District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.456/2019.
Date of Institution: 17.09.2019.
Date of Order: 16.09.2022.
Udaivir, aged about 46 years son of Shri Bhim Singh resident of village Sagarpur, Tehsil Ballabgarh, District Faridabad. Aadhar card No. 2754 2470 9923.
…….Complainant……..
Versus
1. M/s. Royal Sundaram Alliance Insurance Company Limited, Rider House, Ground & First floor, Plot NO. 136, Sector-44, Gurugram – 122002 (Haryana) through its Managing Director/Principal Officer.
2. Dr. Kapil Bhatia, Ballabgarh Nursing Home, 64-65, Mukesh Colony, Ballabgarh – 121004, District Faridabad.
…Opposite parties……
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: Kr. Virender Singh Bhati, counsel for the complainant.
Sh. Sachinder Bhatia, counsel for opposite party No.1.
Dr. Kapil Bhatia in person on behalf of opposite party No.2.
ORDER:
The facts in brief of the complaint are that the complainant obtained a medical claim insurance policy bearing NO. LLA0008914000100 covering the risk form 4th December 2017 to 3rd December 2018 for a sum of Rs.5,00,000/- which includes the insurance of wife of the complainant namely Mrs. Shyamwati and daughter namely Vaishnavi duly issued by the opposite party No.1. On 29.08.2018 the complainant was suffering from cough and breath and thus he got admitted in Ballabgarh Nursing Home i.e. opposite party No.2 and remained there upto 3rd September 2019 on the basis of above said mediclaim policy and the complainant immediately informed the opposite party No.1 about his ailment and hospitalization. Accordingly at that time the complainant got completed each and every required formality. As already submitted hereinabove, the complainant informed the opposite party No.1 immediately about ailment/sickness of the complainant as well as about his admission in the said hospital and at that time they did not raise any objection about the same. After that the complainant contacted the opposite parties, then he was directed to submit the original medical bills and treatment documents and accordingly the complainant submitted all original documents to opposite party No.1 company. However, the claimed amount was Rs.36,790/- on account of hospitalization expenses, being spent by the complainant. Inspite of submission of all requisite documents by the complainant, the opposite party No.1 had failed to release the payment of claimed amount to the complainant, as the opposite party No.1 issued letter dated 20.10.2018 to the name of the complainant, vide which the opposite party No.1 had stated that “the patient was admitted for Arti with FI with Acute Gastritis as stated in discharge summary. However, the scrutiny of the claim records submitted and verification of additional record reveal gross discrepancies and did not reveal a condition warranting in patient hospitalization.” Hence, the opposite parties did not consider the claim of the complainant on the above grounds. The complainant sent legal notice dated 04.04.2019 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) release the payment of Rs.36,790/- alongwith interest @ 17% p.a. from the date of its due till realization of whole amount, immediately.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that it was submitted that the complainant admitted in Ballabgarh Nursing Home for a problem of cough, fever, headache and vomiting, weakness and ghabrahat and for this the hospital diagnoses that the complainant was having ARTI with AF1 with acute gastritis and admitted on 29.08.2018 and discharge don 13.08.2018 and hospital charged an amount of rs.36,790/- from the complainant. Further the complainant applied for reimbursement from the opposite party by filing the claim form and depositing the requisite documents and after going through the complete documents by the opposite party and after scrutinizing the claim record the opposite party issued a letter dated 20.10.2018 stated that the after scrutiny the claim records submitted and verification of additional record revealed gross discrepancies and did not reveal a condition warranty in patient hospitalization, hence they regretted their inability to consider the claim of the above grounds therefore, in view of the above facts and reasons the claim of the complainant closed by the opposite party as per the terms and conditions of the insurance policy. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Instead of filing written statement on behalf of opposite party No.2, Dr. Kapil Bhatia, MS Ballabgarh Nursing Home has made a statement that patient Udaivir was admitted in Ballabgarh Hospital on 29.08.2019 and discharge don 3.09.2018 as a case of fever with respiratory and abdominal complaints. Concerned TPA was informed about the admission via email. copy of which was attached alongwith. But nobody form the insurance company/TPA came to check the status of the patient during the time he was admitted in the hospital.
Patient was quite sick at the time of admission with complaints of fever, cough, shortness of breath, headache, vomiting and pain abdomen. He was unable to take any medication orally because of being sick and toxic and needed urgent admission which was clearly documented in the first prescription. I as a treating doctor confirmed that patient was sick and needed admission.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– Royal Sundaram Alliance Insurance Company Limited with the prayer to: a) release the payment of Rs.36,790/- alongwith interest @ 17% p.a. from the date of its due till realization of whole amount, immediately. 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, letter dated 05.12.2017,, Annexure C-2 – receipt dated 03.09.2018, Annexure C-3 – Request for cashless hospitalization,, Annx.C-4 – bill dated 03.09.2018, Annx.C-5 – Discharge summary, Annx.6 to 87 – GST invoices,, Annx-9 Breakup pathology charges, Annx.-10 – Adhaar card, Annx-11 – legal notice.
On the other hand counsel for the opposite party No.1strongly agitated and opposed. As per the evidence of the opposite party No.1, affidavit of Shri Kathiravan. N, Authorized representative of opposite party, Royal Sundaram General Insurance Company Ltd., Ex.R-1 – policy alongwith terms and conditions,, Ex.-2 – Medical Investigator,, Ex.-3 – repudiation letter dated 20.10.2018.
7. In this case, the complainant obtained a medical claim insurance policy bearing NO. LLA0008914000100 covering the risk form 4th December 2017 to 3rd December 2018 for a sum of Rs.5,00,000/- which includes the insurance of wife of the complainant namely Mrs. Shyamwati and daughter namely Vaishnavi duly issued by the opposite party No.1. On 29.08.2018 the complainant was suffering from cough and breath and thus he got admitted in Ballabgarh Nursing Home i.e. opposite party No.2 and remained there upto 3rd September 2019 on the basis of above said mediclaim policy and the complainant immediately informed the opposite party No.1 about his ailment and hospitalization. The claimed amount of Rs.36,790/- on account of hospitalization expenses, being spent by the complainant. Opposite party repudiated the claim of the complainant vide letter dated 20.12.2018 on the ground that “the patient was admitted for Arti with FI with Acute Gastritis as stated in discharge summary. However, the scrutiny of the claim records submitted and verification of additional record reveal gross discrepancies and did not reveal a condition warranting in patient hospitalization.”
8. After going through the evidence led by the parties, the Commission is of the opinion that when the doctor advised the patient to admit in the hospital, the patient is layman person he has to take the admission in the hospital on the advice of the doctor. He cannot deny and some of the investigations are not possible without the admission of the hospital because doctor need the patient for the observation. In the interest of justice, the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the T&C of the policy 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 parties are 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: 16.09.2022 (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.
