District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 343/2021.
Date of Institution:15.07.2021
Date of Order: 12.05.2023.
Nisha Rani 874, Gali No.2, New Tilpat Amarnagar, Faridabad, Haryana - 121003.
…….Complainant……..
Versus
Raheha QBE General Insurance Co. Ltd., P &G Plaza, Ground floor, Cardinal Gracious Road, Chakala, Andheri East, Mumbai - 40 099.
…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 was a policy holder of the respondent's company having Policy Number RQBE01-101616-20-000 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, 1.P.Colony. Sector 30-33, Faridabad, Haryana 121003 on 02/11/2020 with the complaint of Fever, Severe Pain Abdomen, burning maturation, vomiting and loose motion for the last 2 days. The complainant was diagnosed with UTI, Sepsis & Gastroentitis and after successful treat the complainant got discharged from the hospital on 06/11.2020. The complainant paid a sum of INR 54,646/- (Fifty four thousands six hundred forty six only) to the hospital as against the treatment and the same amount was claimed from the respondent. The due intimation of claim was given to the respondent on 03/11/2020. Subsequently, claim documents were sent through mail and the hard copy of claim documents along with duly filled in claim form was dispatched to the respondent. Upon receiving of the physical documents, the claim was registered bearing 23301163 on 26/11/2020. A query was raised by the respondent on 12/12/2020 which was ably replied to by the complainant on the same day. After the verification of the claim by the respondent both from the complainant as well as from the hospital, the complainant got the letter of rejection of claim from the respondent in the month of January. It was submitted that the hard copy of the rejection letter had been misplaced and complainant had requested the respondent to send the soft copy of the same but the respondent has not sent it yet. It is submitted that claim was rejected on the basis of the fact that the hospital was only 10 bedded and that it had not been registered under Clinical Establishment Act. The company knew it very well that only 50 bedded hospitals were qualified to be registered under clinical establishment Act in Haryana and that registration of the hospital under the said Act is 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 was submitted that policy brochure of every insurance company had the same definition of hospital and obviously if the definition had such meaning as the respondent is 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 54,446/- along with 12% interest commencing form 30 days after receiving of the claim document by the company till its actual realization.
b) pay Rs. 25,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 20,000 /-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 02/11/2020 and was diagnosed with Sepsis with AGE with UTI with Hepatomegaly and discharged on 06/11/2020 but from the relied upon documents, it is 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 peri pher of the provisions and more particularly the word "deficiency as defined under section 211) & word "service" as deed section 2:42) and the Protection Act 201 fair trade practice as defined section 247of the Consumer 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 that the complainant was admitted at Sattya Hospital on 2.11.2020 and was diagnosed with sepsis with AGE with UTI with Hepatomegaly and discharged on 06.11.2020 but the insurance company had not received any intimation till 27.11.2020. however, the insurance company had received documents on dated 27.11.2020 vide claim form dated 18.11.2020 through Medi Assist TPA. After that, the 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 violate 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, had arrived at the decision in closing such claim vide final closure letter dated 21.01.2021. At the same time , the insurance company had deputed an independent investigator viz. merlot health Services to investigate the matter so as to ascertain the genuineness of the claim, however, partially the insurance company had received another claim of Mrs. Mousam & Mrs. Indu from the sane hospital with same diagnosis with same line of treatment but there was non-cooperation at the end of the treating hospital to share hospitalization detail/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 is being run under Private Limited
Company Not only this the insurance company have 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 have 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 21/01/2021. which decision cannot be termed unconscionable at all. 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 WAs 6036. As per NMC portal Registration No 6030 & 6036 were not registered with Dr CM Goswami. Industry analysis-mail received from ICICI Lombard and Care health Insurance limited stating suspicious activities noted at Satya hospital, Faridabad wherein numerous fraudulent claims have been reported. There were 3 claims were received by Raheja QBE from the same hospital with similar set of ICPS... and same treating doctor... Details as under:
Claim No. | 22757515 | 22925826 | 23301163 |
Policy No | RQBE01-101345-20-000 | RQBE01-101613-20-000 | RQBE01-101616-20-000 |
Policy source | Policy Bazaar | Policy bazaar | Policy Bazar |
Policy period | 04.05.20-03.05.21 | 11.06.2020- 10.06.2021 | 11.06.2020-10.06.2021 |
Name of patient | Indu | Mousam | Nisha Rani |
Diagnosis | Urinary Tract Infection and Sepsis | Urinary Tract Infection and Sepsis | Acute Gastroenteritis with Urinary Tract Infection |
Claimed amount | 48544 | 48421 | 54649 |
Address of the hospital | Sattya Hospital, Faridabad, Haryana | Sattya Hospital Faridabad, Haryana | Sattya Hospital, Faridabad, Haryana. |
ICP | Same set | Same set | Same set. |
Treating doctor | Dr. C.M.Goswami | Dr. C.M.Goswami | Dr. C.M.Goswami |
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 Company Ltd. with the prayer to: pay a sum of INR 54,446/- along with 12% interest commencing form 30 days after receiving of the claim document by the company till its actual realization.
To establish his case the complainant has led in his evidence,
Ex.CW1/A – affidavit of Nisha Rani, Ex.CW1/a p insurance policy, Ex.CW1/2 – discharge summary,. Ex.CW1/3 – email. Ex.CWWW1/4 – final bill, Ex.CW1/5 – email dated 25.11.2020, Ex.CW1/6 – email dated 12.12.2020 , Ex CW1/7 – Haryana Clinical Establishments.
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 Kiran Nikam, Deputy Manager – claims(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, Ex.R-3 – Discharge summary, Ex.R-4 – Final bill, Ex.R-5 – letter, Ex.R-6 – Certificate of registration,, Ex.R-7 – Consultant doctors, Ex.R-8 (colly) – History and Physical Examination sheet,, Ex.R-9 – Physicians’s orders, Ex.R-10 (colly) – medication cahrt, Ex.C-11 - GST invoice,, Ex.R-12 - Haematology routine, Ex.R-13 – email dated 21.01.2021, Ex.R-14 – email dated 10.03.2021`, Ex. Ex.R-16 – email dated 1003.2021.
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.
