ORDER

20.08.2024

Sh. Sanjay Kumar, President

1. The factual matrix of the present case is that officials of OP2 approached to complainant and proposed for the Medi-claim policy of all the family members, painting very rosy pictures about the benefits and services offered by the OP2. It is further stated that the said official lured the complainant to go for Medi-claim insurance for himself and other family members and explained the benefits of the scheme and also stated that in case of the hospitalization of the insured, the medical bills, will be directly by the insurance company.
2. It is stated that the complainant got influenced by the benefits and services described by the official of OP2 and relying on the information given by him, the complainant showed his inclination to go in for the Medi-Claim insurance for himself and his family. It is further stated that official of OP2 got the proposal form signed by the complainant after asking several questions about their medical history etc. to be covered which were truly and fully answered by complainant, but the said official did not fill up the proposal form instantly and assured the complainant and her husband that it will be filled up at later stage.
3. It is stated that complainant believing the assurance given by the official of the OP2 took the Medi-claim policy, which continued and presently complainant along with his family are insured under the policy no.222701/28/16/P105/872920 with the OP2 for the period of 03.08.2016 to 02.08.2017. It is further stated that after taking the Medi-claim policy, the complainant got the renewal of his policy from time to time with OPs on the assurance that every ailment or disease requiring hospitalization  at least for 24 hours was covered and the total benefits payable would be to the extent of sum insured.
4. It is stated that in the late evening of 07.03.2017, the complainant, who otherwise is living a healthy, life, got severe chest pain on the left side. It is further stated that the pain was uncontrollable and he was taken to nearby doctor Sh. S.K. Nagrani, MBBS. It is further stated that Dr Nagrani after seeing the condition of the complainant advise to take the complainant to hospital for better treatment. It is stated that family members of the complainant, considering the OP1 a big hospital, which is having fame in the locality, took the complainant to the OP1 with the hope that the complainant would get better treatment.
5. It is stated that the concerned doctors of the OP1 diagnosed the complainant and admitted him in the ICU. It is further stated that at the time of admission of the complainant, the representative of the OP1 enquired from the family members of the complainant whether the complainant has been covered under any Medi-claim insurance or not.
6. It is stated that the family members of the complainant categorically informed that the complainant is insured with OP2. It is further stated still the concerned officials of the OP1 to deposit a sum of Rs.15,000/- which the family members of the complainant deposited. It is stated that the family members keep on asking the condition of the complainant, but the concerned doctors of the OP1 did not give any satisfactory reply. It is further stated that the concerned doctors took many signatures from the complainant and the family members.
7. It is stated that on 09.03.2017, the complainant got discharged with the advice to do follow checkup. It is further stated that when the complainant enquired about the reason, they informed that the condition of heart of the complainant is normal. It is stated that the bill raised by the complainant was Rs.36,398.42. It is stated that the complainant enquired about the mediclaim, for which the concerned officials of the OP, who advise to file the claim for reimbursement. It is further stated that on 14.03.2017, the complainant submitted his claim alongwith the relevant papers and medical bills etc. for reimbursement witht eh OP3 with the request to settle the claim of the complainant at the earliest.
8. It is stated that OP3 on receipt of claim of the complainant asked the OP1 to provide certain documents of the complainant vide letter dated 21.03.2017 with a view to process the claim of the complainant. It is further stated that the complainant has immediately provided all the documents to the OP2 on 24.03.2017. It is stated that after about one week, the OP3 vide undated letter rejected the claim of the complainant that the complainant could be managed on OPD basis, therefore, the claim of the complainant cannot be reimbursed.
9. It is stated that the complainant after perusal of above said opinion was shocked to find that the observation made by the OP3 is not correct and the complainant on receipt of the said letter approached and made a request to Dr. Naveen Bhamri, of OP1. It is further stated that the OP1 some how after great persuasion issued the letter dated 11.05.2017 duly signed by Dr. Naveen Bhamri, of the OP1. It is stated that the complainant again on 18.05.2017 made a representation with the OP3 with the request to re-consider the claim of the complainant. The complainant also submitted the letter issued by the OP1.
10. It is stated that since that day, the complainant has made several visits to the office of OP1 and OP3 but to no avail. It is further stated that the complainant being a lay man unable to understand that if the version of the OP is correct then why the complainant had to stay in the hospital of OP1 for one day and if the version of the OP3 is correct than the complainant requires full attention, care and treatment then the complainant’s claim should have been passed.
11. It is stated that complainant feeling cheated with the unfair trade practices of the OP as the OPs are giving contradictory statements and the complainant is suffering from mental and financial loses. It is further stated that the OP2 and 3 have not made due application of mind to the actual facts and circumstances of the case and disposed off the claim of the complainant in a perfunctory manner. It is stated that OP hurriedly grabbed the premium and when the time for payment of the benefit arose, they have raised several irrelevant queries and that too in piecemeal and the manner in which the matter has been disposed off, only shows that right from the intimation of the facts of hospitalization of the complainant, they started searching for the points on which the claim of complainant could be repudiated which also falsifies the assurances given by the representative of OP2 and 3 at the time of taking proposal and premium for the insurance of the complainant.
12. It is stated that OP2 and 3 committed acts of deficiency of service and unfair trade practice as they convincing the insurance  proposal, not fully describing the limitation and exclusions at the time before finalizing the insurance proposal and latter repudiating the claim on such false grounds, not directly paying with the hospital and repudiating the claim without due application of mind to the actual facts and circumstances of the case. It is further stated that the acts of omission and commission of OP have caused extreme hardship, mental agony, harassment inconvenience and inflicted financial cost to the complainant.
