of weight in a short period of two months. The complainant shared all such aspects with the treating medical practitioner at Kailash Nursing Home that his illness is very much persisting and the earlier diagnosis was inconclusive and it was opined that further diagnostic investigations were required to deduct the root of illness. The paragraph no. 9 of the complaint makes complete detail thereof.
2.2. On 12.02.2019 (when complainant was indoor patient) the C.T. entroclysis/enterography image test of complainant was conducted for which he was admitted at Doctor Doda Diagnostic and Healthcare Ultrasound Center on the advise of treating medical practitioner. The complainant was admitted in the lab at Old Rajender Nagar and remained there for over 3 hours for investigation procedure. In the opinion of treating medical practitioner, it was expedient that a careful diagnosis of small intestines region of the complainant must be conducted, since complainant was experiencing stomach pain, nausea and vomiting, which are also symptom of stomach cancer. At this diagnostic procedure did not reveal cause of persisting illness and it was concluded for further clinical evaluation was necessary to deduct the illness of complainant by adopting the best available evidence gathering tools.
2.3. It was in guidance and advice of the treating medical practitioner that complainant requires advance enteroscopy in follow-up. Therefore, in continuation of his seeking treatment for his persistent illness and following the advice and direction of treating medical practitioner, the complainant took appointment of specialist doctor at Ganga Ram Hosptial, New Delhi, which had necessary clinical capabilities for conducting invasive enteroscopy to obtain direct view of deeper regions of the small intestines. The complainant informed OP on its dedicated customer helpline about the status of ongoing treatment and about the treating medical practitioner’s advice for such advance testing to diagnose the cause of illness. The complainant was advised by OP’s personnel that test procedure was to be conducted at Sir Ganga Ram Hospital although it did not qualify for a cashless claim and the complainant may have guidance from the treating doctor for reimbursement, post-completion of procedure.
2.4. On 21.02.2019 ante-grade double balloon enteroscopy test was conducted followed by retrograde double balloon enteroscopy on 22.02.2019 at Ganga Ram Hospital, its result was delivered on 26.02.2019 and no abnormalities inside the small intestines were found. The test results helped put to rest the worst case fear and an anxiety of the complainant and his family. Then again it was followed by visits to treating doctor at Kailash Nursing Home for further follow up and advices.
2.5. The paragraph no. 17 onward of the complaint are pertaining to lodging of the claim by the complainant and its repudiation by the OP. Briefly, the complainant applied for reimbursement of medical expenses on 15.03.2019 for sum of Rs. 71,459/-, the OP split them into two claims viz. claim no. 41147 for Rs. 20,542/- and another claim no.409568 for Rs.50,917/-. There was also email correspondence between the parties. However, by letter dated 26.03.2019 the claim of Rs. 20,542/- was repudiated by OP on the ground that original cash receipt and day care summary, bill break-up were not provided (letter at page 115 of the paper-book of the complainant). By another letter dated 28.03.2019 (at page 118) the other claim of Rs. 50,917/- was also repudiated by the OP on the ground of permanent exclusion clause 8.16 of the policy that evaluation, investigation are not covered and hospitalization was not justified. The complainant opposed it that the plea of OP is contrary to record as all documents were furnished to the TPA/OP and invoking of clause 8.16 is even against the policy cover note issued; the OP cannot act against the terms of policy contract, since there is specifically mentioned ‘none- against permanent exclusion clause, if any’. The OP was also issued legal notice dated 11.05.2019 but there is no compliance and reply. The complainant has valid case of reimbursement of medical bills, within the parameter of policy but it was repudiated, it is severe deficiency in service. That is why the complaint for claim amount of Rs. 71,459/-, compensation of Rs. 70,000/- for causing mental agony, pain, harassment suffered due to wrongful acts of material deception and unfair trade practice of OP, cost of Rs. 15,000/- apart from interest at the rate of 12% pa.
