Delhi

East Delhi

CC/792/2015

VIDHU METHAM - Complainant(s)

Versus

NIC - Opp.Party(s)

22 Feb 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)
GOVT. OF NCT OF DELHI
CONVENIENT SHOPPING CENTRE, FIRST FLOOR, 
SAINI ENCLAVE, DELHI – 110 092

C.C. NO. 792/15

Ms. Vidhu Methani
D/o Shri S.K. Methani
R/o 43-B, Old Anarkali
Delhi – 110 051                                            ….Complainant
    Vs.    
National Insurance Co. Ltd.
Through its General Manager
Branch Office 1566/3, Charch Road
Kashmiri Gate, Delhi – 110 006                            ….Opponent

Date of Institution: 29.10.2015
Judgment Reserved on: 22.02.2017
Judgment Passed on: 28.02.2017
CORUM:
Sh. Sukhdev Singh (President)
Dr. P.N. Tiwari  (Member)
Ms. Harpreet Kaur Charya (Member)

Order By : Ms. Harpreet Kaur Charya (Member)

JUDGEMENT 
    This complaint has been filed by Ms. Vidhu Methani, the complainant against National Insurance Co. Ltd. (OP) praying for directions to OP to refund Rs. 1,01,983/- alongwith interest @ 24% p.a.; Rs. 50,000/- towards compensation for suffering of harassment, mental tension, pain and agony and Rs. 11,000/- as litigation charges. 
2.    The facts in brief are that the complainant was insured under mediclaim policy no. 360401/48/14/8500001899 from 17.11.2014 to 20.11.2015.     On 05.02.2015, the complainant was diagnosed with H1N1 influenza, for which she was firstly admitted to Max Super Speciality Hospital, but later, on 06.02.2015, was shifted to Indraprastha Apollo Hospital as the Max Hospital had recommended shifting the complainant.  The complainant was admitted in the Apollo Hospital from 06.02.2015 to 12.02.2015.  Cashless claim was denied to the complainant by OP due to which the complainant had to pay Rs. 81,983/- as hospitalization expenses and Rs. 20,000/- on account of tests at Max Super Speciality Hospital.  It is stated in the complaint that the complainant was a regular customer of OP for past 10 years and the instant claim was the first claim lodged with OP.   
    Legal notice dated 20.07.2015 demanding reimbursement of the expenses to OP was neither replied nor complied.  Hence, this present complaint alleging deficiency in services on part of OP. 
    Original policy bearing no. 360401/48/14/8500001899, prescription of Max Hospital, result of suspected case of H1N1 lab report, invoice cum receipts, lab investigation reports dated 03.02.2015, invoice cum receipt dated 03.02.2015 issued by Max Hospital, Bills issued by Indraprastha Apollo Hospital, discharge summary, claim rejection letter dated 08.04.2015, claim form of Park Mediclaim Consultants Pvt. Ltd. (TPA), certificate of the treating doctor dated 21.03.2015 and rejection letter dated 13.03.2015 are annexed with the complaint.  
3.    OP was served with the notice of the complaint where after they filed their written statement, taking plea that the claim of the complainant was not admissible as per clause 4.18 of the terms and conditions of the policy document, where the patient was treated with oral tablets during the period of hospitalization, which could have been done in OPD also.  Hence, the claim was rightly repudiated, thus no deficiency could be attributed to OP.  Mediclaim policy prospectus and rejection letter by TPA are annexed with the reply.  
4.    Replication to the WS was filed on behalf of the complainant, wherein the complainant denied all the contents of the WS and reiterated the contents of her complaint.  
5.    Evidence by way of affidavit was filed by both the parties, where Ms. Vidhu Methani, the complainant herself deposed on oath the contents of the complaint and reliance was placed on Ex.CW1/1 - policy, Ex.CW1/2 and Ex.CW1/3 – copy of the Aadhar card and election card respectively, Ex.CW1/4 – E-prescription of Max Hospital and result as Ex.CW1/5, copy of Lal Path Lab report bill as Ex.CW1/6, copy of invoices of YES bank as Ex.CW1/7, invoices issued by Max Hospital as Ex.CW1/8, copy of lab investigations report as Ex.CW1/9 (colly), discharge summary of Apollo Hospital as Ex.CW1/11, reply of Mediclaim as Ex.CW1/12, mediclaim form as Ex.CW1/13 (colly), copy of rejection letter as Ex.CW1/14 & Ex.CW1/15 and legal notice and postal receipts as Ex.CW1/17.
6.    We have heard the arguments on behalf of the Ld. Counsel for the complainant as well as for OP.  Perusal of the material placed on record reveals that the complainant was first admitted in Max Hospital after H1N1 throat swab was positive.  Discharge summary reveals that patient got admitted in isolation room (in view of infective nature of disease).  Further, a certificate issued by Apollo Hospital dated 21.03.2015 stating that the complainant had respiratory distress at the time of admission, so in view of developing any serious complication, she was admitted in hospital, this is further substantiated by endorsement dated 31.03.2015 on rejection letter by TPA dated 12.02.2015, which also states that the swine flu in condition of the complainant could not have been treated on OPD basis as the complainant had respiratory distress and could have gone to ARDS, so admission was necessary. 
    Thus, what can be culled out from the above observations is that the doctor being a specialist is the best person to judge the line of treatment and method to be adopted.  When it has been endorsed by the treating doctor that the hospitalization was necessary for the treatment of H1N1 in the instant case, OP cannot deny the claim on the ground that the same could be treated on OPD basis.  OP cannot follow a straight jacket formula in each and every case.  If in the instant case, treating doctors considered hospitalization of the complainant was is the best interest of her health, then complainant should not be made to suffer by repudiating her claim.  Hence, we direct OP to reimburse the complainant with Rs. 81,983/- as medical expenses with 9% interest from the date of payment till compliance of this order.  We further award Rs. 20,000/- as compensation inclusive of litigation expenses.   Order be complied within 30 days from the receipt of order.      
Copy of the order be supplied to the parties as per rules.
File be consigned to Record Room.

 

(HARPREET KAUR CHARYA)                (SUKHDEV SINGH)
Member                             President