Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.91 /08.05.2018
C1. Kamal Kanojia son of Sh R L Kanojia,
R/o 412-C, Poket-2, Mayur Vihar, Phase-I
New Delhi-110001
C2. Archana Kanojia wife of Sh Kamal Kanojia ,
R/o 412-C, Poket-2, Mayur Vihar, Phase-I
New Delhi-110001 …Complainants
Versus
OP - National Insurance Company Limited ,
through its General Manager, Jhandewalan Branch,
Third Floor, Deendayal Upadhyay Bhawan,
7E, Jhandewalan Extn., Swami Ram Tirath Nagar,
New Delhi -110055 ...Opposite Party
Date of filing: 08.05.2018
Coram: Date of Order: 23.07.2024
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
FINAL ORDER
Inder Jeet Singh , President
It is scheduled today for order (item no.)
1.1. (Introduction to case of parties) –The complainants have grievances of deficiency of services against OP for want of reimbursement of medical claim of hospitalized/ treatment of complainant no.1 despite the complainant no.2 has been subscribing Pariwar Mediclaim Policy for several years for them. The medi-claim was partly allowed and partly declined on first occasion, when treatment was taken from Max Hospital from 22.02.2017 to 27.02.2017 and completely declined on second occasion when treatment was taken from Institute of Liver and Billiary Sciences (ILBS) from 27.02.2017 for two days. That is why the present complaint for reimbursement of medical bills and expenses of Rs. 90,274/- with interest at the rate of 18%pa, damages of Rs. 1 lakh, cost of Rs. 1 lakh and other appropriate relief.
1.2. The OP filed its written statement and denied allegations of deficiency of services on the ground since the claim was not made out as clause 4.10 of the terms and conditions applies. The complainant no.1 was hospitalized with complaint of acute hepatitis and his admission was mainly done for investigation and evaluation purposes, which is not covered under the policy. That is why, there is no deficiency of services.
2.1. (Case of complainant) –The complainant no.2 has been subscribing medi-claim policy known as National Pariwar Mediclaim for the several years and lastly it was get renewed from 09.10.2017 to 08.10.2017 vide policy no. 350201501710003295 against premium of Rs. 11,231/- [hereinafter referred as policy or insurance policy]. The family of complainants is covered under the policy. As per policy, the expenses related to hospitalization, room charges, procedure, x-ray, dialysis, pre and post hospitalization from 15 & 30 days, cashless facility etc. are covered to be payable by the insurer/OP. (the paragraph 4 of the complaint reproduces as extracted from the policy). Thus complainant no.1 being husband of complainant no.2 as well as their children are covered under the Pariwar Mediclaim Policy.
2.2. On 20.02.2017 complainant no. 1 suddenly felt cold and high fever besides severe headache, he thought it would be normal seasonal flue but when fever did not came down and medical condition did not improve even on 21.12.2017; then on 22.12.2017, he went to emergency ward of Max Hospital at Patpatganj to consult doctor. He was advised immediate hospitalization and to conduct various tests, the complainant no.1 had no other option but to obey the advice of doctor and admitted in the hospital. Then various tests were conducted but hospital could not lead to any finding except that he is suffering from severe disease and requires long hospitalization. The complainant remained in the hospital from 22.02.2017 to 27.02.2017 but doctor remained clueless about the disease and they did not come to any conclusion nor there was any improvement in the health of complainant no.1, therefore, he got discharged after 5 days and doctors were suspicion of liver infection. The complainant lost the faith in that hospital and decided to take second opinion from the hospital ILBS.
The complainant was discharged on 27.02.2017 and discharged summary was issued (para 10 of the complaint reproduces an extract from the discharge summary, with observation that patient is being discharged on request with plan to shift to ILBS for further management). The complainant paid bills of Rs. 76,383/- to the Max Hospital but OP1 had reimbursed partly amount of Rs. 65,641/-. There was deficiency of payment of Rs. 10,742/- being coverable from the OP in this complaint.
2.3 On 27.02.2017 the complainant was taken to ILBS, where he was kept for treatment for two days and he was discharged on 01.03.2017; he was diagnosed of acute hepatitis, for which discharge summary was issued. The bill dated 01.03.2017 was generated for Rs. 77,252.12p (comprising Rs. 2,400/- for consultation + Rs. 1632.01p on consumable +Rs. 62,038.75 on investigation/treatment + Rs. 1181.36 on pharmacy + Rs. 10,000/- on room rent). The complainant had paid Rs.30,400/- on 27.02.2017 at the time of admission and remaining amount of Rs. 46,852/- was paid at the time of discharge from ILBS. The OP failed to pay any amount of bill paid to ILBS.
Moreover, further an amount of Rs. 2,790/- was paid at Dr. Lal Path Lab after discharge and Rs. 2790/- for further tests, which makes out total claim amount raised of Rs. 79,532/- for reimbursement being bona-fide expenses and treatment but OP failed to pay them.
2.4 The OP took very casual approach to consider the valid claim and the claim was rejected telephonically that complainant no. 1 was not diagnosed with any particular diseased, that is why he cannot get any payment from the insurance company, whereas the complainant was diagnosed of acute hepatitis for which he was treated at ILBS, besides appropriate certificate of in-patient was issued by ILBS. The paragraph 17 to 23 of the complaint mentions about email correspondence or correspondence between the complainant no. 1 and the OP to consider and reconsider the claim, the complainant was asked vital chart, it was provided on 05.10.2017 and it was again asked, just as a repetition and to harass the complainant, it was also provided again on 05.12.2017, however, the claim was not considered and amount was not released. Moreover, one of the payments rejected was of Rs. 2,400/- by stating that the same are pre or post visit charges, whereas there was nothing pre and post visit charges. The complainant was constraint to issue legal notice dated 02.02.2018, it was not complied but OP had issued letter dated 18.03.2018 taking an excuse that expenses on x-ray, diagnostic and lab examination etc are not covered. That is why the complaint against OP for reimbursement of bill amount of Rs. 90,274/- (consisting balance amount of Rs. 10,742/- pertaining to bill paid in Max Hospital and medical bill amount etc of Rs. 79,532/- pertaining to ILBS hospital and other expenses).
2.5 The complaint is accompanied with copies of – policy document, prospectus printout of policy, discharge summary issued by Max Hospital and of ILBS, emails exchanged from time to time, legal notice dated 02.02.2018 and letter dated 18.03.2018.
3.1 (Case of OP)- The complaint is opposed by the OP that it is a false complaint; the claim of complainant was not covering within the terms of policy. The parties are bound by the terms and conditions of policy. It is National Pariwar Mediclaim policy in the name of complainant no.2. The complaint fails to make out case of deficiency of services.
3.2. On scrutiny of documents including discharge summary submitted by complainants and opinion of TPA on the panel of OP, it was observed that complainant no.1 was hospitalized in ILBS from 17.02.2017 to 01.03.2017 as a c/o acute hepatitis to manage conservatively and the claim of the complainant was found not admissible as per clause 4.10 of the terms and conditions of the insurance policy. Moreover, the admission was mainly done for investigation and evaluation purposes but medi-claim policy does not cover the expenses incurred on diagnostic and evaluation purposes, the same can be carried out as out-patient procedure, vide exclusion clause no. 4.10. Moreover, as per this clause no. 4.10 charges incurred at hospital or nursing home primarily for diagnostic, x-ray or lab examination nor consistent with or incidental to diagnosis are under exclusion. That is why the claim was rightly repudiated. There is no deficiency of services and the complaint is liable to be dismissed.
3.3 The reply is accompanied with Pariwar Mediclaim for policy terms and conditions and opinion of TPA, recommending repudiation of claim.
4. (Replication of complainant) –The complainant filed rejoinder, which is reply to the written statement as well as explanations by referring the documents as well as the complaint. The written statement is not supported with the affidavit of concern person to show that it has authority to file the written statement. The OP invokes clause no. 4.10 of the insurance policy but there exists no such terms and conditions ever agreed or executed between the parties. The terms and conditions filed has no sanctity as it does not bear signature of the any of the party to treat it as a contract or admission of terms and conditions of the policy; even the terms and conditions are not on the official letter head of OP. Otherwise as per clause 4.10 as stated by OP, it applies when a person goes to hospital for diagnostic and investigation purposes, which is not applicable since complainant no.1 was suffering from diseases 'acute hepatitis' and discharge summary was issued. Moreover, the discharge summary of Max Hospital also indicates that complainant no. 1 was suffering from 'liver disease'. The complaint is correct.
5.1. (Evidence)-In order to prove the complaint, the complainant led his evidence on the pattern of complaint and rejoinder with documents.
5.2. The OP also led its evidence through Sh. Raghunath Pawar, Admin. Officer and the evidence is replica of written statement with documents.
6.1 (Final hearing)-Both the parties were given opportunity to file their written arguments, therefore, the complainant as well as the OP filed their written arguments, each of the written arguments are blend of pleading and written statement.
6.2. The parties were also given opportunity to make oral submission, therefore, Sh. Rakesh Mittal, Advocate for complainant and Sh. V. K. Gupta, Advocate along-with Sh. Avdesh Kumar, Advocate for OP made the oral submissions.
