BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.
Complaint Case No.229 of 2019.
Date of institution: 06.08.2019.
Date of decision:22.01.2021.
Harish Ahluwalia S/o Amar Singh Ahluwalia, correspondence residing A-119 Dda Sheds, 2nd floor, Okhla Industrial Area Delhi, New Delhi-110022, permanent residence of Village H.No.3702, Devi Mandir Road, Om Market Fatehpur, Tehsil Pundri, Distt. Kaithal.
…Complainant.
Versus
- Religare Health Insurance Company Ltd. Vipul Tech., Tower-C, III Floor, Sector-43, Gold Course Road, Gurgaon, Pin-122009, through its Managing Director/Authorized Person.
- Cygnus Super Specialty Hospital, Sector-20, HUDA, Ambala Bye Pass Road, Kaithal through its Authorized Person.
….Respondents.
Before: Sh. D.N.Arora, President.
Sh. Rajbir Singh, Member.
Smt. Suman Rana, Member.
Present: Sh. Krishan Kumar Dhull, Advocate, for the complainant.
Sh. Rajesh Kumar Kaushik, Advocate for the OP.No.1.
Op No.2 exparte.
ORDER
D.N.ARORA, PRESIDENT
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 with the averments that the complainant purchased a health insurance policy bearing No.12317860 dt. 30.03.2018 from the Op No.1 (Online method) valid for the period 31.03.2018 to 30.03.2019 and the same was renewed on 30.03.2019 and the same was valid for the period 31.03.2019 to 30.03.2019 and paid the premium amount of Rs.19,471/- online through Policy Bazar Pvt. Ltd. It is further alleged that the complainant was suffering from swelling and pain on right leg/upper thigh, so, he approached the Op No.2 on 22.05.2019 where he was admitted for treatment. As per terms and conditions of policy, the Op No.2 applied for cashless medical treatment of complainant on 23.05.2019 alongwith documents of plan care, progress sheets, medication chart, vital chart and certificate issued by the doctor regarding the health of complainant. The Op No.1 made some query and Op No.2 replied the query of Op No.2 on 25.05.2019 regarding the health status of complainant and after receiving the reply of Op No.2, the Op No.1 rejected the cashless claim of treatment of complainant and advised to file the reimbursement will all respective documents. The complainant was admitted in the hospital from 22.05.2019 to 28.05.2019 where he spent the amount of Rs.33,988/- on his treatment and the complainant lodged the claim with the Op No.1 and submitted all the necessary documents but the Op No.1 repudiated the claim of complainant on 01.07.2019 and send the denial letter dt. 26.06.2019 on the ground “Admission not justified”. The said letter is wrong and illegal. So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint. Hence, this complaint.
2. Upon notice, the OP No.1 appeared before this Commission, whereas Op No.2 did not appear and opted to proceed against exparte vide order dt. 20.09.2019. Op No.1 contested the complaint by filing reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the complainant has concealed the true and material facts from this commission; the true facts are that the complainant was issued a Health Insurance Policy in question by the Op company. The complainant filed a request for availing cashless facility which was duly received by the Op company. The complainant was admitted to Cygnus Super Specialty Hospital, Kaithal on 22.05.2019 and the Op company raised query to the complainant vide deficiency letter dt. 23.05.2019 and 24.05.2019 and the query reply was received by the Op company. On the basis of documents received alongwith the cashless request form, query reply and findings of the investigation undertaken, it was found that the possibility of pre-existing disease could not be ruled out as patient had a pasty history of DVT but the exact duration could not be ascertained due to non-submission of necessary documents. Accordingly, the Op company denied the cashless request vide denial letter dt. 26.05.2019. Thereafter, the complainant filed a Reimbursement Claim with the Op company and the complainant was admitted in the hospital from 22.05.2019 till 28.05.2019. As per the Discharge Summary, the complainant was diagnosed with DVT LL LIMB. Accordingly, the Op company raised a query vide deficiency letter dt. 17.06.2019 and asked for the following documents and information:
i. Exact duration and pasty history of present ailment with Ist consultation paper and all past treatment records. DVT.
ii. Pre-hospitalization OPD treatment record. ALL OLD RECORDS.
On the basis of documents received and findings of the investigation undertaken, the Op company came up with the following observations:-
- As per the Discharge Summary of the complainant, the body vitals of the complainant were found to be normal without necessitating any need for hospitalization. Further as depicted in the Discharge Summary, the complainant was treated conservatively without any surgical intervention which could otherwise have been managed on OPD basis.
- That the complainant was subjected different tests and investigations. All the results of the tests done came out to be normal and can be managed on OPD basis only without any need for hospitalization of the complainant on IPD basis.
- As per the Final Bill, it is pertinent to mention here that more than 50% of the billed amount, that is, Rs.16,800/- has been spent on room accommodation only which duly signified that the hospitalization was done for seemingly with a commercial intent without any medical justification for the same.
Thus, in the light of the above-noted observations, the Op company rejected the reimbursement claim of insured under caluse 4.2 (1) read with Annexure-II (71) of the Policy Terms and Conditions as hospitalization for investigation and Evaluation is permanently excluded from the policy benefits vide letter dt. 26.06.2019. There is no deficiency in service on the part of Op. On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.
3. The complainant tendered into evidence affidavit Ex.CW1/A and documents Annexure-C1 to Annexure-C48 and thereafter, closed the evidence.
4. On the other hand, the Op No.1 tendered into evidence affidavit Ex.RW1/A and documents Annexure-R1 to Annexure-R10 and thereafter, closed the evidence.
5. We have heard the learned Counsel for both the parties and perused the record carefully.
6. Admittedly, the complainant has taken the health family policy for the sum of Rs.5,00,000/- as per Annexure-R1 for the period 31.03.2018 to 30.03.2019 and again renewed the same for the period 31.03.2019 to 30.03.2020 which covers the complainant and his three family members. It is also not disputed that as per Annexure-C22 the complainant remained hospitalized from the period w.e.f. 22.05.2019 to 28.05.2019 for the treatment Swelling & Pain Right Leg/Upper Thigh and he incurred the amount of Rs.28,000/- as per Annexure-C8 and paid the amount as per receipt Annexure-C9 and the complainant further incurred the amount of Rs.3,000/- as per Annexure-C10 and as per Annexure-C5 he incurred the amount of Rs.2368/- and he spent the amount Rs.200/- as per Annexure-C4 and further incurred Rs.244/- as per Annexure-C7. In this way, the complainant incurred the total amount of Rs.33,988/-. The Op has taken the first objection that as per terms and conditions of policy Annexure-R1 as per exclusion clause-4 and sub section 4.2 i.e. permanent exclusion sub clause 1 that any claim in respect of any insured person for arising out or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the Policy Terms and Conditions and as per the clause 1, any item or condition or treatment specified in List of Non-Medical Items (Annexure-II to Policy Terms and Conditions). We have gone through the Annexure-II, list of Expenses Generally Excluded and at Sr.No.71, Hospitalization for evaluation/diagnosis purpose but from the perusal of discharge summary, it is clear that the complainant remained admitted in the hospital with the treatment Swelling & Pain Right Leg/Upper Thigh and the complainant remained in the hospital as indoor patient for the period of six days and he took the treatment of the above-said disease and the hospital has given the treatment to the complainant, so, the above-said objection of the Op is not sustainable in the eyes of law because the complainant never remained as OPD patient and he remained as indoor patient. The hospital has given the certificate Annexure-C24 and Annexure-C40 by the treating doctor and has given the detail of treatment which was given by the hospital to the complainant. The Op No.1 has taken the another objection that the expenses incurred by the complainant on medical treatment are very excessive. On this point, he has drawn our attention that the hospital has taken the excessive rent of room rent @ Rs.2800/- per day for the period 22.05.2019 to 27.05.2019 which becomes Rs.16,800/-. We have gone through the terms and conditions of the policy. As per Annexure-C46 in the column of Schedule of Benefits, it is mentioned that the complainant is entitled Hospitalization Expenses (in-patient Care and Day Care Treatment) and complainant is entitled the expenses of single private room but it is not mentioned that how much rent of the room, the complainant is entitled. So, without any detail of the entitlement of the room charges as per terms and conditions, we have no option to give the benefit of room charges as charged by the hospital @ Rs.2800/- per day from the complainant. So, the above-said contention of Op that the complainant has claimed the excessive amount on the treatment as room rent charges is not sustainable in the eyes of law. There is no dispute that the complainant has incurred the amount on the medicines as per Annexure-C8. Hence, we are of the considered view that the complainant is entitled for the amount of Rs.33,988/- as expenses incurred by him on his treatment. Therefore, we find that the Op No.1 has wrongly repudiated the claim of complainant on the ground that and there is deficiency in service on the part of Op No.1.
7. Thus, in view of above discussion, we allow the complaint against the Op No.1 and direct the Op No.1 to pay Rs.33,988/- to the complainant alongwith interest @ 9% p.a. from the date of filing of present complaint till its realization to the complainant and Op No.1 is further directed to pay Rs.5,000/- as lump sum compensation on account of harassment, mental agony including the litigation charges. Let the order be complied with within 45 days from the date of preparation of copy of this order. A copy of this order be sent to both the parties free of cost. File be consigned to the record room after due compliance.
Announced in open court:
Dt.:22.01.2021.
(D.N.Arora)
President.
(Suman Rana), (Rajbir Singh)
Member Member.
