Chandigarh

DF-II

CC/206/2021

Sh. Rajinder Paul Pathela - Complainant(s)

Versus

Mukat Hospital Heart Institute - Opp.Party(s)

Adv. Rohit Goswami

25 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	206 of 2021
Date  of  Institution	:	24.03.3021
Date   of   Decision	:	25.11.2022

 

 

 

 

 

 

Rajinder Paul Pathela, resident of House NO.3201, 2^nd Floor, Sector 27-D, Chandigarh

 

             …..Complainant

 

Versus

 

1]  Mukat Hospital Heart Institute, (A Unit of City Clinic Pvt. Ltd.), SCO No.47-49, Sector 34-A, Chandigarh through its director

 

2]  Care Health Insurance Company Limited, Unit No.604-607, 6^th Floor Tower C, Unitech Cyber Park, Sector 39, Gurgaon 122001 Haryana through its M.D.

 

3]  Care Health Insurance Company Limited, SCO No.56-57-58, 2^nd Floor, Sector 9-D, Chandigarh through its Branch Manager.

 

4]  Punjab National Bank through its Chief Branch Manager, SCO 48, Sector 26-D, Chandigarh.

 

    ….. Opposite Parties

 

BEFORE:  SMT.PRITI MALHOTRA    PRESIDING MEMBER 

                    SH.B.M.SHARMA                 MEMBER

                               

Argued by  : Sh.Rohit Goswami, Adv. for complainant.

Sh.Anant Pal, Adv. for OP No.1 along with Sh.Manoj Kumar, Senior Manager.

 

              Sh.Ramdeep Partap Singh, Adv. for OPs No.2 & 3.

Sh.Sourav Dogra, Adv. proxy for Sh.Ajay Sapehia, Adv. for OPs No.4.

PER PRITI MALHOTRA, PRESIDING MEMBER

         Concisely put, the complainant, duly insured under Health Insurance Policy of OPs NO.2 & 3, valid from 30.1.2020 to 29.1.2021 (Ann.C-1), unfortunately suffered fever on 25.10.2020; on test his Covid-19 report came positive, so he visited OP No.1 Hospital on 29.10.2020 to get proper treatment.  The OP Insurance Company initially approved an amount of Rs.50,000/- to the hospital towards the hospitalization of complainant under cashless treatment (Ann.C-3). It is stated that at the OP No.1 Hospital proper care of complainant was not taken and further the Remdesivir injections at higher cost were provided to him. Ultimately, the complainant was discharged from OP NO.1 Hospital on 6.11.2020 and he was made to pay bill of Rs.2,32,546/- even though the OP Insurance Company gave further approval of Rs.1,36,549/- apart from earlier approval of Rs.50,000/- i.e. totaling to Rs.1,86,549/-  (Ann.C-4 to C-6).  It is submitted that the complainant and his family members with great difficulty arranged the amount and paid the bill to OP No.1 Hospital.  The matter was brought to the notice of OP Insurance Company but they did not resolve the issue nor made him the payment. Thereafter, the complainant due to ill health was admitted in Max Hospital and incurred medical bill for an amount of Rs.90,500/-, which was denied by the OP Insurance Company and the complainant has to pay at his own.  The complainant sent legal notice to OPs about illegal deduction and rejection of claim, but to no avail. Hence, this complaint.

 

2]       The OP No.1 Mukat Hospital has filed reply and while admitting the factual matrix of the case, stated that proper treatment was given to the complainant.  It is denied that complainant or his family member were ever asked to buy any medicine or injection e.g. Remdesivir injection from tie-up chemist.  It is stated that the condition of the complainant was improved with the treatment of answering OP.  It is admitted that Rs.50,000/- was approved by OP Insurance Company towards the treatment of complainant and that final bill of Rs.2,32,546/- was raised.  However, it is denied that the complainant was compelled to make the bill payment, rather the complainant made the payment with a condition that as soon as Insurance Company would release the payment to the Hospital, he would collect back his money from answering OP and would make the adjustment of the payment accordingly.  It is submitted that an amount of Rs.35,907/- was given back to the complainant on 4.1.2021 and another amount of Rs.38,882/- is still lying with answering OP, which complainant despite being intimated refused to collect.  Pleading no deficiency in service and denying other allegations, the OP No.1 has prayed for dismissal of the complaint.

         The OPs No.2 & 3 have also filed reply and while admitting the factual matrix of the case, stated that the complainant/insured approached answering OP with cashless claim as he was hospitalized on 29.10.2020 being Covid-19 Positive patient and had high fever, in Mukat Hospital.  The total cashless claim amount was Rs.2,32,548/- and the answering OPs approved the claim for Rs.1,86,549/- as per policy terms & conditions (Ann.R-2 & R-3).  It is submitted that the insured complainant was again hospitalized on 6.11.2020 at Max Hospital, Mohali and discharged on 23.11.2020 and there the cashless claim was raised for Rs.6,88,175/- against which the answering OP approved the claim for Rs.4,84,688/- per policy terms & conditions (Ann.R-5 & R-6). Pleading no deficiency in service and denying other allegations of the complainant, the OPs NO.2 & 3 have prayed for dismissal of the complaint. 

         The OP No.4 (Punjab National Bank) has also filed reply stating that the answering OPs had no role in issuance of insurance policy as well as to release the medical claim to the complainant.  It is stated that neither answering OPs NO.4 & 5 had issued the policy nor had made any commitment qua treatment etc. as alleged, hence there is no role of answering OPs in settling the claim of complainant.  Further the complainant has alleged deficiency in service and negligence qua Mukat Hospital and Insurance Company. Denying other allegations being not related and for want of knowledge, the OPs NO.4 & 5 have prayed for dismissal of the complaint.  

 

3]       Rejoinder has also been filed by the complainant thereby controverting the assertions of the OPs made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have perused the entire record including written arguments.

 

6]       From the record, it is proved that the complainant was duly insured under health insurance policy issued by OPs No.2 & 3 for the period from 30.1.2020 to 29.1.2021 and during the policy period, he remained admitted & treated firstly at Mukat Hospital, Chandigarh from 29.10.2020 to 6.11.2020 and incurred expenses to the tune of Rs.2,32,548/- against which Rs.1,86,549/- has been approved by OP Insurance Company.  Thereafter, the complainant was again admitted & treated at Max Hospital, Mohali from 6.11.2020 to 23.11.2020 and raised bill for an amount of Rs.6,88,175/- against which the Insurance Company approved it for Rs.4,84,688/-.

 

7]       The OP No.1 has admitted that an amount of Rs.38,882/- pertaining to the complainant is still with it, which complainant alleged to have refused to collect.

 

8]       The OP Insurance Company very well know that the complainant has been treated on both occasions at Mukat Hospital, Chandigarh and Max Hospital, Chandigarh being suffered from Corona (Covid-19), therefore, the deductions made by them to the tune of Rs.45,997/- and Rs.90,500/- against the claims lodged by complainant, are unjustified, which clearly amounts to deficiency in service.

 

9]       Taking into consideration the above discussion and findings, we are of the opinion that the OPs No.1, 2 & 3 remained deficient in their service.  Therefore, the present complaint is allowed against OPs No.1 to 3 with directions as under:-

a)  OP No.1 shall refund an amount of Rs.38,882/- to the complainant, along with interest @9% p.a., from the date of discharge i.e. 6.11.2020 till its realization.

 

b)  OPs No.2 & 3 shall reimburse an amount of Rs.45,997/- along with interest @9% p.a. from 6.11.2020 & Rs,90,500/- along with interest @9% p.a. from 23.11.2020, till its realization.

 

c)  The OP No.1 & OPs NO.2 & 3 are also directed to pay to the complainant compository amount of Rs.20,000/- i.e. Rs.10,000/- each towards compensation for the harassment suffered by the complainant as well as litigation cost.

 

         This order shall be complied with by the OP No.1 to 3 within a period of 45 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional cost of Rs.10000/- each, apart from above relief.

 

10]      The complaint qua OP NO.4 stands dismissed.

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

25^th November, 2022                                                     sd/-

(PRITI MALHOTRA)

PRESIDING MEMBER

 

Sd/-

 (B.M.SHARMA)

MEMBER