Punjab

Ludhiana

CC/19/282

Hitesh Sharma - Complainant(s)

Versus

Reliance General Ins.Co.Ltd - Opp.Party(s)

Alok Mohindra Adv.

11 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 282 dated 11.06.2019.                                                        Date of decision: 11.01.2023.

 

Hitesh Sharma S/o. Sh. Jai Kishan Sharma, R/o.1351/2, Sukhram Nagar, Ludhiana-141001.                                                                                                                                                                              ..…Complainant

                                                Versus

1. Reliance General Insurance Co. Ltd., 7^th Floor, Surya Tower, The Mall, Ludhiana0141001 through its Branch Manager/Authorized Signatory.
2. Reliance General Insurance Co. Ltd., Reliance Centre, South Wing, 4^th Floor, Off Western Express Highway, Santacruz (West), Mumbai-400055 through its Manager/Authorized Signatory.  
3. Reliance General Insurance Co. Ltd., R Care Health, No.1-8/89/3/B/40 to 42/KS/301, 3^rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad, Telangana-500081 through its Manager/Authorized Signatory.                                                                                                                                                                       …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Alok Mohindra, Advocate.

For OPs                          :         Sh. Sunil Goel, Advocate.

 

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant got an insurance policy for himself, his wife Smt. Anitka Sharma and sons Anant Sharma and Yagik Sharma vide policy No.2001262828001712 valid from 02.12.2016 to 01.12.2017 having sum assured of Rs.3,00,000/-. Immediately after elapse of the said policy, the complainant got a fresh policy No.200121728280001519 valid from 02.12.2017 to 01.12.2018 for a sum assured of Rs.3,00,000/-. The said policy was further renewed vide policy No.200121828280002335 valid from 02.12.2018 to 01.12.2019 and there is a continuity of the said insurance policy from time to time since 02.12.2009. During the subsistence of the policy i.e. from 02.12.2017 to 01.12.2018, son of the complainant namely Anant Sharma started suffering from swelling with decreased mobility and pain in his right knee and right ankle and as per medical advice, he got the MRI of the right knee and right ankle from Mayyo Imaging & Diagnostic Centre, Ludhiana on 30.04.2018. When the problem persisted, the complainant consulted the doctors in the CMC & Hospital as an OPD patient and during his treatment, he was advised to undergo various diagnostic examinations by the doctors which were duly got done by the patient but the swelling and pain did not subside and as such the concerned doctor opined that the son of the complainant needs to be got admitted in the hospital for further treatment. Thereafter, son of the complainant was admitted in the CMC & Hospital, Ludhiana under hospital unit No.C-7817890 dated 10.05.2018. At the time of admission, son of the complainant explained the symptoms and problems faced by him regarding swelling in right knee and right ankle and pain and due to the said reason, there is restriction in the right knee join movement and also limp on right leg and that is why his family through it proper to consult the doctors in the said hospital and get the medical advice and he has been admitted in the hospital. The same was recorded by the staff of the hospital. The son of the complainant was referred to Department of Pediatrics of the hospital and orthopedic consultation was also taken and it was diagnosed that he is suffering from juvenile Rheumatoid Arthritis and duet o the said reason there is right knee swelling with decreased mobility and mild tenderness, right ankle mild swelling with slight restriction of ankle movement. The son of the complainant remained admitted in the hospital from 10.05.2018 to 12.05.2018 and was discharged on 12.05.2018 on improvement of his condition. CMC & Hospital, Ludhiana issued discharge summary on 12.05.2018 and the details regarding diagnosed illness and investigations as well as medicines were mentioned in the discharge summary. After discharge of his son from the hospital, the complainant lodged the claim with the opposite parties for the payment of Rs.41,818/-  for reimbursement of the amount spent on the treatment and medicines of the patient but the opposite parties did not approve the claim and repudiated the same vide letter dated 25.06.2018 on the ground that “As per received documents patient “Anant Sharma” was admitted for Juvenile Rheumatoid Arthritis. As per documents submitted need of hospitalization is not justified as admission is only for observation and investigation and treatment taken is possible on OPD basis. Hence we regret to confirm “Non-admissibility of claim”.  The complainant further alleged that the repudiation of the claim is totally wrong, against the facts and record of the hospital and the said repudiation letter is liable to be set aside and the complainant is liable to be paid the expenses incurred by him during hospitalization of his wife and other benefits, if any, as per term of the policy in view of the following reasons:-

a. That the son of the complainant was regularly taking treatment as an OPD patient and had got done all the diagnostic examination and investigations as advised by the doctors and as such it cannot be said that he was hospitalized only for observation and investigation.

