Punjab

Ludhiana

CC/19/396

MS.Sanya Sahi - Complainant(s)

Versus

M/s Religare Health Insurance Co.Ltd - Opp.Party(s)

Dalip Saggi Adv.

02 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:396 dated 20.08.2019.                                                         Date of decision: 02.06.2023.

 

Ms. Sanya Sahi, aged 19 years daughter of Shri Sachin Sahi son of Shri Brij Bhushan Sahi, Resident of House No.117, Country Homes Colony, Samrala Road, Khanna, District Ludhiana.                                                                                                                                                          ..…Complainant

                                                Versus

1. M/s. Religare Health Insurance Company Limited, Vipul Tech Square, Tower ‘C’, 3^rd Floor, Sector 43, Golf Course Road, Gurgaon-122009, through its Managing Director.
2. M/s. Religare Health Insurance Co. Ltd., B-XIX/122/3/1, Ist Floor, Golden Plaza Mall, Mal Road, Ludhiana through its Manager.

…..Opposite parties 

Complaint Under section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Gaurav Saggi, Advocate.

For OPs                          :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the case are that father of the complainant Sh. Sachin Sahi purchased online medi-claim Floater policy under Care Plan from the opposite parties for himself and his family members i.e. Sonia Sahi, wife, Samridhi Sahi and Sanya Sahi daughters and Saksham Sahi son for a sum of Rs.5,00,000/- vide policy No.12295214 w.e.f. 27.03.2018 to midnight of 26.03.2020 by paying the premium of Rs.27,907/- under Single Premium Payment mode and he was allotted ID No.59620412. The complainant stated that in terms of the policy, he and his family members were entitled to hospitalization expenses (in-patient care & day care treatment, pre-hospitalization & post hospitalization medical expenses), ambulance cover, organ donor cover, domiciliary hospitalization, automatic recharge, second opinion, alternative treatment, no claim bond and annual health check up benefits. According to the complainant, she suffered from Enteric Fever for which medical assistance was sought at V.M.K. Hospital, A Multi Specialty Hospital and on seeing her unstable, she was admitted as indoor patient on 30.03.2019 for investigations and better management of the ailment and discharged on 04.04.2019  with advice of follow up treatment. Father of the complainant Sh. Sachin Sahi incurred Rs.30,850/- on her treatment. The complainant submitted the claim with the opposite parties on 10.04.2019 regarding her treatment but they rejected the claim illegally in unjustified and arbitrary manner on the grounds that admission not justified and could have been manage on OPD basis. The complainant stated that opposite party was not competent to reject the claim on the ground mentioned in letter dated 23.05.2019 because it is the medical expert attending on her to see justification of treatment of the complainant by keeping her as an indoor patient and not the insurance company.     

                   The complainant further stated that she suffered from Acute pain in her abdomen (Acute Cholecystiris with Cholelithiasis) for which medical assistance was sought from VMK Hospital, Khanna and for investigations of the exact ailment, she was admitted as indoor patient in the said hospital on 07.04.2019 and she remained admitted till 10.04.2019. On seeing no improvement in her conditions despite treatment, the medical expert advised for surgical consultations on 10.04.2019 and suggested for taking her to Fortis Hospital, Mohali for better management of her ailment. The complainant was given referral letter on 10.04.2019 for further management. VMK Hospital, Khanna charged a sum of Rs.14,450/-. Father of the complainant submitted a claim for reimbursement of medical expenses incurred at VMK Hospital, Khanna along with duly authenticated documents issued by the concerned doctor which was registered by opposite parties as claim No.90990654 but they denied the claim vide their letter dated 05.07.2019 on the grounds ‘Non disclosure of hypertension in patient Mr. Sachin Sahi.’ which is illegal, unjustified and arbitrary. However, her claim cannot be denied by the opposite parties on account of alleged Non disclosure of hypertension in patient Mr. Sachin Sahi, father of the complainant which shows non application of judicious mind to the facts and circumstances of the case of the complainant.

