Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that since 2005, the complainant has been purchasing Family Health Optima Insurance Plan policy from other insurance company and the said policy was ported with the opposite party vide policy no. P/211222/01/2024/002434 for the period 15.06.2023 to 14.06.2024, covering complainant and his family. Alleged that during the policy period, on the unfortunate day of 14.07.2023 at about 5:00 pm, complainant fell down from the stairs in his house and got injuries on his knee and on 15.07.2023 complainant got medically checked from Gupta Hospital, Bagha Purana and after taking medicines for 10 days, when complainant did not feel well, then on 25.07.2023 complainant went to Fortis Hospital, Mohali for his medical check-up and complainant spent approximately Rs.50,000/- in the abovesaid hospitals. Thereafter, the complainant again did not recovered then finally on 09.09.2023 complainant got medically checked from Amandeep Medicity Hospital, Amritsar, where complainant was suggested for a surgery of left knee PCL avulsion and complainant spent approximately Rs.2,60,000/- in the said hospital. Alleged that the complainant admitted in the said hospital for the period 18.09.2023 and discharged on 21.09.2023.
After discharge from the hospital, the complainant lodged the claim with Opposite Party for reimbursement of the medical bills and also completed all the required formalities and submitted all the required documents with the opposite party, but the Opposite Party vide letters dated 24.10.2023 and 11.11.2023. Alleged further that the opposite party repudiated the rightful and lawful claim of the complainant on the false and frivolous ground that the insured patient was admitted and treated in an excluded provider (hospital). Alleged further that at the time of issuance of the policy, the opposite party never issued any terms and conditions of the policy documents. As such, the alleged terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. Alleged further that from the medical record, it is clear that complainant was admitted in the hospital in emergency conditions. The act of Opposite Party is illegal, unwarranted and uncalled for. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to reimburse the medical claim of the complainant amounting to Rs.2,60,000/- alongwith future interest @ 12% per annum from the date of payment to the treating hospital till its actual realization.
b) To pay an amount of Rs.50,000/- on account of bills paid in Fortis Hospital and compensation for mental tension and harassment.
c) To pay an amount of Rs.51,000/- as cost of complaint.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present pre-mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan-2021 bearing no.P/211222/01/2024/0790864 valid from 15.06.2023 to 14.06.2024 covering the complainant self and her spouse Pooja Rani and dependent children namely Josh Taneja and Karuna for a sum of Rs.5,00,000/- for the first time. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party is subject to the terms and conditions of the insurance policy. Averred further that the insured preferred the claim within 3 months from the porting of the policy vide claim no.CIR/2024/211222/0790864. The insured has requested for cashless and submitted the medical expenses towards the treatment ‘PCL Avulsion’ at Amandeep Medicity, Amritsar on dated 18.09.2023 to 21.09.2023. As further evaluation was required to ascertain the onset of injury. Hence the claim was denied vide letter dated 11.09.2023 and the insured was required to lodge the claim for reimbursement with all necessary documents wherein the claim could be considered on merit basis. Thereafter, the insured has submitted the claim for reimbursement and on scrutiny of claim documents, the insured was asked to furnish the following documents vide letter dated 05.10.2023:-
i. Declaration letter stating the detailed circumstances of the injury with date, time and place.
ii. FIR/MLC/AR Copy;
iii. Operative x-ray films prior and post to the hospitalization;
iv. X-ray films and reports.
v. Treatment details taken immediately after injury.
