Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 280/12.12.2017
Mr. Rajesh Choubey s/o Mr. Sudhir Choubey
r/o A-8, 3rd Floor, West End Enclave, Vasant Vihar, Delhi …Complainant
Versus
OP1: The Oriental Insurance Company Ltd.
Regd. Office: Oriental House, P.B. No. 7307,
A-25/27, Asaf Ali Road, New Delhi-110002
OP2: Vidal Health Insurance, TPA
B-25, 1st Floor, Sec-1, behind Indian Oil Building,
Noida-NCR, Uttar Pradesh-201301 ...Opposite Parties
Date of filing: 12.12.2017
Date of Order: 06.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Inder Jeet Singh, President
ORDER
1.1. (Introduction to case of parties) – The complainant filed the complaint containing allegations of deficiency and negligence in providing the services by OP1 and OP2 as during the subsistence of valid medical claim, the reimbursement was denied.
1.2. Whereas, the OPs opposed the complaint, precisely that hospitalization of beneficiary of policy was just for evaluation and not for treatment, the terms and conditions of policy do not permit claim for evaluations.
2.1. (Case of complainant) – The complaint gives introduction about his employer that he is in Level-6/Group-D service in Daimler India Commercial Vehicles Pvt. Ltd. OP1 has provided medi-claim policy to the employees (including family members of employees) of Daimler India Commercial Vehicles Pvt. Ltd. The complainant applied to OP2/TPA for cashless facility by way of his representation.
2.2. On the basis of representation of OP1, the complainant agreed to take insurance policy for him and his family members, he became holder of policy no. 411200/48/2017/3012 (IC no. CHE-0I-D0365-001-0003054-B) since 04.09.2014. The policy was renewed, also in October 2016.
Complainant’s father started feeling and suffering from weakness in both limbs, speech difficulty, hypothyroidism with progressive motor system disease-both LMN & UMN; to ascertain it he was taken to AIIMS on 20.12.2016 and he was found suffering from EPS S/O preganglionic involvement of bulbar, cervical and lumbo sacral segments with e/o active dnervation & ongoing re-innvervations. When his condition was deteriorated, he was admitted in Christian Medical College Vellore on 31.03.2017 for his further evaluation & treatment for weakness of both the lower limbs, speech difficulty, distal upper limb weakness. He was examined and it was observed that he had bilateral foot drop (L>R) with feature of both UMN and LMN involvement with fasciculation’s noted in left thigh and tongue. Further, differentials considered were motor neuron disease, paraneoplastic causes. EMG/NCV was done and it showed that asymmetric motor axopathy with denervation noted in bulbar, cervical and lumosacral myotomes, which suggested that his weakness has been progressive and worsening since onset. He was discharged on 06.04.2017. OP2 was required to reimburse the medical expenses but OP2 had rejected the claim on the ground that as per document furnished, it does not justify stay in the hospital and cashless facility was not possible, despite the OP2 admits ailments in its email dated 03.05.2017. The OP2’s email also takes cognizance of the fact that currently there is no cure for motor neuron disease despite that the plea of stay in the hospital was not justified. Otherwise, OP2 cannot suggest that hospitalization was not required for such incurable disease as the patient has to follow the procedure and treatment opted by the doctor for curing the disease, else patient would be considered as negligent.
2.3. The complainant took the policy to have cashless facility in order to secure financially in contingency but it was not cared and helped by OP2 by declining cashless facility. OP1 and OP2 are negligent in providing the service, there is deficient services and unfair trade practice. Since the complainant had paid bills of Rs.77,204.62p, which were not refunded. The complainant also gave legal notice dated 16.08.2017 to pay the amount but no result. That is why, the complaint for refund of Rs. 71,204.62p along with interest at the rate of 18% pa, apart from compensation of Rs. 5,00,000/- as damages for mental agony, pains suffered by the complainant owing to deficiency in services and unfair trade practice besides cost and other relief in his favour.
2.4. The complaint is accompanying with the record of OPD card and other evaluation by AIIMS, letter of intent with salary components issued by Daimler in favour of complainant, rejection letter dated 03.04.2017 by OP, email, discharge bills inclusive of labs and other services, bills for pharmacy, discharge summary, medi-claim insurance policy, letter of additional information/clarification of 01.04.2017, 03.04.2017, 06.04.2017 and legal notice dated 16.08.2017 with postal receipts and service track report.
3.1 (Case of OP1)- The OP1 opposed the complaint that it is liable to be dismissed because of the fact that hospitalization was primarily for diagnosis/evaluation purposes, coming under exclusion clause 4.10, that is why the claim was rightly repudiated. Since the insurance policy is a contract between the parties, they are bound by the same, consequently there is no deficiency of services or any negligence on the part of OP. There is no cause of action against the OP. The OP denies the allegations of complaint under the aforementioned objections. The complaint is liable to be dismissed.
3.2. Whereas, the complainant filed detailed reply, which is in fact reiteration of complaint but with explanations as to how the disease was discovered and appropriate consultancy was done followed by admission of the beneficiary. Further, subsequent to discharge of complainant’s father, he was readmitted in other hospital on 20.01.2018 and he was discharged on 13.02.2018 for the same illness/ disease, since illness have become more chronic and consequently he died on 17.03.2018 to his illness. The claim was lodged bona-fide but it was declined without justify reasons.
3.3. (Case of OP2)- The OP2/TPA failed to appear and filed reply, it was proceeded ex-parte on 20.03.2018.
4.1 (Evidence)- Complainant Rajesh Choubey led his detailed affidavit of evidence, it is replica of complaint along with documents.
4.2. OP1 also led its evidence by filing affidavit of Bharti Mukul Kalra, Manager and it is partly on the basis of written statement and additionally email dated 07.02.2018 and terms and conditions of policy, annexed first time with affidavit (without leave of the Commission, as these documents were not filed with written statement).
5.1. (Final hearing)- The complainant filed written arguments by compiling the facts, features, documents and IRDAI (TPA – Health Services) Regulations, 2016 to demonstrate deficient services and unfair trade practice on the part of OPs. Similarly, OP1 has also filed written arguments, which are extracts from the written statement and its affidavit of evidence.
5.2. Sh. Sachin, Advocate for complainant and Sh. S.K. Tyagi, Advocate for OP1 presented their oral submissions, which is factually based on the pleading and evidence.
6.1 (Findings)- The contentions of both the sides are considered keeping in view the material on record. By taking stock of all the circumstance together, the short issue is 'whether the complainant’s father's admission in the hospital as indoor patient was just for evaluation or for evaluation and treatment', since OP1 contends that admission was not required for evaluation and the same can be without admission in the hospital. Since it is the core issue, accordingly, the record will be assessed and issue will be determined.
6.2. The cashless facility was declined by OP2 by its rejection letter dated 03.04.2017 by making remark “not payable” and this remark precedes other remarks provisional diagnosis “progressive motor system disease with both UMN and LMN involvement for PEG insertion after swallowing” .
6.3. There is email correspondence and the email reproduces the contents of discharge summary dated 06.04.2017, since complainant’s father remained indoor patient from 31.03.2017 to 06.04.2017.
6.4. Prior to it, as appears the OP2 had sought additional information/ clarification from treating hospital about the need for admission for this patient and there are responsive remarks “for diagnosis and treatment optimization and decision on PEG insertion” (on letter dated 01.04.2017 at page no. 48) and there are also remarks “admitted for evaluation and doing optimization” (on letter dated 06.04.2017 at page no. 50).
