Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-10/2021
1. Rajinder Gulati s/o Dr. B.M. Gulati
R/o C-1/30, Mianwali Nagar, Rohtak Road, Delhi-110087
2. Ms. Anchal Gulati d/o Rajinder Gulati
R/o C-1/30, Mianwali Nagar, Rohtak Road, Delhi-110087 …Complainants
Versus
OP1- The Divisional Manager
The Oriental Insurance Company Ltd.
16/20, WEA, Ist Floor, Padam Singh Road,
Near Shastri Park, Karol Bagh, New Delhi-110005.
OP2- D.G.M. –Incharge, Regional Office-I,
Hansayla Building, Bara Khamba Road,
Connaught Place, New Delhi-110001
OP3- Raksha Health Insurance TPA Pvt. Ltd. ,
14/3, Mathura Road, Faridabad, Haryana ...Opposite Parties
Senior Citizen Case
Date of filing: 13.01.2021
Date of Order: 24.07.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Inder Jeet Singh, President
ORDER
1.1. (Status of the parties)- Complainant no. 2 Ms. Anchal Gulati is an employee of Bennett Coleman & Co. Ltd. and she is beneficiary of Group Medical Insurance Policy no. 21200/48/2019/831 with effect from 01.06.2018 to 31.05.2019, which has been obtained by her employer Bennett Coleman & Co. Ltd. from OP1/ the Oriental Insurance Co. Ltd.. OP2 is In-charge, Regional Office-I of the Oriental Insurance Co. Ltd. its supervises the functioning of OP1 and also of TPA/OP3 Raksha Health Insurance TPA Pvt. Ltd., who is engaged by OP1 to process and settle medical claims as well as cashless facility, apart from reimbursement of medical claims. Complainant no. 1 is father of complainant no. 2, he being father and one of the family members, is entitled to the benefits under the Group Mediclaim Insurance Policy.
1.2. (Introduction to disputes of the parties) – The complaint was filed with allegations of deficiency of services as complainant no.1 because of medical exigencies reported to emergency of the Max Super Specialty Hospital, Shalimar Bagh, New Delhi. He was admitted as indoor patient and treatment was given to him and after four days he was discharged, however, the cashless facility was denied and later valid medi-claim was repudiated without any cogent reasons. That is why complaint has been filed for reimbursement of the amount of Rs. 56,586.72/- along with interest at the rate of 12% pa from 12.03.2019 till realization of amount, apart from Rs. 10,000/- as post operative treatment expenses. He also claims compensation of Rs. 1,00,000/- for harassment, mental pain and agony besides cost of Rs. 33,000/-.
1.3. Whereas the complaint has been opposed by the OP1 and the OP2 by their joint written statement that complaint is not bona-fide, there is no deficiency of any services on their part and as per complainants’ own record, inclusive of discharge summary, “the patient was kept on oral tablet, can be managed on OPD basis”. Moreover, there was deficiency of documents on the part of complainants and as per clause 4.10 of the policy that “expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes, which is not followed by active treatment for ailment during the hospitalization period”. The claim was rightly repudiated.
OP3 also opposed the complaint that it is Third Party Administrator and by virtue of MOU between OP1 and OP3, it is nominated for arranging to process the claim of insurance policy as per norms and conditions laid down by OP1, consequently appropriate recommendation for repudiation was made. The OP3 is just a facilitator for processing the claims. Its name is liable to be strike off from the array of parties in the complaint.
2.1. (Case of complainant) – The complainant no. 1, aged about 61 years, a senior citizen was admitted at late night at Max Super Specialty Hospital, Shalimar Bagh, New Delhi with backache associated with pain radiating to left leg, burning sensation in left foot, difficulty in walking etc. and was diagnosed acute lumbosacral radiculitis with lumbar canal stenosis (increases since last two days). He had anxiety on admission and he is known case of CABG and HTN that justifies admission. Because of anxiety and other co-morbidities, since complainant no. 1 is known heart patient was admitted for further evaluation to the Max Hospital late at night in an emergency condition.
2.2. He was started with treatment with IV-fluids, IV-antibiotics and other supportive medication, MRI spine lumbar was done, which had shown discoverterbral degenerative changes as mentioned most marked at L4-L5 level. There were other tests and monitoring, MRI was done in the middle of night due to emergency. The complainant no. 1 was administered injection depomedrol in left sacroiliac joint under all aseptic precautions on 04.012019 in the operation theater. He was admitted in the hospital in the night of 01.01.2019 and he was discharged on 04.01.2019 with advised medication and rest at home, which complainant no.1 continued inclusive of medication and physiotherapy for months together and it is still continuing.
2.3. The complainant no.1 incurred medical expenses of Rs.46,586.72p during his hospitalization for medical treatment from 01.01.2019 to 04.01.2019, the claim along-with original medical treatment documents bills etc., were directly forward to OP3/TPA for settlement of the claim but it was refused on 04.01.2019 by OP3 with remarks “patient kept on oral tab can be managed on OPD basis, hence cashless facility cannot be provided kindly submit for reimbursement”.
It was taken up again with OP3 but it was again declined by letter dated 12.03.2019 and it was finally repudiated on 27.03.2020 on the ground that it violates clause no. 4.10 and the treatment given can be done on day care or OPD basis. Whereas, the components of treatment, apart from IV. medi-cation, MRI, the complainant no. 1 was also operated upon in the operation theater, which cannot be done in the day care or OPD basis. The complainant no. 1 has also spent a sum of Rs.10,000/- approximately on account of post operative medical treatment, physiotherapy etc., which are other than hospitalization treatment expenses of Rs.46,586.72p. In fact, the medical policy issued for the beneficiaries/ complainants was cashless but complainants were forced to pay the medical bills and expenses at the time of discharge on 04.01.2019.
The repudiation of valid claim is on vague and flimsy ground that the treatment/ hospitalization was in violation of exclusion clause 4.10 of the policy. The OP1 and OP2 have not denied or repudiated the claim but it is OP3 who finally denied the claim on 27.03.2020 on vague and flimsy grounds. There is deficiency of services for want of providing proper facilities in terms of policy condition and it has caused harassment, mental agony and pain for which complainant deserves compensation apart from other reimbursement of valid claims of medical bills/ expenses.
3.1 (Case of OP1 and OP2)- OP1 and OP2 filed their joint reply. The status of insurance policy is not denied. However, they opposed the claim vehemently that complainants came before the Commission without clean hand and by suppressing the true and material facts; there is breach of terms of policy, there is no cause of action in favour of complainants and against the OPs and complaint is abuse of process of law. There is no deficiency of services on the part of OPs and as per clause no. 4.10 of the policy (already reproduced in para no. 1 above), the claim was repudiated.
3.2. The complainants have filed only two pages of insurance policy and factually the policy is in 4 pages, apart from terms and conditions of policy, which also includes clause no. 4.10, the same are being filed with the written statement. However, the policy was not issued in the name of complainant no. 2 but the complainant no. 1 is beneficiary in the policy.
As per discharge summary of complainant no. 1 and investigation reports, MRI spine lumber was done on 02.01.2019 and not in the middle of night due to emergency; the complainant mentions administration of Inj. depo-medrol in the operation theater on 04.01.2019, it is the date of discharge. There is no record of prescription for physiotherapy, otherwise bills of physiotherapy has also not been filed. OP3/TPA declined the cashless facility, it was based on medical related documents, since it was observed that patient was kept on oral tablet, which can be managed on OPD basis; it was also informed by communication dated 04.01.2019. OP3 had not repudiated the claim by letter dated 12.03.2019 whereas, by letter dated 13.02.2019 and other letters dated 11.02.2019 and 28.02.2019, the complainant no.2 was requested to submit certain documents for processing the claim but documents were not received by OP3, that is why final reminder dated 12.03.2019 was issued to furnish the documents within 15 days, failing which the claim shall be repudiated, if no reply is received. There was also no repudiation by letter dated 27.03.2020, since the letter was sent by OP3 to OP1; it was not addressed to and meant for complainants at all. It was recommendation for repudiation by OP3 to OP1, that too based on record. Moreover, the OP1 also sent pre-repudiation letter dated 29.03.2019, to complainant no. 1 at her official address informing them that their claim is liable to be repudiated as per clause no. 4.10 of the policy and they are given one more opportunity to send necessary clarification within 2 weeks from the date of receipt of letter, failing which the claim shall stand repudiated. Thus, on 22.04.2019 the claim was repudiated by OP1 after examining the reply/document furnished but no new fact had emerged.
3.3. In the discharge summary, no-where it is mentioned that the complainant no. 1 was operated nor there is any document to prove the operation of complainant no. 1, the complainant failed to furnish the record despite requisition from them. There is no prescription of physiotherapist or bills pertaining to the same of Rs. 10,000/-. There could not be any scope for grievances of cashless facility as the circumstances explained were from the scrutiny of record furnished.
3.4. Since the claim was assessed and repudiated within the parameters of terms and conditions of the policy vis-à-vis for want of furnishing the relevant record, there is no deficiency of services on the part of OPs to be liable for reimbursement of medical claim or any damages whatsoever. The complaint is liable to be dismissed.
3.5. (Case of OP3) - OP3 explains that it is a registered company under the Companies Act, it is licensed TPA under IRDA Act, 2008 to act as a facilitator for the processing of the claim.
The OP3 also opposed the complaint that it is Third Party Administrator and by virtue of MOU between OP1 and OP3, it is nominated for arranging to process the claim of insurance policy as per norms and conditions laid down by OP1, consequently appropriate recommendation for repudiation was made. The OP3 is just a facilitator for processing the claims. Its name is liable to be strike off from the array of parties in the complaint. The complaint is liable to be dismissed qua OP3.
4. (Replication of complainant) – The complainant filed rejoinder to the joint reply of OP1 and OP2 and allegations of written statement are denied in-toto except the admitted facts by the OPs. The replication also reiterates the complaint and its contents again to reaffirm accompany. The complainant also explains that there is an addendum to the discharge summary in respect of investigations and treatment, to be read in totality instead of in piece-meal. There was also surgery at point 85 Epidural (Aneas) on 03.01.2019.
5.1. (Evidence)- Complainant Sh. Rajinder Gulati filed his detailed affidavit of evidence along with the documents, which he had filed with the complaint; which comprises copy of insurance policy, discharge summary along with addendum, investigation reports, receipts of bills paid to the hospital, detail of bills, correspondence received from OP3, legal notice sent to OP1, OP2 and OP3, track report of service of legal notice.
5.2. OP1 and OP2 filed affidavit of Sh. Shishyapal, Manager In-charge, Legal Cell, the Oriental Insurance Co. Ltd. as their evidence, it is detailed affidavit on the lines of written statement. The evidence refers documents, which were filed with the written statement; those documents are insurance policy (4 pages), terms and conditions of the policy, copy of discharge summary, copies of letters and pre-repudiation letter dated 29.03.2019 and repudiation letter dated 22.04.2019 in support of their plea.
5.3. Whereas OP3 has not led any evidence since it abstained from appearance after filing the reply.
6. (Final hearing)- The complainants and OP1 & OP2 filed their respective written arguments and it was followed by oral submissions by complainant no.1 (practicing Advocate) for complainants and Sh. Kanwar Kochhar, Advocate for OP1 & OP2. The contentions of both the sides are not repeated here as the same will be dealt appropriately.
Complainant no.1 during oral submissions fortifies his contentions while replying upon Canara Bank vs United India Insurance Co. & Ors. I (2020) CPJ99 (SC), wherein insurance policy pertaining to fire accident in cold storage and losses happened to farmers were dealt with, it was held that coverage provisions should be interpreted broadly and if there is any ambiguity, the same should be resolved in favour of insured vis-à-vis exclusion clauses must be read narrowly. Further reliance is also placed on Karnavati Veneers Pvt. Ltd. vs New India Assurance Co. Ltd. AIR 2023 SC 987 that when material documents are available with the insured and they were also examined by the surveyor, who had assessed the loss after inspection of spot as well as the assessment of surveyor was not disputed by the insurance company, it was held that repudiation of claim was not sustainable and interest was allowed from the date of surveyor’s report.
7.1 (Findings)-The rival contentions are considered, keeping in view the material on record as well as the oral explanations in the form of submissions of the parties. The crucial issue raised by the OP1 & OP2 is that complainant was admitted an indoor patient for evaluation and diagnosis but it was manageable in OPD, it is not covered under the policy. Whereas, the complainants explains the exigencies that it was treating doctors/hospital who admitted the complainant no. 1 as indoor patient, as the treatment given to him could not be possible in OPD but as indoor patient.
Secondly, there are also juxtaposition stand with regard to contents of discharge summary, as OP1 & OP2 contend that the component of surgery is not mentioned in discharge summary and administration of injection Depomedrol is mentioned in addendum.
7.2.1 There are rival plea on the point of repudiation letters as well as reasons of repudiation of claim. First of all point of repudiation letters will be discussed in this paragraph and the other point will be discussed in the next paragraph.
According to complainant the repudiation letter was issued on 12.03.2019 by OP3 (Annexure-C, at page-16 of the complainant’s paper book) and then on 27.03.2020 by OP3 (Annexure-C, page-27). The complainant has not received any other letter dated 29.03.2019 and 22.04.2019 (being relied upon by the OP1 & OP2 as Annexure-F & G, at pages no. 34 & 35 of the paper book of OPs). Since the repudiation letters were issued on 12.03.2019 and 27.03.2020, the same were received and filed with the complaint.
7.2.2. Whereas, on the other side OP1& OP2 have reservation that letter dated 12.03.2019 was not a repudiation letter but it was a final reminder, when certain documents were sought inclusive of certificate from the treating doctor justifying indication for hospitalization in the case. The original papers were also with the complainant. The same were not furnished. The OP1’s letter dated 29.03.2019 was written to complainant no.2 seeking certain information and documents and also she was apprised about clause no. 4.10 vis-à-vis it was also informed in writing that in case information is not furnished, it may be a ground for repudiation of claim; this letter was sent to complainant no.2 at her official address. OP1’s other letter dated 22.04.2019 Annexure-G is the repudiation letter, which was written to complainant no. 2 addressed to her office address that for want of furnishing the record as well as by scrutinizing the record made available, it was found that patient was admitted and diagnosed at acute lumbosacral radiculitis with lumbar canal stenosis, which can be managed on OPD as well as deficiency of documents. Then, the claim was repudiated. However, the complainants have relied upon letter dated 27.03.2020, it was never issued to complainants, it was a letter written by OP3 to OP1; the OP1 & OP2 never written this letter to the complainants.
7.2.3. The detailed submissions of parties are self-explanatory. The letter dated 12.03.2019, on the face of it, is a final reminder. The OPs have also proved similar letters dated 11.02.2019, 13.02.2019, 28.02.2019 and 22.03.2019 being final reminder to complainant no. 2 to furnish the record and other information. The same are not the repudiation letter on the face of it. Moreover, OP1’s letter dated 29.03.2019/Annexure-F is also not a repudiation letter, the letter specifically highlights immediately above date mentioned, as ‘Pre-Repudiation Letter’ and in the conclusion of that letter it is also mentioned that in case the compliances are not done, there may be repudiation of the claim. Thence, by other letter dated 22.04.2019 Annexure-G, after considering response thereto, the claim was repudiated. Therefore, the claim was repudiated on 22.04.2019 and not on other dates of 12.03.2019 and 27.03.2020.(the letter of 27.03.2020 is inter-se correspondence between the office of OP3 and office of OP1).
Now, the other issues being taken.
7.3. The record is also assessed and by taking stock of events narrated by the complainant read with documentary record, keeping in view the submissions of both sides, the following conclusions are drawn:-
(i) The OPs have established letters that certain documents were sought from complainant no. 2 in respect of treatment of complainant no. 1.The complainant no. 1 has also filed one of such letters dated 12.03.2019, being final reminder, however, there is nothing established by the complainants that record was furnished to OPs in response to that letter.
(ii) The rival plea is with regard to management of the ailment either as indoor patient or it would be managed in OPD; the complainant himself narrates that since he had undergone CABG as well as at the time of admission he was suffering from severe pain in lower half of the body, high BP with severe anxiety, when in the emergency. The complainant no. 1 was also given injection Depomedrol on 04.01.2019. He was performed surgery on 03.01.2019 at point 85 Epidural (Aneas), as mentioned in paragraph 3 of the rejoinder. Whereas, the OPs have reservation that administration of injection Depomedrol is not mentioned in his discharge summary as well as there was addendum, which mentions about this injection, but it was on the date of discharge, which suggests that the ailment was manageable in OPD and not as Indoor patient. The patient was given tablets, which also show all was about evaluation and diagnosis. The medical papers show that the patient was examined just for the purposes of evaluation. MRI was also not done in midnight.
(iii) It is matter of record of discharge summary that the name of injection Depomedrol was not mentioned initially but there was addendum of summary prepared on 11.01.2019 that injection Depomedrol administered on 04.01.2019, which is also the date of discharge.
(iv) There is corresponding record of medical bills with the discharge summary, however, there is no billing of any amount of injection Depomedrol. Therefore, the addendum discharge summary in respect of injection Depomedrol is not reconciling with the bills.
(v) Similarly, there is a bill of 03.01.2019 in respect of Epidural (Aneas), under the heading surgery, amongst other items of bills, however, there is no reference of such surgery in the discharge summary or in the addendum discharge summary. To say the discharge summary as well as the billing are not reconciling in respect of surgery.
(vi) The complainants have not referred about the surgery in the entire complaint but it was mentioned in the rejoinder after filing of reply by the OPs. However, the complainant has filed and proved his legal notice dated 15.12.2020 (Annexure-E/page-25 of complainant’s paper book) which does not mention any surgery or Epidural (Aneas). Thus, the discharge summary dated 04.01.2019, addendum discharge summary dated 11.01.2019, legal notice and the complaint are reconciling each other, to the effect they do not mention about such surgery.
(vii) The OPs had sought information and documentary record from the complainant no. 2, apart from certificate from the treating doctor justifying the admission, however, as appears no such records was furnished nor such record is filed in the complaint except complainant’s own version about the statement of his health on the date of admission. The record filed is not supporting the claim and plea of complainant with regard to surgery and requirement of admission for necessary investigation evaluation and active treatment.
(viii) As per terms & conditions of policy clause no. 4.10, proved by the OPs, the expenses for evaluation/diagnostic purposes are not covered but excluded from the purview of policy.
7.4. The conclusion drawn in the aforementioned paragraphs and sub-paragraphs, do not make out case of deficiency of services against OPs, since the parties are governed by terms & conditions of the policy and the facts proved do not complaint.
8. The complaint fails. The complaint is dismissed.
9. Announced on this 24th July 2023 [श्र!वण 2, साका 1945].
10. 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