                   The complainant further stated that on 10.04.2019, she approached Fortis Hospital, Mohali for evaluation of her ailment and its management with complaints of pain in abdomen since 2 weeks along with on and off episodes of vomiting. Pain in abdomen was sudden in onset, gradually progressive, colicky type, non-radiating, non-shifting, associates with on and off episodes of vomiting, non-bilious, non-projectile. All the relevant investigations were done at Fortis Hospital, Mohali and after consent, clearance and PAC patient was taken up for diagnostic Laparoscopy + Laparoscopic cholecystectomey done on 11.04.2019 and as per operative notes:- Grossly distended and thin walled gall blander with edemantous, calot’s triangle adhesions present, cystic duct identified, clipped and cut, cystic artery doubly clipped and cut, gall bladder removed, thick bile with sludge aspirated, patient was discharged on 12.04.2019 with follow up in OPD after 7 days. A sum of Rs.97,471/- were incurred on the treatment of the complainant at Fortis Hospital, Mohali. Her father Sh. Sachin Sahi submitted a claim for reimbursement of the expenses incurred by him at VMK Hospital, Khanna as well as Fortis Hospital, Mohali but the said claims have been rejected by the opposite parties. The opposite party rejected the first claim of the complainant for her treatment at VMK Hospital, Khanna during the period from 30.03.2019 to 04.04.2019 on the ground that the admission in the hospital is not justified and could have been managed on OPD basis whereas the second claim of her treatment at VMK Hospital, Khanna w.e.f. 07.04.2019 to 10.04.2019 was rejected on the ground of ‘Non disclosure of hypertension in patient Mr. Sachin Sahi’ and the claim in respect of her treatment at Fortis Hospital, Mohali during the period 10.04.2019 to 12.04.2019  has been rejected on the ground of ‘2 year waiting period treatment of kidney stone/ureteric stone/lithotripsy/gall bladder stone, two year waiting period. Rejection of the claims of the complainant is illegal, unjustified and arbitrary. The rejection of the claim of the complainant with respect to her admission with VMK Hospital, Khanna on the ground of non-justification of admission to the hospital is without any basis and do not hold good ground, because it was for the treating doctor to see about the justification of her admission in the hospital and opposite party ought have sought for opinion of the treating doctor about the justification of admission of the complainant rather the rejection has been made by opposite party without seeking any clarifications and justifications from the treating doctor.  According to the complainant, the rejection of second claim is also not justified on the ground of non disclosure of Hypertension by patient Sachin Sahi is arbitrary and without application of judicious mind. Moreover, the rejection of claim in respect of expenditure at Fortis Hospital, Mohali is also without justifications. As the policy was purchased telephonically/online and details were disclosed as enquired by the concerned official of the opposite party and no proposal form was asked for by the opposite party before issuing the insurance policy nor the opposite party got all the members of family of the complainant medically examined prior to issuance of the insurance policy. According to the complainant, the disease of hypertension cannot be treated as pre-existing disease as the same is controllable by medication etc. and she is living normal and healthy life by doing all her duties. However, the opposite parties had issued a notice for cancelation of policy No.12295214 vide letter dated 27.05.2019 and for forfeiture of entire premium on the ground of concealment of material facts/pre-existing ailments at the time of proposal. The said notice was replied by the complainant through letter dated 22.06.2019 but the opposite parties had not conveyed any decision about the cancellation of his insurance policy. The rejection of the claim of the complainant is unjustified, illegal, and arbitrary and against the provisions of the policy. In the end, the complainant has prayed for issuing directions to the opposite parties to pay a sum of Rs.3,42,771/- with interest @18% per annum along with litigation expenses of Rs.22,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, misrepresentation and concealment of facts, lack of cause of action. The opposite parties stated that the complainant was covered under policy No.12295214 w.e.f. 27.03.2018 to 26.03.2020 covering the complainant, her father Sachin Sahi and other family members for a sum insured of Rs.5,00,000/- subject to policy terms and conditions. According to the opposite parties, the complainant was hospitalized for Entric Fever in VMK Hospital, Khanna from 30.03.2019 to 04.04.2019 and filled reimbursement claim by claiming an amount of Rs.30,851/- vide claim No.90940594 on receipt of which the opposite party sent query dated 07.05.2019 and reminder dated 17.05.2019 requesting for demanding the documents, which are reproduced as under:-

• Pre hospitalization OPD treatment record
• Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart with temperature chart.

On receiving the said documents, some facts came upfront which are reproduced as under:-

• As per the discharge summary, the complainant was admitted for history of fever with an temperature of 100 degree F and all other body vitals in normal state. Please note that the said treatment could had been managed on OPD basis only without any need for hospitalization.
• Complainant was subject to various tests and investigations which could had been administered on OPD basis only without any need for hospitalization of the complainant.