It has been observed that there are various discrepancies in the documents submitted to Opposite Party. The Opposite Party found that all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented by the insured. Therefore, the Opposite Party was not in a position to admit the claim, as per terms and Specific Conditions. No.18 of the policy issued to insured. Hence claim was rejected and conveyed to Insured vide letter dated 11.11.2023. Averred further that on going through the hospital documents, the following abnormalities were noted:
i) Time of discharge recorded in DS of the patient is 11.55 on 21.09.2023 while in the Final bill the TOD is 1.23 on 21.09.2023.
ii) Anaesthesia record, OT Notes, DS, FB, IR’s MB’s were not provided by the hospital.
iii) Vital charts available in ICP’s are not recorded at regular intervals. Vitals are recorded at 11.00 pm, 04.00 pm and 10.000 pm on 18.09.2023 and only once on 21.09.2023. Further these are not signed by the nursing staff.
iv) ICP’s are stereotyped and not recorded/maintainable in a professional manner.
v) Final Bill is not signed by the patient of the attendant of the patient.
vi) The bill is typed on plain paper through computer and is neither signed by the patient nor by attendant of the patient.
vii) The payment has been made on 18.09.2023 and 21.09.2023 for Rs.140000/- and Rs.20000/- respectively. The pharmacy bill is available for single day for 21.09.2023 while as it should have been issued on daily basis.
viii) The investigation reports have been issued by Ampath lab which is owned by hospital and all the investigation reports do not bear UHID and IPD no. of the patient.
ix) As per query reply of the patient, he fell down from stairs in evening of 14.07.2023 and sustained injury in his left knee and no MLC/FIR was lodged by insured patient.
x) Hospital has charged Rs.70000/- for operation including Rs.9938/- for Anesthesiast fee but the hospital did not provide Anaesthesia record including OT Notes for reasons best known to them.
xi) Further, policy was ported to our company on 15.06.2023 and no PED was declared at the time of porting of policy. The DS of Fortis hospital dated 25.07.2023 shows that patient is a case of HCV Positive in 2014 and this fact was not disclosed at the time of porting of policy.
xii) In ICP, Dr. notes have been recorded by person from 18.09.2023 to 21.09.2023 and at only one place the Dr. has written the vital parameters of the patient. Almost entire vital charges have been written by same person and not signed by any of nursing staff.
xiii) The vital charges also do not show particulars regarding UHID, IPD no, room no, TOA, DOA etc and it is difficult to identify as to whom patient these charts pertain to. The vitals have been recorded at irregular intervals of time.
xiv) The medication chart also does not reflect various particulars of the like UHID, IPD no., room, no., TOA, DOA, etc.
On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C28.
4. On the other hand, Opposite Party has placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP/A alongwith copies of documents Ex.OP1 to OP16.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is well proved on record that the complainant availed Insurance policy namely ‘Family Health Optima Insurance Plan-2021’ for the period 15.06.2023 to 14.06.2024 covering self and his spouse and dependants children. It is also proved on record that during the policy coverage, the complainant fell down from the stairs in his house and got his checkup from Gupta Hospital, Bagha Purana and Fortis Hospital, Mohali, Thereafter he got admitted in Amandeep Medicity Hospital, Amritsar with chief complaints of Left Knee Pain for 2 months and where he was diagnosed as Left Knee PCL Avulsion (583.522A) GR IV CM : MFC (M24.10.), MJOA (M50.01.) Varus (M21.10). It is also proved on record that at the time of admission, the complainant applied for cashless pre authorization, but the same was denied vide letter dated 11.09.2023 (Ex.OP7). Thereafter, after discharge from the hospital, the complainant lodged the claim with Opposite Party for the reimbursement of the medical expenses, which was also repudiated by the Opposite Party vide letter dated 11.11.2023 (Ex.OP16).
7. The perusal of the record reveals that the Opposite Party repudiated the claim of the complainant vide letter dated 11.11.2023 on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of PCL Avulsion.
We observe various discrepancies in the documents submitted to us. We find all the details regarding the investigation and treatment of the insured patient are not transparently evident. The full facts of the case may not have been presented to us. Therefore, we regret we are not in a position to admit your claim, as per the terms and conditions no.18 of the policy issued to you.
We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.”
