Chandigarh

DF-I

CC/928/2022

PARMINDER SINGH - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE CO. LTD - Opp.Party(s)

DEVINDER KUMAR

01 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/928/2022
Date of Institution	:	16/11/2022
Date of Decision	:	01/01/2024

 

Parminder Singh s/o Sh. Balwant Singh, Jandhi Kathgarh, Nawanshahr, Punjab 144522.

… Complainant

V E R S U S

Star Health and Allied Insurance Co. Ltd., SCO No.5-A, Second Floor, Madhya Marg, Chandigarh 160008.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Sh. Inderjit Singh, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Parminder Singh, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on 8.6.2022, complainant took a mediclaim policy namely “Family Health Optima Insurance Plan” (hereinafter referred to as “subject policy”) for himself and his wife, Smt.Baljit Kaur valid w.e.f. 9.6.2022 to 8.6.2023 (Annexure C-1) on payment of premium of ₹21,789/- with sum insured of ₹5.00 lacs for both.  On 24.9.2022, Smt. Baljit Kaur (hereinafter referred to as “insured patient”) suddenly fell ill and had severe chest pain, high grade fever and vomiting, as a result of which she was taken to the Fortis Hospital (hereinafter referred to as “treating hospital”). On seeing her condition, she was admitted on the same day and after treatment was discharged on 27.9.2022.  The treating hospital had sent cashless request (Annexure C-2) for ₹90,000/- to the OP/insurer on the day of admission of the insured patient, but, the same was rejected on 27.9.2022 (Annexure C-3) on the ground that the diagnosis was for AFI gastritis and the patient should have been treated on OPD basis and was not required hospitalisation.  Even the treating doctor had sent a clarification to the OP on 27.9.2022 (Annexure C-5) at 11:30 a.m. that the patient was presented in emergency and she had acute chest pain, high fever and vomiting etc. and she required admission in the hospital. The treating hospital had raised bill for ₹86,359.34 (Annexure C-6), but, since the claim was rejected another bill of ₹1,03,165.74 (Annexure C-7) was raised and when the complainant resisted, he was asked to pay ₹83,165/-.  Since the complainant was not having cash at that time, the aforesaid amount was paid by his brother through card as per receipt of the hospital (Annexure C-8) and payment slip (Annexure C-9).  In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice.  OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, concealment of facts, cause of action etc.  However, it is admitted that the subject policy was issued to the complainant and his wife and the same was valid at the relevant time.  It is further alleged that at the time of initiating the cashless hospitalisation request, medical record and the documents submitted by the hospital did not in any manner show any such medical condition and circumstances which necessitated OPD admission of the insured patient and the hospitalisation and IPD treatment was not warranted.  However, certain documents were required for further action which were sought vide letter dated 26.9.2022 and since those documents were not submitted and the complainant had also not filed any claim of reimbursement with the answering OP, in the absence of the same, there can be no question of reimbursing any amount to the complainant.  It is further alleged that the complainant is required to submit the aforesaid documents including all original bills, receipts etc. alongwith other additional information so that his claim may be processed.  It is further alleged that there is no violation of the terms and conditions of the policy by the answering OP. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied. The consumer complaint is sought to be contested.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant and his wife namely Smt. Baljit Kaur had obtained the subject policy (Annexure C-1) from the OP/insurer with sum insured of ₹5.00 lacs for both and the same was valid w.e.f. 9.6.2022 to 8.6.2023, and due to the sudden illness of the insured patient, she was admitted in the treating hospital (Fortis Hospital) w.e.f. 24.9.2022 to 27.9.2022, as is evident from the discharge certificate (Annexure C-4) and the cashless treatment request made by the complainant through (Annexure C-2) was denied/ rejected by the OP vide letter dated 27.9.2022 (Annexure C-3) on the ground that the patient did not require hospitalisation, the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in denying/rejecting the cashless treatment request of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP is justified in denying/ rejecting the cashless request and the consumer complaint of the complainant, being premature, is liable to be dismissed, as is the defence of the OP.
   2. In the backdrop of foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy (Annexure C-1), request for cashless treatment (Annexure C-2), rejection of said request by the OP (Annexure C-3), discharge summary (Annexure C-4) and the certificate (Annexure C-5) issued by the doctor of treating hospital and the same are required to be scanned carefully.
   3. Perusal of copy of the terms and conditions (Annexure C-1) indicate that the complainant and his wife Smt. Baljit Kaur were covered under the subject policy w.e.f. 9.6.2022 to 8.6.2023 with sum insured of ₹5.00 lacs. Annexure C-2 is copy of request for cashless hospitalisation which indicates that treating hospital had sent the said request to the OP/ insurer with expected cost of hospitalisation to the tune of ₹90,000/-. Annexure C-3 is copy of rejection of authorization for cashless treatment which indicate that the request for approval for the insured patient was denied by the OP. Relevant portion of the said letter is reproduced below for ready reference :-

“We have scrutinized your request for approval for cashless treatment of the above insured patient for the diagnosed disease of AFI/ GASTRITIS.

After perusal of the documents submitted, we are of the view that the condition of the insured patient does not require hospitalization and he/she could have been treated as an outpatient.

We are therefore unable to consider the approval for cashless treatment of the above diagnosed disease.”

4. Annexure C-4 is copy of discharge summary dated 27.9.2022 which clearly indicates that insured patient was diagnosed with “Acute Ferbile Illness? ENTERIC ? VIRAL ACUTE GASTRITIS” and relevant portion of the same is reproduced below for ready reference :-

“Diagnosis

ACUTE FEBRILE ILLNESS? ENTERIC? VIRAL

ACUTE GASTRITIS

Presenting Complaints

Patient admitted to FHM Triage with chief complaint of left sided chest pain x 2 day, fever since 1 day and increased micturition. Now, admitted for further evaluation and management.

