DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.

                                                                   RBT/CC/1223/2018

Complaint No.1223 of 2018

                                                                   Date of Institution: 28.11.2018

                                                                   Date of Decision: 08.02.2022

Rajesh Kumar age 50 years, S/o Sh. Karam Chand Gupta, R/o House No.177,     Sec-4B, Shastri Nagar, Mandi Gobindgarh, Punjab. 147301         

                                                                                                                 …………....Complainant(s)

                                                Versus

1. The Managing Director, Apollo Munich Health Insurance Co. Ltd., Central processing centre, 2^nd and 3^rd floor, iLabs Centre, Plot No.04-405, Udyog Vihar Phase III, Gurgaon, 122016, Haryana.
2. The Managing Director, Max Super Specialty Hospital, Mohali – A Unit of Hometrail Estate Pvt. Ltd., Near Civil Hospital, Phase-6, Mohali, Punjab - 160055

..………........Opposite Party(s)

Complaint under Section 12 of Consumer Protection Act 1986

Quorum

Sh. Pushvinder Singh, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

Present: Sh. Anuj Sharma, counsel for Complainant.

               Sh. Nitin Thatai, counsel for OP No.1

               Complaint is not admitted against OP No.2

Order By

Pushvinder Singh, President

1.                The present complaint has been filed by the complainant(hereinafter referred to as ‘CC’) against the opposite parties (hereinafter referred to as “OPs”) with a prayer to direct the OPs to reimburse the medical expenses paid by the CC along with interest, cost and compensation.
2.                 The CC filed this complaint stating that he got a health insurance policy from the OP No.1 by paying a premium as assessed by OP No.1 and as per health insurance policy the CC himself, his son namely Shivam Gupta and his wife namely Smt. Mamta Rani Gupta were duly insured. On 02.02.2018 son of CC namely Shivam Gupta suddenly fell ill and suffered severe pain in his head and due to this CC taken him to Max Healthcare Hospital, Mohali i.e. OP No.2 for treatment. The doctors on duty of Max Healthcare Hospital, Mohali received a total sum of Rs.6760/- and the said amount was not claimed by the CC.
3.                   On 23.02.2018 son of CC again suffered severe pain in his head and due to his critical condition, he was again taken to Max Healthcare Hospital, Mohali in emergency ward. The doctors on duty after detailed investigation advised the son of CC for admission in view of his condition and unbearable pain. Son of CC remained as indoor patient for more than 24 hours and an amount of Rs.41,287/- was received by the doctors. Thereafter, CC made a request for cashless treatment but the same was rejected by OP No.1 with the assurance that the Company will reimburse the amount at the later stage. Then the bill was paid by the CC.  After that CC applied for the reimbursement of the amount of Rs.41,287/- but the claim was illegally rejected on the false and vague grounds.
4.            Notice of the complaint was given to the OPs No.1 & 2, but the complaint was not admitted against OP No.2. OP No.1 filed a written reply/version to the complaint alleging that the admission of patient was not necessary. In this regard it is submitted that neither the patient required to be admitted nor this has to be seen and decided by the duty doctors treating the patient and not by any third-party. The patient could have been treated as an OPD patient, which is not covered under the insurance policy obtained by the CC. OP denied all other allegations of the complaint and prayed for dismissal of the complaint. 
5.                   We have heard the counsel for the parties and gone through the file. It is an admitted fact that the CC and his son Shivam Gupta were having insurance policy for healthcare of OP No.1. Copy of policy has been produced by the CC as Ex.C-1.
6.                   The case of CC is that his son Shivam Gupta suffered severe headache on 23.02.2018 and he was taken to Max Healthcare Hospital Mohali. After investigation, he was admitted in the hospital and treated as indoor patient for more than 24 hours. A medical bill of Rs.41,287/- was paid by the CC when the cashless treatment claim of CC was denied by the OP No.1. After payment of Rs.41,287/- the CC applied for reimbursement. We find that the claim of reimbursement was also declined by the OP No.1 stating that admission of son of CC in the hospital was not necessary. He could have been treated as outdoor patient which is not covered in the medical insurance policy. The CC has produced copy of discharge summary as Ex.C-6 which shows that son of CC was taken to the hospital on 23.02.2018 at around 10.00 AM with the complaint of severe headache and was discharged on 24.02.2018. In the discharge summary advice of the doctors is mentioned at page no.2 and the son of the CC was advised to get admission in the hospital in view of the severe pain.
7.                  So, we find that when the son of CC was advised to admit in the hospital then it cannot be accepted that the patient could have been treated as OPD patient and accordingly we are of the considered opinion that the OP No.1 cannot avoid his liability to pay and reimburse the medical bill i.e. Rs.41,287/- of the son of CC.
8.                  In view of our abovesaid discussions, the present complaint is allowed  and the OP No.1 is directed to pay a sum of Rs.41,287/- to the CC and CC is also entitled to recover the abovesaid amount along with simple interest @ 9% per annum which is a reasonable rate of interest from the date of admission in the hospital till realization of amount.. The OP No.1 is also directed to pay a sum of Rs.10,000/- to the CC towards compensation for mental and physical harassment and litigation expenses. Copy of this order be provided to the CC and the OP No.1 free of cost. The compliance of this order be made by OP No.1 within 60 days from the date of receipt of certified copy of the order and thereafter file be returned back to District Consumer Commission, Mohali, for consignment.

Announced:

08.02.2022

 (Pushvinder Singh)

                                                                              President

                                                                             (Manjit Singh Bhinder)

                                                                             Member