District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.349/2021.
Date of Institution: 20.07.2021.
Date of Order: 15.06.2022.
Subhash Chander Agarwal S/o late Shri Virender Kumar Agarwal R/o House NO. 83, Sector-8, Faridabad.
…….Complainant……..
Versus
1. The Chief Manager, The Oriental Insurance company Limited, 5B/4 B.P.Second floor, Ralway Road, NIT, Faridabad – 121001.
2. M/s. Medi Assist. Insur, No. 4/1, 1BC Knowledge Park, Tower D, 4th floor, Bannerghatta Road, P.O.Bangalore – 560 029.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. S.K.Jhunthra , counsel for the complainant.
Sh. Anuj Gupta, counsel for opposite party No.1.
Opposite party No.2 ex-parte vide order dated 02.02.2022.
ORDER:
The facts in brief of the complaint are that the complainant and his wife named Smt. Kalpna Agarwal were covered under mediclaim policy bearing No. 272400/48/2020/5671 dated 30.08.2019. The amount of mediclaim policy was Rs.5,00,000/- and under this policy, the complainant alongwith his wife named Smt. Kalpna Agarwal were entitled for claim under the said policy for any type of ailment during the period of hospitalization and the complainant made a payment of Rs.19,587/- on account of premium including GST. The wife of the complainant i.e. Smt. Kalpna Agarwal was not feeling well and she was complaining severe pains in joints, headache, body pain and fever etc. and therefore, the complainant approached to Sir Ganga Ram Hospital, New Delhi on 21.01.2019 for treatment and after checking, prescribed certain medicines. Due to severe problem, joints pains, headache and continuous fever, the complainant again approached to Sir Ganga Ram Hospital, New Delhi for treatment of his wife and after checking, doctor advised to admit Smt.. Kalpna Agarwal immediately but no bed was available on 04.10.2019 and, therefore, the wife of complainant was got admitted on 05.10.2019 as per advise of Dr. Atul Kakkar of Sir Ganga Ram Hospital, New Delhi and the complainant informed the opposite party through email on 06.10.2019 regarding hospitalization of Smt.. Kalpna Agarwal as per terms and conditions of the opposite parties. Smt. Kalpna
Agarwal wife of the complainant was discharged from Sir Ganga Ram Hospital, New Delhi on 11.10.2019. The complainant submitted the bills including the medicine after discharged from the hospital i.e. total amounting to Rs.2,10,279/- (Rs.1,77,646/- + Rs.32633/-) on 18.10.2019 and dated 10.12.2019 to opposite parties for payment as per mediclaim policy. The opposite parties refused to make the payment of Rs.2,10,279/- to the complainant vide claim NO. 20773384 & claim NO. 21206881 on the ground that “No active line of management, patient went under various investigation which can be done on OPD basis.” The observation of opposite party No.2 i.e. TPA was totally wrong and devoid of any valid ground and also ignored the treatment of the Doctor of Sir Ganga Ram Hospital, New Delhi which was a very reputed and old hospital in Delhi NCR. Before refusing the payment of Rs.2,10,279/- to the complainant on account of medical bills, it was the duty of the opposite party NO.2 to discuss about the line of treatment of complainant’s wife i.e. Smt. Kalpna Agarwal from Dr, Atulkakkar of Sir Ganga Ram Hospital, New Delhi and the concerned doctor of the hospital had to decide the line of treatment according to the problem of the patient not the opposite part No.2. It was totally wrong i.e on the part of opposite party No.2 to reject the medical bills to the tune of Rs.2,10,279/- without any reason. As per Medical policy “The patient is entitled for medicines and investigation charges for 2 months after discharge from the hospital” and the complainant submitted the bills amounting to Rs.32,633/- on 10.12.2019 vide claim NO. 21206881 and the said claim was also based on the previous claim No. 20773384 and the same was also denied by the opposite parties. The total amount paid by the complainant i.e. Rs.2,10,279/- on account of the treatment of the complainant’s wife. The complainant sent legal notice dated 22.03.2021 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the payment of Rs.2,10,279/- on account of medical claims/bills to the complainant alongwith interest @ 24% p.a. from the date of submission of medical bills i.e. 18.10.2019 & 10.12.2019 till realization.
b) pay Rs.50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000/- as litigation expenses .
2. Opposite party No.1put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the present complaint was not maintainable in its present form, reason being the complainant was trying to play hide and seek under the garb of present complaint since he had actively not placed on record copy of any treatment record advising admission of the patient, hospitalization detailed final bill, post hospitalization claimed bills. Since by not producing these documents the complainant had deprived the Hon’ble Commission from valuable chance of going through and examining the contents of these documents as well as adjudicate whether only investigations were conducted or any line of treatment was adopted by hospital, what was the condition of the patient, what was the room rent charged by hospital, how much amount of hospital bill was towards investigations only, whether the claimed post hospitalization bills were having any concerned with the admission, whether same were towards OPD consultation, whether these bills were admission, whether same were towards OPD consultation, whether these bills were admissible and payable under the terms and conditions of the insurance policy in question. It was further submitted that after receiving the claim form for hospitalization claim of the complainant the same was got processed by opposite party No.2 during the investigation of the claim by the term of opposite party NO.2 consisting doctors it was brought to their notice that as per discharge summary:
i) Patient was in her usual state of health when she hospitalized with pain in bilateral knee, insidious in onset, associated with stiffness of points and mild grade fever.
ii) Patient was admitted for further evaluation and management.
iii) Patient was diagnosed for Bicytopenia (Bone Marrow report awaited), lleocolic ulcers? (Colonic Biopsy Awaited) & Hypertension.
iv) Investigation such as Test for Dengue, typhoid, Malaria, Scrub typhus, ANA and ANA profile, Anti CCP, PET Scan, Bone marrow and few other tests were carried out.
v) Tablet medication such as Pentasa was given to the patient during her stay in hospital.
vi) At the time of discharge various reports were lef awaited and the certain tablets were prescribed.
On the basis of above facts the team of opposite party No.2 comprising doctors opined that patient had not taken any active line of tratment during the aforementioned hospitalization period. Therefore, this claim falls under the exclusion clauses No. 4.9, 4.13 and 4.19 of the policy. The above fact was intimated to the complainant by the answering opposite party vide letter dated 06.12.2019. It was pertinent to mention that patient visited Dr. Atul Kakkar in OPD of Sir Ganga Ram Hospital, Delhi on 04.10.2019 and said doctor prescribed certain tests including PET scan and no advice of any admission as indoor patient was written by that doctor. This was the complainant who with a sole motive to transfer the entire burden of investigation expenditure upon the answering opposite party in active connivance with doctor got herself admitted for evaluation purpose, whereas all the tests could have been very well conducted without admission, but in that scenario the entire expenses have to be borned by the complainant. The post hospitalization calim of the complainant was also processed and on scrutiny of the claim documents by their panel of doctors it was observed that the patient Ms. Kalpna Agarwal aged about 58 years was admitted with diagnosis of bicytopenia, hypertension and was trated conservatively. In accordance with the available documents, it was observed that the patient had not taken any active line of tratment during the aforementioned hospitalization peiod. Therefore, the claim falls under the exclusion clauses NO. 4.9, 4.13 and 4.19 of the policy and the main claim was denied on the basis of aforesaid clause of the policy. Not only this under the garb of post hospitalization claim the complainant tried to claim OPD consultantion charges bills of the docator of apollo hospital, SitaRam Bhartia Hospital, medicine bills without showing their cotinujation prescaription slip by Dr. Atul Kakkar of Sir Ganga Ram Hospital, Delhi under whom patient was admitted, the X-ray and blood testing charges bills of more than 60 days prior to admission without showing their prescription slips by Dr. Atul Kakkar of Sir Ganga Ram Hospital, Delhi. Hence, the post hospitalization claim was also not found admissible under the terms and conditions of the insurance policy issued and the answerin opposite party intimated the complainant about non admissibility of the claim vide letter dated 20.02.2020, therefore the complainant was not entitled to invoke the jurisdiction of the Hon’ble DCDRC. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Notice issued to opposite party NO.2 on dated 11.01.2022 not received back either served or unserved. Tracking details filed in which it had been mentioned that “Item Delivery Confirmed”. Case called several time since morning but none appeared on behalf of opposite party No.2. Hence opposite party No.2 was hereby proceeded agaisnt ex-parte vide order dated 02.02.2022.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties – Oriental Insurance Co. Ltd. with the prayer to : a) make the payment of Rs.2,10,279/- on account of medical claims/bills to the complainant alongwith interest @ 24% p.a. from the date of submission of medical bills i.e. 18.10.2019 & 10.12.2019 till realization. b) pay Rs.50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000/- as litigation expenses .
