Delhi

West Delhi

CC/18/430

MANJEET SINGH - Complainant(s)

Versus

THE NEW INDIA ASSURANCE - Opp.Party(s)

03 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-III: WEST

C-BLOCK, COMMUNITY CENTRE, PANKHA ROAD, JANAK PURI

NEW DELHI-110058

 

Complaint Case No. 430/2018

 

IN THE MATTER OF:

 

1. MANJEET SINGH,

S/O SHRI ANUP SINGH,  

                                          

2. SMT. TARVINDER KAUR,

W/O SHRI MANJEET SINGH,

 

Both residents of :

C-39, HARI NAGAR.

NEAR CLOCK TOWER,

NEW DELHI-110064,

                                                                                …....COMPLAINANTS

 

VERSUS

 

1.THE NEW INDIA ASSURANCE CO. LTD.

 (DIVISIONAL OFFICE CODE NO: XIV (311400),

SECOND FLOOR, C-5-VISHAL ENCLAVE,

NAJAFGARH ROAD, RAJOURI GARDEN,

NEW DELHI-110027                                                          .…..OPPOSITE PARTY No.1

 

2. MEDANTA HOSPITAL

THROUGH MEDICAL SUPERINTENDENT,

SECTOR-38, GURUGRAM,

HARYANA -122 001.                                                          …... OPPOSITE PARTY No.2

 

3.RAKSHA HEALTH INSURANCE,

TPA, PVT. LTD. FIRST FLOOR,

14/3, MAIN MATHURA ROAD,

FARIDABAD-121 003                                               …….. OPPOSITE PARTY No.3

 

 

DATE OF INSTITUTION:    JUDGMENT RESERVED ON:           DATE OF DECISION:

31.10.2018 22.05.2023  03.06.2023

 

CORAM

Ms. Sonica Mehrotra, President

Ms.Richa Jindal, Member

Mr. Anil Kumar Koushal, Member

 

Present: Mr. Prakash Mulchandaney, counsel for the complainant

               Alongwith complainant in person.

                Mr. Mandeep Singh Kapur, counsel for OP No.1

               Mr. Aditya along with Mr. Madhukar Pandey for OP No.2

               OP NO.3 ex parte.

 

ORDER

 

Per: Anil Kumar Koushal, Member

 

          Facts as culled out from the record of this case are noted hereunder:

1.       Complainants submit that they were insured under mediclaim policy no: 31140034172500000287 issued by  OP No.1 for the period from 09.07.2017 to 08.07.2018 for the sum insured of Rs.5 Lakhs each, along with other family members.   It is submitted that on 29-08-2017, complainant No.2 was admitted in OP No.2 hospital because of the acute abdominal pain and elevated liver enzymes. Complainant No.2 remained hospitalized from 29-08-2017 to 01-09- 2017 because of her above conditions.  As per hospital records, her stay in the hospital was very much necessary as she was diabetic and further suffering from acute hepatitis. It was also confirmed by the doctors that her ailment could not be treated in OPD and hospitalization was must.    It is submitted that during her stay in the hospital,   liver-biopsy, MRI, and Gastro Duodenoscopy was carried out to ascertain the nature of infection and right medication.  For undergoing all these procedures safely and as per hospital SOP, she was continuously administered I.V. (Intra Venous) antibiotics so that she may not suffer from any secondary infection. All these procedures required hospitalization and such procedures were not possible for the patient by taking treatment  in O.P.D. It is submitted that while undergoing all these procedures, the three days stay in the hospital was very much required considering her physical conditions and as per report of doctor of Medanta Hospital.  According to complainants, after discharge from the Hospital, the claim for reimbursement of medical expenses in the sum of Rs.1,50,565/ -was submitted to OP No.3, which was acknowledged by OP No.3 vide its letter dated 10.10.2017.

2.       On 10.11.2017, OP No.3  herein wrote a letter to OP No.1 recommending  repudiation of the subject claim on a very flimsy ground that MRI Lever could have been done to the patient in the OPD and the hospital admission was not necessary, hence the claim stands rejected.  It is submitted that OP No.3  deliberately and mischievously rejected the claim with mala fide intentions despite knowing the facts that MRI was not the single procedure but there were at least five to six medical procedures which were carried out besides MRI. All these procedures are  enumerated as follows:-

a. Liver Biopsy.

b. MRI of liver.

c. Gastro-Duodenoscopy.

d. Serum-Creatinine Test.

e. Ophthalmology test to assess condition of eyes as the patient was acute

    diabetic.

 

          f. Besides all these procedures, continuous I.V. (Intravenous) antibiotic

             was administered to the patient to arrest septicemia condition which

             was life threatening.

 

All these procedures were carried out to diagnose her disease correctly from which she was suffering and to recommend proper medication to improve her falling health conditions and severe pain in the abdomen.

3.       Complainants further submit that the most important and pertinent fact in the case is that the recommendation letter of  repudiation of the claim by OP No.3 has been signed by a Dentist named Jhumar Sehgal, who is just a B.D.S and as per the qualification, his field of operation is restricted to Dentistry only. It raises a doubt as to  how a dentist can recommend a rejection of medical claim related todiagnosis and treatment of complex diseases related to physical body except dentistry.

4.       The complainant also wrote a letter to the Sr. Divisional Manager  of OP No.1  on 08-12.2017 regarding the illegal rejection of the medical claim and to review the same. With this letter the complainant also annexed the letter of concerned Doctor explaining urgency  of hospital admission. However,  no effort were  made by OPs 1 and 3 to help the complainant resulting in unjust and illegal gain to OPs 1 & 3 and  loss to the complainants. The complainant through the said letter also informed OP No.1 that if no action was taken, legal remedy will be sought by the complainants.

5.       For redressal of his grievance,  complainant  No.1 also lodged various complaints in the office of the Insurance Ombudsman, Asaf ali Road, New Delhi. Although the complaint was registered by them but they never did anything to assist the gullible insured.

6.       It is submitted that the complainants are paying insurance premium for the last 18 years. The OPs 1 & 3 have committed breach of trust. The main object and purpose of getting insured is frustrated.  The following reliefs are claimed in this complaint:

          a. Allow the complete mediclaim amount of Rs. 1,50,565/-.

b. Allow the compensation amount of Rs.1,00,000/-

C. Allow the Litigation Charges of Rs.50,000/-

7.       Complainant attached Copies of insurance policy, Medanta Hospital Doctor’s certificate dated 09.09.2017, discharge summary of hospital along with medical  record, repudiation letter dated 10.11.2017, final repudiation/closure of claim file by OP No.1 dated 22.1.2018, letter dated 08.12.2017 for review of claim rejection, complaint registration with Insurance Ombudsman on 11.6.2018, query letter from OP No.3 dated 10.10.2017, medical record of Medanta hospital.

8.       On admission of the complaint on 31.10.2018, notice was issued to OPs.  All the OPs filed their respective written statements.

9.       OP No.1 submitted that there has been no deficiency of services on its  part.  The claim submitted by the complainant was examined and after examining the documents as provided by the complainants it was noticed that complainant No.2 was admitted for the evaluation of the ailment and not for the actual treatment and accordingly the claim was not admissible and same was repudiated by the TPA/OP No.3 in terms of condition no. 4.4.11 of the policy.   From the documents on record it was noticed that the wife of the complainant, i.e. complainant No.2 was a known case of Acute Hepatitis, Macular Amyloidosis and Diabetes.  

10.     It is further submitted that the present complaint as filed by the complainants is not maintainable as it involves complex question of law and facts which cannot be decided on summary basis and, therefore, is  liable to be dismissed.

11.     OP No.1. did not deny the coverage under the  policy. However it is submitted that the indemnification under the policy was strictly governed by the terms and conditions of the policy.  It is denied that as per  records of the hospital the hospitalization of the complainant was necessary in view of the ailment of diabetes from which she was suffering, whereas she has remained admitted for the evaluation of ailment and not for actual treatment.   It is denied that she was suffering from infection and it was not possible to undergo the process in the OPD. The discharge summary has been simply obtained in order to make wrongful gain. The various tests which have been mentioned in the complaint nowhere  affirm that complainant no.2  was suffering from a particular ailment and was given any particular treatment to control the disease. All the tests mentioned itself show that same were carried out to assess the health of complainant no. 2.

12.     OP No.1 denied that the doctor who has recommended for  repudiation of the claim was not competent and was not authorized to sign on the repudiation and was not conversant with the various ailments from which the complainant no. 2 was suffering from.  It is denied that the complainants are entitled to any sum of                 Rs.1,50,565/- as claimed. In fact no amount is payable under the policy since the claim was not admissible in terms of the policy conditions.

13.     OP No.1 took the objection that this Commission has no territorial jurisdiction to entertain the present complaint as no  part of cause of action has arisen within the jurisdiction of this Commission.  Accordingly, OP No.1 prayed for dismissal of the complaint with special costs.

14.     In rebuttal to the averments of OP NO.1, complainant filed rejoinder and denied all of them in toto. Complainants submitted that  OP no. 1 is misleading this Commission by stating that  complainant No.2 was admitted in the hospital for evaluation purpose only, which is absolutely false and concocted. The complainant was admitted not for evaluation purpose but for actual treatment of acute abdominal pain and elevated liver enzymes. The complainant remained in the hospital from 29.08.2017 to 01.09.2017 as her ailment could not be treated in the OPD. During the hospitalization, she was continuously administered intra venus antibiotics, so that she may not suffer from any secondary infection. The  Doctor of OP No.2 Hospital has also issued a Certificate that her admission in the hospital was very much necessary.   It is absolutely false and ridiculous statement that M.R.I. and Biopsy could be done in the OPD.  Complainants reiterated and reaffirmed the averments made in the complaint.

15.     In the written statement filed by OP No.2 Hospital, it was  denied that there has been any deficiency in service or any negligence on its part  or its doctors nor are there any allegations in this regard in the entire body of Complaint.  Moreover, there is no relief sought against OP No.2. The present Complaint is bad for mis-joinder of parties as the answering OP is neither a necessary nor a proper party to the present dispute as no relief has been sought from the answering OP and as such no cause of action whatsoever arose against the answering OP.

16.     OP No.2 admitted that on 29 08.2017 Mrs. Tarvinder Kaur (Complainant No. 2), a known case of diabetes mellitus, presented with complaints of decreased appetite and abdominal pain on and off since the past 2 months, was admitted in its Hospital for the treatment of acute abdominal pain and elevated liver enzymes along with further evaluation and management. As the Complainant No 2 was insured under a mediclaim policy, therefore as a standard practice, the complainant  was asked to deposit a nominal amount of Rs.10,000/- at the time of admission. On the same day, Complainants/attendants gave an undertaking that “in the event of rejection/reduction by TPA out of the amount sanctioned under pre-authorization communication for any reason whatsoever, including misstatement, non-disclosure of existing disease at the time of taking of mediclaim policy, non-disclosure of previous disease in the pre-authorization form, non-payable items or room rent/ ICU/ co-payment/ major or minor diseases capping/ clauses & undisclosed charges, denial at the time of discharges as per guidelines of TPA/ insurance company, the same would be paid by me before discharge from my personal resources."  In the present case, Complainant No 2 was insured with OP No.1 with OP No.3 as its TPA. OP No.2 Hospital in order to help the patient, contacted OP No.3 on behalf of  Complainant No. 2 after admission and submitted all relevant documents and information along with the request for authorization for cashless services. On 01.09.2017 OP No.2  received a communication from OP  No.3 stating that the cashless request has been denied "HEPATITIS/WILSON DISEASE (HOSPITALISATION SEEMS FOR EVALUATIVE & INVESTIGATIVE PURPOSE ONLY. CASHLESS CANNOT BE EXTENDED). Hence, in light of the above denial letter and the undertaking given by the Complainant/attendants, OP No.2 requested the Complainants to pay the treatment cost directly to it before discharge. The Complainant No. 2 remained hospitalized till 01.09.2017 At the time of discharge, a total bill of      Rs.1,24,035/ was raised. Since Rs.10,000/- was already deposited, the Complainants paid the balance amount of Rs.1,14,035/- without any demur or protest.

17.     OP No.2 admitted that Complainant No 2 was admitted under the Hepatology team with the above stated complaints for which necessary medical investigations were duly conducted by its Doctors including inter alia, Liver biopsy. MRI dynamic study liver with MRCP. Test for Autoimmune markers ANA, Serum Creatinine, Ophthalmology test, Gastro-Duodenoscopy etc.

18.     OP No.2 accordingly prayed for dismissal of the complaint qua it as no cause of action has arisen against OP No.2 in these proceedings and sought deletion of its name from the array of parties.

19.     OP No.2 filed filed with its written statement copy of the letter dated 01.9.2017 written by OP No.3 to OP No.2, copy of the undertaking signed by the sister-in law of complainant No.2 on 29.8.2017.

20.     In rebuttal to the averments of OP No.2, complainant filed rejoinder and  denied all of them.   Complainant denied that OP No.2 was not a necessary party since the treatment  was taken by complainant No.2 in  OP No.2 hospital where all the diagnostic procedures were carried out as mentioned above.  After these tests,  medical prescription  was given suggesting the course of action to be followed to cure the disease.  According to complainants, OP No.2 has wrongly  informed the real  facts of the case to OP Nos. 1 & 3.   The reality of the situation  is that  the ailment of complainant could not be managed as an OPD patient.  Complainants reiterated that OP No.2 is not entitled to any relief  by way of deletion of its name from the array of parties.

21.     In the written statement filed by OP No.3  it is submitted that the mediclaim policy in this case was issued by OP No.1 and OP No.3 is a licensed TPA under IRDA Act 2001 to act as a facilitator for the processing of the claim. The contract is between the insured and the insurer i.e. the complainants and OP No.1. As per the privity of  contract, OP No.1/insurance company by itself or  thorugh its  TPA/OP No.3 is obliged to process the claim as per the terms and conditions of the policy laid down by OP no.1.   The complainants were covered under the mediclaim policy No.31140034172500000287 for the period from 09.7.2017 to 08.7.2018 issued by OP No.1.   On perusal of claim documents it was found that patient admitted with H/O decreased APPETITE and ABDOMINAL PAIN on and off for past 2 months. During hospitalization, only investigations were done, which could have been managed on OPD basis, Hence claim was recommended for repudiation to OP no.1, as per policy clause no. 4.4.11 in accordance with the policy terms and conditions, i.e. "Charges incurred at Hospital primarily for diagnosis, x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any Illness or Injury for which confinement is required at a Hospital.".   It is submitted that OP No.3 is only the recommending authority. However the final decision for settlement of claim needs to be taken by OP no. 1.

 22.    OP No.3 submitted that the  complaint filed qua it is not maintainable as it is not privy to the contract between the complainants and OP No.1. Answering OP  is just a third party administrator who act as a facilitator  between the insurer and insured. 

23.     In rebuttal to the averments of OP No.3, complainants filed rejoinder and denied all of them in toto.  It is submitted that if  OP.3 are registered under the IRDA Act. 2001, they must produce copy of their registration certificate issued by the IRDA and  then only they can claim as authorized facilitator in processing the claims of the concerned insurance company. So far no authorization has been attached with the Written statement filed by it and therefore, the rejection of claim of complainants is illegal.

24.     Complainants submit that  the claim processed by OP No.3  is biased. OP No.3 has simply supplied tailor-made decision to repudiate the genuine insurance claim of the complainant. It has done so just to please its parent company as both OP No.1 and OP.3 are hand in glove with each other to further their cause of illegal gains.    According to complainants, the procedures in the OP No.2 hospital were undergone to assess the disease as per SOP of the Hospital.    Complainants denied that OP No.3 has absolutely  no liability in this case.  For undergoing all these procedures safely and as per hospital SOP, complainant No.2  was continuously administered I.V. (Intra Venous) antibiotics so that she may not suffer from any secondary infection. All these procedures required hospitalization and such procedures were not possible for the patient by remaining in O.P.D  

 25.    Evidence by way of affidavit was filed by the complainant and OPs 1 and 2 respectively.  All the parties exhibited their respective documents filed on record.  OP No.3 did not file either the evidence or their written arguments and accordingly vide orders dated 22.5.2023, its right to file the same was closed.  Written arguments were filed by the complainant. Oral arguments were heard on 22.5.2023 when Mr. Prakash Mulchandaney, counsel for the complainant, Mr. Mandeep Singh Kapur, counsel for  OP No.1 and Mr. Aditya, counsel for OP No.2 made their oral submissions based on the pleadings filed on record.

26.     Before we proceed to deal with the moot point involved in this case, we may refer to the objection taken by  OP No.1 that this Commission does not have jurisdiction to try the complaint as no cause of action has arisen within the jurisdiction of this Commission.  It may be noted that the mediclaim policy in question was issued by the Vishal Enclave, Rajouri Garden Branch, New Delhi of OP No.1 which falls within the territorial jurisdiction of this Commission and therefore, the objection raised by OP No.1 to this effect is baseless and untenable.

27.     The short point involved in this case revolves around the fact whether  the admission of the complainant No.2 in OP No.2 from 29.8.2017 to 01.9.2017  was essential and whether the treatment taken by complainant No.2 could be taken in OPD.  OP No.1 based on the recommendation of its TPA/OP No.3, rejected the claim of complainants on this ground.  Complainants submit that  he has been subscribing to the mediclaim insurance policy of OP No.1 since 2001 continuously  and if the legitimate and genuine claims are not honoured, what is the use of taking the insurance to cover the risk of disease and paying hefty amounts for its cure.

28.     In this regard it is apposite to refer to the certificate of treating Doctor of OP No.2 who observed as under:

          “This is to certify that Mrs. Tarvinder Kaur 48/female, wide UHID Number MM01104722 was admitted in Medanta – The Medicity Hospital (between 29/8/2017 to 01/09/2017) due to pain in abdomen and elevated liver enzymes.  Admission was necessary for further evaluation and treatment”

 

The discharge summary of the said hospital also records under the column “diagnosis and co-morbidities” as follows:

“Acute hepatitis(?Autoimmune,?wilson’s disease), Macular amyloidosis, diabetes mellitus.”  

 

The discharge summary records  that the patient/complainant No.2  was suffering from the decreased appetite and abdominal pain on and off  since last 2 months. We pose a question to ourselves, as to what better course of action was at the disposal of complainant No.2 except to approach the Medical Doctor for assessment of the disease and to suggest proper treatment to avoid risk to her life.   What else was required  by the Insurer/OP No.1 to come to the conclusion that in fact the admission of  complainant No.2 was necessitated to assess the disease from which she was suffering before it was too late.  It is also recorded in the discharged summary that  complainant No.2 had elevated liver enzymes.   In our opinion, the treating Doctor is the best judge to assess what  course of treatment is required  for the patient to save him/her, thereby negating the role of the insurer whose role is limited to  indemnifying the insured against all medical risks by collecting hefty amount in the form of premium.   The insurer, in the absence of opinion of an expert in the field,  is not supposed to decide  the veracity of line of treatment given by the treating Doctor.   The OPs 1 & 3 have relied on the opinion of a BDS Doctor to  come to the conclusion that the hospitalization of complainant No.2 was not  required. We stop short of commenting on the competence of a Dentist to opine about  Hepatology  which is a branch of medicine concerned with the study, prevention, diagnosis and management of diseases that affect the liver, gallbladder, billary tree and pancreas.  This had nothing to do with a Dentist whose opinion was relied upon by OP No.1 in rejecting the genuine claim of  complainant No.2.  No  opinion of  expert Doctor of the field of Hepatology was taken in this regard.

29.     We further find from the letters dated 10.10.2017 and 10.11.2017 issued by OP No.3  to the complainants that the name of Hospital from which the treatment was taken by complainant No.2 has been mentioned therein as “Institute of Liver & Billary Sciences, Sector D-1 Vasant Kunj, New Delhi”.  This creates suspicion in  our mind whether the rejection of the claim of complainant No.2 was genuine or  just a copy paste  of opinion in relation to some other  patient.     

30.     In the case of New India Assurance Company Limited Versus Smt. Usha Yadav & others 2008(3) R.C.R. (Civil) 111, the Hon'ble Punjab & Haryana High Court expressed its anguish and observed as follows:-

"It seems that the Insurance Companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims. The insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus, pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy."

 

31.     For the foregoing conclusions arrived at by us, we hold that the rejection of legitimate and genuine claim  of complainant No.2  by OP No.1 based on  flimsy and non-cogent grounds was arbitrary and against the principles of natural justice.

32.     Since no deficiency in service has been attributed against OP No.2 from which the treatment was taken  by complainant No.2, we absolve OP NO.2 from the outcome of the present proceedings.

33.     Our aforesaid discussion results into allowing the complainant, holding OP NO.1 guilty of deficiency in service and following unfair trade practice in rejecting the genuine claim based on the medical advice of a treating Doctor.  Accordingly, Op NO.1 is directed to reimburse to complainant NO.2  the medical  expenses incurred by her amounting to Rs.1,50,565/-.  For the harassment and mental agony faced by the complainants in pursuing this complaint, OP NO.1 shall pay a sum of Rs.30,000/- as compensation and Rs.20,000/- as litigation expenses to complainant No.2. Let this order be complied with by the OP within thirty days of receipt of copy of this order. 

          A copy of this order shall be supplied free of cost  to parties to the dispute in the present complaint,  upon a written requisition being made in writing  in the name of President of the Commission in terms of Regulation 21 of the Consumer  Protection Regulations, 2020.  File be consigned to record room after pronouncement of order.

 

 (Richa Jindal)                            (Anil Kumar Koushal)                   (Sonica Mehrotra)

    Member                                       Member                                    President