Punjab

Ludhiana

CC/19/283

Jatinder Kumar - 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: 283 dated 11.06.2019.                                                        Date of decision: 11.01.2023.

 

Jatinder Kumar S/o. Sh. Kanti Lal, R/o.B-23/5426, New Shivaji 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 and his wife Smt. Hansa Ben vide policy No.200121828250000046 valid from 16.01.2018 to 15.01.2019 having sum assured of Rs.2,00,000/-. The complainant has been getting the insurance policy from the opposite parties since 14.01.2009. The complainant submitted that during the subsistence of the policy, his wife Smt. Hansa Ben suddenly lost her consciousness on 07.05.2018 and became unresponsive. She was immediately taken to CMC & Hospital where doctors opined that she needs to be got admitted for her treatment. Wife of the complainant was admitted in CMC & Hospital, Ludhiana under hospital unit No.C-7817493 dated 07.05.2019 and at that time the complainant explained the symptoms and problems faced by his wife and the medical staff of the hospital properly recorded the symptoms and previous history of his wife. She was referred to Department of Neurology of the hospital and was kept for treatment and diagnostic examinations. She was discharged on 15.05.2018. The complainant further submitted that the policy is cashless one and at the time of admission of his wife, intimation was duly given to the opposite parties and pre-authorization for Rs.25,700/- was given by the opposite parties vide their letter dated 07.05.2019. Since the treatment was taking a longer period than earlier expected and the amount had to be spent on the treatment so further pre-authorization for Rs.60,190/- was given by the opposite parties vide letter dated 10.08.2018. In the discharge summary dated 15.05.2018 issued by CMC & Hospital, Ludhiana the details regarding diagnosed illness and investigations carried out during the course of hospitalization and medicines was duly mentioned. After discharge of his wife, the complainant lodged the claim with the opposite parties for Rs.1,25,112/- for reimbursement of the amount spent on the treatment and medicines of the patient but the opposite parties did not approve the claim and revoked the pre-authorization vide letter dated 16.05.2018 on the ground that “As per received documents member got admitted with chronic depressive illness and admission primarily appears to be for investigation and evaluation purpose only. No active line of treatment noted. Hence claim is denied. Kindly note previous approval stands null and void.” The opposite parties repudiated the claim vide letters dated 09.07.2018 and 23.08.2018. 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 letters are 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 wife of the complainant suddenly suffered from unconsciousness and lack of responsiveness and when the complainant took his wife to the CMC & Hospital that the doctors advised the patient to get admitted in the hospital.

b. 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.

c. That in the entire medical record of the hospital, it has nowhere been mentioned that the wife 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.

d. That it is evident from the discharge summary and the bills of medicines that the wife of the complainant was administered regular medication during her stay in the hospital and had she been admitted only for observation then a senior citizen of about 63 years of age would not have been given medicines. Moreover the complainant and the doctors would not have played with the health of an aged lady by giving the medicines without any requirement.

e. That even after the discharge from hospital, the wife 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.

f. 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.

g. That after the letter dated 09.07.2018 was issued by the respondents, the complainant again approached the CMC & Hospital to show to them, the false objections made by the respondents. However, the doctors in the Neurology Department of the hospital who hold the degree of MD. DM in Neurology were steadfast in their opinion that hospitalization as required to treat the wife of the complainant. The CMC & Hospital also issued a certificate dated 19.07.2018 in which the detailed line of treatment and diagnosis were mentioned. The said certificate was duly sent to the respondents along with the covering letter written by the complainant.

h. That even after the receipt of all the original documents at initial stage and receiving the certificate dated 19.07.2018, the respondents wrote the letter dated 23.08.2018 wherein they informed that the claim has been repudiated due to the above mentioned reasons.

i. That the CMC & Hospital again issued the certificate dated 22.02.2019 wherein it was reiterated that the patient was admitted with complaints of unresponsiveness and in a drowsy state and with high blood pressure. The oral medicines and injectable medicines were given to the patient and thereafter when the patient responded to the said treatment, she was discharged. It was further reiterated by the hospital that the patient required indoor treatment by getting admitted in the hospital.

j. That the certificate dated 22.02.2019 has also been sent to the respondents by the complainant along with the covering letter dated 22.02.2019. However, the same has no effect upon the respondents and they remain adamant on their false and wrong decision of repudiation of the genuine claim.

k. That the letters dated 09.07.2018 and 23.08.2018 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 wife 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.

l. That the complainant had incurred Rs.1,25,112/- approximately during the course of the hospitalization of his wife 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 wife.

The complainant further submitted that the opposite parties did not enquiry before issuing the repudiation letters dated 09.07.2018 and 23.08.2018 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.25,112/- incurred on the treatment and purchase of medicine for his wife 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 as she was got admitted with Chronic depressive illness therefore admission primary appears to be for investigation and evaluation purposes only. No active line of treatment was noticed. The claim is not good for payment and the same was rightly repudiated and the earlier approval as also rendered as null and void. The patient was shown as admitted with diagnosis of New onset Seizures with SOL under Evaluation with Diabetes Mellitus with Hypertension with Chronic Depressive Illness for medical management. The course in hospital involved investigations around New onset Seizures with SOL under Evaluation with Diabetes Mellitus with Hypertension with Chronic Depressive Illness for medical management i.e. Treated with Oral Rx. The policy terms and conditions opted by the complainant, admission primarily for evaluation and investigation is out of scope of coverage and the claim was repudiated as per health wise policy under clause No.20 and 27 as follows:-

20. Any stay in Hospital without undertaking any treatment or where there is no active regular treatment by the Medical Practitioner.

