Chandigarh

DF-II

CC/1057/2016

Neeta Kumar - Complainant(s)

Versus

The Manager, Cigna Health Insurance - Opp.Party(s)

Anirudh Gupta Adv.

06 Dec 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	1057 of 2016
Date  of  Institution	:	28.12.2016
Date   of   Decision	:	06.12.2017

 

 

 

 

Neeta Kumar w/o Sh.Pawan Kumar, R/o House NO.436/1, Near Garg Clinic, Sector 39-D, Village Maloya, Chandigarh.       

             …..Complainant

Versus

1]  The Manager, Cigna Health Insurance, SCO No.149-50, Sector 9, Chandigarh.

2]  Max Super Speciality Hospital, Near Civil Hospital, Pase-6, Mohali.

             ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

                                MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

For complainant      : Sh.Anirudh Gupta, Advocate

For OPs              : Sh.Sandeep Suri, Adv. for OP-1.

                       Sh.Swapan Shorey, Adv. for OP-2

 

 

PER RAVINDER SINGH, MEMBER

 

 

          The facts in issue are that the complainant purchased a Mediclaim policy from OP NO.1 bearing No.PROHLT010048161 for his family covering the risk cover of Rs.5 lack effective from 24.2.2016 to 22.2.2017 by paying premium of Rs.9285.95 (Ann.C-1 & C-2).  It is averred that the complainant herself fell ill due to Anxiety Neurosis, functional Dyspepsia and has been thoroughly evaluated for cause of fever on 24.9.2016.  It is also averred that the complainant remained admitted in OP No.2 Hospital for treatment from 24.9.2016 to 26.9.2016 and charged a sum of Rs.29,251.46/- (Ann.C-4).  It is further averred that the claim of the complainant was duly approved by Cigna Insurance Company/OP No.1 on 25.9.2016 (Annexure C-3). It is submitted that the complainant submitted the claim with OP No.1 along with all requisite documents and the approval of claim by mail was also received by the complainant on 25.9.2016 (Ann.C-5), but despite of all that the OP No.1 did not release the claim amount of Rs.29,251/-.  Hence, this complaint.

 

2]       Opposite Party No.1 has filed reply and while admitting the factual matrix of the case, stated that the complainant is well aware of the fact that the claim has already been repudiated based on the medical record. It is stated that as per the Discharge Summary, the complainant has been diagnosed with Anxiety Neurosis, Functional Dyspepsia, Tension Headache.  It is also stated that Anxiety neurosis is the psychological disorder most commonly referred to as generalized anxiety and the Tension Disorder is directly related to anxiety.  It is further stated that the claim of the complainant, which was initially approved for the purposes of cashless treatment, was rejected as the final diagnosis of the Hospitalization came out to be Psychiatric/mental related illness, which is a permanent exclusion under the policy.  Pleading no deficiency in service and denying other allegations, OP No.1 has prayed for dismissal of the complaint.

 

         The OP No.2/Max Hospital has also filed reply and while admitting the treatment given to the complainant and bill charged from her, stated that approval/denial of cashless hospitalization as well as acceptance/rejection of reimbursement claim (including disbursement) against the medical insurance policy is a matter between the insured patient and the insurance company/OP No.1 and OP No.2 has no role in it.  Denying other allegations being related to OP No.1 and pleading no deficiency in service, the Opposite Party NO.2 has prayed for dismissal of the complaint.

 

3]       The complainant has also filed replication reiterating the contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

6]       The complainant was admitted in Max Super Speciality Hospital, Mohali on 24.9.2016 and discharged on 26.9.2016. In the Max Hospital, she was diagnosed as under, as per the Discharge Summary dated 25.9.2016:-

“30 YEARS FEMALE WITH NO COMORBIDITES PRESENTED WITH C/O PERSISTANT FEBRISH STATUS ALONG WITH GENERALUISED WEAKNESS, PERSISTANT NAUSEA AND ABDOMENAL DISCOMFORT SINCE PAST 15 DAYS

SHE WAS EXAMINED AND THROUGHLY INVESTIGATED, COMPLETE WORK UP FOR FEVER WAS DONE AND HER TYPHI DOT, URINE ROUTINE WERE FOUND TO BE NEGATIVE, REST ALL LABS WERE ALSO WITHIN NORMAL LIMITS, HER FEVER WAS MONITORED REGULARLY AND WAS DOCUMENTED TO BE LOW GRADE; NOT MORE THAN 100F DURING HER STAY SHE HAD PERSISTANT MILD HEADACHE FOR WHICH SHE WAS TREATED WITH IV PARACETAMOL. SHE WAS MANAGED CONSERVATIVELY WITH IV FLUIDS, PPI’S IV OPTINEURON AND OTHER SUPPORTIVE CARE. IN VIEW OF HER CONSISTANT NAUSEA AND ABDOMENAL DISCOMFORT USG WHOLE ABDOMEN WAS DONE WHICH WAS SUGGESTIVE OF CHOLELITHIASIS, GASTRO CONSULT BY DR NUIKHIL NADKARNI WAS ALSO SOUGHT AND WAS ADVISED UGIE, WHICH THEY REFUSED. PATIENT AND ATTENDANT CLEARLY EXPLAINED THE NEED OF FURTHER EVALUATION AND UGIE BUT THEY WANT TO LEAVE AGAINST MEDICAL ADVISE. THEREFORE IS BEING LAMA TODAY.”

7]       The illness of the complainant for which she was treated in the Max Hospital with effect from 24.9.2016 to 26.9.2016 in no way comes under any definition of mental illness or Parkinson’s or Alzheimer’s disease, which may terms to be under exclusion clause as claimed by OP No.1. The Opposite Party No.1 has without application of mind and using colourable exercise of powers has dismissed the genuine claim of the complainant, which is untenable, without merits and deserves deterrent penal cost to avoid such unfair trade practices adopted by Insurance Companies.

 

8]       Keeping into consideration the facts & circumstances of the case, the claim of the complainant is found legal, valid and payable by OP No.1 i.e. Cigna Health Insurance Company.  The complaint, as such, is allowed with directions to OP No.1/Cigna Health Insurance Company to pay Rs.29,251/- along with interest @6% p.a. from the date of repudiation of claim i.e. 26.9.2016 till realization with compensatory cost of Rs.10,000/- and litigation cost of Rs.5000/-, within a period of 30 days from the date of receipt of certified copy of this order.

9]       However, the complaint qua Opposite Party No.2 stands dismissed.

         Certified copy of this order be communicated to the parties, free of charge. After compliance, file be consigned to record room.

Announced

6^th December, 2017                                                      

                                                                                      Sd/-  

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER