District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.48/2022.
Date of Institution: 21.01.2022.
Date of Order: 06.12.2022.
Smt. Rashmi Verma W/o Late Shri Sudarshan Kumar Verma R/o flat No. 1704, Tower No.2, Princess Park, Sector-86, Faridabad, Distt. Faridabad (Haryana) – 121002.
…….Complainant……..
Versus
M/s. Care Health Insurance Ltd., (formerly known as Religare Health Insurance Co. Ltd.).
Divisional Office: Plot No. 37, B.P.W.G. Tower, Ist floor Neelam Bata Road, NIT, Faridabad, Distt. Faridabad (Haryana) through its Divisional Officer.
Regd. Office: 5th floor, 19, Chawla House, Nehru Place, New Delhi – 110 019.
Corp. Office: Unit No. 604, 6th floor, Tower C, Unitech Cyber, Sector-39, Gurugram – 122001 (Haryana) through its Divisional Officer.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Rajiv Sharma, counsel for the complainant.
Sh. N.K.Garg, counsel for opposite party
ORDER:
The facts in brief of the complaint are that the complainant was the holder of Mediclaim policy of the opposite party company i.e. M/s. Care Health Insurance Ltd. (formerly known as Religare Health Insurance Co. Ltd.) under plan “Care Senior Citizen” bearing policy No. 12976409 dated 07.09.2018 valid from 07.09.2018 to 06.09.2018 in the name of the complainant covering all types of risks relating to all the medical claims for hospitalization expenses for medical/surgical treatment issued by the insurance company and since then this policy had been continuously got renewed by the opposite party till now. The said hospitalization benefit policy had been duly renewed by the opposite party to the complainant vide policy NO. 12976409 valid from 12.09.2019 to midnight of 11.09.2020 . In the month of November 2019, the complainant has having complaint of weakness, breathlessness, feeling uneasy in walking properly, light, headedness, dizziness etc. So on 25.11.2019, the complainant went to Dr. K.K.Mishra M.D. Sr. Consultant-Internal Medicine, Main Market, Old Faridabad and got herself medically examined. After examining the complainant the doctor gave some medicines and advised for some blood tests and asked the complainant to come again after 2 months for re-examination. On or about after two months i.e. on 23.01.2020 the complainant again visited Dr. K.K.Mishra with the lab reports and she was again medically examined by the said doctor and after examination, complainant was advised to get admitted in the hospital due to severe complain of Anemia. As per the medical advice suggested by the above doctor, the complainant was got admitted in Sarvodaya Hospital, YMCA Road, Sector-8, Faridabad for her treatment where she was medically examine dby the consulting and trating doctor Dr. Arvind K. Minz (Internal Medicine) in the said hospital. The complainant was diagnosed as Severe Anaemia with Polyserositis (3 units PCV transfused) and output failure) type II DM-Recently detected. For the treatment as well as to keep the complainant under observance the complainant was remained admitted as indoor patient w.e.f. 25.01.2020 to 28.01.2020 an during her stay in the said hospital, many tests and procedures were adopted and treatment was given by the concerned doctors of the said hospital. At the time of admission in the said hospital, the complainant had deposited all the necessary and required documents to the opposite party Insurance Company. However during the admission period of the complainant on 26.01.2020, a deficiency letter dated, 26.01.2020 demanding some papers from the hospital was sent by the opposite party to the Sarvodaya Hospital. The complainant was discharged on 28.01.2020 and a demand of Rs.75464/- for the treatment, medical bills, medical tests etc. was raised by the hospital as final bill vide No.1-19-20-10558 dated 28.01.2020 which was rejected by the opposite party by saying that “The required documents of the patient/complainant were not being deposited by the hospital in time.” Hence the payment of the above said bill of Rs.75454/- had to be made by the complainant herself from her own pocket. After discharging from the hospital, the complainant applied for the reimbursement of the above said amount of Rs.75454/- and requested the opposite party to make the above payment charged by the hospital at the time of discharge from the said hospital. On 17.02.2020, a mail from the opposite party was received by the complainant with the remarks “we are in receipt of their claim request REM1702202003600, same was under process and would be processed within 15 days. On 26.02.2020 Sarvodaya Hospital got an Authorization letter dated 26.02.2020 from the complainant to authorize Aaizon Healthcare Services to collect and check the hospitalization documents for which the hospitalization verification was required and all the above necessary documents and papers were entrusted to the opposite party and the opposite party assured the complainant that here above reimbursement amount of Rs.75454/- would be paid very soon but inspite of the assurance the complainant was kept on waiting for her reimbursement payment. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the payment of Rs.75754/- alongwith interest @ 24% pa. from the due date till the realization of the said amount to the complainant.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had taken a Health Insurance Care Policy bearing No. 12976409 covering the complainant namely Rashmi verma w.e.f.07.09.2018 to 06.09.2019 for a sum insured of Rs.5,00,000/- subject to policy terms and conditions. The policy was renewed from time to time lastly from 24.09.2021 to 23.09.2022. The complainant approached the opposite party company with a cashless claim request vide claim No. 80367224/00 for her hospitalization. The complainant was admitted at Sarvodaya Hospital Faridabad with effect from 25.01.2020 with a complaint of easily fatigue, exertional dyspnea. The opposite party company on receipt of the said cashless claim sent a query letter dated 25.01.2020 ato provide the following documents necessary for proper assessment of the claim:
i. Exact duration and past history of present ailment with Ist consultation paper and all past treatment records HTN, DM.
ii. Investigation report, supporting diagnoses.
iii. Pre-hospitalization and OPD treatment record;
After investigation of the claim the opposite party company rejected the claim vide rejection letter dated 26.01.2020 for the following:
- Discrepancy in medical documents - Discrepancy over diabetes copd and hypertension,. Hence, cashless rejected. Kindly file for reimbursement.
- Discrepancy in medical documents.
After rejection of the cashless claim, the complainant filed a reimbursement claim NO. 91282188-00 (received on 17.02.2020) with request to expenses incurred on hospitalization of complainant at Sarvodaya Hospital, Faridabad form 25.1.2020 till 28.01.2020 and was diagnosed with severe anemia and polyserositis. Upon receipt of the reimbursement claim an internal investigation was also triggered to check the veracity of the claim, the opposite party company sent a query letter dated 23.02.2020 was also raised and the complainant was asked to provide the following documents:.
i. Treating doctors certificate for etiology of present ailment, etiology of anemia.
ii. Exact duration and past history of present ailment with Ist consultation paper and all past treatment records of anemia, hy6pertension, COPD, diabetes.
iii. Pre hospitalization OPD treatment record of anemia, hypertension, COPD, diabetes.
Thereafter going through the documents, the claim of the complainant was rejected vide letter dated 03.10.2020 on the grounds of discrepancy in medical documents which shows as under:-
i. As per OPD records dated 28.08.2019, patient was a case of DM, COPD and HTN.
ii. But as per ICP/patient assessment record, patient was recently diagnosed for DM II. The said which clearly indicates that the record of hospital had been manipulated to take benefit of the policy in question. Therefore, on the basis of above findings the claim was rejected vide letter dated 03.10.2020 on the basis of following:
i. Reject: Discrepancy in medical documents.
ii. Discrepancy in medical documents.
Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– M/s. Care health Insurance co. Ltd. with the prayer to: a) make the payment of Rs.75754/- alongwith interest @ 24% pa. from the due date till the realization of the said amount to the complainant. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Smt. Rashmi Verma,, Exs.C-1 – adhaar card,, Ex.C-2 – policy certificate, Ex.C-3 – policy certificate, Ex.C-4 = policy certificate,, Ex.C-5 & 6- OPD card, Ex.C-7 to 12– lab tests, Ex.C-13 – Deficiency letter, Rc.C-14 – Discharge summary, Ex.C-15 – Pathology & lab services, Ex.C-16 to 18 – Test report, Ex.C-19 – summary bill of supply, Ex.C-20 – Claim form, Ex.C-21 – email dated 17.2.2020, Ex.C-22 – claim denial letter, Ex.C-23 – email.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW-1/A – affidavit of Karan Setiya, Manager – Legal having its office at Vipul tech Square, Tower C, 3rd floor, Golf Course road, Sector-43, Gurugram, Ex.R-1 policy was renewed from time to time lastly form 24.09.2021 to 23.09.2022, Ex.R-2 – Cashless request, Ex.R-3 – deficiency letter, ExR-4 – denial letter, Ex.R-5 – Claim Form, Ex.R-6 – Discharge summary, Ex.R-7 – Deficiency letter, Ex.R-8 – OPD card, Ex.R-9 – Patient assessment Record, Ex.R-10 – Claim Denial letter.
6. In this case, the complainant has obtained medicalim policy from opposite party (formerly known as Religare Health Insurance Co. Ltd.) under plan “Care Senior Citizen” bearing policy No. 12976409 dated 07.09.2018 valid from 07.09.2018 to 06.09.2018 in the name of the complainant. The said hospitalization benefit policy had been duly renewed by the opposite party to the complainant vide policy NO. 12976409 valid from 12.09.2019 to midnight of 11.09.2020 . In the month of November 2019, the complainant has having complaint of weakness, breathlessness, feeling uneasy in walking properly, light, headedness, dizziness etc. So on 25.11.2019, the complainant went to Dr. K.K.Mishra M.D. Sr. Consultant-Internal Medicine, Main Market, Old Faridabad and got herself medically examined. As per claim denial letter dated 03.10.2020 vide Ex. R-10, opposite party has repudiated the claim of the complainant on the ground of : i. Discrepancy in medical documents. & ii. Discrepancy in medical documents.
7. After going through the evidence led by parties, the Commission is of the opinion that as per OPD records dated 28.08.2019 vide Ex.R-8 , patient was a case of DM, COPD and HTN. As per Patient Assessment Record vide Ex.R-9, patient was recently diagnosed for DM II which clearly indicates that the record of hospital had been manipulated to take benefit of the policy in question. Keeping in view of the above submissions, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 06.12.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
