District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.67/2021.
Date of Institution: 04.02.2021.
Date of Order: 02.09.2022.
Lekhraj, age: 35 Years, S/o Shri Milap Chand R/o House NO. 1325, New Janta Colony, Faridabad, Haryana – 121001 mobile No. 8447773362. …….Complainant……..
Versus
Royal Sundaram General Insurance Co. Ltd., Vishranthi Melaram Towers, No.2/319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai – 600 097.
Branch offi: Unit No. 801A, 8th floor, Devika Tower, Nehru Place, New Delhi.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. Sandeep Yadav, counsel for the complainant.
Sh. Sachinder Bhatia, counsel for opposite party
ORDER:
The facts in brief of the complaint are that on 18.9.2019, the complainant had availed the Smart Cash Plan vide policy No.COA0002569000101 for a period of 18.09.2019 to 17.09.2020 from the opposite party. According to the “Smart Cash Plan”, this plan was a product providing daily cash benefit for each completed and consecutive period of 24 hours stay in the hospital, due to sickness or accident. This plan was a supplement to health insurance covering out of pocket expenses associated with sickness/accident hospitalization like special diet, conveyance expenses to the hospital and back expenses incurred by a family member staying with the patient, and so on. As per the terms and norms of the above mentioned Smart Cash Plan Policy, it was agreed between the complainant and opposite party that the captioned Smart Cash Plan should provide a cushion against the financial burden arisen due to the hospitalization for complainant and at the time of availed the said Smart Cash Plan, opposite party also assured to the complainant and opposite party would provide the daily benefit of Rs.10,000/- per day from the date of hospitalization till his discharge to the complainant. On 25.12.2019 the complainant was admitted to the hospital namely Life Hospital ( A Unit of Tanishka Life Hospital), N.H. Site No.1, Sector-8, Faridabad, Haryana, suffering from fever with cough & cold with Nose Block, Headache & Bodyache and remained there upto 29.12.2019, after discharge from the hospital, complainant had completed all the formalities by sending the bills and all other related documents to the opposite party and opposite party registered the claim of the complainant under claim No. IHI9016250HOC00. The complainant had sent a various email to opposite party regarding consider the claim of the complainant but the opposite party did not consider the claim of the complainant. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay a sum of Rs.30,000/- to the complainant towards the aforementioned liability alongwith interest @ 18% p.a..
b) pay Rs. 20,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 5500 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that a Smart Cash Plan vide policy No. COA0002569000101. It was submitted that a smart cash plan policy issued to the complainant and there was privity of contract between the complainant and the opposite party and both the parties bound with the terms and conditions of the policy and the opposite party being the public concern settled the claim as per the terms and conditions of the insurance policy issued to the complainant. The claim of the complainant had been decided as per the investigation report submitted by the investigator appointed by the opposite party and in this regard the investigator clearly mentioned that there were various discrepancies in the medical record of the complainant wherein he admitted in the lifeline hospital, Faridabad form 25.12.2019 to 29.12.2019 with a complaint of fever, cough and cold, nasal block, headache, body ache from the last three-four days. After going through the complete medical history of the complaint, it came to k now that there were various discrepancies on the medical treatment and found that:-
a) As per vital chart term was normal form 26.12.2019 4 pm. To 29.12.2019 but as per medication chart PCM was given till 29.12.2019.
As per medical record it was clearly mentioned at vital chart/progress note , no medicine of PCM given to the complainant but at the same time of medication chart PCM given on TDS to the patient form 25.12.2019 to 29.12.2019 but at the same time as per his vitals were stable with no spike of fever as per internal record/intake/output chart the patient was having normal temperature from 98 to 101 degree and having SPO2 was 96% to 99% which clearly shows that the patient was stable and having normal fever but it mentioned in the medication order and drug chart.
b) insured mentioned Nebolization was done 2-3 times only but as per medication chart it was done till 29.12.2019 and total 9 times were it one.
c) Editing of date was seen on progress note as per which DOA was 26.12.2019 as shown of the medical record.
d) Editing of time was seen on medication chart of dated 29.12.2019 of the medical record.
e) Medicine bill not available.
f) Reports not available and treating doctor not available at the time of investigation.
g) Insured mentioned Dr. Honey also visited him during hospitalization but as per ICP not a single visit was seen.