13. Complainant is seeking direction against OP1 and 2 to pay all the bills for treatment Rs.36,398.42 with  interest @ 18% p.a from the date of submission and further with pendentlite interest till realization, to direct OPs to pay Rs.50,000/- damages/compensation for harassment, mental agony etc, to pay Rs.13,500/- towards cost and expenses etc and any other order which deems fit and proper.
14. As per record OP1 was served but failed to appear, therefore, proceeded ex parte vide order dated 24.01.2018.
15. OP2 filed detailed WS and taken preliminary objections that there  is no deficiency in service on the part of the answering respondent/OP. It is stated that the complainant is not entitled to file the present complaint, therefore, the present complaint is liable to be dismissed. It is stated that the complainant has not come with clean hands before this Hon’ble Forum and has concealed the material facts, therefore, the present complaint is liable to be dismissed. It is further stated that as per the opinion of the TPA on the panel of the answering OP and the documents including discharge summary submitted by the  complainant, the  claim of the complainant was found not admissible as per clause 4.11 of the terms and conditions of the insurance policy.
16. It is stated that the patient/complainant Praveen Kumar Madan availed treatment in Max Super Speciality Hospital from 07.03.2017 to 09.03.2017 and was diagnosed with Acute Coronary Syndrome and underwent conservative management for the same. It is further stated that United India family medicare policy does not cover the expenses incurred on diagnostic and evaluation purpose where such diagnostic and evaluation can be carried out as outpatient procedure and the condition of the patient does not require hospitalization, vide exclusion clause 4.11, therefore, the answering OP has rightly repudiated the claim and there is no deficiency in service  on its  part. Copy of ins. Policy along with terms and conditions, copy of report dated 08.03.2017 of TPA, copy of repudiation letter, opinion of TPA dated 15.06.2017 remained the same even after representation of complainant are filed on record.
17. On merit all the allegations made in the complaint are denied and reiterated contents of preliminary objections.
18. Complainant filed replication to the WS of OP2 and denied all the allegations made therein and reiterated contents of complaint.
19. The OP3 after service failed to appear and also not filed WS and proceeded ex parte vide order dated 05.09.2018.
20. Complainant filed evidence by way of his affidavit and reiterated contents of the complaint. The complainant relied  on copy of Adhar card Ex.CW1/1, copy of treatment card of Dr. S.K Nagrani Ex.CW1/2, copy of I card issued by OP1 and 2 Ex.CW1/3, copy of discharge summary issued by OP3 Ex.CW1/4, copy of medical bill issued by OP3 Ex.CW1/5, copy of claim form dated 14.03.2017 Ex.CW1/6, copy of letter dated 21.03.2017 issued by OP2 Ex.CW1/7, copy of letter dated 2303.2017 and acknowledgment Ex.CW1/8 (colly), copy of rejection letter Ex.CW1/9 and copy of application for reconsider the claim dated 18.05.2017 with documents Ex.CW1/10 (colly).
21. OP2 filed evidence by way of affidavit which is signed but no name has been written. In the affidavit contents of WS reiterated. OP relied on copy of insurance policy alongwith terms and conditions as Annexure A, copy of report dated 08.03.2017 of TPA Annexure B, copy of repudiation letter Annexure C, and opinion of TPA dated 15.06.2017 after representation of complainant Annexure D.
22. Written arguments filed by complainant as well OP2.
23. We have heard complainant in person. Neither AR nor counsel for OP2 insurance company addressed oral arguments. However, we have gone through the written arguments filed by OP insurance company.
24. It is admitted case of the parties that complainant had taken a mediclaim policy for all his family members from OP2 insurance company for the period 03.08.2016 to 02.08.2017. As per complainant in the evening on 07.03.2017 complainant got severe chest pain on the left side  and as per advise of Dr. S.K. Nagrani taken to OP3 hospital and admitted in ICU. The complainant after treatment discharge on 09.03.2017. The medical prescription of Dr. S.K. Nagrani filed on record which specifically advised admission. As per discharge summary the complainant was admitted and routine investigations were done. The complainant was prescribed Ecosprin, Pan 40mg. Complainant also filed on record a certificate issued by Dr. Naveen Bhamri according to which diagnosis of Acute Coronary Syndrome visible but stress echo was negative.
25. According to OP2 insurance company the claim of the complainant was found not admissible as per clause 4.11 of the terms and conditions of the insurance policy. According to OP the family medicare policy does not cover the expenses incurred on diagnostics and evaluation purpose where such diagnostic evaluation can be carried out as outpatient procedure and the condition of patient does not require hospitalization. The OP2 insurance company and OP3 TPA after receiving all the treatment documents and certificate of Dr. Naveen Bhamri did not carry out enquiry and investigation to the vital fact whether the circumstances in which complainant was admitted can receive the treatment at home by the OP2 insurance company panel or any doctor on the panel of TPA.  The certificate of Dr. Naveen Bhamri categorically issued certificate mentioning the admission of the complainant as there was complaint of chest pain at the left side of the complainant. The treatment and the diagnostic tests carried out at the hospital cannot be done at home. The OP failed to file any medical document or opinion of their panel doctors to rebut the opinion of treating doctor Dr. Naveen Bhamri of the complainant.
26. On the basis of the above discussion in the present facts and circumstances of the case the repudiation letter based on clause 4.11 is unjustified, arbitrary and wrong. The complainant established on record deficiency in service against OP2 insurance company
27. We hold guilty of deficiency in service against OP2 and direct:-

1. To pay Rs. 36,398/- along with 6% interest from the date of filing of the complaint till realization.
2. To pay compensation and legal expenses to the tune of Rs. 12,000/- to the complainant.

28. The OP2 is directed to pay the abovesaid amount within one month from the receiving copy of this order. In case of default OP2 is directed to pay 9% interest on the abovesaid amount. 
29. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  20.08.2024.

     SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER