Before the District Consumer Disputes Redressal Commission, Rohtak.

Consumer Complaint No. 4

Instituted on:  01.01.2024

Decided on:  28.11.2024

Rajat Goyal age 29 years s/o Sh. Hari Om Goyal R/o H.No 435/15, Ram Gali, Gohana, Sonipat-131301.

                                                                                      ….Complainant

Vs

1. Star Health and Allied Insurance Company Ltd. registered &Corporate office 1 New Tank Street, Valluvar, Kottam, High Court, NugamBakkam, Chennai – 600034 through its Managing Director.
2. Star Health and Allied Insurance Company Ltd. having its one of the office situated at 2^nd floor, AshokaPlaza, Delhi Road, Rohtak through its Manager.

……Opposite Parties

COMPLAINT UNDER CONSUMER PROTECTION ACT.

BEFORE: SH. NAGENDER SINGH KADIAN, PRESIDENT.

                   DR. TRIPTI PANNU, MEMBER.

                   DR. VIJDENER SINGH, MEMBER.

Present:       Sh. Rajesh Sharma, Advocate for the complainant.

                   Sh. Gulshan Chawla, Advocate for opposite parties.

                                      ORDER

SH. NAGENDER SINGH KADIAN, PRESIDENT:

1.           Brief facts of the present compliant, as per complainant, are that he had obtained a health insurance policy bearing No. P/211124/01/2024/002754 from the opposite parties, covering himself and his wife Mahima. On 30.10.2023, the wife of complainant was suffering from mild fever and stomach pain. Despite routine investigations which showed normal results, her condition worsened with the fever rising to 102°C by 03.11.2023. She was initially treated at Holy Heart Super Specialty & Trauma Centre, Rohtak from 03.11.2023 to 09.11.2023. However, due to high-grade fever, she was hospitalized from 10.11.2023 to 12.11.2023. Various tests were conducted during the period and the hospital charged an amount of Rs.60830.20 from the complainant. Despite the treatment, her condition required further evaluation. As per the discharge summary of Holy Heart Super Specialty & Trauma Centre, the wife of  complainant was diagnosed for "Pyrexia of Unknown Origin (PUO) with ?Lymphoma ?T.B." As the condition of wife of complainant was not improving and hence, as per advice of the treating doctor, the wife of complainant was got admitted to BLK MAX Super Specialty Hospital, Delhi, from 14.11.2023 to 18.11.2023. The whole body tests of wife of complainant were conducted there. The complainant sought cashless treatment under the insurance policy but he was denied approval by the opposite parties. The claim submitted for reimbursement of hospitalization expenses at both hospitals, were also repudiated by the opposite parties. The claim for Holy Heart Super Specialty was rejected on 20.12.2023 on the ground that the hospitalization was not "medically necessary/does not warrant hospitalisation" and the claim for BLK MAX Hospital was repudiated on 15.12.2023 on the ground that the admission was "primarily for diagnostics and evaluation purposes”. The complainant had incurred Rs. 60,830/- at Holy Heart Super Specialty & Trauma Centre and Rs. 1,90,020/- at BLK MAX Super Specialty Hospital, totalling to Rs.2,50,850/- on the treatment of  his wife. The repudiation of genuine claims on the part of opposite party, amounts to deficiency in service and breach of contractual obligations by the opposite parties. Hence this complaint and it has been prayed that the opposite parties may kindly be directed to pay the amount of hospitalization charges incurred by him i.e. total amount of Rs.2,50,850/- on the treatment of wife of the complainant Mahima along with interest, compensation and litigation charges as mentioned in prayer clause besides any other relief, which this Commission found deem fit and proper, to the complainant.

2.                Notice of the present complaint was issued to the opposite parties. Opposite parties appeared and filed their written statement by taking some preliminary objections and denied each and every statement, allegations or contentions made by the complainant, unless admitted. It is submitted that the complaint of the complainant is not maintainable as the complainant has concealed the material facts and tried to mislead this Commission. The complainant had obtained star health insurance policy on 25.09.2020, which was renewed upto 24.09.2024. The policy in question (Policy no. P/211124/01/2024/002754) for the period 25.09.2023 to 24.09.2024 was issued on the basis of declaration made by the complainant in the proposal form, subject to the policy terms and conditions and the complainant was duly informed of the terms and conditions which were provided alongwith the policy schedule.  For First claim (Holy Heart Hospital), it is contended that the insured Mahima was hospitalized from 10.11.2023 to 12.11.2023 for "Pyrexia of Unknown Origin (PUO) with ?Lymphoma ?T.B." The request for Cashless treatment was denied and the reimbursement claim (Claim no. CIR/2024/211124/1140934) was rejected on the grounds that the company is not liable to make any payment under the policy in respect of any hospitalization which are not medically unnecessary/does not warrant hospitalization. The claim was repudiated under Exclusion code Excl. 36, which excludes hospitalization “not medically unnecessary”. For Second claim (BLK MAX Hospital),  it is contended that the insured was hospitalized from 14.11.2023 to 18.11.2023 for suspected case of T.B. The request for cashless treatment was again denied and the reimbursement claim (Claim no. CIR/2024/211124/1150630) was rejected on the grounds the company is not liable to make any payment for expenses related to any admission primarily for diagnostics and evaluation purposes. The said claim was repudiated under exclusion code Excl. 04(A) whereby the company was not liable to make any payment for expenses related to any admission primarily for diagnostics and evaluation purposes. It is clear from the medical record that the insured was symptomatic since 29.10.2023 prior to the inception on the policy period 25.09.2023. As per CT (Thorax and Abdomen) and PET CT reports, there were extensive lesions in the abdomen, which cannot happen in a few days. The complainant failed to disclose these facts, thereby misrepresented the facts. The complainant has filed this complaint with ulterior motives to harass the opposite party and extract money without any valid ground. The opposite party is a company of high repute and has acted in good faith and rejected the claims as per the terms and condition of the policy. As such, there is no deficiency in service on the part of the answering opposite parties and accordingly, dismissal of the complainant sought by the opposite parties.

3.                Learned counsel for the complainant in his evidence tendered affidavit Ex. CW1/A and documents Ex. C-1 to Ex. C-36 and closed the same on 24.04.2024. On the other hand, learned counsel for the opposite parties in his evidence tendered affidavit Ex. RW1/A  and documents Ex. R-1 to Ex. R-20 and closed the same on 16.10.2024.

4.                We have heard the arguments of learned counsel for the parties, perused the documents placed on record and have gone through material aspects of the case very carefully.

5.                In the present case, the respondent insurance companyhas  rejected the claim of the complainant for the period 11-12/11/2023 of Holy Heart Super Speciality  Trauma Centre Rohtak vide letter dated 20.12.2023 placed on record as Ex.R11 on the ground that : “On a perusal of submitted record, our medical team is of the opinion that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted.  As per Exclusion-code Excl 36 of above policy, the company is not liable to make any payment under this policy in respect of any hospitalization which are not medically necessary/does not warrant hospitalization”.   The second claim of the complainant for the period 14.11.2023 to 18.11.2023 of BLK  Max Super Speciality Hospital has been rejected vide letter dated 15.11.2023   placed on record as Ex.R18 on the ground that: “It is observed from the submitted records that the admission of the insured-person is primarily for investigation and evaluation purpose. As per Exclusion-Investigation and Evaluation-Code ExclNo.04(A) of the above policy, the Company is not liable to make any payment for expenses related to any admission primarily for diagnostics and  evaluation purposes”.      

6.                We have minutely  perused the discharge summary of the patient Mahima Yadav, which is placed on record as Ex.C4 and Ex.C10. As per Ex.C10 the patient was admitted in the Holy Heart Super Speciality hospital on 11.10.2023 with the complaint that “High grade fever with chills, Recurrent Vomiting, Decreased Oral intake, Vertigo” and in the column of Past History it has been mentioned as NAD(No Acute distress). As per  discharge summary Ex.C4 of BKL Max Super Specialty Hospital, the date of admission of patient Mahima is 14.11.2023 and date of discharge is  18.11.2013. The history of present illness is as under: “Patient Mrs. Mahima Yadav  25 years female, was apparently normal 13 days back, then presented with fever and cough since 13 days  and intermittent abdominal pain, no H/O loss of weight, h/o loss of appetite since 1 week. No h/o bowel/bladder disturbances. Now patient is being admitted for further evaluation and management” and present complaint mentioned in this document is “c/o fever and cough since 13 days abdominal pain-on and off-since 10 days”. We have also perused the reconsider case claim request on behalf of Holy Heart Super Speciality Hospital Rohtak to the respondent officials vide letter dated 11.11.2023 which is placed on record as Ex.C26. As per this letter the doctor has described that the patient was suffering from high grade fever from 30.10.2023 and she undergone initial evaluation in Gohana, from which her reports were received. But she did not responded to her treatment. Therefore she visited in Holy Heart Hospital on 03.11.202 after initial treatment, patient advised I/V antibiotics which she received in nearby hospital for one week, to which she has failed to respond. As per this letter, the fever of complainant increased and condition worsened. She was alreadysuffering from disease for last 12 days and not  responded to first time I/V antibiotics. Meaning thereby,  there was no          pre-existing disease to the complainant prior to the present ailment and she was not suffering from any chronic disease and she was admitted by the Holy Heart Super Speciality Hospital  as well as by BLK Max Super Speciality Hospital  for further treatment. In fact, the temperature was not controlled for last 12 days, then she took treatment from Holy Heart Hospital. As per discharge summary Ex.C10, during the course of treatment, it has been mentioned under the headingfinal diagnosis:“PUO(Pyrexia of Unknown Origin-under evaluation) with ? lymphoma ? TB. Urine R/M patient was managed with IV Fluids , IV Antibiotics and other supportive treatment. Now patient is being discharged in stable condition and referred to higher centre for further evaluation”.   Meaning thereby the proper conclusion was not came out in Holy Heart Hospital, then she was referred to higher hospital  BLK Max Super Speciality Hospital. We have minutely perused the repudiation letter placed on record asEx.C27 and Ex.C28. Both the rejection grounds are not proved.The admission was necessary for proper evaluation and diagnosis. Hence the complainant is entitled for the claim amount as assessed by the opposite party through bill assessment sheet Ex.R19 and ExR20. As per Ex.R19, the amount of Rs.172153/- has been assessed against the bill of Rs.190020/- and as per Ex.R20 the amount of Rs.57230/- has been assessed against the bill of Rs.60820/-. Hence the complainant is entitled for the amount of Rs.229383/-(Rs.172153/- + 57230/-).

7.                In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.229383/-(Rupees two lac twenty nine thousand three hundred and eighty three only) alognwith interest @ 9% p.a. from the date of filing the present complaint i.e. 01.01.2024 till its realization to the complainant. Opposite party is further directed to pay Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant. Order shall be complied within one month from the date of decision.

8.                Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.

9.                Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.

Announced in open court:

28.11.2024.

                                                          ........................................................

                                                          Nagender Singh Kadian, President

                                                          ……………………………….

                                                          TriptiPannu, Member

                                                          ……………………………….

                                                          Vijender Singh, Member