To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Shri Subhash Chand Agarwal, Ex.C-1 – insurance policy, Ex.C-2 – OPD card, Ex.C-3 (colly) – patient records,, Ex.C-3 – Advance receipt, Ex.C-4 –email, Ex.C-5 – Discharge summary, Ex.C-6 (colly) – claim form, ex.C-7 (colly) – claim form, Ex.C-8 & 9 – repudiation letters, Ex.C-10 – legal notice.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1, Ex.RW1/A - Shri Ramesh Kumar, Sr. Divn. Manager , Oriental Insurance CoLtd., NIT, Faridabad, Ex.R-1 – Discharge summary, Ex.R-2 – repudiation letter, Ex.R-3 - out patient record, Ex.R4 – repudiatin letter dated 20.02.2022, Ex.R5(colly) - GST Invoice, Ex.R6 – insurance policy, Ex.R7 – prospectus.
7. It is evident from insurance policy vide Ex.C-1 that the complainant and his wife named Smt. Kalpna Agarwal are covered under mediclaim policy bearing No. 272400/48/2020/5671 valid from 30.09.2019 to 29.09.2020.The wife of the complainant i.e. Smt. Kalpna Agarwal was not feeling well and she was complaining severe pains in joints, headache, body pain and fever etc. and therefore, the complainant approached to Sir Ganga Ram Hospital, New Delhi on 21.01.2019 for treatment and after checking, prescribed certain medicines. Due to severe problem, joints pains, headache and continuous fever, the complainant again approached to Sir Ganga Ram Hospital, New Delhi for treatment of his wife and after checking, doctor advised to admit Smt.. Kalpna Agarwal immediately but no bed was available on 04.10.2019 and, therefore, the wife of complainant was got admitted on 05.10.2019 as per advise of Dr. Atul Kakkar of Sir Ganga Ram Hospital, New Delhi and the complainant informed the opposite party through email on 06.10.2019 regarding hospitalization of Smt.. Kalpna Agarwal as per terms and conditions of the opposite parties. Smt. Kalpna
Agarwal wife of the complainant was discharged from Sir Ganga Ram Hospital, New Delhi on 11.10.2019vide Ex.R-1. The complainant submitted the bills including the medicine after discharged from the hospital i.e. total amounting to Rs.2,10,279/- (Rs.1,77,646/- + Rs.32633/-) on 18.10.2019 and dated 10.12.2019 to opposite parties for payment as per mediclaim policy. The opposite parties refused to make the payment of Rs.2,10,279/- to the complainant vide claim No. 20773384 & claim No. 21206881 on the ground that “No active line of management, patient went under various investigation which can be done on OPD basis.”
8. During the course of arguments, Shri S.K.Jhuntra, counsel for the complainant has made a statement that “I only press the bill passed by Sir Ganga Ram Hospital for an amount of Rs.1,61,272/- alongwith medicine bill Rs.16,374/- total amounting to Rs.1,77,646/-.”
9. After going through the evidence led by both the parties and statement of the counsel for the complainant, the Commission is of the opinion that that the complaint is allowed. Opposite parties are directed to process the claim of the complainant as per the statement of the counsel for the complainant given on 6.6.2022 within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 15.06.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
