BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 01^ST DAY OF SEPTEMBER 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1.         This complaint has been filed through Power of attorney holder of the complainant under section 35 of C.P.Act 2019 (herein after referred as “Act”)  against the OPs for the following reliefs.

1. Order the OP to pay the charges paid by the complainant to hospital to the applicant together with cost and expenditure with interest.
2. Any other orders as deemed fit by the Hon’ble Commission.

2. The case of the complaint in brief is as follows:

The complainant has been working as Manager in VM ware soft ware(India) Pvt. Ltd., since 10 years and is the insurance policy holder in the family health insurance plan.

3. The above policy covered the mother of the complainant.  On 22.07.2021 at 3 PM mother of the complainant had developed some critical health problem and according she was admitted to Fortis Hospital, Rajajinagar, Bangalore and she was put on ventilator.  Even though preliminary test were conducted on the mother of the complainant and report indicates that covid test is negative, the mother of complainant was continued on ventilator and she was admitted at 9 pm after waiting in the hospital for six hours.

4. It is further case of the complainant that on 23.07.2021 after 18 hours doctor advised the complainant to get discharge of his mother as they cannot keep non covid patient in the hospital.

5. Even though complainant was entitled to cashless facility, but his request for cashless facility was rejected by the insurance company.  The mother of the complainant was more than 30 hours in the hospital and hospital has collected charges for full of 24 hours.  Therefore rejection of claim of the complainant by the insurance company amounts to deficiency of service.  The complainant has spent Rs.34,638/-.  Hence this complaint.

6. Initially the complaint was filed against Deputy General Manager(Corporate Relations) but subsequently M/s National Insurance Company Limited is impleaded as OP1 and earlier OP1 is treated as OP2.

7. In response to the notice, insurance company alone appears and files version.  The Deputy General Manager of Corporate Relations Family Health Plan Insurance TPA Ltd., neither appeared nor filed version.

8. The insurance company contends that the policy was in force from 04.08.2020 to 03.08.2021.  The mother of the complainant was not inpatient was not hospitalized for 24 hours, therefore, the complainant is not entitled to refund of hospitalization charges.  There is no deficiency of service.  The insurance company advises that the hospital admitted the mother at 9 pm after made her to wait for six hours.  The insurance company requested to dismiss the complaint.

9. The complainant filed affidavit evidence and relied on 4 documents.  OP1 has filed affidavit evidence of Assistant Manager and relied on 1 document. Heard the arguments and perused the written arguments.

10.       The points that would arise for our consideration are as under:-

1. Whether the complainant proves deficiency of service on the part of the OPs?
2. Whether the complainant is entitled to reliefs mentioned in the complaint?
3. What  order?

11. Our answer to the above points are as under:

       Point No.1 :- Affirmative

      Point No.2 :- Affirmative in part

       Point No.3:- As per the final order.

                                REASONS

12.        Point No.1 and 2:    Even though the complainant and Assistant Manager of OP1 insurance company have filed their affidavit evidence in support of their respective contention.

13.        At the first instance we would like to refer the fact which are not in dispute.  The complainant is the employee of VM ware Software(India) Pvt. Ltd., Bangalore and Ex.R1 indicates that the policy bearing No.605400502010000061 was taken for the period from 04.08.2020 to 03.08.2021 by paying premium of Rs.22,69,46,981/- including premium amount of Rs.19,23,27,950/- and CGST/SGST/UTGST for 5492 employees and their dependents in all Rs.25,563/-.  The sum insured amount was Rs.1,90,11,00,000/(One million ninety crores eleven lakh only)  Clause 3.13  has been relied by the OP insurance company of Ex.R2, this clause reads thus;

3.13 Hospitalization means admission in a hospital as an in-patient for a minimum period of 24 consecutive hours except for specified procedure/treatment, where such admission could be for a period of less than 24 consecutive hours.

Relaxation to 24 hours minimum duration for hospitalization is allowed in dialysis, parental chemotherapy, radiotherapy, eye surgery, lithotripsy (Kidney stone removal), dilatation and curettage (D&C), tonsillectomy, dental surgery due to accident, hysterectomy, coronary angioplasty, coronary angiography, surgery of gall bladder, pancreas & bile duct, surgery of hernia, surgery of hydrocele, surgery of prostate, gastrointestinal surgery, genital surgery, surgery of nose, surgery of throat, surgery of appendix, surgery of urinary system chromic knee surgery, laparoscopic therapeutic surgeries, any surgery under anesthesia, treatment of fracture/dislocation excluding hairline fracture, contracture releases & minor reconstructive procedure of limbs.

