Delhi

North

CC/410/2024

NEERAJ TYAGI - Complainant(s)

Versus

NIVA HEALTH INSURANCE CO LTD - Opp.Party(s)

26 Nov 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No.: 410/2024

In the matter of:

Neeraj Tyagi S/o Jayoak Tyagi

R/o- Mangal Bazar wali Gali

Near Indian Public School

Burari Village Delhi-110084                                       …       Complainant

Vs.

Niva Health Insurance

At its registered office:

First floor, C-98

Lajpat Nagar, Part-1

New Delhi-110024

Through its Authorized representative

Director/MD/GM/Etc                                                 …     Opposite Party No.1

 

Kapil Multi Speciality Hospital

At: A-1 Shastri Park mor. Nathupura,

Burari, New Delhi-110084

Through its authorized representative:

Director/MD/GM/Etc.                                      …     Opposite Party No.2

 

ORDER

26/11/2024

 

(Divya Jyoti Jaipuriar)

1. By way of this complaint the Complainant has challenged the repudiation letter dated 27.08.2024 by which M/s Niva Bupa health Insurance Co. Ltd (Opposite Party No. 1) has repudiated the insurance claim of the Complainant for his hospitalisation during the period from 08.07.2024 to 10.07.2024 on the ground that such hospitalisation was for diagnosis and evaluation purpose, which is not covered under the policy terms and conditions.
2. We have heard the arguments on admissibility of the complaint led by Sh. Ramesh Yadav Ld. Advocated for the Complainant on the last date of hearing. The Complainant was admitted in the M/s Kapil Multi Speciality Hospital (Opposite Party No. 2) on 08.07.2024 at 9:31 PM and was discharged on 10.07.2024 at 5:30 PM. At the time of admission of Complainant in the OP-2 hospital, he complained of “fever, generalised weakness and body ache”, which is recorded in the Discharge Summary issued by the OP-2 hospital. The temperature of the Complainant at the time of admission was 100°F and initial diagnosis of his ailment was “Acute febrile illness ? Viral fever”. During hospitalisation certain tests were conducted and Complainant was managed with the IV antibiotics, PPI, IV fluid and other supportive medications. The medical report filed by the Complainant indicates that after his admission, his temperature was 100°F (at 10:30 PM) which fell down to 98°F (at 12 midnight) on the same date and remained below the said level during the entire period of Complainant’s hospitalisation.
3. In the discharge summary, no serious ailment to the complainant has been mentioned. Even the was not diagnosed with any of the ailment which requires hospitalisation for its management. He was having a low grade fever at the time of his admission, which does not require any hospitalisation. When this query was posed to Ld. Advocate for the Complainant that when the Complainant was hospitalised to manage only low grade viral fever without any serious ailment, how the repudiation of claim by the OP-1 is incorrect. In reply of this Ld. Advocate of the Complainant stated that it was OP-2 Hospital and the treating doctor who has recommended hospitalisation of the complainant and such hospitalisation was based on medical advice. He further argued that the OP-1 is liable to honour the claim even if the hospitalisation is for minor ailments.
4. We do not agree with this argument of the Ld. Advocate for the Complainant. The purpose of having a health insurance policy is to manage major ailments and hospitalisations and not for managing minor ailments like managing low-grade fever. The terms and conditions of the policy also makes it very clear that the policy does not cover hospitalisation for managing minor ailments and hospitalisation for diagnosis and evaluation purposes. The hospitalisation of the Complainant is clearly for diagnosis and evaluation of the reasons for “low grade fever” and not for treatment of any major ailment or health condition.
5. At this stage, we would also like to record that the OP-1 in its repudiation letter has referred to the “Policy Terms and Conditions” to repudiate the claim. The Complainant has not filed any policy terms and conditions, but it is also not the case of the Complainant that he has not received the policy terms and conditions along with the policy document. The policy filed by the Complainant clearly indicates that the policy in question was in continuity since 16.03.2022 and the claim in question was filed for the policy renewal period commencing on 16.03.2024. The policy terms and conditions remain unchanged with every renewal unless there is an explicit consent of insured and insurance company. Hence unless the policy terms and conditions as issued with the policy commencing on 16.03.2022, should govern the claim in the current renewal period of the policy. Assuming that the Complainant did not receive the policy terms and conditions with the commencement of first policy on 16.03.2022, as substantial time has already elapsed since issuance of the first policy (16.03.2022), the Complainant cannot raise the issue of non-supply of the policy terms and conditions in this complaint. Even otherwise, the Complainant has not raised the issue of non- supply of policy terms and conditions in this complaint. Hence, it is assumed that the Complainant was in possession of policy terms and conditions and is also aware of the policy terms and conditions.
6. The policy terms and conditions which are available on website of the OP-2 clearly indicate the hospitalisation for diagnosis and evaluation purpose are not covered under the policy. The admission and treatment of the Complainant in the OP-2 hospital, as per the hospital records including the discharge summary, was clearly for diagnosis and ascertaining the reasons for low grade fever. The low grade fever is not an ailment which requires compulsory hospitalisation for its management. Neither primary diagnosis nor investigations during hospitalisation indicate any illness which requires compulsory hospitalisation. Hence, the repudiation of claim by the OP-1 appears to be based on correct premise and does not require any interference of this Commission.
7. Ld. Advocate for the Complainant also argued that the hospitalisation of the Complainant was recommended by the treating doctor at OP-2 hospital and if the hospitalisation was not warranted, there is clearly a deficiency of service by the treating doctor and the hospital. However, in the entire complaint, the complainant has also not alleged any specific deficiency on part of the OP-2 hospital or even the treating doctor. The treating Doctor has not even been arrayed as a party in this complaint. In absence of any specific pleading alleging deficiency of service by OP-2 hospital and the treating doctor and also in view of non-impleadment of treating doctor as Opposite Party in this Complaint, we cannot examine the liability of OP-2 hospital and the treating doctor.
8. Hence, for the reasons explained above, we do not find any merit in this complaint and the same is dismissed at admission stage itself.
9. Office is directed to supply the copy of this order to the parties as per rules.. Thereafter, file be consigned to the record room. Ordered accordingly.

 

 

 

 

___________________________

Divya Jyoti Jaipuriar, President

 

 

 

 

___________________________

Harpreet Kaur Charya, Member