ORDER

18.10.2024

Sh. Sanjay Kumar, President

1. The factual matrix of the present case is that complainant received a telephone call from OP2 for family medical insurance policy and the complainant booked a Family insurance policy with OP2.
2. It is stated that after that one agent came at residence of complainant and received premium of Rs.14920.00 by cheque from his home i.e Tri Nagar, for a sum insured to the tune of Rs.10 lakhs on dated 09.03.2015 for a period of One year vide policy no.110101/11001/1000366418-2. It is further stated that at the time of the above  mentioned policy, complainant was assured by the agent of OP2 that the above mentioned policy is a very good policy and helpful to your medically expenses bill and its continues with previous policy, and your policy have all gains from previous policy as well as our new benefits also. It is stated that on the assurance given by the official of OP2 complainant bought the above mentioned medical policy.
3. It is stated that complainant assured by the OP, that complainant got “IS REGISTERED AND LICENSED AS A HOSPITAL OR NURSING HOME WITH THE APPROPRIATE LOCAL AUTHORITIES AND IS UNDER THE SUPERVISION OF A DOCTOR IN ATTENDANCE 24 HOURS A DAY AND IT NOT,”. It is further stated that after that assurance the complainant purchased such policy and the OP.
4. It is stated that the complainant’s daughter was hospitalized at Hospital of OP1 from 03.09.2015 to 06.09.2015 for four days, due to fever. It is further stated that due to such problem the doctor admitted in hospital and diagnosis and diagnosis i.e its High Grade Fever. It is further stated that complainant approached to OP2 telephonically for cashless mediclaim as it was assured that before discharge cashless medical claim would be passed. It is stated that complainant was shocked when officials of OP2 rejected the claim with remark “cashless facility cannot be granted as need of hospitalization is not established on the available documents. However insured can file the claim for reimbursement post completion of the treatment with all documents”.
5. It is stated that complainant paid Rs. 17,750/- to hospital and his daughter was discharged. It is stated that complainant sent all documents to OP within seven days from the discharge from hospital and lodged claim of Rs.25,330/- on 29.04.2016. It is stated that as demanded by OP some other papers were also submitted on 08.07.2016. It is further stated that complainant was shocked to receive a letter that his claim is repudiated under section VI-C-viii b of the terms and conditions of the policy.
6. It is stated that OP failed to provide services and duty bound to pay the claim of the hospitalization as policy. It is stated that the claim is legitimate. The complainant is seeking Rs.25,330/- with upto date interest and compensation for Rs.50,000/- on account of deficiency of service/unfair trade practice, physical pain, mental agony and harassment and also cost of litigation of Rs.5500/-.
7. OP1 filed WS. It is stated that the real dispute is between complainant and OP2 but OP1 has been unnecessarily impleaded as party. It is stated that on 03.09.2015 at about 2.15 pm one patient namely Ms. Tanvi Aggarwal (Female) aged about 18 years was admitted in OP1 hospital and referred to Dr. Pramod Yadav who was earlier treating the patient at his clinic, “Balaji Health Center”, Tri Nagar, Delhi, with symptom of severe pain. It is stated that at the time of admission in the hospital the clinical condition of the patient needed hospitalization, accordingly admitted under the supervision of treating doctor. It is stated that the patient was discharged on 06.09.2015. It is further stated that during treatment patient was allotted bed no.203 and as per advise of treating doctor certain tests were conducted and the details are mentioned in the medical history sheet. The OP1 filed on record medical history sheet.
8. It is stated that the father of the patient Sh. Vinayak Aggarwal signed all necessary documents/consent with the hospital authority on the admission form. It is stated that the father of the patient was apprised to the hospital administration authority that patient is covered with cashless medical policy, accordingly information and request were made to OP2 insurance policy vide letter dated 03.09.2015. It is stated that the relevant documents were provided to OP insurance company for process vide letter dated 04.09.2015 but the cashless facility was rejected. It is stated by OP insurance company that cashless facility cannot be granted as need of hospitalization is not established based on the available documents. However, insured can file the claim for reimbursement with all medical and financial record. The admissibility of the claim would be decided post review of the documents and policy conditions.
9. It is stated that OP1 hospital provided due services to the patient and after recovery discharge on 06.09.2015 and there was no negligence on the part of OP1 hospital. It is stated that present complaint is liable to be dismissed.
10. Complainant filed rejoinder to the WS of OP1 and admitted the facts with regard to admission and treatment at the hospital. The complainant also admitted the fact with regard to rejection of cashless medical claim by the OP insurance company.
11. OP insurance company initially was Apollo Munich Health Insurance Co. Ltd. but during the proceedings it has been taken over by HDFC Ergo General Insurance. Accordingly the OP2 substituted and impleaded.
12. OP2 filed detailed WS and taken preliminary objection that present complaint is pre mature, misconceived, misrepresented, devoid of merit, crafty, colored, uncalled for and unsustainable in terms of the insurance policy, therefore, liable to be dismissed. It is stated that the proposal form is the basis of insurance contract. It is stated that the decision of insurance company whether to grant insurance cover to the applicant/proposal solely depends upon the various facts, disclosure, information, statements and declaration made by the application/ proposal in the proposal form. It is further stated that the various terms of insurance contract/cover including the premium amount, maturity amount etc. depends solely upon the said facts, disclosure, information, statements and declaration in the proposal form. It is stated that insurance contract is based on the principal of utmost good faith “uberrima fides”.
13. It is stated that the policy kit contains all relevant documents which were duly sent and admittedly received by the complainant. It is stated that proposer never approached OP insurance company either seeking any clarification relating to the policy or raising objection to any of the terms and conditions of the policy implying thereby that the policy terms and conditions are acceptable to the complainant.
14. It is stated that the policy covered only in-patient treatment wherein hospitalization for period more than 24 hours and hospitalization for period less than 24 hours would be considered day care, however, in case of day care its only sum ailments and treatment which are categorically mentioned under the policy are covered. It is stated that OP insurance company is not deficient in providing services to the complainant. It is stated that on 03.09.2015 cashless was received from OP1 hospital for patient Tanvi Aggarwal, complainant’s daughter who got admitted with C/o High Grade Fever, Abdomen Pain and probable diagnosis of Pyrexia Unknown Origin, Thrombocytopenia, Dengue Fever and estimated duration of stay of three days and estimated cost of Rs.30,000/-.
15. It is stated that the post reviewing the documents it was noted the available documents are not sufficient to process the cashless, therefore, documents were required such as admission notes, treatment chart, vital chart and investigation reports in support of diagnosis. It is further stated that post reviewing the reply received was noted on the basis of IPD record that during the hospitalization, all parameters were within normal limits without any complication or adverse finding, therefore, cashless was rejected stating “cashless facility cannot be granted as need of hospitalization is not established on the available documents. However insured can file the claim for reimbursement post completion of the treatment with all documents”. The admissibility of the claim would be decided post review of the documents and policy conditions.
16. It is stated that on 30.04.2016 the claim was submitted with date of admission 03.09.2015 and date of discharge 06.09.2015 with final claim amount of Rs.25,330/-. It is stated that from the available documents it was noticed that patient was admitted for the management of Enteric Fever and underwent conservative management and later on patient discharge with advise. It is further stated that post scrutiny of documents its was noticed that (on the basis of IPD record) during the hospitalization all parameters were within normal limits without any complication or adverse finding. It is stated that the platelet count remain within the normal limit also the diagnosis kept as enteric fever but the report found to be normal and also the all other investigation report noted as normal, therefore, the claim was rejected. It is stated that complaint is liable to be dismissed.
17. The OP relied on judgments of Authority under Yeshashwini Wima Yojana Vs. Mumtaz Begum RP No.1173/2007 (NC), General Assurance Society Ltd. Vs. Chandumall Jain & Anr. (1966) 3 SCR 500, Oriental Insurance Co. Ltd. Vs. Sony Cheriyam AIR 1999 Supreme Court 3252 and United India Insurance Co. Ltd. Vs. Harchand Rai Chandanlal appeal no.6277/2004 decided on 24.09.2004 (SC).
18. On merit all the allegations are denied and contentions of preliminary objections are reiterated. It is stated that complainant is not entitled to any relief claimed in the complaint.
19. Complainant filed rejoinder to the WS of OP2 and denied all the allegations made therein and reiterated contents of the complaint. It is stated that the doctor checked the patient and admitted for further investigation as per clinical condition of the patient she was admitted in the hospital on  03.09.2015 and discharged on 06.09.2015. It is stated that complainant is entitled to all the reliefs claimed in the complaint.
20. Complainant filed evidence by way of his affidavit and reiterated contents of the complaint.
21. OP2 insurance company filed evidence by way of affidavit of Deepti Rustogi Vice President Legal. In the affidavit contents of WS reiterated. OP insurance company relied on copy of power of attorney Ex.OP-1, copy of policy terms and conditions Ex.OP-2, copy of authorization form Ex.OP-3, copy of additional information request dated 03.02.2015 Ex.OP-4, copy of cashless denial letter dated 04.09.2015 Ex.OP-5 and copy of claim form, medical reports and claim repudiation letter Ex.OP-6 (colly).
22. Written arguments filed by OP insurance company. As per record OP1 neither filed evidence nor written arguments. Complainant also not filed written arguments.
23. We have heard complainant in person and Sh. Raghav Gupta proxy for Sh. R.K Gupta counsel for OP insurance company. None appeared on behalf of OP1 hospital.  
24. It is admitted case of the parties that complainant got health insurance “Easy Health Individual Standard” covering himself his wife, son and daughter from OP Insurance Co. HDFC Ergo General Insurance Co. (previously Apollo Munich Health Insurance Co. Ltd.). It is admitted that the daughter of complainant Tanvi Aggarwal admitted at OP1 hospital from 03.09.2015 to 06.09.2015 for four days as suffering from High Grade Fever. It is admitted that OP2 insurance company denied the cashless facility thereafter complainant lodged the claim alongwith all medical documents.
25. OP Insurance Co. alleged that as per section VI C viii b of the policy kit the OP Insurance Co. would not pay for any claim if the conditions for which treatment would have been done on an OPD basis without any hospitalization. The claim was rejected fundamentally by invoking the abovesaid clause that need for hospitalization not established. We have gone through the entire original medical record filed by OP1 hospital which establish that patient Tanvi Aggarwal admitted with history of High Grade Fever and remained admitted for three days i.e. more than 24 hours. The treating doctor Sh. Parmod Yadav given a specific certificate on 05.09.2015 and also answer the referred query by the OP Insurance Co. The treating doctors specifically mentioned that  the patient could not be managed without hospitalization and admission was mandatory. The OP Insurance Co. has not taken any medical opinion to contradict the observations and conclusion of treating doctor who specifically mentioned that hospitalization was mandatory. In these circumstances the OP Insurance Co. illegally, unfairly and unjustifiably invoked section VI C viii b. The rejection of claim is unfair, unjustified and illegal.
26. On the basis of above observation and discussion complainant established deficiency of service on the part of OP2 Insurance Co., therefore, we direct OP2:-

1. To pay Rs.25,330/- alongwith 6% interest per annum from the date of filing of present complaint till realization.
2. To pay compensation of Rs.8000/-.

27.  The OP2 is directed to pay the above entire amount within 30 days from the date of receipt of this order. In case of default directed to pay interest @ 9% per annum till realization. File be consigned to record room.
28. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  18.10.2024.

      SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER