Haryana

Karnal

CC/81/2018

Gurjeet Singh - Complainant(s)

Versus

Religare Health Insurance Company Ltd - Opp.Party(s)

Sanjeev Kumar

29 May 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 81 of 2018

                                                          Date of instt. 02.04.2018

                                                          Date of Decision 29.05.2019

 

Gurjeet Singh aged about 31 years, son of Gurmej Singh, resident of village Makhu Majra, District Karnal.

 

                                                                        …….Complainant

                                        Versus

 

1. Religare Health Insurance Company Ltd., Vipul Tech Square, Tower-C, 3^rd floor, Golf Course Road, Sector-42, Gurgaon, through its Senior Branch Manager.

2. Indusind Bank Ltd., Newal, District Karnal.

3. Amritdhara Hospital, ITI Chowk, Karnal.

                                                                        …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

            

 

 Present:  Shri Sanjeev Manglora Advocate for complainant.

                  Shri Ashwani Popli Advocate for opposite party no.1.

                   Shri Suraj Kanwar Advocate for OP no.2.

                   Shri Vishal Goel Advocate for OP no.3.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a Health Insurance Policy no.11501507 w.e.f.9.8.2017 to 8.9.2018 from the OP no.1 through OP no.2 which is cashless and reimbursement policy. The complainant has suffered from Dengue Fever as a result of which he admitted in Amritdhara Hospital, ITI Chowk, Karnal i.e. OP no.3 for his treatment and he remained admitted in the Hospital from 7.10.2017 to 13.10.2017. Complainant lodged complaint with the OP no.1 within stipulated period vide complaint no.90436696 and also submitted the relevant documents with the office of OP no.1 as per the requirement. The complainant has spent an amount of Rs.30,000/- on his treatment, medical bills, hospital charges, Doctor’s fees etc. The complainant received a letter dated 10.1.2018 issued by OP no.1 vide which the claim of the complainant is rejected illegally and unlawfully. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, OP no.1 appeared and filed written version raising preliminary objections with regard to maintainability; locus standi; cause of action; complainant is estopped by his own act and conduct from filing the present complaint and concealment of true and material facts. On merits, it is pleaded that the OPs had issued policy of health insurance to the complainant bearing policy no.11501507 w.e.f.09.08.2017 till 08.08.2018. The complainant alongwith his spouse, daughter and son were covered under the policy for a Sum Insured of Rs.3,00,000/- subject to Policy Terms and Conditions. Complainant was admitted at Amritdhara My Hospital, Karnal from 7.10.2017 till 13.10.2017 wherein the complainant was diagnosed with Pyrexia (Fever).The complainant in his respect filed a Reimbursement Claim with the OP company on 9.11.2017. It is further pleaded that on the basis of the documents received from the complainant, the following observation were made:-

Discharge Summary: As per the Discharge Summary all the vitals of the complainant were well within normal range. The complainant at the time of admission in the hospital was in conscious state. That at the time of initial examination at the concerned Hospital, the complainant’s body vitals recorded were as follows:

.  Blood Pressure-130/90 mmHg

.  Pulse- 78/min

.  Temp-99F

 It is further pleaded that as per the Progress Notes issued by the Treating Doctor, the body vitals of the complainant are normal and that the complainant is specifically mentioned to be afebrile (Without Fever) as on 8.10.2017, that is, on the second day of the hospitalization only. The complainant was however still kept hospitalized without any need for same. Further, the General Condition of the complainant is mentioned to be “Better” and that the complainant has no further complaints throughout the hospitalization.  It is further pleaded that as per TPR (Vital Chart Sheet) prepared by Amritdhara My Hospital, the vitals of the complainant were well the normal range.

3.             As per the final bill bearing bill no.1932 issued by the treating hospital dated 13.10.2017, it is pertinent to mention here out of the total billed amount of Rs.25,380/-, Rs.17,100/- has been incurred only on Room Charges (Including Rs.900/- as admission charges for 6 days). It is pertinent to mention here that the complainant has been charged Rs.10,000/- as bed charges for one day only, which is quite inflated and seemingly points out to the commercial pursuit of hospitalization done with a malafide intention of drawing wrongful gains at the cost of the OP. Rs.8280/- have been incurred as consultation charges, nursing charges and other investigation charges. Therefore, more than 65% of the total billed amount has been charged for Room Charges only which signify that the Hospitalization was done with a seemingly commercial pursuit and without any medical necessity. It is further pleaded that the complainant was subjected to various investigations, such as HIV 1 & 2 Antibiotics screening test, Malaria, P. Vivax, Widal Test, Culture Aerobic Blood, Urine Examination, Hepatitis B, Hepatitis C Virus, Weil Felix Test, Chikungunya IGB Antibody. The reports of all the above investigation are reported to be normal with no active illness or disease diagnose. The patient underwent various investigations which were not required as per the complaints and the diagnosis of the complainant. Further, all the investigations can be done on OPD basis only without any need of admitting the complainant on OPD basis. The OP no.1 on the basis of observation mentioned above and justification provided by the complainant, concerned authority rejected the reimbursement claim, vide letter dated 10.1.2018. Hence there is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             OP no.2 in his reply stated that the complainant does not come under the definition of consumer, provided under section 2(i)(d) of Consumer Protection Act against and qua the OP, there is no contract and any type of consideration has taken place between the OP no.2 and has not charged any kind of premium of insurance policy from the complainant. All the risks and liabilities are covered by the OP no.1 only had issued the policy to the complainant. OP no.2 only provides the banking services to the people for deposit and withdrawal of the money. OP no.2 bank stated herein that the role of the OP is limited as to a corporate agent/facilitator and whereas the actual insurance is issued by the OP no.1 and as such complaint cannot be filed against the OP no.2.  There is no deficiency in service on the part of the OP no.2 and prayed for dismissal of the complaint.

5.             OP no.3 filed its separate written version raising preliminary objections with regard to maintainability; locus standi and there is no deficiency in service on the part of the OP no.3. On merits, it is pleaded that if the complainant has obtained any Health Insurance Policy, then OP no.3 is having no concern with that policy. It is further pleaded that for treatment of Dengue Fever, the complainant remained admitted with OP no.3 from 7.10.2017 to 13.10.2017 and spending amount of Rs.30,000/- on his treatment, medical bills, hospital charges and doctor fees. There is no deficiency in service on the part of the OP no.3. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

6.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C3 and closed the evidence on 24.01.2019.

7.             On the other hand, OP no.1 tendered into evidence affidavit of Arvind Singh Ex.RW1/A and documents Ex.R1 to Ex.R8. OP no.3 tendered into evidence affidavit of Dr. Rajiv Gupta Ex.OW1/A and closed their evidence on 16.5.2019. OP no.2 led no evidence.

8.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

9.             The case of the complainant is that he purchased a Health Insurance Policy from the OP no.1 through OP no.2, valid from 9.8.2017 to 8.9.2018, which is cashless and reimbursement policy. The complainant has suffered from Dengue Fever as a result of which he admitted in Amritdhara Hospital, ITI Chowk, Karnal i.e. OP no.3 for his treatment and he remained admitted in the Hospital from 7.10.2017 to 13.10.2017. Complainant lodged complaint with the OP no.1 and also submitted the relevant documents with the office of OP no.1. The complainant has spent an amount of Rs.30,000/- on his treatment, medical bills, hospital charges, Doctor’s fees etc. But OP no.1 repudiated the claim of the complainant illegally, vide letter dated 10.1.2018.

10.            On the other hand, the case of the OP no.1 is that Complainant was admitted at Amritdhara My Hospital, Karnal from 7.10.2017 till 13.10.2017 wherein the complainant was diagnosed with Pyrexia (Fever). As per admission and discharge record, all the vitals of the complainant were well within normal range at the time of admission in the hospital.  The reports of all the investigation are reported to be normal with no active illness or disease diagnose. The patient underwent various investigations which were not required as per the complaints and the diagnosis of the complainant. All the investigations can be done on OPD basis only without any need of admitting the complainant on IPD basis. The OP no.1 on the basis of observation mentioned above and justification provided by the complainant, concerned authority rejected the reimbursement claim, vide letter dated 10.1.2018.

11.              The case of the OP no.2 is that there is no contract and any type of consideration has taken place between the OP no.2 and has not charged any kind of premium of insurance policy from the complainant. All the risks and liabilities are covered by the OP no.1 only had issued the policy to the complainant. OP no.2 only provides the banking services to the people for deposit and withdrawal of the money. OP no.2 bank stated herein that the role of the OP no.2 is limited as to a corporate agent/facilitator and whereas the actual insurance is issued by the OP no.1 and as such complaint cannot be filed against the OP no.2. OP no.2 relied upon the judgment of Hon’ble Supreme Court in case titled as Virender Khullar Versus American Consolidation Services Ltd. decided on 16.08.2016 in Civil Appeal no.9217 of 2012 and in Andhra Pradesh State Consumer Disputes Redressal Commission Hyderabad on 30.07.2010 in F.A. no.86 of 2008 in the matter of Andhra Bank Credit Card Division Versus Mrs.Dinas, wherein it has been held that bank who only acted as an agent cannot be fastened with insurance liability and on this ground also the complaint is liable to dismissed against OP no.2.

