11. A letter purported to be issued by Dr.Ravinder Babu, Medical Superintendent, Apollo Hospital dated 08.11.2013 addressed to the Company’s authorized claim Investigator M/s Lavanya & Co., wherein it is mentioned that ‘ the duration of the past history of the present illness was mentioned as 2 years as per the patient statement. In a few days after the discharge, the patient has approached the consultant Dr.Sudhir and informed that there was an error in the duration of disease mentioned earlier and the actual duration of the illness is one and half month and not two years as mentioned earlier. Hence, the duration was changed and discharge summary was reissued….so the duration of the illness has been recorded as stated by the patient”.
12. A perusal of five documents clearly show that there were ambiguities in the documents the opposite party had to conclude that a serious fraud of fabrication of documents and medical records has been undertaken by the Apollo Hospital authorities so as to create a false alibi and the same was brought to the notice of Commissioner of Police, Hyderabad. The Ombudsman also rejected the complaint filed by the complainant sighting reason that the amount mentioned in the complaint is above Ombudsman limit. As per judgement of the Hon’ble Supreme Court in Ravneet Singhy Bagga vs KLM Royal Duth Airlines (2000) 1 SCC 66 where the Supreme Court has held that the rendering of deficient service has to be considered and decided in each case according to the facts of that case for which no hard and fast rule can be laid down. Inefficiency, lack of due care, absence of bonafides, rashness, haste or omission and the like may be the factors to ascertain the deficiency in rendering the service. Hence, the opposite party prayed for dismissal of the complaint.
13. The complainant in proof of his case filed his affidavit and got Exs.A1 to A13 marked while on behalf of the opposite party, its Assistant Manager, Operations filed his affidavit and got Exs.B1 to B3 marked.
14. Counsel for both parties present and were heard. Both parties have filed their respective written arguments.
15. The points that arises for consideration are :
i) Since fraud, manipulation etc alleged whether
this Commission can entertain the complaint ?
(ii) Whether the opposite parties rendered deficient
service as pleaded by the complainant ?
(iii) Whether the complainant is entitled for the
amount as claimed ?
(iv) To what relief ?
16. The case of the complainant is that being induced by Bajaj FinServ he took two Master Policies from the opposite party and they covered Accelerated Critical Illness Benefit. Critical illness includes first heart attack, coronary artery disease requiring surgery, stroke, cancer, kidney failure, major organ transplantation, multiple sclerosis, aortic surgery, primary pulmonary hypertension, Alzheimer’s disease and paralysis. The first policy bearing No.0223291728 for the basic sum of Rs.10 lakhs and the rider sum of Rs.10 lakhs totalling Rs.20 lakhs and date of commencement of risk was 30.11.2011 and for which he paid premium of Rs.71,160/-.
17. The second Group Policy bearing No.0223291728 for a basic sum of Rs.40 lakhs for which a premium of Rs.1,42,320/- was collected by the opposite party and date of risk of the policy was 26.03.2012. Both the premium amounts was paid by way of loan to the complainant by M/s Bajaj Finserv to be paid in EMIs. While so the complainant suffered with multiple sclerosis and took treatment as inpatient from 28.08.2012 to 31.08.2012 in Apollo Hospitals. After the discharge from hospital on 02.09.2012 he made two insurance claims for Rs.20 lakhs and Rs.40 lakhs totalling to Rs.60 lakhs to the opposite party. The opposite party settled first policy claim for Rs.10 lakhs and the second policy claim for Rs.4 lakhs. In the second insurance policy the sum assured was shown as Rs.4 lakhs instead of Rs.40 lakhs and therefore, the opposite party settled the claim at Rs.4 lakhs. Thereafter the complainant brought the typographical mistake to the notice of the opposite party who after long persuasion corrected the sum assured as Rs.40 lakhs but the date of commencement of risk was shown as 23.04.2013 instead of 31.03.2012 and the premium paid was shown as Rs.1,44,960/- when the complainant paid only Rs.1,42,320/-. Therefore the complainant requested the opposite party to make payment of the balance amount after deducting Rs.4 lakhs which was already paid. The officials of opposite party instead of paying the balance amount pointed out certain hyper technical deficiencies in the discharge summary issued by Apollo Hospital stating that the signatures in the discharge summary have been forged and fabricated to manipulate the documents and also pointed out that the complainant is a known case of multiple sclerosis for the last 1 ½ year has not been disputed or rectified. Having said so the opposite party opined that the infirmities are glaring in medical records has been found and hence the same need to be investigated by the police authority and therefore the opposite party shall not entertain any further claim or grievance under certificates of insurance bearing Nos.0254506270 and 0264646328. Though the complainant got issued legal notice dated 27.02.2014 to the opposite party demanding payment of the balance amount but despite receipt of the same there was no response from the side of opposite party. Hence, the complainant filed the present complaint with the above said reliefs.