27. Charges incured primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any disease, illness or injury, for which confinement is required at a Hospital/or at home under domiciliary hospitalization as defined. 

                   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. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 and Ex. C4 are the copies of policy schedule valid from 16.01.2018 to 15.01.2019, Ex. C2 and Ex. C6 are the copies of email dated 11.02.2019, Ex. C3 and Ex. C5 are the copies of denial of cashless request dated 16.05.2018, Ex. C7 is the letter written by complainant, Ex. C8 and Ex. C11 are the copies of certificates dated 19.07.2018, 22.02.2019 of Department of Neurology, CMC & Hospital, Ludhiana, Ex. C9 is the copy of Aadhar card of the complainant, Ex. C10, Ex. C13 are the copies of bills, Ex. C12 is the copy of letter written by the opposite parties Ex. C14 is the copy of rejection of claim dated 12.02.2019, Ex. C15 to E. C24 are the copies of patient cases notes, Ex. C25 and Ex. C26 are the copies of report dated 12.05.2018 of Department of Neurology, CMC & Hospital, Ex. C27 to Ex. C30 are the copies of test report, Ex. C31 is the copy of certificate dated 12.05.2018 of Department of Neurology, Ex. C32 is the copy of cashless claim, Ex. C33 is the copy of pre-authorization request form, Ex. C34 is the copy of claim repudiation letter dated 23.08.2019, Ex. C35 is the copy of discharge summary dated 15.05.2018, Ex. C36 is the copy of claim repudiation letter dated 09.07.2018, Ex. C37 to Ex. C40 are  the copies of lab reports 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 16.01.2018 to 15.01.2019, Ex. R2 is the copy of health claim form,  Ex. C3 is the copy of report dated 09.05.2018, Ex. R4 is the copy of clam repudiation letter dated 20.08.2019 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 clause No.20 and 27 of the insurance policy Ex. C1 = Ex. R1 which reads as under:-

20. Any stay in Hospital without undertaking any treatment or where there is no active regular treatment by the Medical Practitioner.

27. Charges uncured primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any disease, illness or injury, for which confinement is required at a Hospital/or at home under domiciliary hospitalization as defined. 

The claim has been repudiated on the premise that the admission primarily for evaluation and investigation is out of scope of coverage of the terms and conditions of 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. C35 which is reproduced as under:-

‘Discussion: Mrs. Hansa Ben was admitted in the hospital with sudden onset unresponsiveness for 3-10 minutes after which she became consciousness. She was not aware of what had happened during that episode. Possibility of new onset seizure in the adult with differential diagnosis of CVT, Stroke, meningoencephalitis, SOP has been considered she had history of loss of appetite and weight. Possibility of malignancy has been considered. MRI Brain with venogram was normal apart from left T2 frontal hyperintensity with is not enchaining with contract. CECT chest and abdomen were normal, Sonomammography was normal CSF analysis was normal, AFT showed sympathetic dysfunction. MR spectroscopy report is awaited. Psychiatry consult was sought for her chronic depressive illness. Drug doses were adjusted. OMES consult was sought for dentures. She is stable and is being discharged.’

Further the counsel for the complainant has referred to the opinion of Dr. Raviteja, Senior Resident DM, Department of Neurology, Christian Medical College & Hospital, Ludhiana contained in Ex. C8 wherein it has been specifically opined that the patient needed admission because she had two episodes of unresponsiveness over period of one week and this cannot be managed on OPD basis. The counsel for the complainant has also drawn the attention of this Commission towards certificate Ex. C11 where it was also observed that she was managed with injectable antiepileptic medications, hence she responded to the medications. Two day later in the ward, she had similar episode of unresponsiveness. As per this certificate, as the patient presenting with loss of consciousness with tonic posturing of limbs, keeping possibility of seizure needs urgent management as indoor patient. Hence the required management including treatment and investigations were done for this patient.

9.                It is evident from the aforesaid evidence of the complainant that in the opinion of the treating doctor and specialist, the admission of the patient was urgently required. It may also be noticed that there was a sudden loss of consciousness about half hour prior to the admission, which necessitated the admission. It was not a pre-appointed health check-up. The ailment of the patient was diagnosed and treated when she was in the hospital itself. On two occasions, there were episodes of unresponsiveness within one week. Had she not been admitted in the hospital there could have been possibility of more serious repercussions to her health. 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. It is pertinent to observe that the policy obtained by the complainant was cashless one and at the time of admission, upon receiving the intimation, pre-authorization to the tune of Rs.25,700/- was duly accorded by the opposite parties as the treatment was taking a longer period than earlier expected. So a sum of pre-authorization was also enhanced to Rs.60,190/- on 10.08.2018. So it is evident that initially the opposite parties were also of the opinion that the admission at this stage is required. 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.25,112/- spent on treatment of wife of the complainant along with interest @8% per annum from the date of admission i.e. 07.05.2018 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.25,112/ spent on treatment of wife of the complainant along with interest @8% per annum from the date of admission i.e. 07.05.2018 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.

 

 

Jatinder Kumar Vs Reliance General Insurance Co. Ltd.           CC/19/283

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.25,112/- spent on treatment of wife of the complainant along with interest @8% per annum from the date of admission i.e. 07.05.2018 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.