2.6. The complaint is accompanying with documentary record of premium receipt, insurance certificate, terms and conditions, authorization letter dated 24.01.2019, medical report, discharge summary dated 24.01.2019. Further authorization letter dated 14.02.2019 of second episode of hospitalization, medical test reports, doctor Doda’s imaging test report, discharge summary dated 14.02.2019. The complainant has also filed the test report carried at Ganga Ram ospital, cash receipts, email, SMS of claim rejection, repudiation letter/ email dated 26.03.2019, repudiation letter/ email dated 28.03.2019 and copy of legal notice.
3.1 (Case of OP)- The OP filed detailed written statement with record, it is also voluminous since it has been split into various heads as general submissions, preliminary objections, preliminary submissions, reply on merit and reproduction of certain clauses from the policy.
Briefly, the OP does not dispute certain facts with regard to first episode of hospitalisation, its pre authorization, second episode of hospitalization and its pre-authorization. However, the OP justifies that the parties are governed by terms and condition of the policy, the rejection/ repudiation letters were issued in terms of the policy. The reply is accompanied with proposal form the claims lodged by the complainant, the other record which were furnished by the complainant to the OP. As per clause no. 8.16 of the policy that hospitalization of complainant in Sir Ganga Ram Hospital was done only for evaluation and investigation purposes, which is not covered in policy. The terms and conditions of policy binds both the parties, therefore, principle of estopple applies and the complainant cannot file the claim or complaint against that terms and conditions of the policy.
In the cover note there is mentioning of word ‘none’ which the complainant is claiming in support of his claim, however, the legend ‘none’ appears in the column Permanent Exclusions of the insurance certificate but it basically applies on any adverse declared pre-existing medical or physical condition or treatment of the insured person, if specifically mentioned in the schedule of insurance certificate and disclosed at the time of taking the policy and has been accepted by the insured person. Since there is specific exclusion clause, it does not permit hospitalization for the purposes of evaluation and investigation; therefore, the bills raised were pertaining to just investigation and evaluations. The claim was not permissible within the policy and that is why it was repudiated.
3.2. The claim no. 411147 was disallowed since original cash receipt, day care summary and bill break-up was not provided, apart from it was not in consonance with clause no. 8.16 of the policy. The other claim no. 409658 was also rightly disallowed in consonance with the terms and conditions of the policy especially clause 8.16.
In view of the facts and features of the case, being within the parameter of insurance policy, there is no deficiency of services or what to talk of severe deficiency of services. The complaint is liable to be dismissed.
4. (Replication of complainant) - The complainant filed replication and he opposed all the allegations of the written statement. The complainant has been reaffirmed correct. Further, the defence taken by the OP is highly restrictive, arbitrary apart from mis-interpretation of terms and conditions of policy in a way that is unfair and detrimental to the right and valid claim of complainant. The OP is also misleading by referring clause 8.16 (Hospitalisation not justified) but by reading clause 12.23 (evidence based clinical practice), the OP is giving incomplete and restrictive meanings to avoid medical claim. Moreover, clause 9.1a also mandates that patient is bound by advise, guidance and directions given by treating doctor. However, OP is penalizing the complainant, for following all the instructions of treating doctor, by denying valid claim. The OP is very cleverly narrating selected facts and suppressed the material facts as it would expose misconduct of OP as well it would demolish the defence. The claim was intimated to OP on 15.3.2019 during the recovery period and not on 17.3.2019 as alleged. It was 24.3.2019, when complainant had received communication seeking specified addition information (of break-up of day care bill dated 21.2.2019) and immediately on 24.3.2019 the information was sent to OP by two emails addresses, it was delivered at one of email addresses. Just after two days thereof, on 26.03.2019, email was sent to complainant of repudiating the claim, the same letter was filed with the complaint (at page 115 of complaint) but OP filed repudiation letter of 16.5.2019 (at page 71 of reply), it is fabricated and it is not acceptable. The OP is further misleading that despite furnishing the record, which were received by the OP, it had issued repudiation letter dated 28.3.2019 (at page 118 of complaint) but OP filed repudiation letter bearing date 16.5.2019 (at page 73 of reply), it is fabricated, it is being denied by complainant. The replication also denies all other allegation of reply, by reproducing clause 8.16 and substance of clause 12.23, to emphasize that complainant was under medical advice, instructions, follows up and he raised valid claim. The exclusion clause does not apply because it was made non-applicable.
