District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No. 237/2021.

 Date of Institution:15.4.2021.

Date of Order: 12.5.2023

Mrs. Mousam W/o Utkarsh Singh, H.NO. 9, Block 19, Spring Field Colony, Sector-31, Faridabad, Haryana – 121003.

                                                          …….Complainant……..

                                                Versus

Raheja QBE General Insurance Co. Ltd. P&G Plaza, Ground floor, Cardinal Gracious Road, Chakala, Andheri East, Mumbai – 400 099.

                                                                              …Opposite party

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. Santosh Goswami  , counsel for the complainant.

                             Sh. Rakesh Dabaas, , counsel for opposite party.

ORDER:  

                   The facts in brief of the complaint are that  the complainant wass a policy holder of the respondent's company having Policy Number RQBE01-101613-20-000 and the policy was active at the time of admission of the complainant in the Hospital and also at the time of putting up the claim.  The complainant got hospitalized in Sattya Hospital, 376, I.P.Colony, Sector 30-33, Faridabad, Haryana 121003 on 07/09/2020 with the complaint of Fever, Burning Mituration, Pain in lower abdomen and the complainant was diagnosed with UTI & Sepsis. Subsequently the complainant got discharged on 12/09/2020.  The complainant incurred a sum of INR 48421/- (Thirty two thousands eight thousands seven hundred forty two) only towards the treatment including the pre-hospitalization expenses. The due intimation of claim was given to the respondent on 08/09/2020. Subsequently, claim documents along with duly filled in claim form was despatched to the respondent consequent to which claim number bearing No. 22925826 was generated by the respondent on 05/10/20220. Certain query were raised by the respondent on 07/10/2020 which was replied by the complainant on 08/10/2020 and required documents were sent to the respondent's TPA though the mail might have been bounced. Subsequently, the complainant sent many mails to the respondent seeking the status of the claim. The documents required by the respondent's TPA were again sent via mail as well as via courier in the month of January which was acknowledged by the respondent's TPA on 14/01/2021. It was submitted that most of the mails sent by the complainant got bounced.  In the last week of January the complainant got the letter of repudiation of claim dated 13/01/2021 from the respondent. It was submitted that claim was rejected on the basis of the fact that the hospital was only 10 bedded and that it has not been registered under Clinical Establishment Act.  The company knew it very well that only 50 bedded hospitals are qualified to be registered under clinical establishment Act and that registration of the hospital under the said Act was not mandatory for processing a claim. It was further submitted that the definition of hospital under the policy brochure of the respondent company refers to the Medi-claim and has nothing to do with a reimbursement claim. The reimbursement claims of patients who got treatment from the said hospital have been approved by almost every insurance company. It is submitted that policy brochure of every insurance company has the same definition of hospital and obviously if the definition has such meaning as the respondent was trying to convey, none of the reimbursement claim had been approved by the insurance company. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite party to:

a)                pay a sum of INR 48,421/- alongwith 12% interest commencing form 30 days after receiving of the claim document by the company.

 b)                pay INR. 20,000/- as compensation for causing mental agony and harassment .

c)                 pay INR. 10,000 /-as litigation expenses.