Past History/ Comorbidities

No comorbidities

H/O Cholecystectomy

H/O Hysterectomy

Physical Examination

On admission, Conscious, oriented. vitals- WNL, Chest- Bilateral air entry equal, CNS- NAD, Abdomen- Soft, Non-tender.

Course In The Hospital

Patient admitted with above said complaints. Initial investigation showed- Hb-13.2, TLC-13.09, PLT-334, HbA1C-6, Na-138, K-4.36, SGOT-58, ALP-125, LDH-286, Total Billirubin-0.83, T. Protein-7.7, Creat-0.8, CRP-23.1, Trop-T-7.4, T3-3.19, T4-1.26, TSH-3.14, PCT- 0.100. Initially patient started on intravenous antibiotic [Inj Tazact], antacids, IV fluid, analgesics, multivitamin and other supportive treatment. Rapid typhi IGM, Malarial antigen- not detected. Dengue virus IGM- 0.01 and Dengue NS1 antigen shows 0.13. Urine and blood cultures showed no growth. On 26/9/22 Investigation showed-Hb-12.7, TLC-8.15, PLT-300. 2D ECHO done s/o LVEF 55%, No RWMA. B/L Mammography was done s/o breast have scattered fibro-glandular parenchyma (ACR-Type B). Small lymph nodes are seen in bilateral axilla. Now patient is stable and is getting discharged under following medical advise.

Status At Discharge

STABLE

xxx                    xxx                    xxx

Discharge Advice On Follow Up

FOLLOW UP IN OPD AFTER 5 DAYS WITH PRIOR APPOINTMENT WITH BLOOD REPORTS.”

 

5. Annexure C-5 is the certificate issued by the doctor of the treating hospital which clearly indicate that the insured patient required hospitalisation due to her admission in the emergency department with complains of acute chest pain, high grade fever and recurrent vomiting etc.  The relevant portion of the same is reproduced below :-

    “This pt presented to emergency department of FHM with c/o acute chest pain, high grade fever, recurrent vomiting.

ECG showed T inversion in Lead 5 and managed accordingly.

TLC count was high, so pt required I/V antibiotics, I/V antiemetics, IV fluids and supportive treatment

Hence required admission.”

6. Annexure C-6 is copy of inpatient detail running bill which indicate that total bill to the tune of ₹86,359.34 was raised.  However, copy of deposit receipt dated 28.9.2022 (Annexure C-8) and payment slip (Annexure C-9) indicate that an amount of ₹83,165/- only was paid/deposited by the complainant with the treating hospital. 
7. The main ground for denial/rejection of the cashless request of the complainant by the OP is that the patient did not require hospitalisation and she could have been treated as an outpatient.  However, we are of the view that no insurance company can decide the line of treatment to be given to a patient, rather it is only the doctors who can decide about the treatment, including the decision if the patient was required to be admitted in the hospital or not.  The ultimate decision as to how a patient is to be treated vests only with the doctor who is well versed and expert, both academically as well as through experience, and little scope is left to the patient or his relative to decide the manner in which the ailment is to be treated. Not only this, opinion of the doctor who treated the patient is more truthful than insurer’s opinion which is based on examination of case papers. It was also held by the Hon’ble Madhya Pradesh State Commission in the case of New India Assurance Company Limited Vs. Anand Gaurana, 2010 CTJ 77 (CP) (SCDRC Madhya Pradesh) that -

“If a person seek admission to a hospital at the instance of his general practitioner and in the process undergoes various tests necessary for the diagnosis and treatment of his ailment, the insurance company is liable to reimburse him the expenses so incurred under its mediclaim policy held by him.” 

Hence, it is safe to hold that the act of OP in denying/ rejecting cashless treatment request of the complainant certainly amounts to deficiency in service on its part and present consumer complaint deserves to succeed.

8. Another defence taken by the OP is that the complainant has not even filed the reimbursement claim with the OP and, therefore, the OP is not able to process the claim.  However, when it has come on record that the OP has already denied/rejected the cashless request by taking decision that no hospitalisation of the patient was required and despite of the fact that complainant has tendered all the documents, including the bills, and the copy of the same had already been supplied to the OP even during the pendency of the consumer complaint, and even then the OP has not deemed it proper to process the genuine claim of the complainant, it is safe to hold that the aforesaid act of the OP also amounts to deficiency in service and unfair trade practice as the insured is not required to repeatedly approach the OP/insurer for processing the claim. It is generally seen that Insurance Companies at the time of inception of policy receive hefty premium from the consumers, but, try to repudiate their genuine claims on one or the other ground.  The Hon’ble National Commission in Amira Foods (India) Ltd. & Anr. vs National Insurance Co. Ltd., II (2015) CPJ 429 (NC) has held as under :-

“….. The very purpose of insurance stands defeated, if the needful is not done by the Insurance Company. The purpose of insurance companies is not to charge hefty premiums but to perform their duties, as well……”

9. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint and the present consumer complaint deserves to succeed.
10. Now coming to the quantum of relief, since the complainant has proved the receipt and payment slip (Annexure C-8 & C-9 respectively) through which he paid the amount of ₹83,165/- to the treating hospital, it is safe to hold that OP/insurer is liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment caused.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

1. to pay ₹83,165/- to the complainant alongwith interest @ 9% per annum from the date of payment by the complainant i.e. 28.9.2022 onwards.
2. to pay an amount of ₹15,000/ to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/01/2024 hg		Sd/- [Pawanjit Singh] President
		Sd/- [Suresh Kumar Sardana] Member