CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.66/2010
- MRS. MALTI CHAUHAN
W/O SH. O.P. CHAUHAN,
R/O 16-C, PRASAD NAGAR,
KAROL BAGH,
NEW DELHI-110005
- MR. SANDEEP CHAUHAN
S/O MRS. MALTI CHAUHAN
R/O 16-C, PRASAD NAGAR,
KAROL BAGH,
NEW DELHI-110005
…………. COMPLAINANTS
VS.
- M/S PARAMOUNT HEALTH SERVICES
B-2, THIRD FLOOR, G.K. ENCLAVE-II,
NEW DELHI-110048
- SIR GANGA RAM HOSPITAL
SIR GANGA RAM HOSPITAL MARG,
RAJINDER NAGAR,
NEW DELHI-110060
- M/S RELIANCE GENERAL INSURANCE CO. LTD.,
PLOT NO.60, A BLOCK,
OPPOSITE STATE BANK OF INDIA,
OKHLA INDUSTRIAL AREA, PHASE-III,
NEW DELHI-110020
…………..RESPONDENTS
Date of Order: 07.12.2015
O R D E R
A.S. Yadav – President
In brief the facts of the case are that complainant No.2 is a insurance policy holder of OP-3 of which complainant No.1 was beneficiary. On 07.05.2007, complainant No.1 went to OP-2 as she was suffering from severe headache, body pain, swelling all over the body and high blood pressure. Dr. Atul Kakkar, Head of the Department of Medicine of OP-2, after observing the condition of the complainant No.1 advised for immediate admission of the complainant in the hospital for her treatment. On the advice of the said doctor, complainant No.1 was immediately admitted in the said hospital and remained under the treatment of the doctors of OP-2. Complainant No.1 was discharged from hospital on 14.05.2007.
It is further stated that the mediclaim policy under which complainant No.1 was covered was cashless policy and this fact was apprised to OP-2 by the complainant. OP-1 was also duly informed regarding admission of the complainant in the hospital however OP-1 vide letter 09.5.07 refused to accord the preauthorization for hospitalization of complainant No.1 and the complainants were asked to send the claims documents for consideration of reimbursement. OP-1 was immediately informed by OP-2 through Dr. Atul Kakkar vide the note dated 10.05.07 that “Patient is admitted in hospital as patient has depression and requires behavioural therapy. May require ECJ for which hospitalization is required”. The total bill raised by OP-2 for treatment of complainant No.1 was Rs.61,834/- which was to be paid directly by OP-1 to OP-2. All the bills for reimbursement were submitted by complainant No.2 to OP-1. OP-1 vide letter dated 27.6.07 rejected the insurance claim for reimbursing the amount incurred on the medical treatment of complainant No.1 on the ground which reads as under:-
“Mrs. Malti Chauhan 62 years female admitted in Sir Ganga Ram Hospital from 07.5.07 - 14.5.07 with diagnosis of hypertension, Rheumatoid arthritis and anxiety neurosis. It is seen that the hospitalization is primarily for investigation and evaluation. As per policy clause 4.9 hospitalization primarily for evaluation and investigation not covered. Hence this claim stands repudiated”.
It is further stated that complainant vide his letter dated 10.09.2007, once again requested OP-2 to reimburse the amount at the earliest. However OP-1 vide letter dated 13.03.2008 rejected the claim of the complainants. It is prayed that OPs be directed to reimburse the amount of Rs.61,834/- alongwith interest @ 18% p.a and also to pay Rs.3 lakhs towards compensation.
Initially the complaint was filed against OP-1 and OP-2. Thereafter an application was filed for impleading OP-3 stating therein that at the time of serving the Dasti Notice upon the Third Party Administrator(TPA)/OP-1, the complainant was made to understand that OP-3 who has issued the policy is a necessary party.
OP-1 was proceeded ex parte. OP-2 in the reply took the plea that they have been impleaded unnecessarily as there was no deficiency in service on their part. It is further stated that complainant No.1 was first seen by Dr. Atul Kakkar in OPD on 24.04.2007. She was suffering from hypertension. Rheumatoid arthritis and multiple acute onset complaints like feeling heaviness in head, decrease sleep, unable to get up from bed for a period of month Patient had definite synovitis(inflmationa) at all small joints of the hand and she was rightly advised hospitalization and she was admitted on 07.5.07 in the respondent hospital for the aforesaid complaints. Complaint No.1 informed them that the patent covered under cashless health insurance policy and accordingly immediately OP-2 through its doctor Atul Kakkar informed OP-1 on the same day i.e. 10.05.07.
OP-3 took the preliminary objection that the complaint against OP-3 is not maintainable as claim of the complainants was rejected vide letter dated 170.6.2007 and their representation was rejected vide letter dated 13.03.2008 whereas OP-3 has been arrayed after expiry of more than two years of the repudiation of the claim. Hospitalization was primarily for investigation and evaluation, treatment could have been done on OPD basis. As per policy condition 2.2 and exclusion 4.9 as hospitalization was primarily for investigation and evaluation, treatment could have been done on OPD basis. These facts are substantiated form the final bill itself wherein out of the bill of Rs.61,834/- for hospitalization of seven days, the entire cost of Rs.61,189/- is pertaining to room rent, lab investigation and doctor consultation charges alone and medicines only for an amount of Rs.645/-. Moreover patient was suffering from major depression i.e anxiety neurosis for which psychiatry treatment was given by Dr. Anita Mahajan, treatment related to psychiatric disorders are not payable across the insurance industry. It is submitted that there was no deficiency in service on the part of OP-3.
We have heard Ld. Counsel for the parties and carefully perused the record.
It is submitted by Ld. Counsel of OP-3 that insurance is a contract between the parties and they are bound by terms and conditions of the contract. In his reply, he has referred to clause No.2.2 and exclusion 4.9 of the insurance policy. The healthwise policy pertaining to OP-3 is placed on record. In para 2 there is one clause 2.2 but the same is not referring to investigation and has referred to sum insured. There is no clause as 4.9 in the policy placed on the record. It was for the insurance company to prove on record those policies and it was for the insurance company further to prove that the contract containing the terms and conditions of the policy were duly signed by complainant No.2. Assuming for the sake of argument that these clauses were there in the contract, they are at all not attracting the facts of the present case. Complainant No.1 was not admitted in the hospital on her own rather she went to OP-2 for medical check up where the doctor looking at the ailment to which the complainant was suffering felt it necessary to admit the complainant. Insurance company is nobody to challenge the decision of the treating doctor as to whether patient requires admission or the treatment can be taken in OPD. OP-2 has specifically stated in their written arguments “It is submitted that the complainant(Mrs. Malti Chauhan), 62 years female was first seen by Dr. Atul Kakkar in OPD on 24.04.07. She was suffering from hypertension. Rheumatoid arthritis and multiple acute onset complaints like feeling heaviness in head, decrease sleep, unable to get up from bed for a period of month Patient had definite synovitis(inflmation) at all small joints of the hand and she was rightly advised hospitalization and she was admitted on 07.5.07 in the respondent hospital for the aforesaid complaints”.
OP-1 vide their letter dated 27.06.2007 rejected the insurance claim for reimbursing the amount incurred on the medical treatment of complainant No.1 on the ground which reads as under:-
“Mrs. Malti Chauhan 62 years female admitted in Sir Ganga Ram Hospital from 07.05.07 - 14.5.07 with diagnosis of hypertension, Rheumatoid arthritis and anxiety neurosis. It is seen that the hospitalization is primarily for investigation and evaluation. As per policy clause 4.9 hospitalization primarily for evaluation and investigation not covered. Hence this claim stands repudiated”.
It is very strange that on what basis OP-3 came to the conclusion that complainant No.1 did not require any admission. The treating doctor definitely came to conclusion that the patient require admission and the complainant was rightly admitted taking into consideration the ailment from which she was suffering.
It is ridiculous to say that the large amount was spent on room charges and investigation and only a sum of Rs.645/- was spent on medicine. We are failed to understand that since when the amount spent on medicine has become a criteria for judging whether a patient require admission or not. Doctor has advised that complainant required admission and nobody can challenge that. Repudiation of claim by OP-1 was without any logic. In fact it has become a tendency of the insurance companies to repudiate the claim on flimsy ground and forcing the persons to approach the court. It is a case of clear cut deficiency in service on the part of OP. So far as the claim is time barred is concerned, the same is without basis. The letter vide which the claim was rejected was sent by OP-1 to complainant and in fact OP-1 was the TPA of OP-3. Even the representation made by complainant to reconsider her case was considered by OP-1 and the same was rejected by OP-1 only when the notice was served, OP-1 informed complainant that OP-3 is a necessary party and accordingly OP-3 was impleaded. Representation of complainant was rejected on 13.03.2008. Present complaint was filed on 17.01.2010 hence the same was very much in time.
OP-1 is directed to pay a sum of Rs.61,834/- alongwith interest @ 10% p.a. from June 2007. OP is further directed to pay Rs.10,000/- as compensation and Rs.5,000/- towards litigation expenses.
Let the order be complied with within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (A.S. YADAV)
MEMBER PRESIDENT
