Punjab

Ludhiana

CC/18/400

Sachin Goel - Complainant(s)

Versus

SBI General Insurance Co.Ltd - Opp.Party(s)

Ashwani Kumar adv

08 Sep 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:400 dated 20.06.2018.

                                                Date of decision: 08.09.2021. 

Sachin Goel S/o. Sh. Davinder  Goel, R/o. House No.25, Block-C, New Kitchlu Nagar, Hambran Road, Ludhiana.                                                                                                                                                        ..…Complainant

                                       Versus

1. SBI General Insurance Company Limited having one of its office at Ground Floor, Sahni Plaza, Near Dada Motors & Indian Oil Petrol Pump, G.T. Road, Dholewal Chowk, Ludhiana service through its Branch Manager/Authorized officer.

2. Paramount Health Services (TPA) Pvt. Ltd., having its office at Plot No.A-442, Road No.28, M.I.D.C., Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukhmani Mandir, Thane West, Pincode-400604.                                                                                                                               …..Opposite parties 

 

Complaint U/s. 11 & 12 of the Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Complainant Sh. Sachin Goel in person.

For OP1                         :         Sh. Vyom Bansal, Advocate.

For OP2                         :         Exparte.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                Shorn of the unnecessary details, the case of the complainant is that he obtained a mediclaim policy for himself and his family members on 08.05.2015 from OP1 which was valid from 22.04.2015 to 21.04.2016. It was further renewed on 22.04.2016 and was valid till 21.04.2017. The policy was further got renewed to 23.04.2018. In the month of July 2016 onwards, the complainant started suffering from the problem of sleeplessness which  kept aggravating. The complainant would remain awake for whole of the night and which resulted in severe headache for days together. The complainant consulted many doctors, who were of the opinion that the problem was related to the neuro and some neurologist should be consulted. Accordingly, the complainant contacted Dr. Jai Raj Pandian who is a Head of the  Department at CMC Hospital, Ludhiana. On 12.07.2017, the complainant visited the said doctor vide private OPD card bearing No.C-7754823. After the check up, Dr. Jai Raj Pandian admitted the complainant in the hospital. As a result, the complainant remained admitted in CMC Hospital from 17.07.2017 to19.07.2017. During the period of admission, various tests  were conducted on the complainant and after receiving the reports, the complainant was diagnosed and advised some medicines and a discharge summary  was prepared on 19.07.2017. At the time of discharge, the cashless treatment was denied to the complainant and the complainant was asked to make the payment of Rs.27,891/-.  On 05.08.2017, the complainant submitted documents in original with OP1 raising a claim of Rs.27,891/- in respect of his treatment. However, on 10.08.2017, the complainant received an email whereby he was asked to supply some documents which were required for processing the claim. On 21.08.2017, the complainant sent all the documents to the Mumbai office of OP2, but the claim was not disbursed. Eventually, on 01.11.2017, the complainant was informed that his claim had been repudiated. However, no reason was assigned. In the end, it has been requested that the OPs be directed to pay the claim of Rs.29,711/- along with interest @12% per annum and compensation of Rs.33,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, OP2 did not appear and was proceeded against exparte.

3.                The complaint has, however, been resisted by OP1. In the written statement filed by OP1, it has been pleaded that the complainant was insured under the Group  Health Insurance Policy vide insurance policy no.152527-0000-00 for the period from 22.04.2016 to 21.04.2017 for a maximum sum of Rs.1,00,000/-. The claim lodged by the complainant was duly registered and it was administered by Paramount Health Service TPA Pvt. Ltd. A pre authorization/cashless request on behalf of the complainant was received from CMC Hospital, Ludhiana, which was declined vide letter dated 19.07.2017 on the ground that as per submitted documents, the given line of treatment was possible on day care basis. Thereafter, the reimbursement of the claim was lodged by the complainant  and it was found that the treatment undergone by the patient was not covered under the policy and the same was rejected vide letter Annexure-R4. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C36 and closed the evidence.

5.                On the other hand, the OP1 submitted affidavit Ex. RA of Sh. Jitendra Dhabhai, Authorized Signatory of OP1 along with documents Ex. R1 to Ex. R3 and closed the evidence.

6.                We have heard the learned counsel for the parties and have also gone through records.

7.                During the course of arguments, the complainant has contended that he was remained admitted in CMC Hospital from 17.07.2017 to 19.07.2017 as he was suffering from sleeplessness and was admitted in the hospital for the aforesaid period, as per the advise of the doctor. The complainant has further referred to Ex. C30, which pertains to the treatment given by the complainant. In report Ex. C30, it is concluded that overnight PSG shows features of non-restorative sleep patterns and further that there are no features of obstructive sleep apnea. The complainant has further contended that the he was got admitted in the hospital on the advise of the doctor. The complainant has further referred to the certificate Ex. C23 wherein it has been clarified that the complainant was admitted with the complaints of chronic insomnia for 1 years duration and further that he was having bilateral lateral rectus palsy with proptosis with bilateral absent ankle jerks. It is further mentioned in the certificate Ex. C23 that in view of the raised ICP and peripheral neuropathy, the complainant had to be admitted to rule out conditions like IIH and Vasculitis, which if not treated urgently could potentially worsen.  MRI brain with optic cuts and overnight PSG was normal. The complainant was managed with B12 injections and wakefulness agents like Modafinil and, thereafter, discharge in stable condition. According to the complainant, it is evident from certificate C-23 that his hospitalization was a medical necessity and therefore, the repudiation of the claim on the part of the OPs cannot be justified.

8.                On the other hand, the counsel for OP1 has argued that the claim is not maintainable and the same has been rightly repudiated. He has further contended that since there is no merit in the complaint, the same deserves to be dismissed.

9.                Having heard the complainant and counsel for OP1 and after going through the record carefully, we are of the considered view that in the written statement filed by OP1, there is a reference to a letter Annexure-R4 vide which the claim is said to have been rejected on the ground that the treatment undergone by the patient was not covered under the policy. This letter has been referred in para No.3 of the factual submission of the written statement, but the date of the letter is not mentioned and the blank has been left. It is noteworthy that as Annexure-R4 has also not been found to be attached with the written statement. Again in para No.3 of the written statement, there is a reference to letter vide which the claim was rejected, but again the date of the letter is not mentioned. In the affidavit Ex. RA of Jitendra Dhabhai, Authorized Signatory of OP1, again there is a reference to rejection letter Ex. R4, but surprisingly enough, Ex. R4 has not been placed on record. OP1 has tendered document Ex. R1 to Ex. R3 only. Ex. R1 is the certificate of insurance, Ex. R2 is a request for cashless hospitalization and Ex. R3 is a letter to denial of cashless access. In the letter Ex. R3, it has been mentioned that since the treatment was possible on day care basis, the claim was being declined. However, the rejection letter Ex. R4 referred to in the written statement as well as affidavit, has not been placed on file for which an adverse inference has to be drawn against OP1. Moreover, in the certificate Ex. C23, the doctor concerned has given different opinion that the complainant had to be admitted in the hospital to rule out the condition IIH and Vasculitis which if not treated urgently could potentially worsen. The counsel for the OPs has further not been able to refer to any terms and conditions of the policy under which the claim made by the complainant in respect of his hospitalization is not payable. In these circumstances, in our considered view, it would be just and proper if the OPs are directed to disburse the claim lodged by the complainant in respect of his hospitalization from 17.07.2017 to 19.07.2017 from CMC Hospital, Ludhiana strictly in accordance with terms and conditions of the policy.

10.              As a result of above discussion, the complaint is allowed with an order that the OP1 shall disburse the claim lodged by the complainant in respect of his hospitalization with CMC Hospital, Ludhiana from 17.07.2017 to 19.07.2017 strictly in accordance with terms and conditions of the policy within 40 days from the date of receipt of copy of order. The OP1 is further held liable to pay a composite costs and compensation of Rs.5,500/- (Rupees Five Thousand Five Hundred only) to the complainant. Payment of compensation shall be made within a period of 30 days from the date of the receipt of the copy of this order. However, complaint against OP2 is dismissed as OP2 is only a third party administrator. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.         

11.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:08.09.2021.

Gobind Ram.