As per opposite parties, on finding that the hospitalization of the complainant was not justified and she could had been managed on OPD basis only, her claim was rejected as per clause 4.2 (1) read with Annexure II (71) for hospitalization for diagnostic/evaluation purposes and claim rejection letter dated 23.05.2019 was sent to the complainant. The relevant clause is reproduced as under:-

“We have reviewed the claim filed by you retaining to Health Insurance policy (12295214) and hereby inform you that the claim is not payable as per policy terms and conditions listed below:-

• Admission not justified could have been managed on OPD basis.
• Admission not justified.

                   The opposite parties further stated that the complainant was again hospitalized for AC pain abdomen (Acute Cholecystitis with Cholelithiasis) in VMK Hospital, Khanna from 07.04.2019 to 10.04.2019 and she claimed an amount of Rs.14,456/- vide reimbursement claim No.90990654. The claim was received on 21.06.2019.  The opposite parties stated that the policy holder (another Insured) in the present policy of the complainant, had also filled claims with the opposite party company for the hospitalization of the policy holder, Mr. Sachin Sahi in VMK Hospital, Khanna for Fever on 06.05.2019 and in Fortis Hospital Mohali on 11.05.2019. The said claims was denied for "Hospitalization Not Justified" and "Non Disclosure of Hypertension" respectively. The denial of the claims was communicated to the policy holder vide letters dated  02.07.2019 and 13.05.2019 respectively. The policy holder is contesting the denial of claims before this Commission vide Consumer Complaint No. 395/19. Non disclosure of material facts of Hypertension on part of the policy holder also rescinds the contract of insurance ab intio. Accordingly the current claim of the complainant was also denied for Non Disclosure of Hypertension on account of the policy holder vide clause 7.1 of the Policy Terms and Conditions and denial of the Claim was communicated to the Complainant vide letter dated 05.07.2019, which is reproduced as under:-

"We have reviewed the claim filed by you retaining to Health Insurance policy (12295214) and hereby inform you that the claim is not payable as per policy terms and conditions listed below:

• NON DISCLOSURE OF HYPERTENSION IN PATIENT MR. SACHIN SAHI.
• NON DISCLOSURE

The complainant was again hospitalized for Gall stone disease in Fortis Hospital from 07.04.2019 to 10.04.2019 and she claimed an amount of Rs. 90,000/- vide cashless claim No. 80265840/80266097.  On receipt of the cashless claim, the opposite parties sent query dated 11.05.2019 seeking following information:

• COMPLETE INDOOR CASE PAPERS WITH ADMISSION NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING NOTES AND VITAL CHART.
•  EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL PAST TREATMENT RECORDS HYPERTENSION
• INVESTIGATION REPORT SUPPRTING DIAGNOSIS
• PRE HOSPITALISATION OPD TREATMENT RECORD
• TREATING DOCTPR’S CERTIFICATE JUSTIFYING THE PROLONGED/NEED OF HOSPITALIZATION.

On receipt of the documents (cashless form), it appeared that the complainant had claimed for Gall Bladder Stone which is not covered for 2 years from the inception of the policy. Therefore, the cashless claim of the complainant was also denied vide clause 4.1 (ii) (11) of the policy terms and conditions and rejection was communicated through letter dated 11.04.2019, operative part of which is reproduced as under:-

“2 year waiting period: Treatment of kidney stone/Ureteric stone/Lithotripsy/Gall Bladder Stone.

The opposite parties further stated that in the light of non disclosure of material facts of hypertension on behest of the policy holder, Mr.Sachin Sahi, father of the complainant the, policy was cancelled as per clause 7.13 read with clause 7.1 of the policy terms and conditions vide notice for cancellation dated 27.05.2019 and policy cancellation letter dated 13.11.2019.  

