District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.610/2021.
Date of Institution: 30.11.2021.
Date of Order: 07.12.2022.
Mr. Harish S/o Shri Dharamveer, R/o village Neemka, P.O.Neema, District Faridabad, Haryana.
…….Complainant……..
Versus
1. Principal Officer/Branch Manager, Manipal Cigna Health Insurance Company Limited, E-75, 7th floor, Himalaya House, 23 KG Marg, Connaught Place, New Delhi – 110 001.
2. Manipal Cigna Health Insurance Company Limited, 401/402, Raheja Titanium, Western Highway, Goregaon (East), Mumbai – 400 063.
3. Administrator/Medical Superintendent, Raj Nursing Home, Clinic Site No.6, Sector-3, Faridabad, Haryana - 121004.
…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. Inderjeet Singh, counsel for the complainant.
Sh. Rakesh Dabass, counsel for opposite parties Nos.1 & 2.
Sh. Ravi Nagpal, counsel for opposite party No.3.
ORDER:
The facts in brief of the complaint are that the complainant Harish and his family members namely Mrs. Pniky, son Prashant & daughter Divya were insured with M/s. Manipal Cigna Health Insurance Company Limited since 29.04.2017. On 28.09.2021 the wife of the complainant namely Pnky flet severe chest pain. The pain was so severe that she was unable to move or walk. Due to such a high pain, complainant took her to IBS Ashwani Hospital, Plot NO. 8, D/1, YMCA Road, Sector-11, Faridabad. After thorough examination done by doctor Ashwani wadhawan and on the basis of ECG done at the hospital, doctor prescribed medicines for 5 days. The total expenses incurred by the complainant for this visit to the doctor were Rs.1025/-. On 03.10.2021, the complainant again took her to another nearest hospital namely Raj Nursing Home, Site No.6, Sector-3, Faridabad, Haryana. The wife of the complainant was admitted in emergency for the treatment at a cashless facility. The various clinical and laboratory tests/examinations were conducted upon the patient/wife of the complainant and was given treatment in the said hospital on 03.10.2021. During the treatment in hospital, on 05.1`0.2021, the cashless claim was denied by the opposite parties Nos.1 & 2 . On getting this information at around 15:04 hrs. on 05.10.2021, complainant sent an email to the opposite parties at around 18:23 hrs. the same day requesting them to approve the cashless facility. The opposite parties responded to the email of the complainant issuing a ticket NO. 6334385396 stating that their support team was working on it and would get a revert within next working day. On 06.10.2021, patient Pinky was discharged from the said hospital. And the payments for medical expenses were paid by the complainant due to no response from the opposite parties regarding approval of the cashless facility.. The payment of Rs.30,926/- for the medical treatment done during the hospitalization was paid by the complainant partly in cash and partly through his debit card. The complainant spent a sum of Rs.31,951/- on the treatment of his wife. Complainant duly submitted his claim papers with opposite parties for the above stated expenses incurred by the complainant on the treatment of his wife. The opposite party also denied the reimbursement of medical expenses vide email dated 05.11.2021 on the pretext that the medical treatment of complainant’s wife could not be covered. The reason mentioned in the rejection intimation through email dated 05.11.2021 was “Denial Clause ID-VIII 20. If any claim made by the insured person was in any respect fraudulent or if any false statement or declaration was made or used in support thereof or if any fraudulent means or devices were used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy all benefits under this policy should be forfeited. 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) reimburse the cost of Rs.31,951/- already spent by the complainant in medical treatment of his wife alongwith the pendent lite and future interest @ 18% p.a.
b) reimburse the expenses of the ongoing medical treatment of the complainant’s wife.
c) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
d) pay Rs. 25,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos. 1 & 2 refuted claim of the complainant and submitted that the complainant neither ha dany cause of action nor locus standi in lodging of the present complaint before this Hon’ble Commission, reason being, the complainant had submitted ‘claim form’ dated Nil alongwith relied upon documents with regards to treatment of his wife Pinky w.e.f 03.10.2021 to 06.10.2021 from Raj Nursing Home, Faridabad so received by M/s. medi Assist Insurance TPA private Limited being the authorized agency, so as to process the claim of the opposite parties Nos.1 & 2. After scrutiny of the claim papers, an independent investigator viz. Prompt Investigators was deputed to verify the treatment record as well as ascertain the status of the hospital in question. After verification, the said investigator had prepared and submit his report dated 01.11.2021 by incorporating all facts and circumstances therein as well as annexing the Xerox of indoor treatment record. Since it had been established from the claim documents as well investigation report so got conducted by the opposite parties Nos.1 & 2 that the claim of the complainant was a fraudulent claim as defined under clause NO. VIII.24 so incorporated in the insurance policy. Thus, the insurance policy had treated the subject claim a “No claim” by closing the file in terms of “letter of intimation” dated 05.11.20221. Opposite parties Nos.1 & 3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. 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 on 03.10.2021 patient Pinki visited in emergency with complaint of Severe Chest Pain and Ghabrahat with associated sweating. She was admitted and managed withi/v PPI’s, I/v analgesics, alongwith other supportive treatment. Relevant investigations were done. Cardiac markers and 2D ECHO were done to rule out cardiac emergency and patient was discharged on request on 06.10.2021 with diagnose Anypical Chest Pain with Acute Vertigo. It was pertinent to mention here that preauthorization notification was sent to the concerned TPA/insurance company, but no approval was granted from the TPA/insurance company and the same was duly informed ot the patient and her attendants. On05.10.2021, hospital TPA desk received email denying for extending cashless facility for this claim. Explanation and consideration mail was sent to TPA which was again denied for cashless facility. An investigator from insurance company came to hospital for physical investigation of patient/case and all required details were provided to the investigator by the hospital. Thereafter on request patient was discharge with follow up advice on dated 06.10.2021. Opposite party No. 3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– Manipal Cigna Health Insurance & Ors. with the prayer to: a) reimburse the cost of Rs.31,951/- already spent by the complainant in medical treatment of his wife alongwith the pendent lite and future interest @ 18% p.a. b) reimburse the expenses of the ongoing medical treatment of the complainant’s wife. c) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . d) pay Rs. 25,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW-1/A – affidavit of Shri Harish, Ex.1/1 (colly) – payment receipt, Ex.CW-1/2 & 1/3 – email dated 05.10.2021,, Ex.CW1/4 – discharge of request,, Ex.CW-1/5 – bill, Ex,CW-1/6 - email dated 20.10.2021 regarding rquest for reimbursement claim , Ex.CW-1/7 - Reimbursement claim rquest for your Manipal Cigna, Ex.CW-1/8 – OPD card.
On the other hand counsel for the opposite parties Nos.1 & 2 strongly
agitated and opposed. As per the evidence of the opposite parties Nos.1 &2 – Ex.RW1/A – affidavit of Shri Jaswinder Singh Shekhawat, Senior Manager (Legal), Manipal Cigna Health Insurance Company, Limited, 401402, Raheja Titanium, Western Expess Highway, Goregaon (East), Mumbai,, Ex.R-1 - policy, Ex.R-2 – Questionnaire for insured/patient/proposer, claim No. 26262890,, Ex.R-3 – Self Declaration of the insured, Ex.R-4 – Investigation report, Ex.R-5 – Investigation report, Ex.R-6 - Questionnaire of Dr. M.Sharma/Dr. M.K.Rana, Ex.R-7 – Room categories, Ex.R-8 – bill, Ex.R-9 – Pre-admission record, Ex.R-10 – discharge of request,, Ex.R-11 - reimbursement claim request for your Manipal Cigna-ProHealth Protect V4.
Opposite party No.3 has led in his evidence Ex.RW-2/A – affidavit Dr. Raj Bala Mudgil, C/o –Site No.6, Near Aggarwal Public School, Sector-3, Faridabad.
7. In this complaint, the complainant Harish and his family members namely Mrs. Pniky, son Prashant & daughter Divya were insured with M/s. Manipal Cigna Health Insurance Company Limited since 29.04.2017. On 28.09.2021 the wife of the complainant namely Pnky flet severe chest pain. The pain was so severe that she was unable to move or walk. Due to such a high pain, complainant took her to IBS Ashwani Hospital, Plot NO. 8, D/1, YMCA Road, Sector-11, Faridabad. It is evident from Ex.CW-1/1 after thorough examination done by doctor Ashwani wadhawan and on the basis of ECG done at the hospital, doctor prescribed medicines for 5 days. The total expenses incurred by the complainant for this visit to the doctor were Rs.1025/-. On 03.10.2021, the complainant again took her to another nearest hospital namely Raj Nursing Home, Site No.6, Sector-3, Faridabad, Haryana. The wife of the complainant was admitted in emergency for the treatment at a cashless facility. As per Ex.CW-1/2 the cashless claim was denied by the opposite parties Nos.1 & 2 i.e insurance company. Ex. Per email vide Ex.CW-1/4, On 06.10.2021, patient Pinky was discharged from the said hospital. And the payments for medical expenses were paid by the complainant due to no response from the opposite parties regarding approval of the cashless facility. Asper Ex.CW1/5 the payment of Rs.30,926/- for the medical treatment done during the hospitalization was paid by the complainant partly in cash and partly through his debit card. As per Ex.CW1/7 the opposite party also denied the reimbursement of medical expenses vide email dated 05.11.2021 on the pretext that the medical treatment of complainant’s wife could not be covered. The reason mentioned in the rejection intimation through email dated 05.11.2021 was “Denial Clause ID-VIII 20.
8. After going through the evidence led by the parties, 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 T&C of the policy within 30 days 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: 07.12..2022 (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.
