Delhi

North East

CC/55/2016

Shri Surender singh - Complainant(s)

Versus

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

23 Oct 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 55/16

 

In the matter of:

 

	Shri Surender Singh S/o Shri Ramji Lal R/o A-73 B-Block Village Gokal Pur, Delhi-110094	Complainant
	Versus
1       2	Religare Health Insurance Company Ltd. Regd. Office: D3, P3B, District Centre Saket, New Delhi-110017   Pushpanjali Medical Centre A-15, Pushpanjali Vikas Marg Extn., Delhi-110092	Opposite Parties

 

DATE OF INSTITUTION:      JUDGMENT RESERVED ON:               DATE OF DECISION :

11.02.2016 23.10.2019 23.10.2019

 

N.K. Sharma, President

Ms. Sonica Mehrotra, Member

Order passed by Ms. Sonica Mehrotra, Member

ORDER

1. Briefly stated facts giving rise to the present complaint as culled out by the complainant are that he had taken Floater Health Care Policy for himself and his family, including his wife and three children from OP1 in 2015 and the same was renewed vide policy no. 10156437 w.e.f. 20.10.2015 to 19.10.2016 for a total sum assured of Rs. 5,00,000/- against payment of premium of Rs. 27,835 to OP1. The complainant’s wife Kiran was suffering from headache and vomiting from the night of 21.10.2015 but her condition started worsening from that night and her earlier treating doctor N.K. Gupta whom she was showing herself since 17.10.2015 being on leave, the complainant rushed his wife early morning to OP2 hospital on 22.10.2015 at 7:30 AM where she was diagnosed to be suffering from acute gastritis and acute enteritis and was treated by Dr. Mukesh Ajmera in the said hospital under admission and advice / treatment from 22.10.2015 to 24.10.2015. OP1 rejected the cashless facility request of the complainant and therefore on discharge from OP2, the complainant had to pay the entire medical bill amount of Rs. 21,256/- inclusive of admission medication and pharmacy charges to OP2 from his own pocket. Thereafter, complainant lodged mediclaim reimbursement with OP1 vide claim form no. 90146857 dated 30.10.2015 submitted on 02.11.2015 under the signature and seal of the treating doctor of OP2 alongwith the medical records and bills. OP1, vide email dated 17.11.2015 to complainant sought treating doctor certificate justifying need for hospitalization alongwith complete medical case paper with ancillary / related documents. Dr. Ajmera, vide response thereto dated 21.11.2015 attach the requisite indoor case papers of the complainant’s wife and justified her admission due to being a case of febrile illness in the form of nausea, vomiting, abdominal pain and inability to eat alongwith abdominal distention and low urine output suggestive of severe dehydration with enteritis. However, OP repudiated the claim of the complainant vide letter dated 15.12.2015 holdings that the claim was not payable as per policy terms and conditions since admission was for investigation and evaluation which is not payable and insured being  febrile with all vital parameters normal at the time of hospitalization which was for investigation. Therefore feeling aggrieved at the unfair, unjustified and uncalled for repudiation by OP1 as an act of unfair trade practice deficiency in service resulting harassment of the complainant, the was compelled to file the present complaint praying for issuance of direction against OP1 to reimburse the medical bills to the tune of Rs. 21,566/- (hospitalization and pharmacy) alongwith compensation of Rs. 30,000/- towards mental and physical agony and Rs. 30,000/- towards litigation cost.
2. Complainant has attached copy of policy certificate alongwith premium acknowledgement, copy of claim form “care” dated 30.10.2015, copy of  discharge summary issued by OP2 pertaining to complainant’s wife diagnosis and treatment from date of admission 22.10.2015 to date of discharge 24.10.2015 alongwith entire medical history of treatment, medical bills, lab investigation report, email enquiry from OP1 dated 17.11.2015, reply thereto dated 21.11.2015 by Dr. Mukesh Ajmera (treated doctor)  and repudiation letter dated 15.12.2015.
3. Notice was issued to the OPs on 29.02.2016. Both OPs entered appearance. OP2 was a performa party and no relief prayed against it but was arraigned to the extent on complainant’s wife having undergone treatment in the said hospital. Vide its reply OP2 took the defence that it was a performa party and therefore liable to be deleted from the array.
4. OP1 filed its written statement in which while admitting the factum of the insurance coverage having been extended to the complainant in 2014 vide policy no. 10156437 w.e.f. 20.10.2014 to 19.10.2015 and renewal of the same in 2015-16 on addition of third child of complainant, took the preliminary objection that the claim of complainant was rightfully repudiated as per clause 4.3 (a) (i) of policy terms and conditions read with Annexure C-71 thereof which dealt with permanent exclusions under the policy and stipulated that any admission / hospitalization for evaluation / diagnostic purpose, being permanently excluded was not payable. OP1 submitted that when the complainant had approached it through OP2 for cashless facility for his wife treatment / hospitalization, there was no clear disease mention and therefore vide query dated 22.10.2015, OP1 had asked OP2 to provide the necessary information regarding need for hospitalization and upon examining the claim in the light of documents, it was observed that all health indicator of complainant’s wife in ultrasound, liver function and hematology were normal and no reason for hospitalization or clearly outlined disease was given by either the complainant or OP2 and therefore hospitalization only for further evaluation and investigation which could have been done on OPD basis and therefore vide letter dated 23.10.2015 to OP2, OP1 rejected / denied the claim on the said ground. Further OP2 urged that, prior to repudiation in December 2015, it had taken medical opinion from an independent Dr. C.H. Asrani regarding hospitalization of complainant’s wife and the said doctor after examining the entire case was of the opinion that there were no clinical features (symptoms or signs) that necessitated hospitalization all of which were possible on OPD basis were empirical treatment could have been given. OP1 relied upon the discharge summary of complainant’s wife issued by OP2 which also clearly mentioned that she was admitted for further Evaluation and Management. OP1 therefore contended that there was no deficiency of service on its parts in repudiating the claim of the complainant since it was done as per policy terms and conditions as also was the cashless facility denied on similar ground and prayed for dismissal of complaint.
5. OP1 has attached copy of policy terms and conditions, copy of pre-authorization request form dated 22.10.2015 alongwith query letter dated 22.10.2015 for providing need for hospitalization and letter dated 23.10.2015 declining cashless hospitalization facility to complainant, copy of claim form dated 30.10.2015, copy of medico-legal opinion of Dr C.H. Asrani dated 10.12.2015, repudiation letter dated 15.12.2015, copy of discharge summary issued by OP2, copy of vital chart complainant’s wife prepared by OP2 during her period of admission on 23.10.2015, copy of hospital investigation report, copy of summary bill dated 24.10.2015 raised by OP2 on medical expenses incurred by complainant’s wife during hospitalization and copy of policy certificate issued by OP1 in favour of complainant in 2014 and 2015.
6. Rejoinder to the written statement of OP1 was filed by the complainant in rebuttal to the defence taken by OP1 as hospitalization merely for the purpose of investigation and evaluation and submitted in this regard that complainant’s wife was earlier being treated by Dr. N.K. Gupta since 17.10.2015 for fever, vomiting and headache for which medicine was prescribed for three days but on 21^st October night, her condition worsened for which she had to admit to OP2 in emergency in the early morning hours of 22.10.2015 due to her earlier aforementioned treating doctor on leave. Complainant relied upon clause 1.24 and 1.25 “Emergency” and “Emergency Care” of policy terms and conditions which are applicable in the case of complainant’s wife as her medical condition was squarely covered under the said clauses requiring immediate treatment for sudden and unexpected severe illness to prevent serious impairment. Complainant also relied upon clause 1.2 and 1.10 of policy terms and conditions “Acute” and “Chronic Condition” to explain his wife’s condition at the time of admission with OP2 hospital and also as per the discharge summary issued by OP2 whereby his wife admitted with complaint of acute gastritis and acute enteritis. Complainant further relied upon the report / advice dated 21.11.2015 issued Dr. Mukesh Ajmera (treated doctor) who had advised USG of entire abdomen of complainant’s wife which showed enlarged liver and spleen with fatty changes and justified the tests undergone by his wife under the direction of the said doctor to rule out the suspected epidemic of dengue rampant at the relevant period and also typhoid and no other doctor report has any value other than that of the treating doctor who has personally examined and treated the patient. Complainant further urged that the language of discharge summary “further evaluation and management” simply meant that the patient was under treatment of some other doctor but since symptoms were recurring, therefore, required consistent evaluation and management of condition lest it worsened. Dr. Ajmera hand written note was a manifestation of necessity of hospitalization and therefore complainant prayed for the relief claimed.
7. Evidence by way of affidavit was filed by the complainant exhibiting all documents relied upon / filed alongwith complaint as Ex CW 1/A to CW 1/E .
8. Evidence by way of affidavit was filed by OP1 exhibiting documents relied upon / filed alongwith written statement as Ex R1 to R9.
9. Evidence by way of affidavit was filed by OP2 submitting that complainant’s wife admitted there and treated between 22.10.2015 to 24.10.2015 and was charged Rs. 21,256/- for the said treatment inclusive of medicine. Additional evidence by way of affidavit was filed by OP2 vide which it exhibited the earlier query of OP1 dated 22.10.2015 and response thereto Dr. Ajmera dated 21.11.2015 as exhibited CW 1/C and CW 1/D and additionally placed on record and subsequent post repudiation query dated 17.02.2016 by OP1 to OP2’s Dr. Ajmera insurance claim pertaining to wife in the light of consultation paper issued by erstwhile Dr. Gupta and necessity for hospitalization rather than OPD. OP2 vide reply dated 22.03.2016 opined that the admission was due to suspected case of dengue since illness was symptomatic of the said disease alongwith abdominal distention and low urine output and given that the patient (complainant’s wife) was suffering from fever for past six days and severe headache, it was deemed fit to admit her and therefore the same justifies hospitalization as being a genuine case. The said letter and response were exhibited as R2W1 and R2W2.