18. On the other hand the case of the opposite party is that the complaint is liable to be dismissed on the ground of non-joinder of necessary parties as the complainant obtained policies through Bajaj Finserv Ltd. As the data provided by the Master Policy Holder only. Life assured was hospitalized during 28.08.2012 to 31.08.2012 and was diagnosed of multiple sclerosis as per the discharge summary dated 31.08.2012. The medical documents and discussion portion of the discharge indicated history of complaints related to the said illness since 1.5 years. Under admission order dated 28.09.2012 indicated life assured as asymptomatic 2 months back and then developed decrease in vision. As the discrepancy was pointed out during claim assessment life assured submitted another corrected version of “discussion” portion of the medical documents wherein multiple sclerosis was corrected as diagnosed 1.5 month back. Based on the above information and clarifications accelerated critical illness claim under policy 0264646328 was settled by the opposite party on 03.01.2013 for Rs.4,00,000/- as the sum assured under this policy as per system was Rs.4,00,000/- also opposite party settled ACI claim of Rs.10 lakhs pertaining to policy No.0254506270 on 03.01.2013. The complainant on receipt of claim amount of Rs.14 lakhs under both the policies lodged one complaint stating that the sum assured under policy no.0264646328 should have been Rs.40 lakhs and not 4 lakhs. On verification it was observed that the policy no. 0264646328 was wrongly issued for Rs.4 lakhs instead of Rs.40 lakhs due to incorrect data submitted by Bajaj Allianz Finance Limited at the time of issuance. In the meantime complainant had lodged a complaint in IGMS portal of IRDA for not receiving ACI claim for balance amount of Rs.36 lakhs. During the process of redress of the complainant grievance, it is observed that the company is in possession of several variants of the discharge summary issued by M/s Apollo Hospital, Hyderabad from where the complainant had taken medical treatment during the period 28.08.2012 till 31.08.2012. A letter was also issued by Dr.Ravinder Babu, Medical Superintendent, Apollo Hospital dated 08.11.2013 addressed to the Company’s authorized claim Investigator M/s Lavanya & Co., wherein it is mentioned that ‘ the duration of the past history of the present illness was mentioned as 2 years as per the patient statement. In a few days after the discharge, the patient has approached the consultant Dr.Sudhir and informed that there was an error in the duration of disease mentioned earlier and the actual duration of the illness is one and half month and not two years as mentioned earlier. Hence, the duration was changed and discharge summary was reissued. Therefore, a perusal of five documents clearly shows that there are ambiguities in the documents and the opposite party had come to conclusion that a serious fraud of fabrication of documents and medical records has been undertaken by the Apollo Hospital authorities so as to create a false alibi and the same was brought to the notice of Commissioner of Police, Hyderabad. Therefore, the complainant is not entitled for any relief whatsoever and not entitled to claim and recover anything from this opposite party.
19. There is serious allegation against hospital authorities that the hospital authorities have played fraud by fabricating the documents and medical records so as to create false alibi in order to claim assured sum. Admittedly, the opposite party initially without going through the material papers settled the claim of two policies at Rs.14 lakhs. Later, the opposite party came to know the discrepancies in the discharge summary when the complainant lodged a complaint in IGMS portal of IRDA for not receiving ACI Claim for balance amount of Rs.36 lakhs. Then the opposite party verified the discharge summary issued by M/s Apollo Hospital, Hyderabad and found that there are ambiguities in the documents which are as follows:
- If the duration of the earlier illness mistakenly mentioned as 1 ½ years instead of 1 ½ month then there cannot be a mistake of the Apollo Hospital regarding medical advice/treatment which is mentioned as “interferon’s were restarted” which has been subsequently changed to “ interferon’s were to be started immediately”.
- As per the letter of Dr.Ravinder Babu, Medical Superintendent, Apollo hospital dated 08.11.2013 the complainant had approached the Hosptial for correction fo the records a few days after the discharge if that is so how come the page 3 of 4 of the discharge summary which the complainant had submitted bears the date of 31.08.2012 as the date of audit of the summary, if rectifications had been done after a few days fo his discharge it is impossible that the audit of the discharge summary was conducted on 31.08.2012 which is prior to issuance of the rectified discharge summary.
- The rectified discharge summary sent to the company by the complainant through his email dated 06.11.2013 from his personal email ID
- In the discharge summary there are insertions/deletions made by hand and attested by one person by writing his name as “Sudhir” bears the Hospital Stamp in Original but the revised discharge summary does not.
- The word ‘BBF’ has been inserted in the discharged medication of the revised discharge summary which had never been found in any of the other variants of the discharge summary.
- The signatures of Dr.Ravindra Babu, Medical Superintendent, Apollo Hospitals, Hyderabad is different on the discharge summary as provided by the complainant, the attested discharge summary, medical case papers and in the letter dated 08.11.2013 which he himself had signed. This casts aspersions that the signatures have been forged and fabricated to manipulate the documents.
- The fact that the complainant was a known case of multiple sclerosis for the last 1 ½ years as detailed in any of the variants of the discharge summary has never been disputed or rectified.
20. Ex.A5 is the copy of discharge summary of the complainant dated 31.08.2012 issued by the Apollo Hospital, Neurology Department wherein in the ‘Discussion’ it is mentioned as follows:
Discussion:
Mr.JYOTHI NATH SPG CHITTA, 39 years gentleman got admitted with diminution of vision unsteadiness while walking 2 months before. His symptoms have been improving since then, 2 months ago he had similar complaints, was diagnosed to have multiple sclerosis and was put on disease modifying treatment. During this second event (after a month) neurological examination revealed RAPD, left sided cerebellar sign and sensory loss over lateral part of face on the right side, positive Rhobergs. His routine blood chemistry was unremarkable. Visual evoked potentials revealed prolonged P100 Latencies bilaterally, CSF Analysis showed normal proteins and cells, reports of OCB & Anti NMO antibodies are awaited. MRI brain and spine showed 4 periventricular T2 hyperintensities without gadolinium enhancement and without infratentorial spinal cord, brainstem lesions. Diagnosis of multiple sclerosis was confirmed and IV MP for 3 days was given followed by papering doses of steroids and interferons were to be started immediately. He is being discharged in stable condition with the following medical advice.
DISCHARGE MEDICATION
- TAB. OMNACORTIL 40 MG PER ORAL ONCE DAILY FOR 3 DAYS (Steroid)
20 MG PER ORAL ONCE DAILY FOR 3 DAYS
10 MG PER ORAL ONCE DAILY FOR 3 DAYS
5 MG PER ORAL ONCE DAILY FOR 3 DAYS, THEN STOP
- TAB. PANTODAC 40 MG PER ORAL ONCE DAILY FOR 2 WEEKS(APD)BBF
- INJ. REBIF 44 MCG SUBCUTANEOUS 3 TIMES A WEEK (MULTIPLE SCLEROSIS
- CAP.RENERVE PLUS 1 CAP PER ORAL DAILY FOR 1 MONTH (Vitamin)
-
21. On the other hand, Ex.B3 is also the copy of discharge summary of the complainant dated 31.08.2012 issued by the Apollo Hospital, Neurology Department wherein in the ‘Discussion’ it is mentioned as follows:
Discussion:
Mr.JYOTHI NATH SPG CHITTA, 39 years gentleman got admitted with diminution of vision unsteadiness while walking 2 months ago. His symptoms have been improving since then. One and half year back he had similar complaints, was diagnosed to have multiple sclerosis and was put on disease modifying treatment (interferon), but discontinued in between. During this second event (at this admission) neurological examination revealed RAPD, left sided cerebellar sign and sensory loss over lateral part of face on the right side, positive Rhobergs. His routine blood chemistry was unremarkable. Visual evoked potentials revealed prolonged P100 Latencies bilaterally, CSF Analysis showed normal proteins and cells, reports of OCB & Anti NMO antibodies are awaited. MRI brain and spine showed 4 periventricular T2 hyperintensities without gadolinium enhancement and without infratentorial spinal cord, brainstem lesions. Diagnosis of multiple sclerosis was confirmed and IV MP for 3 days was given followed by papering doses of steroids and interferons were to be started immediately. He is being discharged in stable condition with the following medical advice.
DISCHARGE MEDICATION
- TAB. OMNACORTIL 40 MG PER ORAL ONCE DAILY FOR 3 DAYS (Steroid)
20 MG PER ORAL ONCE DAILY FOR 3 DAYS
10 MG PER ORAL ONCE DAILY FOR 3 DAYS
5 MG PER ORAL ONCE DAILY FOR 3 DAYS, THEN STOP
- TAB. PANTODAC 40 MG PER ORAL ONCE DAILY FOR 2 WEEKS(APD)BBF
- INJ. REBIF 44 MCG SUBCUTANEOUS 3 TIMES A WEEK (MULTIPLE SCLEROSIS
- CAP.RENERVE PLUS 1 CAP PER ORAL DAILY FOR 1 MONTH (Vitamin)
22. From the above it is clear that there are discrepancies in the two discharge summaries. As rightly stated by the opposite party if the earlier illness mistakenly mentioned as 1 ½ years instead of 1 ½ month there cannot be a mistake in the treatment given. In the first discharge summary i.e., ex.A5 at page 3 of 4 Mr.Sudhir had signed the discharge summary and in Ex.B3 it was signed by B.Priyanka. if the complainant approached the hospital for correction of the records a few days after the discharge bears the date as 31.08.2012 as the date of audit of the summary and if rectifications had been done after a few days of his discharge it is impossible that the audit of the discharge summary was conducted on 31.08.2012 which is prior to issuance of the rectified discharge summary. It is also to be noted that in Ex.B3 there is hospital stamp whereas in Ex.A5 it does not bear the hospital stamp. In Ex.B3 at Tab Pantodac 40 mg per oral once daily for 2 weeks (APD) it was not written as BBF but in Ex.A5 it was written as BBF.
23. The opposite party also filed letter issued by Dr.Ravinder Babu, Medical Superintendent to Mr.R.Ashivini Kumar M/s Lavanya and Company, Insurance Investigators, Banglaore which is as follows:
With reference to the above subject and your letter dated 7th November 2013, please note that we have issued a discharge summary primarily soon after the patient was discharge on 31st August, 2012
The duration of the past history of the present illness was mentioned as 2 years as per the patient statement. In few days after the discharge, the patient has approached the Consultant-Dr.Sudhir and informed that there was a error in the duration of disease mentioned earlier and the actual duration of the illness is one and half month and not two years as mentioned earlier. Hence, the duration was changed and discharge summary was reissued. Clinically it is difficult to estimate the exact duration of this illness and moreover this patient did not visit hospital earlier to this. So the duration of illness has been recorded as stated by the patient.