6.3 The submissions of both the sides are not repeated here, since the written arguments are based on the case of the parties, which have already been referred.
7.1 (Findings)-The rival contentions are considered keeping in view the material on record in all its forms. After taking stock of all such material, the following conclusions are drawn:-
(i) There is no dispute of issue of insurance policy in the name of complainant no.2 and it covers complainant no.1 also. There is no dispute of complainant no.1 treatment in Max Hospital and subsequent to in ILBS Hospital.
It is also matter of record, being not disputed, that there is no authority of letter filed to be in favour of author of written statement duly authorized to sign, verify and file the written statement. The rubber stamp affixed reflex this designation of Admn Officer, who himself has no implied power or authority under law to sign, verify and file the written statement.
(ii) The complainant no.1 is making claim of balance amount of Rs. 10,742/- pertaining to treatment in Max Hospital, however, the complainant has not proved any record that the partly claimed was wrongly appreciated nor any evidence that remaining amount of Rs.10,742/- is payable by OP. Thus, the complainant no.1 could not prove his case of claim of balance amount of Rs. 10,742/-.
(iii) The OP has proved opinion of TPA recommending that the claim pertaining to ILBS in respect of treatment of complainant no.1 is not payable because the admission was for the purposes of investigation and evaluation. This plea of OP confirms case of complainant no.1 that the claim was declined telephonically which also confirmed subsequent communication between the parties. The complainant no.1 also proved letter dated 18.03.2018/Annexure 12 that claim was declined on the same ground that hospitalisation\ was for investigation and evaluation.
However, the record speaks contrary to it- firstly, in the discharge summary dated 27.02.2017 issued by Max Hospital the complainant no.1 was diagnosed of acute liver failure. Lab investigations showed deranged LFT and prolonged INR. On the same very day i.e. 22.07.20217, the complainant no. 1 was admitted in ILBS hospital and he was discharged on 01.03.2017, the discharge summary mentions that complainant no.1 was managed with IV fluids and antibiotics; the complainant was diagnosed of 'acute hepatitis' (etiology viral). To say, it reflects that the complainant no.1 was given appropriate treatment there is no such observation in the discharges summary that patient was admitted just for the purposes of investigation but for evaluation and management of hepatitis, it was in continuation after getting discharge from Max Hospital (in its discharge summary also it mentions) and treatment continued in ILBS.
(iv) The complainants have proved that the complainant no. 1 was admitted and treated at ILBS Hospital, they have also proved the medical bills of Rs. 79,532/- on account of such treatment, hospitalisation etc. They have lodged the claims with the OP, however, the amount of Rs. 79,532/- was not reimbursed.
(vi) The aforementioned conclusion also proves that for want of reimbursement of valid claim, it amounts to shortcoming and deficiency of services.
The complainant is held entitled for amount of Rs. 79,532/- from the OP/Insurer.
7.2. The complainant has claimed interest at the rate of 18%pa. Since complainants had parted with their money despite having insurance cover, therefore, it would be appropriate to compensate them in lieu of deprive of that amount, thus simple interest at the rate of 5%pa from the date of complaint till realization of amount of Rs. 79,532/- is allowed in favour of the complainants and against the OP.
7.3. The complainant also claimed damages of Rs. 1 lakh in lieu of trauma, mental pain and agony but no specific evidence has been led to compute as to how huge amount of Rs. 1 lakh for damages is made out. Since there was deficiency of services on the part of OP to reimburse the valid claim and for which the complainants were trying hard, therefore, compensation of Rs. 10,000/- is determined in favour of complainants and against the OP.
The complainants claimed litigation cost of Rs. 1 lakh since they were constraint to file the complaint to seek his valid claim, and other directions in their favour and against the OP. The request is plausible that legal notice was served and after exhausting that remedy, the complaint was filed, therefore, cost of Rs. 7,000/- in favour of complainants and against OP is determined.
8. So, the complaint is allowed in favour of complainants and against OP to pay/reimburse amount of Rs. 79,532/- alongwith interest at the rate of 5%pa from the date of complaint till realization of the amount to the complainants, besides damages of Rs. 10,000/- and cost of Rs. 7,000/- The amount will be payable within 45 days from the date of this order, failing which the OP will be liable to pay the enhanced simple interest at the rate of 7%pa on amount of Rs. 79,532/-. The OP will be at liberty to deposit the amount in the Registry of this Commission by way of valid instrument in favour of any of the complainants.
9. Announced on this 23rd day of July 2024 {श्र!वण 1, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances, besides to upload on the website of this Commission.
[ijs-93]
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