This condition will also not apply in case of stay in hospital of less than 24 hours provided-

1. The treatment is such that it necessitates hospitalization and the procedure involves specialized infra structural facilities available in hospitals.
2.  
2. Due to technological advances hospitalization is required for less than 24 hours only.

Procedures/treatments usually done in outpatient department (OPD) are not payable under the policy even if converted to Day Care Surgery Procedure or a inpatient in hospital for more than 24 hours.

14.  The claim of the complainant is Rs.34,638/- with cost and expenses.

15.  Ex.A1 to A4 are not in dispute.  Ex.A1 is cashless authorization letter issued by Fortis Hospital on 23.07.2021 stating that expected date of admission of patient by name Prabha Iyengar(mother of the complainant) on 22.07.2021 at 12 noon and expected date of discharge 24.07.2021.  If this period is taken into consideration it was about 48 hours.  Whereas Ex.A2 inpatient summary bill indicates that the patient was admitted on 22.07.2021 at 9.12 pm and discharged on 23.07.2021 at 5.57 pm.  Ex.A3 is the notice and Ex.A4 is the denial of cashless service stating that hospitalization was less than 24 hours.

16.  As per clause 3.13 the patient like mother of the complainant was supposed to be hospitalized for 24 hours.

17.  Before adjudicating the merits of the case about deficiency of service and entitlement of the reliefs, it is relevant to refer section 34 of the C.P. Act which envisages that the District Commission has pecuniary jurisdiction where the value of the goods or service paid as a consideration does not exceed one crore and if the complaint is filed after 31.12.2021 such consideration does not exceed fifty lakhs.  This complaint came to be filed on 21.02.2022.  It means on the date of filing of this complaint, this commission had jurisdiction upto fifty lakhs. According to the admitted insurance policy some premium including CGST/SGST/UIGST paid was Rs.22,69,46,981/- but this premium covers life’s of 25563.  If the total consideration paid is divided by 25563 the actual consideration paid by person would be Rs.8,878/-.  Therefore this Commission has jurisdiction.

18.  The insurance company rejected the claim of the complainant only after consideration of the admission time from 22.07.2021 to 23.07.2021.  But letter of hospital authority indicates that the expected date of admission was 22.07.2021 at 12 mid night and expected date of discharge was 24.07.2021 at 12 midnight, which is more than 24 hours.  Even though inpatient summary bill indicates the hospitalization period less than 24 hours which expenses shows that the patient was supposed to wait for preparing records before admitting the patient in the hospital.  It is the clear case of the complainant that his mother was waited for six hours before actual admitted her for hospitalization purpose.  If this six hour is taken into consideration the total period has spent by the mother of the complainant was 3 pm on 22.07.2021 and discharge on 23.07.2021 at 5.57 pm.  The insurance company has not counted the expected hospitalization period preliminary time spent by the mother of the complainant in the hospital before showing her hospitalization period on 23.07.2021 at 5.57 only.  Therefore the insurance company is not right in rejecting the claim of the complainant referring clause 3.13 of the terms and conditions.

19.  Even though complainant relies on paper cuttings, but these paper cutting cannot be taken into consideration.  In the absence of full text of orders of either National Commission or Supreme Court of India.  The OP insurance company is liable to refund Rs.34,638/- and cost of litigation is Rs.1,000/-.  Accordingly we answer point NO.1 and 2.

20.  POINT NO.4: In view of the discussion referred above, complaint requires to be allowed in part.  OP1 insurance company is liable to refund R.34,638/- with Rs.1,000/- cost of litigation to the complainant.  The complaint against OP2 Deputy General Manager(Commercial relations) Family Health plan insurance required to be rejected.  In the result, we proceed to pass the following;

                             O R D E R                            

1. The complaint is Allowed in part against OP1 National Insurance Company limited and complaint against OP2 Deputy General Manager, Corporation Relations is dismissed.
2. OP1 M/s National Insurance Company Limited shall refund Rs.34,638/- with litigation cost of Rs.1,000/- to the complainant.
3. OP1 National Insurance Company shall comply this order within 30 days from this date, failing which it shall pay interest at 10% p.a., after expiry of 30 days on R.34,638/- till realization.
4. Furnish the copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 01^ST day of September, 2022)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1 :

HAV*