5.1. (Evidence)- The complainant led his evidence by filing his detailed affidavit with documentary record filed with complaint, coupled with certificate u/s 65B of the Indian Evidence Act 1872 in respect electronic record filed. He also reproduces certain clauses from the insurance policy in support of his plea.
5.2. On the other side OP lead had led evidence by filing affidavit of Chandrika Bhattacharya Chief Manager Legal, it is a detailed affidavit being replica with documents of written statement, it also refers insurance policy clauses (by partly reproducing it) to establish that hospitalisation was not justified within the terms and conditions of policy.
6. (Final hearing)- At this stage, both the sides filed their respective written arguments followed by oral submissions by Shri Harveer Singh Chadha, Advocate for complainant and Ms. Nimisha Sharma, Advocate for OP.
7.1 (Findings)- The rival contentions are considered, keeping in view material on record. There is no dispute of relationship of the complainant and the OP as of the Insured and the Insurer respectively, the tenure of policy period, two episodes of admissions of complainant in Kailash Nursing Home, pre-authorisation and sanction of bills thereto and also admission in Sir Ganga Ram Hospital.
However, the dispute is regarding entitlement of reimbursement of medical bills amount of claim lodged post discharge from Kailash Nursing Home and from Sir Ganga Ram Hospital; dispute of reasons for repudiation of claims, apart from allied disputes on point of furnishing of documents to OP, dates of repudiation letters furnished by OP. All of them will be discussed and determined.
7.2.1 First of all the issue of furnishing or non-furnishing of documents to OP is being taken.
Accordingly to complainant, all the documents were furnished to the OP along-with claim form. However, OP contends that the complainant was asked to furnish the record and break-up of day care but it was not furnished. But complainant also supplements that there two email addresses, the record was sent, however, it was success in one email address and acknowledgment was confirmed to him on whatsapp.
7.2.2 To resolve this issue, it needs to look into the documentary record filed and proved by the parties. The OP has proved claim form (which is at page no.30-31, which has been repeated at page 44-45 of OP's paper book). It is a single claim form furnished by complainant for entire bills of Rs.71,459/-. This claim form is prescribed form by the OP. In section-P, the complainant had given detail as well as furnished the bills apart from other information in the form. In addition, there is prescribed check-list of documents of claim form by OP (at page 42-43 of its paper-book), it also shows acknowledgement of papers.
The OP had sought additional information by its letter dated 17.3.2019 "please provide the break-up of day care bill dated 21.2.2019" (page 106 of paper book of complainant). Then complainant sent the requisite information/documents as per emails (page 107-112), which was acknowledged by OP vide whatsapp message (page 113). Moreover, the complainant has also proved that record of break-up and bills (at pages 94-104), which was sent by email.
To say, the complainant was asked additional information and documents by OP, which was furnished by complainant as desired. However, the OP had split the claim into two claims by assigning claim no. 41147 for bills of Rs.20,542/- of 22.2.2019 and claim no.409658 for bills of Rs.50,917/- of other bills from January 2019 to March 2019. Therefore, it is held that documentary record issued by OP stand proved that all requisite information and documents were furnished to the OP by the complainant.
7.3.1 Secondly, dates of repudiation letters are being considered. There are rival plea and explanations.
7.3.2 The case of complainant is that claim no. 41147 of Rs.20,542/- was repudiated vide letter dated 26.3.2019 and claim no. 409658 of Rs.50,917/- was repudiated vide letter dated 28.3.2019 (pages 115 & 118 of complaint). However, the OP filed repudiation letter dated 16.5.2019 in respect of claim no. 41147 of Rs.20,542/- and repudiated letter dated 16.5.2019 in respect of other claim no.409658 (Annexure R4 and Annexure-R5 at pages 71 and 73 of reply). The complainant contends that both the letters are fabricated.
7.3.3 Whereas, it is explained on behalf of OP that repudiation letters were issued to the complainant, however, the Annexure R-4 and Annexure-R5 bear the dates of 16.5.2019, both letters are bearing date of printing of letter i.e. 16.05.2019. It happened because of technical reasons with the tool and machine. They are not fabricated letters. Otherwise, the claims were repudiated.
7.3.4 In order to determine this issue, it is to be analysed from pleading and evidence. The paragraphs no.19 and 20 of the complaint mention dates 26.3.2019 and 28.3.2019 and it also refers both letters of 26.3.2019 and 28.3.2019. The complaint and documents are matching each other.
However, the OP in its written statement (dated 17.09.2019) does not mention exact dates of repudiation nor such dates of letters of 26.3.2019 and 28.3.2019 of repudiation. It just narrates letter dated 28.3.2019 is matter of record. However, OP files Annexure-R4 and Annexure-R5 (both dated 16.5.2019) in support of its plea. There is no explanation in the written statement about dates of Annx. R4 and Annx. R5 that they are printing dates of letters. Moreover, there is no explanation even in evidence led. What appears is that on the one side the OP in its reply says that one of letter dated 28.3.2019 is matter of record and it silent about other letter but simultaneously filed repudiation letters of 16.5.2019 in support of plea. The OP is appearing to be in dilemma. In addition, if letter bears the date when the same are generated, then it would also means dates (26.3.2019 and 28.3.2019) appearing on repudiation letters are printed date and actual date would be some other date.
There is another documentary record of whatsapp proved by the complaint. The first whatsapp message is of 25.3.2019 and second message is of 27.3.2019 [at pages 113 and 114 in respect of claim no.411147 and 409658] that claims cannot be approved in terms of policy and further details will be given on email. Thence those letter were issued. Thus, it concludes that on 25.3.2019 and 27.3.2019 OP had formed opinion or repudiated the claim that claims cannot approved in terms of policy and then letters dated 26.3.2019 and 28.3.2019 were issued.
It remains mystery or otherwise, the OP could not explained how it could be treated printed date of 16.5.2019 on letters, when usually letter are issued with date. It is also not reconciling that if letters were generated during the course of preparing or filing with written statement, then written statement is of 17.9.2019, which is after 4 months of letters bearing date 16.5.2019. But, the legal notice dated 14.5.2019 was served to OP, it was not replied by OP. The dates 16.5.2019 mentioned on Annexure R-4 and Annexure R-5 are around date of legal notice. With this conclusions, the issue stand disposed off. But the contents of repudiation letter produced by complainant are same in the letters produced by OP (except dates).
7.4.1 The Last issue is core issue whether the complainant is entitled for claims lodged or was it properly repudiated by virtue of exclusion clauses. It needs to assess the contents of repudiation letters. Further, the OP refer clause 8.16 being permanent exclusion clause but the complainant opposed it on the basis of other clauses in the insurance policy contract, therefore, it is appropriate to reproduce them -
"Clause 8 Permanent Exclusions - A permanent exclusions will be applied on any medical or physical condition of an insured person, if specifically mentioned in the Schedule of insurance certificate and has been accepted by You. This option will be used for such conditions (s) or treatment (s) that otherwise would have resulted in rejection of insurance coverage under the policy to such insured person.