2.                 Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that  at the very threshold the present complaint, the present complaint was not maintainable, reason being, the complainant was admitted at Sattya Hospital, I.P. Colony, Faridabad on 07/09/2020 and was diagnosed with Urinary Tract Infection & Sepsis and discharged on 12/09/2020 but from the relied upon documents, it was evident / established that the said hospital did not fulfill the criteria of a hospital as defined under clause No. 2 (XV) so incorporated in the insurance policy. Not only this, the complainant had violated the terms & conditions of the insurance policy by not supplying the requisite documents to the insurance company despite numerous correspondence so as to process the claim at the end of the insurance company. As such, the issue under the present complaint did not fall under the per-pheri of the provisions and more particularly the word "deficiency" as defined under section 2(11) & word "service" as defined section 2(42) and the word "unfair trade practice" as defined section 2(47)of the Consumer Protection Act, 2019. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon'ble Commission, reason being, from the relied upon documents, it was evident/established that the complainant was admitted at Satya Hospital on 07.09.2020 and was diagnosed with Urinary Tract Infection & Sepsis and discharged on 12.09.2020 but the insurance company had not received any intimation 12/09/2020 However, the insurance company had received documents vide claim form dated 25.09.2020 through Medi Assist TPA. After that, insurance company raised queries to the complainant vide letter & reminders thereto but in turn, the complainant had not forwarded any response in reply thereto thus the complainant had violated the terms & conditions of the insurance policy by not supplying the requisite documents to the insurance company so as to process the claim despite numerous correspondence at the end of the insurance company, hence, the insurance company, in compelling circumstance, have arrived at the decision in closing such claim vide Final Closure letter dated 13.01.2021 in continuation of previous letters & reminders thereto dated 07.10.2020, 18.10.2020 & 26.10.2020. At the same time, the insurance company had deputed an independent investigator viz. Oracle Investigation Agency to investigate the matter so as to ascertain the genuineness of the claim, however, parallely the insurance company had received another claim of Mrs. Nisha Rani & Mrs. Indu from the same hospital with same diagnosis with same line of treatment but there was non-cooperation at the end of the treating hospital to share hospitalization details / records. On persistent follow-up the treating hospital confirmed that it was not registered. The insurance company had received letter from the treating hospital that the said hospital was being run under Private Limited Company. Not only this, the insurance company had received letter from treating doctor Dr. Chandra Mohan Goswami on 07.01.2021 that the hospital was 10 bedded hospital only. Whereas, as per clause No. 2(XV) of the insurance policy the Hospital criteria states the requirement of 15 beds for population above 10 lakhs. As per latest update the population of Faridabad population was 4.2 million (42 lakhs). As such, in view of the above, the insurance company had repudiated the case under not fulfilling the definition of the Hospital' as per the policy and non-submission of requisite claim documents vide repudiation letter dated 13.01.2021. which decision cannot be termed unconscionable at all..

Definition of registered hospital as per insurance policy is hereby reproduced:

Definitions: 2 (xv) Hospital - means any institution established for Inpatient Care and Day Care Treatment of illness and/or injuries and which had been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act or complies with all minimum criteria as under:

a)                has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and at least 15 inpatient beds in all other places;

b)                 has qualified Nursing staff under its employment round the clock;

c)                has qualified Medical Practitioner(s) in charge round the clock;

d)                has fully equipped operation theatre(s) of its own where surgical procedures are carried out

e)                maintains daily records of patients and will make these accessible to the Insurance company's authorized personnel.

Certain irregularities were also noted in the claim documents which follows:

1.                Investigation reports are signed by treating doctor Dr C M Goswami and Lab Technician. It was not certified by any registered pathologist.

2.                As per investigation report, the treating doctor name (Dr C M Goswami) is not mentioned under Consultation Doctors list

Registration certificate of Dr C M Goswami allegedly issued from Haryana Medical Council (HMC) with registration No 6036, did not bear official stamp of the authorised signatory. On all the claim documents submitted Registration number of Dr C M Goswami was 006030 but on the registration certificate of doctor submitted the registration number is 6036. As per NMC portal Registration No 6030 & 6036 are not registered with Dr CM Goswami

Details as under:

The hospital was suspicious/blacklisted hospital and many fraudulent  claims had been reported at this hospital … as per industry analysis.  Claims of Indu & Mausam were already pending in Consumer Commission, now the insurance company had received notice for the remaining two claims reported with Raheja QBE (Nisha Rani).  Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                The parties led evidence in support of their respective versions.

4.                 We have heard learned counsel for the parties and have gone through the record on the file.

5.                In this case the complaint was filed by the complainant against opposite party–Raheja QBE General Insurance Co. Ltd.. with the prayer to: a)  pay a sum of INR 48,421/- alongwith 12% interest commencing form 30 days after receiving of the claim document by the company.  b)pay INR. 20,000/- as compensation for causing mental agony and harassment . c)  pay INR. 10,000 /-as litigation expenses.

                   To establish his case the complainant  has led in his evidence,  Ex.CW1/A –Mousam, CW1/1 – insurance policy, Ex.CW1/2 – Discharge summary, Ex.CW1/3 – Final Bill, Ex.CW1/4 – reimbursement claim, Ex.CW1/5 -  letter dated 13.01.2021.

