District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 148/2022
Date of Institution: 10.03.2022.
Date of Order:07.03.2023.
Ram Kishan Yadav age 65 years S/o late Shri Gokul Chand Yadav, r/o H. NO. 95/21A, NIT, Faridabad - 121001.
…….Complainant……..
Versus
1. National Insurance Co. Ltd., situated at 5C/1& 2, B.P. Railway Road, Neelam Chowk, Faridabad-121001 (Hr.) through its branch head/office head/Auth. Signatory/Branch Manager/Div. Officer/Sr. BM/Accountant etc.
2. Safeway Insurance TPA Pvt. Ltd., NO. 815, Vishwas Sadan, District Center, Janakpuri, New Delhi – 110 058. Through its office head/Auth. Signatory/Circle Head/Zone Head/Controller etc.
3. QRG Super Speciality Hospital (Also known as – QGR Medicare Ltd.) Plot NO.1, Sector-16, Faridabad – 121002 through its Security & Auth. Personal/CMO/office head /Auth. Signatory/Concerned Doctor/M.O./Sr.MO/Accountant etc.
…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: Sh. Dharmender Sharma, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 27.04.2022.
Sh. Deepak Daima, counsel for opposite party No.3.
ORDER:
The facts in brief of the complaint are that the complainant had taken a mediclaim policy from the above said opposite party No. 1 through its authorized agents existing policy continuously renewed vide policy NO. 361100/50/21/0008409 upto next year i.e. 2022. The complainant was continuously remains consumer of oppositepartiesNos.1 & 2 since many years and now insurance was valid form 31.10.2021 up till now i.e 30.10.2022. On 24.11.2021 the complainant was got admitted with opposite party No.3 with a complaint of Acute Onset Blurring vision intermittently since today morning. According to the sumptom the opposite party No.1 diagnosis as per medical term precautionary. The patient was discharged on dated 26.11.2022 in a stable condition with the follow up advice mention in discharge summary dated 26.11.2021. The complainant never wants to take undue services of opposite parties. The condition on dated 24.12.2021 told to be the preliminary symptoms of stroke. This was the reason that’s why the complainant at once take decision to get medical treatment before anything became more worse and wrong. The complainant was admitted on 24.11.2021 and his necessary diagnosis was conducted on the observation of Dr. Sameer Gupta, MD, (Medicine) DM Neurology) posted than with opposite party No .3. The treating doctor also sent a letter to opposite parties Nos.1 & 2 mentioning therein the critical position of the complainant as indoor patient in their hospital having UHID No. 100179711. The consulting doctor provide his valueable treatment to the complainant to save his valuable life and treatment opinion with his letter dated 26.11.2021 to opposite parties Nos.1 & 2 when they did not sending their approval for cashless treatment of complainant in their hospital at the time of discharge however the opposite parties Nos.1 & 2 give their approval of Rs.25,000/- initially to opposite party No.3 as per knowledge of complainant but lastly refused to pay. As per letter contents of treating doctor letter dated 26.11.2021 to opposite parties Nos.1 & 2 as “Pt. Ram Kishan Yadav whose case was denied on the grounds of evaluation & investigation purpose wanted to drawn his kind attention over the clinical status which entailed Pt. registered to be admitted and managed under medical supervision was that pt. had developed sudden onset of severe headache with bluming of vision since morning and after management of the same was diagnosed of TIA (transient ischemic attack) psot circulation with mobile atheroma @ St injection which required injectable LMWH supportive medications with other baseline injectables because post circulation TIA was a semi form of stroke which further if lest untreated can lead to stroke as well for the reason pt. was put on IV LMWH under medical supervision and only needful investigation was done as per clinical protocol for further management of progression of disease. Kindly reconsider the case again. The complainant deposited the treatment amount of Rs.60,000/- (after negotiation) with opposite party No.3 on dated 26.11.2021 on denial the medical treatment amount claim by opposite parties Nos.1 & 2. Emergency charges Rs.900/- were also paid by the complainant on dated 24.11.2021. The complainant submitted his claim total in Rs.60,900/- (treatment charges &Other charges) with opposite party No.1. For reimburse of claim, some of the documents i.e. the entire original bills, documents, discharge report and others original reports use for the purpose of honor the claim were also called by opposite parties Nos.1 & 2, The complainant at once submitted whole the above original documents with opposite parties Nos.1 & 2.
The complainant paid all the hospital bills at the time of discharge i.e Rs.60,000/- in cash on dated 26.11.2021 but being the consumer of opposite parties Nos.1 & 2 could not repudiate his hospitalization bill. Complainant requested them to make the payment but he did not care the request of complainant. The original treatment documents, reports, letter of treating doctor dated 26.11.2022 were also taken by the opposite parties Ns.1 & 2 by saying that don’t worry, Sir if he did not get the medical treatment bill amount now then they would consider later on positively. On 11.2.2021 opposite party No.1 delivered a copy of letter by mention the exclusion clause 4.4. of the mediclaim policy and refuse to disburse the treatment claim amount on baseless reason by stating as “Refer to TPA letter dated 02.02.2022 it was observed that no active line of treatment was given to the patient during hospitalization hence admitted solely for investigation. Therefore, the claim was repudiated under said clause which states “Expenses related to any admission primarily for diagnostics and evaluation purpose only were excluded. 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) pay the hospital amount and post discharge expense in total i.e. Rs.60,900/- to complainant alongiwth interest @ 24% P.A.