We shall not be liable to make any payment under this policy directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following, unless specially mentioned elsewhere in the policy. (page 29)
xxx
"Clause 8.16 - Hospitalisation not justified - Admission solely for the purposes of physiotherapy, evaluation, investigation, diagnosis or observation services or not consistent with standard treatment guidelines (as reerred by Clinical Establishments (Registration & Regulation) Act 2010 and amendment thereafter) of the Evidence Based Clinical Practice".(page 30)
xxx
"Clause 12.23 - Evidence Based Clinical Practice means 'process of making decision for inpatient care using current best evidence in conjugation with clinical expertise'. (page 36)
"Insurance Certificate issued to complainant -
Permanent Exclusion, if any. 'None" (page 21)
"9.1 Claim Administration - On te occurrence or discovery of any illness/injury that may give rise to a claim under this Policy, the Claim Procedure set out below shall be followed -
(a) the direction, advice and guidance of treating Medical Practitioner shall be strictly followed. We shall not be obliged to make any payment that are bought about or contributed to as a consequence of or failure to follow such directions, advice or guidance." (page 31)
7.4.2 According to OP the claims were properly repudiated as mentioned in the letters, since parties are bound by the terms and conditions of policy. The complainant's hospitalisation was also not justified for evaluation and tests, therefore, it was within the policy term and conditions. The exclusions clause applies to all policy holders and even heading of clause is 'permanent exclusions'. The remarks 'none' against that column is applied on any adverse declared pre-existing medical or physical condition of treatment of insured person.
7.4.3 But the complainant opposes it. His treatment was in continuous even during and after his second discharge, which was with medical advices, instructions, follow up and recommendation. The root cause was to be discovered to avoid relapse, which is concerned with complainant being young, his family and also with OP in larger meaning. Since the tools, technology, equipment and specialists were at Ganga Ram Hospital, there was constraint to go there, however, it was in continuous of the same treatment. The claims are genuine. There was no reasons to decline valid claim. Moreover, the clause being invoked by OP is not applicable since, the permanent exclusions clause has not been made applicable by mentioning 'None' against clause-8, being terms and condition of policy. The complainant has also paid huge premium to buy this policy.
7.4.4 By taking into account of stock of rival contentions and material of documentary evidence, the following conclusion are drawn-
(i) In the discharge summary dated 14.2.2019 (page 84) of second episode, the complainant was recommended 'preventive advice - ante-grade enteroscopy' in follow up. In fact , the complainant remained indoor patient from10.2.2019 to 14.2.2019 and in between on 12.2.2019, he had undergone CT enteroclysts/enterography at Dr. Doda's Diagnostics & healthcare. After his discharge , the follow up was done at Kailash Nursing Home and then at Sir Ganga Ram Hospital. It was in continuation of series of diagnoses, treatment etc. In addition, before approaching the Sir Ganga Ram Hospital, the complainant had contacted OP, sought information and it was also advised that complainant may go to Sir Ganga Ram Hospital but there will not no pre-authorisation/cash-less facilities.
(ii) Had those test, investigation and evaluation been during the phase of indoor patient in Kailash Nursing Home, if all those technology, tools and equipment been there, the OP would have considered the bills alongwith other pre-authorisations. But claim was declined because he was discharged with those recommendations and follow up.
(iii) the repudiation letter dated 26.3.2019 gives reasons 'original cash receipt and day care break up not provided', however, it is contrary to its acknowledgement of record as well as the receipt of record was also confirmed by whatsapp message. Moreover, in whatsapp message, it was communicated that claim cannot be approved in terms of policy but it no so mentioned in the letter dated 26.3.2019.
Is it fair on the part of OP that first it prescribe claim form, specified column are there, it was duly filled in by complainant. Then requisite record mentioned in the form was also filed by the complainant.
Thereafter beyond that prescribed form, other record was called and it was also furnished under acknowledgement. Therefore, repudiation of claim on such ground of 'want of furnishing the original record', means that claim is valid but original were not furnished. There is also improvement in the letter, since it was not so advised in the whatsapp message. The OP cannot derive any benefit that further information is to be furnished in email, once a party is being communicated, it ought to have been completely informed. Thus, it is held that repudiation of claim of Rs.20,542/- in respect of claim no.411147 was improper and wrong on the part of OP. The OP cannot take defence, what was not initially communicated.
(iv) the repudiation letter dated 28.3.2019 658 of Rs. 50,917/- in respect of claim no.409 gives reasons "as per submitted documents it is found that hospitalisation done only for evaluation, investigation purposes. Hospitalisation not justified, hence claim repudiated as per policy terms and condition policy clause 8.16".
However, by reading the entire insurance policy contract, especially clause no.8 (inclusive of 8.16) with clause no.12.13 and also specific clause on the face of insurance certificate 'permanent exclusion if any - none', communicates that the clause no.8 including clause no. 8.16 would not be applicable. Had there been no expression 'none', the meaning would be that permanent exclusion would be read for exclusion purposes. But by specially mentioning it 'none', means clause 8 of permanent exclusion would not be applicable. In fact, clause 8 itself mandate that appropriate variance may be subjected in the Schedule and it was style 'None' against permanent exclusions. The OP contends that it was from the point of 'pre-existing disease', but it is neither so mentioned nor it appears to be so linked. Thus exclusion clause(s) will not be applicable to the present case of complainant.
(v) the complainant was indoor patient upto 14.2.2019, the investigations and diagnosis was already started and it was in continuation of that procedure to ascertain the root cause during and after discharge of complainant vis a vis it was to avoid re-occurrence of such episodes (since there were already two episodes). There was admission for single day in the day care in Sir Ganga Ram Hospital. Had those test, investigation, evaluation, procedure been during the phase of indoor patient in Kailash Nursing Home, (subject to those tools, technology, equipment, etc) and prior to discharge, then the OP would have considered it.
(vi) in case, the situation is visualized that there was discharge on 14.2.2019 and then later complainant had undergone other procedure, test etc. in day care at Sir Ganga Ram Hospital, then it would be the case being set up by the OP. Whereas, in case the situation is taken from record, that it was 12.2.2019, the process started at Dr. Doda's Healthcare and the complainant was discharged on 14.2.2019 with strict advices, then it continued by availing the facilities at Sir Ganga Ram Hospital, which is case of complainant. On 21.02.2019 the Antegrde double balloon enteroscopy test was conducted followed by retrograde double balloon enterrosocpy on 22.2.2019 at Ganga Ram Hospital, its result were delivered on 26.02.2019.
The circumstances of continuity are leaning in favour of complainant, because of certain constraint of tool, technique and equipments etc.,
(vii) there is also clause no.12.63 of post hospitalisation medical expenses, in respect of same condition for which it was hospitalised, this also applies in favour of complainant,
(viii) the conclusions in sub-paragraph (i) to (vii) above, proves the case of complainant that repudiation of claims was contrary to documentary record and also contrary to terms and conditions of policy contract, particularly what does not applicable to complainant was invoked against claim of complainant. It is deficiency of services on the part of OP.
So, the complainant is held entitled for reimbursement of claim amounts of Rs 71,459/-=Rs.20,542+Rs.50,917/-. This amount includes post discharge expenses of the first episode, of the second episode treatment in Kailash Nursing Home and in continuity thereof of day care expenses etc at Sir Ganga Ram Hospital.
7.5. The complainant claims interest of 12 % pa but as such there is no specified rate of interest. Since the complainant has parted with his money, therefore, interest at the rate of 6% pa from the date of complaint till realization of amount in favor of complainant will meet both ends.
7.6. The complainant seeks compensation of Rs. 70,000/- on account of mental pain, harassment and agony and cost of Rs. 15,000/-. The complainant is self employed businessman. He has not mentioned his financial status, income or sources of income for the purposes of evaluating the compensation amount but he is young man of 31 years of age. However, the circumstances of ailment, claim for medical expenses and efforts made are speaking that he had faced difficulty, inconvenience and other trauma, particularly he has been approaching the OP as well as writing to the OP to pay his legitimate balance medical bills amount, therefore, compensation of Rs. 20,000/- is allowed in his favour and against the OP. Cost is also quantified as Rs. 10,000/-.
8. Accordingly, the complaint is allowed in favour of complainant and against the OP to refund/ reimburse medical bill amount of Rs.71,479/- along-with simple interest @ 6%pa from the date of complaint till realization of amount; apart from to pay compensation of Rs.20,000/- & costs of Rs.10,000/- to complainant.
OP is also directed to return/pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, the interest will be 8% per annum on amount of Rs.71,479/-.
9. Announced on this 20th July, 2023 [आषाढ़ 29, साका 1945].
10. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