                    On the other hand counsel for the opposite party strongly agitated and opposed.  As per the evidence of the opposite party Ex.RW1/A – affidavit of Mr. Kiran Nikam, Deputy Manager (legal), M/s. Raheja QBE General Insurance Co. Ltd., Ground Floor, P&G Plaza, Cardinal Gracious Road, Chakala, Andheri (East), Mumbai , Ex.R-1 – insurance policy, Ex.R-2 –Claim Form Part – A, Ex.R-3 – Discharge  summary, Ex.R-4 – invoice, Ex.R-5 -  Visitation Inputs, Ex.R-6 – Oracle Investigation Agency, Ex.R-7 – Certificate of Registration, Ex.R-8 – certificate, Ex.R-9 – Laboratory declaration form, Ex.R-10 – Oracle Investigation agency, Ex.R-11 – letter dated 13.01.2021.

6.                As per email Ex.R-14 it looks that the complainant’s hospital as well as the counsel are the same in all 5 cases. It creates doubt. i.e. the complainant has obtained so many policies from different company.   The details are as under:

Sl. No.        Complaint No.               Title

1.                343/2021              Nisha Rani    Vs.  Raheja QBE

Policy No.                      :         RQBE01-101616-20-000

                                                Valid from 11.06.2020 to 10.06.2021

Address of Hospital        :         Sattya Hospital Faridabad

Disease                           :         Fever, Severe Pain Abdomen, burning        

                                                maturation, vomiting and loose motion.

Date of admission           :         02.11.2020

Date of discharged          :         06.11.2020

Claimed amount             :         INR 54,646/-

2.                235/2021              Nisha Rani          Vs.    ICICI Lombard

Policy No.                      :         4128i/H/1663255384/00/000

                                                Valid  upto 03.02.2021

Address of Hospital        :         Sattya Hospital Faridabad

Disease                           :         Fever, Headache, Pain and Swelling in

                                                Perennial area.

Date of Admission          :         08.10.2020

Date of discharge            :         10.10.2020

Claimed amount             :         INR 32,742/-

3.                237/2021              Mousam             Vs.    Raheja QBE Gen. Ins.

Policy No.                      :         RQBE01-10613-20-000 

                                                Valid from 11.06.2020 to 10.06.2021.

Address of the hospital : Sattya Hospital Faridabad

Disease                           :         Fever, Burning Mituration, Pain in lower

                                                Abdomen

Date of admission           :         07.09.2020

Date of discharge            :         12.09.2020

Claimed amount             :         INR 48421/-

4.                90/2021                Natwar Thakur   Vs. Max Bupa Health Ins.

Policy No.                      :         30262595

Address of the hospital : Sattya Hospital Faridabad

Disease                           :         dehydration, ARF and Deranged LFT

Date of admission           :         8.10.2020

Date of Discharge           :         14.10.2020

Claimed amount             :         INR 48,325/-

5.                80/2021                Brij Bihari           Vs. Raheja  QBE GIC Ltd.

Policy No.                      :         RQBE01-101345-20-000

                                                Valid from 04.05.2021 to 03.05.2021

Address of the hospital : Sattya Hospital Faridabad

Disease                           :         Fever, burning micturation, body pain, 

                                                vomitting

Date of admission           :         13.06.2020

Date of Discharge           :         18.06.2020

Claimed amount             :         INR 48,554/-

7.                As per the counsel for the opposite party argued at length and stated at Bar that as per the investigation report of opposite party it seems that all the 5 cases mentioned above belongs to the same Advocate with the same hospital and same kind of disease and same  amount of the bill.    It creates suspicion of the merit of the cases and during the course of  arguments of the counsel for the complainant in relations with the opposite party i.e owner of hospital etc.

8.                Keeping in view of the above submissions, Commission is of the opinion that all the five cases  comes of collusion. Hence, no deficiency on the behalf of the opposite party has been proved.  Hence, the complaint is dismissed. Copy of this order be sent to the parties concerned free of costs.  File be consigned to the record room.

Announced on:  12.05.2023                                 (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.