b) pay Rs. 25,000/- 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 the complainant was admitted in QRG Health City Hospital – Opposite party No.3 from 24.11.2021 to 26.11.2021 with a diagnosis of Posterior Circulation Transient Ischemic attack but no other active line of was given during the time of hospitalization and complainant was admitted in hospital solely for investigation only thus the claim of the complainant stands non payable as per exclusion clause 4.4 (investigation & Evaluation – (a) Expenses related to any admission primarily for diagnosis and evaluation purpose only were excluded) of the insurance policy so issued in this behalf, hence, the insurance company had treated the subject claim as repudiated by closing the file in terms of letter of intimation dated 11.2.2022. The complainant neither had any cause of action nor locus standi to file the present complaint, reason being, on 02.12.2021, claim form, by enclosing the relied upon documents was submitted by the insured to the insurance company for reimbursement of the final claimed amount as Rs.60,900/- towards indoor hospitalization w.e.f. 4.11.2021 to 26.11.2021. During process of the claim by the TPA –OP No.2 being the authorized agency of the insurance company, it had been established from the submitted documents at the end of the complainant that the complainant had admitted in QRG Health City Hospital – Opposite party No.3 from 24.11.2021 to 26.11.2021 with a diagnosis of Posterior Circulation Transient Ischemic Attach but no other active line of was given during the time of hospitalization and complainant was admitted in hospital solely for investigation only thus the claim of the complainant stands non payable as per exclusion clause 4.4 (investigation & evaluation –(a)Expenses related to any admission primarily for diagnosis and evaluation purpose only were excluded) of the insurance policy so issued in this behalf, hence the insurance company had treated the subject claim as “Repudiated” by closing the file in terms of letter of intimation dated 11.2.2022 by following the guidelines of the insurance company, which decision cannot be termed unconscionable at all. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Notice issued to opposite party No.2 on dated 12.04.2022 not received back either served or unserved. Tracking details filed in which it has been mentioned that “Item Delivery confirmed”. Mandatory period of 30 days not expired. Hence, opposite party No.2 was hereby proceeded against exparte vide order dated 27.04.2022.
4. Opposite party no.3. put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that patient presented with complaints of acute onset blurring vision intermittently since morning of 24.11.2021, he had no history of fever, head trauma, toxic exposure or any other cardiac symptoms. On examination BP was 190/100mm hg. And was diagnosed as a case of posterior circulation TIA with hypertension.
Posterior Circulation TIA also referred as Posterior Circulation stroke corresponds to any infraction occurring with the vertebrobasilar vascular territory, which includes brainstem, cerebellum, mid brain, thalami and areas of temporal and occipital lobes. It was potentially life threatening condition and accounts 20-25% of ischemic strokes. Hence they deemed it’s necessary for urgent medical management under medical supervision for better treatment and avoid any serious complication to patient due to delay in treating as outpatient. In simple words patient needed immediate medical attention. Further, MRI brain withdiffusion and Mr. Angio brain & neck was necessary as per clinical protocol to visualize atherosclerosis and its complication; ulceration, stenosis and complete occlusion as in case of posterior circulation strokes there were impending risks for 48 hours. Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties– National Insurance Co. Ltd. & Ors.. with the prayer to: a) pay the hospital amount and post discharge expense in total i.e. Rs.60,900/- to complainant alongwith interest @ 24% P.A. b) pay Rs. 25,000/- 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, Exs.CW1/A – affidavit of Shri RamKishan Yadav, Ex.C-1 – insurance policy, Ex.C-2 – discharge summary, Ex. C-3 – certificate of Dr. Sameer Gupta,, Ex.C-4 - patient prescription, Ex.C-5 – bill of supply cum receipt, Ex.C-6 – Final bill of supply summary (Cash),, Ex.C-7 – repudiation letter.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 As per the evidence of opposite party No.3 Ex.RW1/1 – affidavit of Dr. M.S.Tanwar, son of Shri N.S.Tanwar, working as Medical Superintendent, Plot No.1, Sector-16, QRG Medicare Ltd.,
8. In this case, on 24.11.2021 the complainant was admitted with opposite party No.3 with a complaint of Acute Onset Blurring vision intermittently since today morning. According to the sumptom the opposite party No.1 diagnosis as per medical term precautionary. The patient was discharged on dated 26.11.2022 in a stable condition with the follow up advice mention in discharge summary dated 26.11.2021. The final bill of the patient was Rs.60,0000/- as per Ex.C-6 . The claim of the complainant was repudiated by the opposite party/TPA vide letter dated 11.02.2022 for the reason that the patient was not need to be admitted .
9. After going through the evidence led by the parties, the Commission is of the opinion that as per Ex.C-3 certificate dated 26.11.2021 issued by Dr. Sameer Gupta, MD (Medicine) DM (Neurology), QRG health City, Faridabad that the patient was suffering from Semi Form of Stooke. Keeping in view of the above , the Commission is of the opinion that the complaint is allowed. Opposite parties Nos.1 & 2 are directed to process the claim of the complainant as per the terms and conditions of the policy within 30 days from the date 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 Nos.1 & 2 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: 07.03.2023 (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.
