Punjab

Ludhiana

CC/21/503

Dinesh Bansal - Complainant(s)

Versus

Star Health and Allied Ins.Co.Ltd. - Opp.Party(s)

A.B.Sharma Adv.

05 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No: 503 dated 29.10.2021.                              Date of decision: 05.08.2024.

 

Dinesh Bansal aged about 55 years son of Sh. S.L. Bansal, Resident of 62-C, BRS Nagar, Near DAV School, Gate No.2, Ludhiana.                                                                                                                      ..…Complainant

                                                Versus

Star Health & Allied Insurance Co. Ltd., Branch Office No.3369, 4^th Floor, Sandhu Tower-II, Ferozepur Road, Ludhiana, through its Branch Manager.                                                                                               …..Opposite party 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Harpreet Singh, Advocate.

For OP                           :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Tersely put, the case of the complainant is that he obtained one health insurance policy bearing No.P/211200/01/2019/007857 from the OP having validity from 31.03.2019 to 30.03.2020 covering his entire family. The complainant regularly paid the premium of the policy. The complainant stated that on 31.10.2019, his daughter namely Kavya Bansal was admitted in Deepak Hospital, Ludhiana due to high grade fever for about 3 days and she was diagnosed for Dengue Fever. She remained admitted in the hospital from 31.10.2019 to 04.11.2019 and the complainant spent Rs.20,132/- towards hospital bill and medicines. The complainant lodged the claim with the OP which was declined vide letter dated 13.12.2019 on the ground that admission was not required for the patient. The complainant further stated that his daughter was admitted in hospital due to his deteriorating condition by the doctors and not as per wishes of the patient. Even the tempering in BP and temperature record has no concern with the patient as the same is maintained by the hospital. Due to denial of his claim, the complainant has suffered mental pain and harassment which amounts to deficiency in service on the part of the OP for which the complainant is entitled for compensation of Rs.50,000/-. In the end, the complainant has prayed for issuing direction to the OP to pay the expenses of Rs.20,132/- along with compensation of Rs.50,000/- and litigation expenses of Rs.25,000/-.

2.                Upon notice, the OP appeared and filed written statement by taking preliminary objections that the complaint is not maintainable; the complainant estopped by his act and conduct and concealment of material facts; lack of jurisdiction etc. The OP alleged that on receipt of the claim, it was duly registered, entertained and processed. The OP further alleged that the complainant had obtained Family Health Optima Insurance policy No.P/211200/01/2019/007857 valid from 31.03.2019 to 30.03.2020 covering the complainant himself, Mrs. Rashmi spouse, Rishab Bansal and Kavya Bansal children for a sum insured of Rs.5,00,000/-. The insurance policy is issued on the principles uberrimae fides. Utmost good faith is a cardinal principle of insurance which means that all the parties to an insurance contract must deal in good faith, making a full declaration of all material facts in the insurance proposal. Material facts are those that would influence underwriters as to whether he should or should not accept the risk. If a party fails to adhere to the principles of utmost good faith, the outcome of the claim may be affected. The insurance policy is issued on the basis of the proposal form. The insurance policy is a contractual in nature and the parties are bound by the terms and conditions of the policy. The claims arising therein are subject to terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The terms and conditions of the policy were explained to the complainants at the time of proposing policy and the same was served to the complainant along with the policy schedule. Moreover, it is clearly stated in the policy schedule “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached.”  The OP further stated that it one of the conditions No.6 in the policy that “The company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or devices, mis-representation by the insured person or by any other person acting on his behalf.”

                   The OP further stated that a claim was preferred in the 7th month of the policy with it in respect to the medical management of Ms. Kavya Bansal with final diagnosis AFI with NSIAg +ve with enteritis with recurrent vomiting with Deepak Hospital, Ludhiana with date of admission as 31.10.2019 with date of discharge as 04.11.2019. The insured requested a cashless of the medical expenses towards the treatment of AFI with NSIAg +ve with enteritis with recurrent vomiting with Deepak Hospital, Ludhiana on 31.10.2019. The OP approved an amount of Rs.6,000/- based on pre-authorization request and other documents submitted vide cashless authorization letter dated 31.10.2019 clearly stating that this is only the provisional amount, final amount will be worked out once the hospital submits the final bill with discharge summary and other related documents by clearly stating the terms and conditions of authorization in the said letter dated 31.10.2019. Further it is one of the terms and conditions of the authorization that "cashless authorization letter issued on the basis of information provided in pre-authorization form in case mis-representation / concealment of facts any material difference / deviation / discrepancies in information is observed in the discharge summary / IPD records, then cashless authorization shall stand null and void. At any point of time claim processing insurers reserve right to raise queries for any other documents to ascertain the admissibility of the claim.”

                   Immediately on the receipt of request for cashless authorization for health insurance the hospital and the complainant was called upon vide query on authorization of cashless treatment letter was sent whereby the hospital was called upon to supply the following documents:-

• Complete date wise ICP, progress notes, positive investigation reports.

On scrutiny of the cashless document, it was noted that the condition of the patient Ms.Kavya Bansal does not require hospitalization as she could have been treated as an out-patient. Hence, the hospital as well as complainant was intimated vide letter dated 04.11.2019 that the OP is unable to approve the claim and the authorization already given for cashless treatment of the above diagnosed disease stands withdrawn. The said letter dated 04.11.2019 was communicated to the treating hospital as well as to the complainant. Subsequently, the complainant/insured submitted the claim documents for reimbursement for treatment of AFI with NS 1 Ag +ve with enteritis with recurrent vomiting for Rs.20,132/-. The OP further stated that on scrutiny of the claim documents, it is observed that:

• All investigation reports are within normal limits.
• As per the Indoor case records tampering are noted in the BP recordings and temperature chart.

The medical team of the OP after scrutinizing all the medical records including the investigation reports is of the opinion that the hospitalization of the insured patient is not warranted for the above diagnosis. Further, in the indoor case record tempering is noted in the BP recording and temperature chart and as such, there is a discrepancy in the material facts in the medical records which amounts to misrepresentation. The OP further stated that as per condition No.6 of the policy obtained by the complainants it is clearly stated that if there is any misrepresentation of material facts whether by the insured person or any other person acting on his behalf the OP is not liable to make any payment in respect of any claim. Hence, after scrutinizing the documents placed in the claim file and after due application of the mind by the officials/doctors of the respondents, the claim of the complainant in respect to the treatment of Ms Kavya Bansal was repudiated as no claim vide letter dated 13.12.2019 on legal, valid, enforceable grounds.

                   On merits, the OP reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of repudiation letter dated 13.12.2019, Ex. C2 is the copy of discharge summary of Deepak Hospital, Ex. C3 is the copy of retail invoice dated 04.11.2019 and closed the evidence.

4.                On the other hand, counsel for the OP tendered affidavit Ex. RA of Sh. Sumit Kumar Sharma, Senior Manager of the OP along with documents Ex. R1 is the copy of policy terms and conditions, Ex. R2 is the copy of policy schedule, Ex. R3 is the copy of proposal form, Ex. R4 is the copy of pre-authorization request, Ex. R5 is the copy of Field Visit Report, Ex. R6 is the copy of cashless authorization letter dated 31.10.2019, Ex. R7 is the copy of rejection and withdrawal letters dated 04.11.2019, Ex. R8 is the copy of query on enhancement of amount letter dated 05.11.2019, Ex. R9 is the copy of rejection and withdrawal letters dated 05.11.2019, Ex. R10 is the copy of vital chart, Ex. R11 is the copy of Indoor Case Papers, Ex. R12 is the copy of Claim Form, Ex. R13 is the copy of discharge summary, Ex. R14 is the copy of final bill, Ex. R15 is the copy of medical test reports, Ex. R16 is the copy of repudiation letter dated 13.12.2019, Ex. R17 is the copy of billing assessment sheet and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Admittedly, the complainant purchased a Family Health Optima Insurance Plan Ex. C1 from the OP for himself, his wife Smt. Rashmi, son Rishabh Bansal and daughter Kavya Bansal. Daughter of the complainant Kavya Bansal was admitted at Deepak Hospital, Ludhiana 31.10.2019 and the complainant submitted request for cashless hospitalization for medical insurance policy Ex. R4 and the OP vide Cashless Authorization Letter dated 31.10.2019 Ex. R6 approved an initial amount of Rs.6000/- and the final amount was to be worked out on submission of final bills with discharge summary and other related documents. However, later on the said approval was rejected and withdrawn vide letter dated 04.11.2019 Ex. R7, dated 05.11.2019 Ex. R9  on the ground that the insured patient does not require hospitalization and he/she could have been treated as an outpatient. Daughter of the complainant Kavya Bansal was discharged from the hospital on 04.11.2019 vide discharge summary Ex. C2 = Ex. R13 and the complainant incurred an expenses of Rs.20,132/- vide final bill Ex. C3 = Ex. R14. The complainant submitted a claim of Rs.20,132/- vide claim form Ex. R12 but the same was repudiated by the OP vide repudiation letter dated 13.12.2019 Ex. C1 = Ex. R16. The operative part of Ex. C1 = Ex. R16 is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of dengue fever.