Hence, in view of the above discrepancies found at the time of investigation it clearly proves that there were discrepancies in the medical record and intentionally manipulated to get benefits for the medical compensation to the complainant under the present policy in the collusion with the hospital. It was further submitted tha tin view of the above facts and circumstances, it was clearly proves that the insued was the repeat complaint for trivial infection and unduly prolonged hospitalization and only a case of week positive of typhoid and it did not require in patient hospitalization but inspite of this the hospital admitted in the hospital for 5 days within intention for getting the claim of Rs.10,00/- per day daily benefit as per the provision of the present policy and alongwith this patient/complainant had his previous claim for similarly or rather same kind of condition paid to the complainant prior to the present complaint, therefore the opposite party issued the repudiation letter dated 30.03.2020 stated the claim as no claim and observe that documents submitted did not the revel a condition writing hospitalization, further gross discrepancies were noted. It was further stated that the complainant filed the present complaint for claiming the amount of Rs.30,000/- but failed to clarify the detail of claimed amount demanded in the present complaint as he availed the reimbursement of the medical bills from his mediclaim i.e HDFC Ergo. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Royal Sundaram General Insurance Company Ltd. with the prayer to: a) pay a sum of Rs.30,000/- to the complainant towards the aforementioned liability alongwith interest @ 18% p.a.. b) pay Rs. 20,000/- as compensation for causing mental agony and harassment. c) pay Rs. 5500 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Lekhraj,, Ex.C1 – Smart Cash Plan, Ex.C-2 – email dated 28.09.2020, Ex.C-3 – Repudiation letter dated 30.03.2020, Ex.C-4 – Discharge summary,, Ex.C-5 – letter dated 29.9.2020 regarding demand of Rs.30,000/- alongwith interest @ 18% p.a., Ex.C-6 & 7 – postal receipts, Ex.C-8 – Adhaar card.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.R/A – affidavit of Shri Kathiravan, Sp. Narayanassamy, working as Senior Legal Executive, M/s. Royal Sundaram General Insurance Co. Ltd., Office at No.1, 2nd floor, Subramaniam Building, Club House road, Chennai
– 600 011, Annx.A – Smart Cash Plan, Annx. B – Discharge summary, Annx.C – Admission Form, Annx.D – General Consent Form, Annx.E – True Value Investigation Services,, Annx.F – Progress Notes, Annx.-G – Medication order and drug administration chart,, Annx.H – Intake/output chart, Annx.I – Repudiation letter, Annx. J – Prescription of Dr. Rajeev Gupta, Annx. K – Nurses Notes, Annx.L – Initial Assessment (Indoor patient).
6. The complainant filed a complaint with the prayer of Rs.30,000/- which was spent by the complainant for his admission. Opposite party has repudiated the claim of the complainant vide repudiation letter dated 30.03.2020 on the ground that “The documents submitted does not reveal a condition warranting hospitalization. Further, gross discrepancies were noted. Hence we regret our inability to consider your claim on the above grounds. As per Discharge summary vide Ex.C4 that the complainant was admitted in the hospital namely Life Hospital suffering from fever with cough & cold with Nose Block, Headache & Bodyache and remained there upto 29.12.2019. The counsel for the complainant agitated on the ground that they have spent more than Rs.30,000/- for his treatment.
7. It is evident from Admission Form vide Annexure C, the patient was admitted in Life Hospital on 25.12.2019. As per inpatient bill dated 29.12.2019 the patient was admitted in the hospital from 25.12.2019 to 29.12.2019 in which the room charges were charged by the opposite party from the complainant Rs 2500/- x 4 days = 10,000/-. The patient cannot suggest to the doctor for the admission of the patient.
8. After going through the evidence led by the parties, the Commission is of the opinion that opposite party has repudiated the claim of the complainant on the ground that there is no sufficient evidence. Only to say that there is no need for hospitalization is sufficient. Hence, repudiation is not justified. Resultantly, the complaint is allowed.
9. Opposite party is directed to:
a) pay Rs.23,250/- which was spent by the complainant vide Annx. C in page 8 alongwith interest @ 6% p.a. from the date of filing of complaint till its realization.
b) pay Rs.1100/- as compensation on account of mental tension, agony and harassment.
c) pay Rs.1100/- as litigation expenses to the complainant.
Compliance of this order be made within 30 days from the date of receipt of copy of order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 02.09.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