8. The perusal of the record reveals that in the written reply, the Opposite Party mentioned the discrepancies allegedly found by them in the medical record of the complainant, which is mentioned as under:-
i) Time of discharge recorded in DS of the patient is 11.55 on 21.09.2023 while in the Final bill the TOD is 1.23 on 21.09.2023.
ii) Anaesthesia record, OT Notes, DS, FB, IR’s MB’s were not provided by the hospital.
iii) Vital charts available in ICP’s are not recorded at regular intervals. Vitals are recorded at 11.00 pm, 04.00 pm and 10.000 pm on 18.09.2023 and only once on 21.09.2023. Further these are not signed by the nursing staff.
iv) ICP’s are stereotyped and not recorded/maintainable in a professional manner.
v) Final Bill is not signed by the patient of the attendant of the patient.
vi) The bill is typed on plain paper through computer and is neither signed by the patient nor by attendant of the patient.
vii) The payment has been made on 18.09.2023 and 21.09.2023 for Rs.140000/- and Rs.20000/- respectively. The pharmacy bill is available for single day for 21.09.2023 while as it should have been issued on daily basis.
viii) The investigation reports have been issued by Ampath lab which is owned by hospital and all the investigation reports do not bear UHID and IPD no. of the patient.
ix) As per query reply of the patient, he well down from stairs in evening of 14.07.2023 and sustained injury in his left knee and no MLC/FIR was lodged by insured patient.
x) Hospital has charges Rs.70000/- for operation including Rs.9938/- for Anesthesiast fee but the hospital did not provide Anaesthesia record including OT Notes for reasons best known to them.
xi) Further, policy was ported to our company on 15.06.2023 and no PED was declared at the time of porting of policy. The DS of Fortis hospital dated 25.07.2023 shows that patient is a case of HCV Positive in 2014 and this fact was not disclosed at the time of porting of policy.
xii) In ICP, Dr. notes have been recorded by person from 18.09.2023 to 21.09.2023 and at only one place the Dr. has written the vital parameters of the patient. Almost entire vital charges have been written by same person and not signed by any of nursing staff.
xiii) The vital charges also do not show particulars regarding UHID, IPD no, room no, TOA, DOA etc and it is difficult to identify as to whom patient these charts pertain to. The vitals have been recorded at irregular intervals of time.
xiv) The medication chart also does not reflect various particulars of the like UHID, IPD no., room, no., TOA, DOA, etc.
9. We are of the considered view that all the discrepancies as mentioned above seems highly absurd and are beyond the control of the complainant to comment upon, since all the documents so pointed out are being prepared at the hospital end as per the treatment given. Further, the said discrepancies are not mentioned in the repudiation letter dated 11.11.2023 issued by Opposite Party, so the same are not maintainable. It is basic principle of law that whoever alleges something is under bounden duty to prove the same. Had the Opposite Party get verified from the hospital concerned about the discrepancies, they allegedly noticed, then they would have been justified in repudiating the claim, if anything contrary to the claim get proved. However, there is no document showing that it ever get verified from the hospital concerned about their queries/discrepancies as alleged. Opposite Party has failed to prove any malafide on the part of the complainant and evidently had taken treatment from the hospital in question.
10. Thus, in our considered opinion, the claim of the complainant for the reimbursement of the medical expenses incurred on his treatment is genuine and payable by the Opposite Party-Insurance Company.
11. In these circumstances, the repudiation of the genuine claim of the complainant by the Opposite Party is unjustified.
12. Vide instant complaint, the complainant claimed the amount of Rs.2,60,000/- spent by him on the treatment, which is duly proved on record vide Ex.C26. Hence, we allow the same.
13. In view of the discussion above, we allow the complaint of the complainant in part and direct the Opposite Party to pay an amount of Rs.2,60,000/-(Rupees Two Lakh Sixty Thousand only) to complainant. Opposite Party is further directed to pay compository cost of Rs.10000/-(Rupees Ten Thousand only) to be paid to the complainant on account of compensation and litigation expenses. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party is burdened with additional cost of Rs.10,000/-(Rupees Fifteen Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