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents i.e. Ex. C1 is copy of policy documents, Ex. C2 is the copy of claim form, Ex. C3 is the copy of claim denial letter dated 23.05.2019, Ex. C4 is the copy of deficiency letter dated 25.06.2019, Ex. C5 is the copy of claim denial letter dated 23.05.2019, Ex. C6 is the copy of non-registration of claim, Ex. C7 is the copy of claim denial letter dated 05.07.2019, Ex. C8 is the copy of notice dated 27.05.2019 for cancellation of policy, Ex. C9 is the copy of reply dated 22.06.2019 to notice for cancellation of policy and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Kashif Nazki, Manager (Legal) of the opposite parties along with documents Ex. R1 is the copy of policy documents, Ex. R2 is the copy of policy terms and conditions, Ex. R3 is the copy of claim form, Ex. R4 is the copy of discharge summary dated 04.04.2019 of V.M.K. Hospital, Ex. R5 is the copy of investigation report, Ex. R6 is the copy of claim denial letter dated 23.05.2019, Ex. R7 is the copy of claim form, Ex. R8 is the copy of claim denial letter dated 05.07.2019, Ex. R9 is the copy of request for cashless hospitalization for medical insurance policy, Ex. R10 is the copy of non-registration of claim dated 11.04.2019, Ex. R11 is the copy of notice dated 27.05.2019 for cancellation of policy and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Admittedly, father of the complainant Sh. Sachin Sahi purchased online medi-claim Floater policy Ex. C1=Ex. R1, Ex. R2 under Care Plan from the opposite parties for himself and his family members including the complainant. Firstly, the complainant remained admitted at V.M.K. Hospital, Khanna from 30.03.2019 to 04.04.2019 and incurred medical expenses of Rs.30,850/- regarding which father of the complainant submitted claim on 10.04.2019 vide claim form Ex. R3 with the opposite parties. However, seeking certain explanations vide letters dated 07.05.2019 and 17.05.2019, the opposite parties rejected the said claim on the grounds that admission is not justified and could have been managed on OPD basis only. The claim of the complainant was rejected vide claim denial letter dated 23.05.2019 (Ex. C3 = R6) by invoking clause 4.2 (1) read with Annexure II (71) for hospitalization for diagnostic/evaluation purposes, which reads as under:-

          “We have reviewed the claim filed by you pertaining to Health Insurance    Policy (12295214) and hereby inform you that the claim is not payable as per policy terms and conditions listed below:-

• Admission not justified could have been managed on OPD basis.
• Admission not justified.

The relevant clause 4.2 (1) read with Annexure II (71) is reproduced as under:-

          “4.2. (1) Any item or condition or treatment specified in List of Non-          Medical items (Annexure-II to Policy Terms & Conditions”

          ………

          “Annexure-II (71)

          Hospitalization for evaluation/diagnostic purpose.”

 

7.                Now the point for consideration arises how it is required to be assessed that the admission is primarily for evaluation and investigation purpose only?

8.                The counsel for the complainant has referred to the extract of the discharge summary Ex. R4 and investigation report Ex. R6 of V.M.K. Hospital, Khanna vide which the complainant was diagnosed of PUO (Enteric Fever) and under the column of brief history it was specificity mentioned that with history of fever. The discharge summary Ex. R4, when read as a whole clearly spells out that necessity arose for her admission in the hospital due to above said reason.  Cumulatively, it appears that prima facie there was a strong case for the admission of the complainant in the hospital. On the other hand, the opposite parties have not produced any opinion of medical expert whereby it was opined that the admission of the complainant in the hospital was not desirable. Even otherwise, no prudent person would expose himself/herself in such an environment of the hospital which is prone to severe infection. Therefore, the repudiation of claim on the premise that the admission primarily for observation and investigation is wholly unjustified.

9.                Secondly, the complainant was hospitalized as indoor patient at VMK Hospital, Khanna from 07.04.2019 to 10.04.2019 due to acute pain in her abdomen where she incurred a sum of Rs.14,450/- on her treatment. Again father of the complainant submitted claim vide claim form dated 10.04.2019 Ex. R7 for reimbursement of medical expenses incurred on the said hospitalization of the complainant but again the opposite parties denied the claim vide their letter dated 05.07.2019 Ex. C7 =  R8 on the following grounds:-

“We have reviewed the claim filed by you pertaining to Health Insurance    Policy (12295214) and hereby inform you that the claim is not payable as per policy terms and conditions listed below:-

• ‘Non disclosure of hypertension in patient Mr. Sachin Sahi.’
• Non disclosure.