10. Written arguments were filed by all parties in reassertion / reiteration of their respective grievance / defence. Complainant filed break up of the hospitalization bill and pharmacy to the tune of Rs. 19,486/- and Rs. 2,080/- respectively. He also relied upon judgment of Hon'ble NCDRC in Praveen Damani Vs Oriental Insurance Company Ltd. in RP No. 1696 of 2005 decided on 03.10.2006 and ICICI Lombard General Insurance Vs. Sanjay Tyagi in FA no. 438/2008 decided 04.08.2017 by Hon'ble SCDRC, Delhi.
11. We have heard the rival contentions of both the parties and have thoroughly examined the documentary evidence placed on record by all parties and have given our anxious consideration to the same. To succinctly bring the rival contentions into focus, it may be stated in brief that the case of complainant is that his wife was suffering from fever, vomiting, inability to eat and headache for almost a week before her admission with OP2 hospital in the early morning of 22.10.2015 when despite oral medication given by Dr. Gupta, her condition worsened requiring emergency medical attention. He has justified his wife admission / hospitalization basing his case on the discharge summary issued by OP2 whereby his wife was diagnosed with acute gastritis and acute enteritis, “Acute Condition” having been defined clearly  in policy terms and condition of the health care policy availed of by the complainant as a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease / illness / injury which leads to full recovery. Complainant also relied upon treating Dr. Ajmera’s remarks dated 21.11.2015 to OP1 justifying the necessity for hospitalization as complainant’s wife was showing signs of severe dehydration and abdominal distention for which she was admitted and had to undergo the requisite test and examination and if OP1 had any confusion / suspicion, it should have personally visited the hospital to see whether hospitalization was justified or not. Therefore complainant submitted that his case was both an acute case and emergency case requiring hospitalization and therefore repudiation of mediclaim by OP1 was unjustified and act of unfair trade practice and deficiency of service. OP1 on the other hand justified the repudiation of claim on grounds of the case of complainant being hit by paramagnet exclusion clause 4.3 (a) (i) of policy read with Annexure C-71 of treatment having been undertaken i.e. hospitalization for investigation / diagnostic purpose and relied upon the discharge summary issued by OP2 with respect to complainant’s wife under the head history of present illness and reason for admission given as “further evaluation and management”, with all vital parameters and test reports of organs well within normal limits and no reason for hospitalization and / or clearly outlined disease given. OP1 also relied upon opinion of independent Dr. Asrani who opined that treatment of complainant’s wife could have been possible on OPD basis without hospitalization. Ironically, a critical / crucial document in this regard was neither filed by complainant or OP1 but instead by OP2, a performa party by way of additional evidence  vide which post repudiation, the fraud control unit of OP1 vide query dated 17.02.2016 had sought additional information / clarification pertaining complainant’s wife case viz aspects of history pertaining to vomiting location of pain in abdomen, necessity of hospitalization instead of management of patient on OPD basis, sequelae of acute febrile illness, reason for diagnosis of enteritis in absence of complaint of loose motion, duration of headache and /or migraine and views whether the patient could have been managed on OPD basis. OP2 vide response dated 22.03.2016 through Dr. Ajmera submitted its opinion before OP1 to the effect that the complainant’s wife had approached OP2 on 22.10.2015 since there was no improvement from previous treatment but on the contrary worsening of condition for which reason OP2 had to give her injectable therapy since she was showing signs of dehydration and was unable to take anything orally and therefore had to be given IV fluids. OP2 further opined that the complainant’s wife was showing symptoms of dengue which was a rampant disease at that particular time with every third patient suffering from such like illness unless proof to the contrary. Investigation were got done particularly ECG to rule out coronary syndrome often in cases of abdomen symptoms and restlessness. The complainant’s wife was since suffering from fever for last six days prior to admission therefore, the same has been labelled as sequelae. In so far as enteritis is concerned, she had abdominal pain and distention commonly associated with diarrhea. The complainant’s wife had severe headache and therefore sibelium medication was prescribed. Lastly, Dr. Ajmera justifies hospitalization of complainant’s wife in view of widespread of dengue scare and complainant’s wife showing symptoms of the said disease with abdominal distention, nausea, vomiting, giddiness, abdomen pain and reduce urine output making hospitalization mandatory and concluded that it was a genuine hospitalization and not unnecessary.

The core question for adjudication therefore is whether OP1 was justified in repudiating the mediclaim reimbursement of expenses incurred by complainant on treatment of his wife at OP2 hospital on ground taken in the repudiation letter and reservation expressed vide query letter dated 17.02.2016 from its fraud control unit to Dr. Ajmera of OP1 that the treatment and management of complainant’s wife could have been done on OPD basis as was also advised / opined by OP1’s empanelled Dr. Asrani’s report and did not require hospitalization. The key determinants to adjudicate on this issue are two-fold: (1) condition of complainant’s wife at the time of admission / hospitalization with OP2 and treatment undergone therein as per history sheets (2) statements / opinion / observation of treating Dr. Mukesh Ajmera of OP2 under whose treatment and observation complainant ‘s wife remained during the entire period of hospitalization 22.10.2015 to 24.10.2015. As regards the first determinants, we are guided by the discharge summary issued by OP2 with respect to complainant’s wife which is suggestive of her suffering from acute febrile illness sequelae, acute gastritis, acute enteritis and history of fever, abdominal pain, distention and nausea, vomiting, giddiness and inability to eat for past three to six days prior to admission to OP2 on 22.10.2015 at 7:37 AM. The history sheets of complainant’s wife also revealed the said ailment for which several tests, x-rays and ultrasound, ECG etc, were got done during the period of hospitalization to rule out suspected dengue, liver disorder, typhoid and / or any serious ailment in view of enlarged spleen and fatty liver. In fact the complainant’s wife’s condition only started to improve 23.10.2015 onwards but she was still not able to take anything orally and was feeling chills. Medication was admitted through IV and injectables. As regards the second determinant, we are guided by the opinion of Dr. Ajmera dated 21.11.2015 given to OP1 and further elaborate explanation pertaining complainant’s wife condition justifying hospitalization given vide response dated 22.03.2016 to the query dated 17.02.2016 of OP1’s fraud control unit both of which opinions are suggestive of the fact that since she was suffering from such severe debilitating condition at the time she was brought to OP1 hospital, admission / hospitalization became imperative and it certainly could not be managed on OPD basis since the patient was showing signs of suspected dengue and her reports revealed enlarge spleen and fatty liver and despite already been medication for more than three to six days prior to admission, her condition only worsened and became critical. However, we have observed that, notwithstanding the aforesaid opinions of the treating doctor of OP2 given to OP1 prior and post repudiation, OP1 showed adamancy in insisting that complainant’s wife was an OPD case and we find ourselves in agreement with Dr. Ajmera’s remark that “if there was any confusion or suspicion, you (OP1) should have personally visited the hospital to see whether hospitalization was justified or not.” Also the fact the due to vide spread epidemic like dengue scare / spread and complainant’s wife showing such fever like symptoms OP1 having deemed fit as per medical protocol not to take any chance but to admit the patient for necessary tests / investigation / evaluation and administration of IV fluids since shewas acutely dehydrated suffering from abdominal distention is well in perspective and corroborates the version OP2 in keeping with and in line with the medicaltreatment records / history which also states that complainant’s wife was in serious condition at the time of admission. We cannot give any credence to Dr. C.H. Asrani opinion / report dated 10.12.2015 and in this regard, we are guided by The Hon'ble National Commission’s observation in Praveen Damani (supra) case has very aptly observed that “here lies the cloud on the bonafide intention of the insurance company in procuring such medical opinion form its paneled doctors who never examined the patient and had no knowledge about his past history.” In our view, therefore, the ailments suffered by complainant’s wife required hospitalization. It appears that OP1 has relied upon preponderance of probability that the complainant’s wife could have been managed on OPD basis without any of his officer having bothered to personally visit OP2 hospital and take a first-hand view of her condition instead of being opinionated baselessly and trivializing her medical condition. We are rather surprised that OP1 tried all means to mechanically reject the genuine claim of the complainant on one ground or the other in a perfunctory manner. The insurance companies are misleading the innocent consumers by introducing such unconscionable and misleading terminologies like “further evaluation and management” under permanent exclusion clause showing total disregard to the fact that that human body itself is a complex structure, having regular changes at molecular level which are undetectable until the signs and symptoms are seen and that every humans suffer trivial or miner health problem during his or her life span. Therefore, if the insurance company only pocket premium with no intention to give any genuine claim to its helpless consumer, it is against public policy and is manifestation of utter disregard and insensitivity towards society and shows lack of apathy. The judgment of Hon’ble Supreme Court in LIC Vs Asha Goel AIR 2001 SC 549 is relevant in this regard in which the Hon’ble Supreme Court held that matter of repudiation of policy should not be dealt with in a mechanical and routine manner, but with extreme care of caution. OP has failed to place on record either by way of any affidavit of the treating doctor who had treated complainant’s wife in OP2 Hospital or examined any official of said hospital to prove its averment / contention of complainant’s wife not requiring hospitalization but could have been managed on OPD basis in support of its defence and in the absence of any such evidence we don’t find force to validate the repudiation letter dated 15.12.2015 issued by OP1 to complainant for declining his claim of reimbursement of medical expenses to the tune of Rs. 21,566/- incurred on the treatment undergone by the complainant’s wife in OP2 from 24.10.2015 to 26.10.2015 on grounds taken therein. Therefore we conclude that OP1 has repudiated the genuine claim of the complainant on wrong premise based on conjecture and surmises without any cogent reason or evidence erroneously relying upon opinion of Dr. Asrani who had not even examined much less treated the complainant’s wife and had no knowledge of her medical history case. We therefore allow the present complaint and direct OP1 to reimburse the medical expenses of Rs. 21,566/ to the complainant alongwith interest @ 6% from the date of filing of the complaint till realization. We further direct OP1 to pay compensation of Rs. 10,000/- to the complainant towards mental and physical agony and Rs. 5,000/- towards cost of litigation. No order passed against OP2 being a perfroma party and no relief prayed against it. OP1 appeared only twice in last two years from November 2017 till passing of this order in October 2019 out of which two attendances, only one was made through counsel in November 2017 and did not either appear or address oral arguments despite having been granted several opportunities to do so by this Forum which shows their utter disregard and casualness towards court proceedings and defence in the said matter.

12.  Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
13.   File be consigned to record room.
14.   Announced on 23.10.2019

 

(N.K. Sharma)     President

(Sonica Mehrotra)  Member