BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 256 of 2017 Date of Institution : 12.10.2017
Date of Decision : 24.1.2019.
Narinder Kumar ( aged about 40 years) son of Sh. Mahabir Parshad Aggarwal, resident of H. No.1, Ward No.3, Near Hanuman Mandir, Kalanwali, District Sirsa.
……Complainant.
Versus.
1. Religare Health Insurance Company Limited, Registered Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi- 110019 through its Regional Manager/ Authorized Signatory.
2. Munish Jindal, Authorized Agent, (Agent Code 10827323) Religare Health Insurance Company Limited, office: situated opposite Spar Banquet Hall, Near LIC Building, Old Civil Hospital Road, Sirsa.
3. Fortis Hospital, Shalimar Bagh, A-Block, North-West Delhi, Delhi- 110088 through its Managing Director/ Authorized Signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. ISSAM SINGH SAGWAL …… MEMBER.
Present: Sh. Vijay Sharma, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite party no.1.
Sh. Parvinder Gaba, Advocate for opposite party no.3.
Opposite party no.2 exparte.
ORDER
The case of the complainant in brief is that complainant in order to secure his family from loss of expenses of treatment as well as to get financial help for securing the health of his family was desired to get a health insurance policy and as such he purchased a family health insurance policy bearing No.10827323 dated 7.10.2016 vide which the complainant and his family was insured with regard to their health w.e.f 15.10.2016 to 14.10.2017. The said policy was purchased by complainant from op no.2 Mr. Munish Jindal agent after every type of assurances given by him. It was also assured by op no.2 on behalf of op no.1 that if any of the member (covered under the policy) is hospitalized for 24 hours or more so, then in that eventuality also, all the expenses to be incurred thereon will be borne by op no.1. The policy comprising all the terms and conditions of the policy received by complainant at his residential address at Kalanwali and the premium was paid to op no.2 at his office at Sirsa. That on 13.5.2017, the wife of complainant Mrs. Priyanka suddenly fell ill and she was suffering from acute pain in abdomen. Then the complainant took her to the local doctor at Kalanwali and got her medically treated but she could not get any relief and her pain became more severe. Then on 16.5.2017, the complainant got his wife hospitalized in Fortis Hospital, New Delhi (op no.3) with the complaints of acute pain in abdomen since three days and pain was radiating from left side to back. It is further averred that wife of complainant was diagnosed by the doctor with “Acute Enteritis with Dehydration and ?UTI”. Blood parameters were sent, which showed anemia with raised HSCRP. She was started on IV fluids, IV Analgesics, IV antibiotics, PPI and other supportive treatment. It is further averred that in view of un-proportionate pain in abdomen, CECT whole abdomen was done which showed hepatomegaly with mildly bulky uterus and showed few iso to hypoechoic intramural lesions, suggestive of fibroids with a simple cyst in right ovary. In view of continued symptoms inspite of IV analgesics, GI surgery reference was sought and advice followed. CX-ray and DEXA scan was done which were normal. It is further averred that due to poor flow to urine, urine routine was done which showed ketones and USG KUB done showed PVRV 100cc (significant). Gynecology reference was sought in view of fibroids and advice followed. The condition of the patient improved gradually with conservative management. Thereafter, she was discharged from the hospital on 19.5.2017. That at the time of admission of wife of complainant in Fortis Hospital (op no.3), the complainant informed the op no.1 through op no.3 and all the medical reports and other documents including bill etc. were submitted by op no.3 to op no.1. That op no.3 issued a bill of Rs.67,795/- on account of medical expenses and hospitalization charges. As per the terms and conditions of the policy, all the medical expenses on the treatment of wife of complainant were to be borne by op no.1 as complainant purchased a cashless policy and the said amount was to be directly paid by op no.1 to op no.3, but at the time of discharge, the said amount was not paid by op no.1 to op no.3 and as such the op no.3 has charged the said amount of Rs.67,795/- from the complainant, which amount was borrowed by complainant from his relatives as well as from the market on interest prevalent in the market. It is further averred that thereafter the complainant contacted the ops no.1 and 2 and requested them to pay the claim amount incurred by him but the ops no.1 and 2 put off the matter with one pretext or the other and finally have refused the claim of complainant vide claim rejection letter dated 10.6.2017 on the false grounds i.e. (i) Hospitalization primarily for investigation and evaluation and (ii) admission not justified, whereas wife of complainant was hospitalized with op no.3 with the complaints mentioned above and she was treated by op no.3 w.e.f. 16.5.2017 to 19.5.2017. As such question of above false grounds does not arise at all, rather the same have been put by op no.1 just to reject the claim. Moreover, if the admission was not justified, then at the very first time of investigation, diagnose, the wife of complainant ought to have been discharged by op no.3 but they kept the wife of complainant in their hospital for four days and have received a total amount of Rs.67,795/- on account of treatment. Hence, if the admission of wife of complainant was not required as per rejection letter dated 10.6.2017, then the complainant is entitled to get the above said amount from the op no.3 alongwith interest thereon as well as compensation on account of harassment etc. That op no.1 and its official have not properly gone through the medical record of wife of complainant and have intentionally rejected the claim of complainant just to usurp the amount of claim. Hence, this complaint.
2. On notice, opposite party no.1 appeared and filed written statement taking certain preliminary objections. It is submitted that true facts are that op no.1 issued a policy to the complainant bearing no.10827323 for sum insured of Rs.5,00,000/- valid from 15.10.2016 till 14.10.2017. The said policy was subsequently renewed for period 15.10.2017 till 14.10.2018. The issuance of the policy and its subsequent renewal were subject to policy terms and conditions. The said policy covered the complainant alongwith his spouse and his two children. The said policy was ported from New India Assurance Company to op no.1 with whom the complainant was insured since 15.10.2009. It is further submitted that complainant approached the op no.1 on 16.5.2017 with a cashless request for hospitalization of the complainant’s spouse at Fortis Hospital, Shalimar Bagh, New Delhi for the treatment of acute enteritis with dehydration and UTI (Urinary Tract Injection). That on reception of the cashless facility request, a query letter dated 16.5.2017 was sent by op no.1 to complainant for providing the necessary documents for proper assessment of the claim that is complete indoor case paper with admission notes, history sheet, doctor notes and vital charts. That on the receipt of the document and evaluation of the same, op no.1 rejected the cashless facility request and the same was intimated to the complainant vide letter dated 16.5.2017 as the said hospitalization was merely for investigation and evaluation and without any medical justification. It is further submitted that thereafter the complainant again approached the op no.1 with a reimbursement claim for the above mentioned hospitalization of the complainant’s spouse with effect from 16.5.2017 to 19.5.2017 for claimed amount of Rs.68,745/-. The said claim was rejected vide claim rejection letter dated 10.6.2017 for the reason that the hospitalization was for investigation and evaluation purposes only and the same is beyond the scope of the policy terms and conditions as the same is excluded under the clause 4.2(i) read with Annexure-II (Entry71). It is further submitted that rejection of the claim was on the basis of the following documents:
As per the Triage sheet dated 16 May 2017, it was stated that the admission was for pain abdomen-“ under evaluation”. It is also pertinent to mention that all the vitals were under limits as specified.
Also as per the Triage H&P sheet dated 16 May 2017, the insured was conscious, oriented and again all the vitals were within limits as specified. Even pain in abdomen was mild i.e. 3/10 which could have been managed on OPD basis only and without any need for hospitalization.
Further, according to the Progress Notes dated 16.5.2017, it is mentioned that the insured was conscious, oriented, afebrile, and abdomen pain was reduced and again all vital were within limits. Further according to the Progress notes dated 17.5.2017 patient was stable, pain in abdomen was under evaluation, Pulse rate, Blood pressure was normal, the patient was on home food and only a syrup was administered to the patient which can be administered on OPD basis. Also as per Progress notes dated 18 May 2017, there was only one episode of vomiting and there was no pain in abdomen and the same dated 19 May 2017 mentions that the patient was stable, there was no pain in the abdomen, no vomiting, and all stable vitals.
Also ultrasound abdomen also reads as normal without signifying any active disease. Further the said test can be conducted on OPD basis only without necessitating hospitalization of the insured.
As per the Haematology test, the white blood cell count was normal i.e. within the normal range and hence signifies that there was no infection. Further the insured was subjected to various investigations. All the investigations can be conducted on OPD basis only without any need for hospitalization.
Vital sign flow sheet from 16 May 2017 to 19 May 2017 shows normal condition of the patient.
Also final bill dated 19.5.2017 indicates that out of the total bill i.e. Rs.67795/-, an amount of Rs.29890/- was incurred only because of the investigation conducted by the Hospital authority for evaluation of pain in abdomen, which could have been managed on out-patient basis. Therefore, 44.9% of the total bill was for the investigation and hence indicates that the hospitalization was for the purpose of investigation/ evaluation only and seemingly with commercial pursuits. It is further submitted that the op no.1 procured an expert opinion from an independent medical Practitioner with respect to the above mentioned hospitalization to substantiate the fact that the hospitalization of the insured was only for investigation/ evaluation purposes and could have been managed on OPD basis only. The opinion concluded that the “Patient could have been comfortably managed on OPD basis and hospitalization was for investigation and evaluation.” It is further submitted that complainant already filed the complaint before this Forum on 29.9.2017 and same was dismissed as withdrawn. With these averments, dismissal of complaint prayed for.
3. Opposite party no.2 did not appear despite notice and was proceeded against exparte.
4. Opposite party no.3 filed written statement taking certain preliminary objections. It is submitted that complainant has not proved any deficiency or negligence of op no.3 and there is no allegation of any kind of deficiency at the end of op no.3. The complainant has filed the present complaint against the answering op only to harass the answering op and further to extract money from answering op. That the wife of complainant was admitted in the op no.3 hospital on 16.5.2017 for acute pain in abdomen. Considering the nature of complication in the health of the complainant’s wife, she was admitted in the hospital for necessary investigation and treatment. It is further submitted that after detail investigation and treatment, she was discharged from hospital on 19.5.2017. That the admission of wife of complainant in the answering op’s hospital was imperative considering her situation for the purpose of investigation and treatment and she was admitted in the hospital at her own free will and consent after understanding the seriousness of her medical situation. The complainant had given his consent for admission of his wife in hospital and a consent form was filed up and signed by complainant. The op no.3 had raised the bill for a total amount of Rs.67,795/- upon the complainant and same was paid by complainant. It is further submitted that op’s hospital had rendered best treatment to the complainant’s wife and same has not been denied by complainant. The complainant has not stated a single word against answering op proving any kind of negligence in the treatment rendered to his wife. There is no role of the answering op in releasing the medi-claim amount to the insured and same has to be done by ops no.1 and 2 only. The agreement was entered between complainant and op no.1 through op no.2 and answering op no.3 was not a party to said agreement. The reason alleged by complainant for rejection of claim amount by ops no.1 and 2 is false and concocted. With these averments, dismissal of complaint qua op no.3 has been prayed for.
5. The parties then led their respective evidence by way of affidavits and documents. The complainant produced his affidavit Ex.C1, copy of claim rejection letter dated 10.6.2017 Ex.C2, copy of letter dated 16.5.2017 Ex.C3, copy of PAN card Ex.C4, copy of client ID of Priyanka Ex.C5, copy of adhar card of Priyanka Ex.C6, copy of discharge summary Ex.C7, copy of bill Ex.C8, copy of detailed bill Ex.C9, copy of detailed bill Ex.C10, copy of order dated 27.9.2017 regarding withdrawal of earlier complaint with permission to file fresh complaint Ex.C11, affidavit of Smt. Priyanka Ex.C12. OP no.1 produced affidavit of Sh. Arvind Singh Naruka, Legal Manager Ex.R1, copy of letter dated 7.10.2016 Ex.R2, copy of letter dated 13.10.2017 Ex.R3, copy of premium acknowledgement Ex.R4, copy of policy certificate Ex.R5, copy of policy certificate Ex.R6, copy of premium acknowledgement Ex.R7, copy of policy terms and conditions Ex.R8, copy of request for cashless Ex.R9, copy of query letter Ex.R10, copy of letter dated 16.5.2017 Ex.R11, copy of claim form Ex.R12, copy of claim repudiation letter Ex.R13, copies of treatment records and bill Ex.R14 to Ex.R20 and copy of opinion/ report of Dr. Manish M. Shetty Ex.R21. Op no.3 produced affidavit of Sh. Mahipal Singh Bhanot Ex.RW3/1, copy of discharge summary Ex.RW3/2, copy of general consent for admission Ex.RW3/3 and copy of bill Ex.RW3/4.
6. We have heard learned counsel for the parties and have perused the case file carefully.
7. Learned counsel for complainant has contended that it is proved on record that complainant had purchased a family health insurance policy bearing No.10827323 dated 7.10.2016 from the opposite party no.1 through op no.2 vide which the complainant and his family members were insured with regard to their health w.e.f. 15.10.2016 to 14.10.2017. It is further proved fact that on 13.5.2017 wife of complainant namely Priyanka suddenly fell ill as she was suffering from acute pain in abdomen. Then complainant took her to the local doctor at Kalanwali and got her medically treated but she did not get any relief and on 16.5.2017 he got his wife hospitalized in Fortis Hospital, New Delhi where she remained admitted upto 19.5.2017. It was a cashless policy but cashless claim was declined by op no.1 and thereafter complainant paid a sum of Rs.67,795/-on account of treatment charges to op no.3. Thereafter, claim was lodged with op no.1 but however same was refused by op no.1 on 10.6.2017 on false ground that hospitalization for investigation and evaluation and admission is not justified. He has further contended that non payment of claim amount clearly amounts to deficiency in service on the part of ops no.1 and 2. It has also been contended that op no.3 has also corroborated the version of complainant by which they have submitted that treatment was required and after thorough investigation and diagnoses, the treatment was given to Priyanka wife of complainant and there is no negligence on the part of op no.3 in diagnosing and giving treatment to the wife of complainant.
8. On the other hand, learned counsel for op no.1 has strongly contended that complainant has lodged a false complaint against op no.1. The policy clause 4.2(I) clearly debars from claiming any amount on account of hospitalization charges on account of investigation and evaluation only. It has also been contended that as per the record of hospital there was only abdomen pain to the wife of complainant namely Priyanka and she could get treatment in OPD and no hospitalization was required at all. Further it has been contended that repudiation has been made by op no.1 on the basis of expert opinion of Dr. Manish M. Shetty Ex.R21. There is no deficiency in service on the part of op no.1. Learned counsel for op no.1 has relied upon judgment of the District Consumer Forum, Palwal in case titled as Deepak Kaushik Versus Religare Health Insurance Company Ltd. CC No.127 of 2015 decided on 26.5.2016 in which medical claim of complainant was declined and further he has relied upon judgment of the District Consumer Forum, Amritsar (Punjab) in case titled as Manish Kumar Vs. Religare Health Insurance Co. & anr. CC No.496 of 2014 decided on 5.5.2015 in which medical claim of complainant was also declined.
9. Learned counsel for op no.3 has contended that admission of wife of complainant in their hospital was required and there is no negligence of op no.3 in providing treatment to the wife of complainant.
10. We have considered the rival contentions of the parties and have gone through the record as well as judgments relied upon by learned counsel for op no.1.
11. It is undisputed fact between the parties that complainant had purchased a medi-claim policy bearing No.10827323 valid from 15.10.2016 to 14.10.2017 from opposite party no.1 through op no.2 on payment of premium in which wife of complainant namely Smt. Priyanka was also covered. It is further undisputed fact that on 13.5.2017 wife of complainant Smt. Priyanka fell ill and she got treatment from local doctor at Kalanwali and thereafter they shifted her to Fortis Hospital, New Delhi i.e. op no.3. She remained admitted there from 16.5.2017 to 19.5.2017 with abdomen pain. The wife of complainant was diagnosed by the doctor with “Acute Enteritis with Dehydration and ?UTI”. Blood parameters were sent, which showed anemia with raised HSCRP. She was started on IV fluids, IV Analgesics, IV antibiotics, PPI and other supportive treatment. In view of un-proportionate pain in abdomen, CECT whole abdomen was done which showed hepatomegaly with mildly bulky uterus and showed few iso to hypoechoic intramural lesions, suggestive of fibroids with a simple cyst in right ovary.
12. It is further undisputed fact that though it was a cashless policy but however cashless claim was declined by op no.1. Thereafter on discharge of patient, complainant had paid a sum of Rs.67,795/- to op no.3 vide bill Ex.RW3/4. It is also proved fact on record that thereafter claim was lodged with op no.1 for reimbursement of the bill amount but same was declined by op no.1 vide repudiation letter Ex.C2 on the ground that hospitalization primarily for investigation and evaluation and admission is not justified. The perusal of the discharge summary Ex.C7 clearly reveals that it finds mention that in view of un-proportionate pain in abdomen, CECT whole abdomen was done which showed hepatomegaly with mildly bulky Uterus and shows few iso to hypoechoic intramural lesions, suggestive of fibroids with a simple cyst in right ovary. So it appears from this discharge summary of op no.3 that the patient namely Priyanka had not gone to Fortis Hospital merely for some investigation and evaluation rather she had gone there with severe abdomen pain which was not controlled by local doctor and she got treatment there after diagnosis of the disease. Though, op no.1 has relied upon expert opinion of their Dr. Manish M. Shetty Ex.R21 while repudiating claim of complainant and though as per report of Dr. Manish M. Shetty there is no evidence of any attempt of treatment prior to hospitalization. Patient was investigated in detail and tests were normal, some irrational tests were also done e.g. chest x-ray and bone densitometry which were also normal and he gave opinion that no hospitalization was required for investigation and evaluation. The perusal of this report Ex.R21 reveals that doctor has not considered all the documents which have been placed on record by the complainant as well as op no.3 and has not given reference of the discharge summary issued by op no.3 while discharging the patient. So it appears from this report of Dr. Manish M. Shetty that he has not gone through all the relevant medical record of the patient and has given his opinion that no hospitalization was required. This opinion of the doctor does not appear to be reliable and trustworthy and same cannot be relied upon while repudiating the claim of complainant.
13. So from the evidence of the parties, it appears that wife of complainant namely Smt. Priyanka was suffering from severe abdomen pain and there was no option for her except to go to the higher institution for medical treatment which she got on payment of Rs.67,795/- and non payment of this amount by op no.1 and repudiating claim of complainant clearly amounts to deficiency in service on the part of op no.1. The judgments relied upon by learned counsel for op no.1 are not applicable to the facts and circumstances of the present case. Since op no.2 is only an agent who got the policy issued from op no.1, he was nothing to do with the policy thereafter and insurance contract was between op no.1 and complainant, so complaint does not appear to be maintainable against him. Similarly, op no.3 has been impleaded by complainant as complainant’s wife got treatment there but from the record it does not appear that there is any negligence or deficiency in service on the part of op no.3. So, complaint against ops no.2 and 3 stands dismissed.
14. In view of the above, we allow the present complaint qua opposite party no.1 and direct the op no.1 to pay the amount of Rs.67,795/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest on this amount at the rate of 6% per annum from the date of order till actual realization. We further direct op no.1 to pay a sum of Rs.3000/- as compensation and Rs.2000/- as litigation expenses to the complainant within above stipulated period. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:24.01.2019. Member District Consumer Disputes
Redressal Forum, Sirsa.