It is observed from the submitted medical records that all investigation reports are within normal limits. Our medical team is of the opinion that the hospitalization of the insured patient is not warranted for the above diagnosis.  

Further, in the indoor case records tampering is noted in the BP recordings and temperature chart. Thus, there is discrepancy in material facts in the medical records which amount to misrepresentation.

As per Condition No.6 of the policy issued to you, if there is any misrepresentation of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

7.                Now the point for consideration arises whether the OP is justified in repudiating the claim of the complainant on the ground of the insured patient being unwarranted for hospitalization for the diagnosis?

8.                The counsel for the complainant has referred to the extract of the discharge summary Ex. C2 = Ex. R13 the insured Kavya Bansal was admitted in Deepak Hospital, Ludhiana on 31.10.2019  with complaints of high grade fever on & off for 3 days, nausea, body ache, vertigo-since morning. She was diagnosed to be AFI with NSIAg +ve with enteritis with recurrent vomiting. The column ‘Course in Hospital’ is reproduced as under:-

“Patient presented with complaint of high fever on & off, nausea, body ache, vertigo. Patient was thoroughly examined & investigated. Pt. was managed with antibiotics, analgesics, PPI’s IV fluids & other supportive m3asure. Pt’s symptoms improved & is being discharged in satisfactory condition.”

The patient was advised to follow up after five days with five days rest. Further as per medical tests reports Ex. R15 in the Hematology test the value of Platelet Counts of the patient was found to be 165.00, 185.00, 163.00, 170.20, 158.80, 155.00 which is much below in the referral range of 150.00 to 450.00. Further the as per discharge summary, the patient was administered with antibiotics, IV fluids and other supportive measures which is not possible without her indoor admission in the hospital. The discharge summary Ex. C2 = Ex. R13, when read as a whole clearly spells out that necessity arose for her admission in the hospital due to above said reason.  Cumulatively, it appears that prima facie there was a strong case for the admission of the complainant in the hospital. On the other hand, the OP has not produced any opinion of medical expert whereby it was opined that the admission of the insured patient in the hospital was not desirable. Even otherwise, no prudent person would expose himself/herself in such an environment of the hospital which is prone to severe infection. Further noticing of tempering the BP recordings and temperature of the OP defies logic and lacks credible evidence. The in-patient record is regularly maintained by nurses/paramedical staff on duty and neither the patient nor his/her attendant had any say in recording the temperature and BP entries. Any inadvertent overwriting by the author of the entry cannot be construed as tempering. So it cannot be concluded that there was any misrepresentation of material facts on the part of the complainant. Therefore, the repudiation of claim on the premise that the admission was not necessary, is wholly unjustified. In the given facts and circumstances of the case, if the OP is directed to settle the amount and reimburse the same with respect to hospitalization of the insured Kavya Bansal at Deepak Hospital, Ludhiana from 31.10.2019 to 04.11.2019  in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment. The opposite parties are also burdened with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is partly allowed with direction to the OP to settle the amount and reimburse the same with respect to hospitalization of the insured Kavya Bansal at Deepak Hospital, Ludhiana from 31.10.2019 to 04.11.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The OP shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                (Sanjeev Batra) 

Member                                             President  

 

Announced in Open Commission.

Dated:05.08.2024.

Gobind Ram.