b. That the son of the complainant was already taking treatment as OPD patient and had there been no need for admitting him as an indoor patient then the doctors would not have advised so and they would have continued giving treatment to the son of the complainant as an outdoor patient.

c. That had there been any wrongful intention on the part of the complainant then he would have allowed his son to suffer from pain for a number of weeks and take treatment as outdoor patient and go for so many diagnostic investigations. It was only when the child could not bear the pain that the doctors advised the patient to get admitted in the hospital.

d.  That the CMC & Hospital is nearly a century old hospital which is one of the premier, prestigious and reputed institution in the entire northern India and is having highly qualified and super specialist doctors and it is beyond imagination and comprehension that such a hospital and doctors will admit any patient only for investigation or observation purposes on their own or on the mere asking of the complainant.

e. That in the entire medical record of the hospital, it has nowhere been mentioned that the son of the complainant has been admitted in the hospital only for investigation and observation purposes. Therefore there is no material on record from which the respondents have drawn the said wrong inference.

f. That it is evident from the discharge summary and the bills of medicines that the son of the complainant was administered regular medication during his stay in the hospital and had he been admitted only for observation then a senior citizen of about 12 years of age would not have been given medicines. Moreover the complainant and the doctors would not have played with the health of the minor child by giving the medicines without any requirement.

g. That even after the discharge from hospital, the son of the complainant was advised to take medicines as follow-up treatment. Had there been no ailment which required hospitalization then there could not have any requirement of follow up medicines.

h. That in case besides the medicines, the doctors opine that diagnostic examination is required then it cannot be held that the only purpose of admission is observation and investigation.

i. That the letter dated 25.06.2018 was issued by the respondents are totally non-speaking one and do not divulge that what is the internal verification that has been conducted by the respondents and which documents have been referred to by them while conducting the said verification. It also does not mention that on the basis of what evidence, it has been concluded by the respondents that the son of the complainant was admitted in the hospital for observation and investigation only. Therefore, it is evident that the said conclusion has been arrived at while sitting in the office by the respondents without going through the facts or the medical record or the history narrated by the complainant to the medical staff of CMC & Hospital, Ludhiana. Therefore, the respondents have acted on a pre-conceived notion and with pre-determined mind that the claim of the complainant has to be repudiated without having any valid reasons for the same.

j. That the complainant had incurred Rs.41,818/- approximately during the course of the hospitalization of his son in the CMC & Hospital, Ludhiana. Even at the time of his discharge, he was advised to remain under regular medication as mentioned in the discharge summary. The complainant had to incur a lot of expenses on the purchase of medicines and visiting the OPD clinic and even now the complainant has to purchase the said medicines by way of follow up treatment of his son.

The complainant further submitted that the opposite parties did not enquiry before issuing the repudiation letter dated 25.06.2018 and have repudiated the claim without application of mind in order to deny the genuine claim of the complainant. The opposite parties have provided deficient services and are liable to pay the amount incurred by the complainant on the hospitalization along with compensation. In the end, the complainant made a prayer for directing opposite parties to pay the amount of Rs.41,818/- incurred on the treatment and purchase of medicine for his son and investigations in CMC & Hospital, Ludhiana along with interest @12% per annum and also to pay compensation of Rs.50,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable and the complainant has not come to the court with clean hands and has suppressed the material facts. The complainant is estopped by his own act and conduct and has no locus-standi to file the present complaint. The opposite parties alleged that from the documents submitted by the complainant, his claim was not found good for payment since as per the received documents, his son Anant Sharma was admitted for Juvenile Rheumatoid Arthritis and therefore the hospitalization is not justified as admission is only for observation and investigation and the treatment was possible on OPD basis. As per the policy terms and conditions expenses incurred in OPD basis are not covered under the policy and the complaint is liable to be dismissed as follows:-

Policy Exclusions

3.3.24 Charges incurred at Hospital primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any illness or injury, for which in-patient care/day care treatment is required.

                   On merits, opposite parties reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CW1/A in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C4 are the copies of policy schedule, Ex. C5, Ex. C6 and Ex.C8 to Ex. C23 are the copies of patient record, Ex. C7 is the discharge summary dated 12.05.2018, Ex. C24 is the copy of X-ray report dated 08.05.2018, Ex. C25 is the MRI right knee joint, Ex. C26, Ex. C29 are the copies of receipt of Mayyo Imaging and Diagnostic Centre, Ex. C27, Ex. C38, Ex. 41, Ex. C42 are the copies of test reports, Ex. C28,  Ex. C30 to Ex. C37, Ex. C40, Ex. C44, Ex. C45 are the copies of bills of medicine etc., Ex. C46 is the copy of aadhar card of the complainant,  Ex. C47 is the copy of repudiation letter dated 25.06.2018  and closed the evidence.

4.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Sh. Suryadeep Thakur, Area Manager (Legal Claims) of the opposite parties along with documents Ex. R1 is the copy of policy schedule valid from 02.12.2017 to 01.12.2018, Ex. R2 is the copy of health claim form,  Ex. C3 is the copy of MRI report dated 30.04.2018, Ex. R4 is the copy of claim repudiation letter dated 21.08.2019 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.      

6.                The claim of the complainant has been repudiated by the opposite parties by invoking exclusion clause No.3.3.24 of the insurance policy Ex. C1 = Ex. R1 which reads as under:-

Policy Exclusions

3.3.24 Charges incurred at Hospital primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any illness or injury, for which in-patient care/day care treatment is required.

The claim has been repudiated on the premise that the admission primarily for observation and investigation and the treatment taken is possible on OPD basis. The expenses incurred in OPD basis are not covered under the policy in question.

7.                Now the point for consideration arises how it is required to be assessed that the admission is primarily for evaluation and investigation purpose only?

8.                The counsel for the complainant has referred to the extract of the discharge summary Ex. C7 which is reproduced as under:-

‘This 11 year old male was admitted with diagnosis of Juvenile Rheumatoid  Arthritis of the right knee and right ankle (oligoarticular) and was admitted to observe and rule out secondary infection as he had undergone aspiration outside for right knee. He was sick looking on admission. He was observed without antibiotics and was started on anti inflammatory drugs and other supportive care. Orthopedic consultation was taken. His joints swelling has decreased significantly and symptomatically better and he has been started on physiotherapy and is being discharged in a stable condition to be reviewed from OPD.’

The counsel for the complainant has also referred to the history recorded by Doctor In-charge Prof. Gurmeet Kaur in Ex. C7 where it was specifically mentioned that the swelling in the right knee and coupled with restriction in knee joint movement is there for the last 4 months. The discharge summary Ex. C7, when read as a whole clearly spells out that Hitesh Kumar juvenile was being taken care at home for the last four months but seeing no perceptible improvement, necessity arose for his admission in the hospital. No prudent person will admit his/her dear one in the hospital conditions where there is risk of contacting infection is more than at home. Moreover, except the affidavit Ex. RA of one Suryadeep Thakur, Area Manager (Legal Claims) of the opposite parties, no other medical evidence has been adduced by the opposite parties to rebut the specific opinion of the medical experts that it was fit case for indoor treatment in the hospital. The affidavit Ex. RA is also verbatim reproduction of the averments of written reply. The opposite parties have also not relied upon in medical literature  or authority to support their claim. In the given facts and circumstances, it cannot be said that the repudiation of the claim is justified and as such, it would be just and appropriate if the opposite parties are directed to pay the medical expenses of  Rs.41,818/- spent on treatment of son of the complainant along with interest @8% per annum from the date of admission i.e. 10.05.2018 till date of actual payment along with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is allowed with an order that the opposite parties shall pay the claim of medical expenses of Rs.41,818/- spent on treatment of son of the complainant along with interest @8% per annum from the date of admission i.e. 10.05.2018 till date of actual payment . The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:11.01.2023.

Gobind Ram.

 

 

Hitesh Sharma Vs Reliance General Insurance Co. Ltd.            CC/19/282

Present:       Sh. Alok Mohindra, Advocate for complainant.

                   Sh. Sunil Goel, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with an order that the opposite parties shall pay the claim of medical expenses of Rs.41,818/- spent on treatment of son of the complainant along with interest @8% per annum from the date of admission i.e. 10.05.2018 till date of actual payment . The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

                

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:11.01.2023.

Gobind Ram.