24. The signatures of Dr.Ravindra Babu, Medical Superintendent, Apollo Hospitals, Hyderabad is different on the discharge summary as provided by the complainant, the attested discharge summary, medical case papers and in the letter dated 08.11.2013 which he himself had signed. Therefore, it clearly shows that the signatures of the Medical Superintendent have been forged and fabricated to manipulate the documents. It is also pertinent to note that in Ex.A5 2 months ago and in Ex.B3 it was one and half year back and in the letter it was stated that “ the patient has approached the Consultant – Dr.Sudhir and informed that there was an error in the duration of disease mentioned earlier and the actual duration of illness is one and half month and not two years as mentioned earlier”. But in Ex.A5 it was mentioned as 2 months and not one and half month as stated in the letter. Ex.A9 is the copy of letter dated 12.11.2013 of the opposite party addressed to the complainant which reads as under:
This is with reference to your aforementioned Certificates of Insurance issued through the Master Policy Holder Bajaj Finance Limited. The premiums for these Certificates of Insurance had been paid directly by the Master Policy Holder. Post receipt of the documents and details, the Certificates of Insurance bearing Numbers 0254506270 & 0264646328 had been issued to you, on 30/11/2011 and 31/3/2012 respectively.
Post receipt of the said Certificates of Insurance bearing numbers 0254506270 & 026464328, no grievances had been received by the Company and hence it was deemed accepted that both the Certificate of Insurance had been issued to your satisfaction.
Thereafter Company had received an Accelerated Critical illness Claim from you, vide claims Nos.224413 and 224414, whereby you had claimed an amount of Nil and Nil, towards the Medical Treatment undertaken by you in Apollo Hospital, Hyderabad, during the period 28/08/2012 till 31/8/2012, for Multiple Sclerosis.
Post receipt of the claim, the Company had paid an amount of Rs.10,00,000/- and Rs.4,00,000/-, being the maximum Accelerated Critical Illness Rider benefits under both the Certificate of Insurance.
Surprisingly the Company is now in possession of several variants of the discharge summary issued by M/s Apollo Hospital, Hyderabad from where you had taken medical treatment during the period 28/08/2012 till 31/8/2012.
Xxxxx
Xxxxx
Xxxxx
In view of the glaring infirmities as stated above, the Company is of the opinion that a serious fraud of fabrication of documents and medical records has been found and hence the same needs to be investigated by the Police Authorities. This fabrication and manipulating of the hospital records seems to have been undertaken so as to create a false alibi, in order to exhort monies for ill gain.
You are requested to cooperate with the Police Authorities during the course of their investigations.
Therefore, the Company shall not entertain any further claims or grievances under Certificates of Insurance bearing numbers 0254506270 & 026464328.
The Copy of this letter is also being sent to Insurance Regulatory and Development Authority, Hyderabad, wherein you had filed a complaint through their IGMS Portal.
25. From the above letter it is clear that the matter was referred to the Police Commissioner of Hyderabad for taking necessary action with regard to serious fraud of fabrication of documents and medical records. The complainant also not clarified with regard to the discrepancies pointed out by the opposite party, he simply stated that these are hyper technical deficiencies. In our view the matter involving the aforementioned several disputed questions of facts, such as issuance of two discharge summaries with several alterations, modifications, forgery of signature of Dr.Ravindra Babu, alteration of past history and the matter involving complicated questions of facts requiring detailed examination and cross examination of witnesses etc, lead us to the well-considered view that the matter can be decided by civil court. As such, the parties are required to be relegated to civil court for proper adjudication of the matter.
26. In “OrientaL Insurance Company Ltd vs Munimahesh Patel” IV (2006) CPJ 1 , the insurance company disputed the genuineness of the documents and the Hon’ble Supreme Court held that where the matter involves adjudication of issues involving disputed factual questions, Consumer Forum cannot adjudicate the matter and the complainant was entitled to seek relief in court of competent jurisdiction.
“9. The Commission noted that the specific stand of the appellant was that there was mis-declaration in the proposal form and the false claim that the respondent’s wife was a teacher which as now appears is not the correct position. It also accepted that she was really not a teacher.
10. Proceedings before the Commission are essentially summary in nature and adjudication of issues which involve disputed factual questions should not be adjudicated. It is to be noted that Commission accepted that insured was not a teacher. Complainant raised dispute about genuineness of the documents (i.e. proposal forms) produced by the appellant.
11. The Commission having accepted that there was wrong declaration of the nature of occupation of the person insured, should not have granted the relief in the manner done.
12. The nature of the proceedings before the Commission as noted above, are essentially in summary nature. The factual position was required to be established by documents. Commission was required to examine whether in view of the disputed facts it would exercise the jurisdiction. The State Commission was right in its view that the complex factual position requires that the matter should be examined by an appropriate Court of Law and not by the Commission.
13. Above being the position, the Commission was not justified to deal with the matter in the manner as was done. In our view, the directions of the State Commission were more appropriate keeping in line with the nature of dispute. Accordingly, the appeal is allowed but with no order as to costs”.
27. The National Commission in ‘Transport Corporation Employees Provident Fund Trust vs Orissa small Industries and another ‘ III(2007) CPJ 316(NC) and ‘Omprakash vs Allahabad Bank’III(2206)CPJ 418, held that the matter involving adjudication of disputed questions of facts has to be tried by competent court. Thus, we are inclined to give opportunity to the complainant to approach competent court for adjudication of the matter.
28. POINT NO.3: In view of finding that the civil court alone is a competent forum to entertain the complaint, there need be no discussion .
In the result, the complaint is dismissed and the complainant is relegated to Civil Court for redressal if she so chooses and in such a situation he is entitled for exclusion of the period spent between filing of the claim till disposal of the Appeal U/s. 14 of the Indian Limitation Act, 1963 for the purposes of limitation in the light of the decision of the Honble Supreme Court of India in Trai Foods Ltd Vs. National Insurance Company Ltd and another reported in (2004) 13 SCC 656. No costs
PRESIDENT MEMBER
07.09.2017
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
NIL
EXHIBITS MARKED
For complainant
Ex.A1 Copy of certificate of Group Insurance Policy No.0223291728 for
sum assured for Rs.10 lakhs
Ex.A2 Copy of certificate of Group Insurance Policy No. 0223291728 with
loan account
Ex.A3 Copy of individual cover details of Membership No.0264646328 for
basic SA Rs.4 lakhs
Ex.A4 Copy of Certificate of Group Insurance Policy No.0243742341
With loan A/c No.4000CD000265694 for Rs.40 lakhs
Ex.A5 Copy of discharge summary of Apollo Hospital dated 31.8.2012
Ex.A6 Copy of Insurance Claim representation dt.02.09.2012
Ex.A7 Copy of email dated 11.02.2013
Ex.A8 Copy of Op letter dated 02.07.2013
Ex.A9 Copy of Op letter dated 12.11.2013
Ex.A10 Copy of legal notice dated 27.02.2014 with postal ackn.
Ex.A11 Copy of bunch of emails
Ex.A12 Copy of HDFC statements
Ex.A13 Copy of Bajaj Finserv Loan Details
For opposite party
Ex.B1 Copy of Admission note by the Apollo hospitals Hyderabad
Ex.B2 Copy of Admission Record issued by the Apollo Hospitals Hyd
Ex.B3 Copy of Discharge Summary (Dept. of Neurology) Apollo
Hospitals, Hyderabad
PRESIDENT MEMBER