12.            The case of the OP no.3 is that the complainant has obtained any Health Insurance Policy, then OP no.3 is having no concern with that policy. For treatment of Dengue Fever, the complainant remained admitted with OP no.3 from 7.10.2017 to 13.10.2017 and spending amount of Rs.30,000/- on his treatment, medical bills, hospital charges and doctor fees

13.            Admittedly, complainant taken a Health Insurance Policy bearing no.11501507 with effect from 09.08.2017 till 08.08.2018 with sum assured of Rs.3,00,000/-. The complainant was admitted with the alleged history of Dengue fever at Amritdhara Hospital Karnal from 7.10.2017 to 13.10.2017 i.e. during the subsistence of the policy. The complainant spent an amount of Rs.30,000/- on the his treatment. This fact was not denied by the OP no.3 i.e. Amritdhara Hospital Karnal. As per the claim denial letter (Ex.R8), the claim of the complainant was repudiated on the ground recorded as follows: “as per submitted documents need for the hospitalization was not justified as the treatment could have been taken on the OPD basis.”

14.            As per admission and discharge record (Ex.R3), all the vitals of the complainant were well within normal range at the time of admission in the hospital. The complainant was in conscious state. At the time of initial examination of the concerned hospital, the complainant’s body vital recorded were as follows:

        .  Blood Pressure-130/90 mmHg

.  Pulse- 78/min

.  Temp-99F

 

As per progress notes (Ex.R4) issued by treating doctor, the body vitals of the complainant were normal and the complainant was specifically mentioned to be afebrile i.e. (without fever) as on 08.10.2017. As per TPR Chart (Ex.R5), the vitals of the complainant were within normal range.

15.            As per lab report (Ex.R7) issued by Dr. Lal Pathlabs, on 8.10.2017 complainant platelet count were 186.0 thou/mm3 and on 13.10.2017 it were 192.0 thou/mm3 which is well within the normal limit. Normal platelet count of a person should be between 150-450 thou/mm3. As per bill (Ex.R6), Rs.17100/- has been incurred only on room charges, including Rs.900/- as admission charges for 6 days, which is quite inflated. The bill amount of Rs.30000/- was not denied by the OP no.3.

16.            We have gone through all the medical record of the complainant. As per medical reports and report of labs, the complainant was admitted in the hospital with the history of Pyrexia (Fever). As per admission and discharge record Ex.R3, the complainant was in conscious state and Temp. was 99F. As per progress note Ex.R4, the body vitals of the complainant were normal and complainant was specifically mentioned to be afebrile. As per TPR Chart Ex.R5 the vitals of the complainant were within normal range and as per lab. reports the platelet count were well within the normal limit. The complainant could have been treated by as an OPD patient. During the course of arguments counsel for the OP no.1 pointed out that, generally, it has become a trend among the Private Doctors of the  hospitals to admit the patients with normal illness under the grab of some serious illness just for the purpose of charging huge amounts from them especially like the present case. There is a force in the argument advanced by the counsel of OP no.1. Thus, we are of the view that at this stage, the act of the OP no.3 i.e. Doctor of Amritdhara Hospital Karnal amounts to deficiency in service and unfair trade practice. Complainant paid Rs.30000/- to the OP no.3 which is not denied by the OP no.3. As per bill Ex.R6, Rs.17100/- has been charged only for the room charges and Rs.3240/- as Nursing charging. OP no.1 is not liable for the same. Thus, we are of the considered view that OP no.3 is liable to refund the amount of Rs.20,340/- (Rs.17000+3240) and remaining amount Rs.9660/- (Rs.30000-20340) be paid by OP no.1 to the complainant. We feel that complainant should be compensated for harassment and litigation expenses. Thus, the complainant is also entitled for the same.

17.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.3 to refund the amount of Rs.20340/- (17000+3240) and OP no.1 is directed to pay the remaining amount of Rs.9660/- (30000-20340) to the complainant with interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the OP no.3 to pay Rs.15,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:29.05.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

                (Vineet Kaushik)

                    Member