6.5. The discharge summary (page 29-33) is in detail, minute information, observation, examination, investigation, discussion, condition at discharge and recommendations have been detailed, from the time patient was brought to the hospital till his discharged with certain recommendations. It also mentions about evaluation done at other hospital. The relevant portion is, for the purposes of present complaint, (at page 30) “he was admitted for further evaluation and treatment”, this summary was written on 06.04.2017, which was subsequent to letter dated 01.04.2017 at page 48 and on 06.04.2017 at page 50 as well as email of 03.05.2017 (page 19) mentions that hospitalization for diagnosis and treatment optimization only. The terms medical treatment has not been defined in the policy issues, generally 'medical treatment' means the management and care of patient to combat disease or disorder. Further, regarding 'barium swallow test', it may be performed an outpatient procedure or as part of stay in the hospital. The way test is done may vary depending upon condition and health care provider's practice. To say, the patient was admitted not only for evaluation but also for treatment; there are both component evaluation and treatment.
6.6. Moreover, OP1 had reservation that there was no active treatment followed or there is exclusion clause 4.10. Its answer is also in discharge summary, which not only gives the history but also evaluation and treatment being followed and to be followed, as it mentions (at page 33) “he has been planned for barium swallow for swallowing assessment and to decide on PEG insertion in view of swallowing difficulty”. It also mentions about feeding options discussed with the son of patient and other course of action including physiotherapy etc. It has also been recommended to do Braium swallow study and review and to follow in neurology OPD after 3 months. The circumstances are suggesting that evaluation and treatment is in continuous process but OP1 contends that it should have been immediately active course of action but the nature of disease talks about continuous evaluation and treatment as recommended. Therefore, the plea of OP does not sustain to invoke the exclusion clause 4.10 against the complainant. The complainant is held entitled for reimbursement of medical bills.
7.1 Consequently, the complainant has established facts of his case of deficiency of service as well as unfair trade practice against OP1 as on the face of record it is manifest that the claim was wrongly declined, the complainant was deprived of cashless facility and he had to pay the medical bills from his own pocket for the treatment of his father/beneficiary. Therefore, complainant is held entitled for reimbursement of amount of Rs.77,204.62p in respect of hospitalization/medical expenses.
7.2. The complainant had paid the amount from his pocket, had it been reimbursed, he would not have been deprived of his money. In addition, there is no concrete evidence of rate of interest of 18% pa as claimed by complainant but it would serve both ends if interest at the rate of 7 % pa is determined. Thus, interest at the rate of 7% pa from the date of complaint till realization of the amount is determined in favour of complainant and against the OP1.
7.3. The complainant seek compensation of Rs.5,00,000/- on account of mental agony and other trauma suffered. By taking into account all the circumstances, especially the relief of reimbursement of hospitalisation/medical expenses are allowed, the complainant is also held entitled for compensation since he had to pursue a lot. Therefore, damages/ compensation of Rs. 15,000/- is allowed in his favour and against the OP1. Cost of Rs. 5,000/- is quantified and allowed in his favour and against OP1.
7.4. No order against OP2/TPA.
7.5. The complainant has introduced facts about hospitalization of his father from 21.01.2018 to 13.02.2018, however, it was not a cause of action in the original complaint, therefore, no finding is being given is respect of this tenure of hospitalization etc, the facts were mentioned in replication as a passing reference.
8. Accordingly, the complaint is allowed in favour of complainant and against the OP1, while directing OP1 to pay bills amount of Rs.77,204.62p along-with interest @7% pa from the date of complaint till realisation of amount, damages/compensation of Rs.15,000/- apart from costs of Rs. 5,000/-. OP1 is also directed to pay the amount within 30 days from the date of receipt of this order.
In case amount is not paid within 30 days from the date of receipt of order, the OP1 will be liable to pay interest at the rate of 9% per annum on amount of Rs.77,204.62p from the date of filing of complaint till its realization. No order against OP2/TPA as held in sub-paragraph 7.4 above.
9. Announced on this 6th July 2023 [आषाढ़ 15, साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