According to the complainant, this claim cannot be denied on account of ground of non disclosure of hypertension in patient Mr. Sachin Sahi which shows non application of judicious mind to the facts and circumstances of the case of the complainant. As per version of the opposite parties, the denial of the claim was communicated to the policy holder vide letters dated 02.07.2019 and 13.05.2019 respectively. Further as per the opposite parties, the policy holder is contesting the denial of claims before this Commission vide Consumer Complaint No. 395/19. Further the opposite parties were under legal obligation to disclose that admission, diagnosis and treatment of the complainant violates the terms and conditions of the policy or it is the complainant (not her father) who was suffering from hypertension.

10.              Further, the opposite parties have not produced any evidence of medical record with regard to diagnosis and treatment of the said pre-existing disease of father of the complainant. Even the report or the affidavit of the investigator was not brought on record to substantiate its claim. In this regard, further reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh the hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.       Therefore, the denial of the claim vide letter dated 05.07.2019 is arbitrary and unjustified.  

11.               Finally, the complainant got treatment from Fortis Hospital, Mohali for evaluation of her ailment and its management with complaints of pain in abdomen since 2 weeks along with on and off episodes of vomiting. Pain in abdomen was sudden in onset, gradually progressive, colicky type, non-radiating, non-shifting, associates with on and off episodes of vomiting, non-bilious, non-projectile. All the relevant investigations were done at Fortis Hospital, Mohali and after consent, clearance and PAC patient was taken up for diagnostic Laparoscopy + Laparoscopic cholecystectomey done on 11.04.2019 and as per operative notes:- Grossly distended and thin walled gall blander with edemantous, calot’s triangle adhesions present, cystic duct identified, clipped and cut, cystic artery doubly clipped and cut, gall bladder removed, thick bile with sludge aspirated, patient was discharged on 12.04.2019 with follow up in OPD after 7 days.  The complainant incurred expenses of Rs.97,471/- for her treatment at Fortis Hospital, Mohali. During hospitalization, father of the complainant submitted a request Ex. R9 for pre-authorization but the said claim was rejected by the opposite parties  on 11.04.2020 vide letter Ex. R10 on the ground of ‘2 years waiting period treatment of kidney stone/ureteric stone/lithotripsy/gall bladder stone. The relevant clause 4.1 (ii) 11 of the policy terms and conditions reads as under:-

          “4.1. Waiting period

          (ii)     Specific Waiting Period: Any claim for or arising out of any of the following illnesses or surgical procedures shall not be admissible during the first 24 (twenty four) consecutive months of coverage of the Insured Person by the Company from the first Policy Period Start Date:

          11.     Kidney Stone/Ureteric Stone/Lithotripsy/Gal Bladder Stone.

 

In this context, it is relevant to point out that the policy was obtained by the father of the complainant w.e.f. 27.03.2018 to mid night of26.03.2020 in the year 2018 by paying single premium of Rs.27,907/- for a sum assured of Rs.5,00,000/-.  As per medical record, the complainant was hospitalized on 07.04.2019 and it falls within two years of waiting period and the claim of the complainant was rightly repudiated by the opposite parties. Since it has been concluded for the reasons enumerated here-in-before that the grounds for denial of reimbursement claims with regard to hospitalization at V.M.K. Hospital, Khanna from 30.03.2019 to 04.04.2019 and further from 07.04.2019 to 10.04.2019 were not justified. In the given facts and circumstances of the case, if the opposite parties are directed to settle and reimburse the claims with respect to hospitalization of the complainant at V.M.K. Hospital, Khanna from 30.03.2019 to 04.04.2019 and further from 07.04.2019 to 10.04.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment. The opposite parties are also burdened with composite costs of Rs.10,000/-.

12.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claims with respect to hospitalization of the complainant at V.M.K. Hospital, Khanna from 30.03.2019 to 04.04.2019 and further from 07.04.2019 to 10.04.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

 

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                     (Sanjeev Batra)

Member                         Member                                       President         

Announced in Open Commission.

Dated:02.06.2023.

Gobind Ram.

 

 

Sanya Sahi Vs Religare Health Insurance Co.                  CC/19/396

Present:       Sh. Gaurav Saggi, Advocate for the complainant.

                   Sh. G.S. Kalyan, Advocate for the OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claims with respect to hospitalization of the complainant at V.M.K. Hospital, Khanna from 30.03.2019 to 04.04.2019 and further from 07.04.2019 to 10.04.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:02.06.2023.

Gobind Ram.