Haryana

Panchkula

CC/167/2020

SUKHWINDER SINGH SANDHU. - Complainant(s)

Versus

UNITED INDIA INSURANCE COMPANY LTD. - Opp.Party(s)

08 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

 

                                                       

Consumer Complaint No	:	167 of 2020
Date of Institution	:	25.06.2020
Date of Decision	:	08.04.2022

 

Sukhwinder Singh Sidhu, resident of House No.5948, Modern Housing Complex, Manimajra, Chandigarh-160101.

                                                                           ….Complainant

Versus

1.     United India Insurance Company Limited, UIIC, Corporate Cell, Vulcan Insurance Building, Ground Floor, 77, V.N.Road, Churchgate,    Mumbai-400020, through its Authorised Signatory.

2.     United India Insurance Company, Regional Officer, SCO-123-124,      Floor No.3, Sector-17-B, Chandigarh-160001, through its Regional      Manager.

3.     M/s Heritage Health TPA Private Limited, Nicco House, 5^th Floor, 2^nd    Hare Street, Kokotta-700001, through its authorized signatory. 

4.     Artemis Hospital, Sector-51, Gurugram-122001(Haryana), through      its authorized signatory.

                                                                    ….Opposite Parties

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019.

 

Before:              Sh. Satpal, President.

Dr. Pawan Kumar Saini, Member.

Dr. Sushma Garg, Member.

 

For the Parties:   Sh.Vinod Mahendru, Advocate for the complainant. Sh.Madan Lal Chaudhary, Advocate for OPs No.1 to 3.

                        Sh.Rohit Goswami, Advocate for the OP No.4.

ORDER

(Satpal, President)

1.             The brief facts of the present complaint are that the complainant is working as an Officer with UCO Bank at Chandigarh and its employer purchased  Group Health Insurance Policy for its employee vide Policy No.5001002818P109953495 valid from 01.10.2018 to 30.09.2019 from the OP No.1 against premium  of Rs.15,483/- per family without GST. The sum insured for each officer as per the Policy Schedule is Rs.4,00,000/- per year per member and in a critical illness Rs.1 lac per  employee is further given to the beneficiary/complainant. Therefore, the complainant is covered for insurance to the extent of Rs.5 lac. Since the complainant was not well and he got treatment from Allahbad and thereafter, he was admitted in Noida Hospital and did not improve there; ultimately, the complainant was shifted and admitted in Alchemist Hospital, Panchkula on 11.12.2018 with a complaint of Headache/ vertigo/vomiting x 12days and altered behavior x 3 days. The attending Doctor Anurag Lamba at Alchemist Hospital diagnosed the complainant for Cerebral Venous Thrombosis Left IJV, left Signoid, left transverse and suprasaggital sinus, seizure/right hemiparesis. The Hospital had charged a sum of Rs.85,245/- from the complainant and was discharged on 14.12.2018. Since the complainant was not completely cured, the Alchemist Hospital referred him for treatment to Artemis Hospital, Gurugram, where he was admitted on 14.12.2018 with a case of cerebral venous Thrombosis referred for Ophthalmic assessment. Attending Doctors in Artemis Hospital, Dr.Vipul Gupta/Dr.Rajshri Niwas Parthasarthy started the treatment of complainant. The complainant remained admitted in Artemis Hospital for nine days and discharged on 22.12.2018. The Artemis Hospital had charged a sum of Rs.6,72,256/- from the complainant. The complainant lodged the claim with the OP No.3, a third party administrator vide letter dated 15.02.2019 for hospitalization under Policy ID HH58.0700381304, wherein all the formalities were completed and the documents were sent to the OP No.3  for processing the claim. In response to letter dated 15.02.2019, the OP No.3(TPA) sent e-mail dated 19.03.2019 seeking certain queries  and the complainant  replied to the same vide letter dated 03.04.2019 mentioning that, at the time of hospitalization, he was not conscious and only for this reason, he could not intimate the OP insurance company within the prescribed time as per the Health Insurance Policy and that the complainant was in ICU for the first three days and was under heavy medication and in trauma. Reply to other queries were also given by the complainant vide his letter at serial no.1 to 5. Vide query no.4, it was stated that the photo copy of original sticker of implant was attached with the letter and the complainant also indicated that he is in the process of obtaining an attested copy of the original sticker of the implant from Artemis Hospital and the same shall be submitted on its receipt. The complainant vide letter dated 11.04.2019 informed the OP No.3 that though he has already submitted the photocopy of sticker of implant but through this letter attested copy of the original sticker, attested by Dr.Vipul Gupta, was also submitted to the OP No.3 for processing the claim wherein they had claimed that the original sticker of the implant is in the possession by the Artemis Hospital. Further, the complainant received e-mail dated 06.05.2019 from the OP no.3 still desiring therein to submit the original sticker of the implant though it was already sent. On the same day i.e. 06.05.2019 the complainant replied to the e-mail dated 06.05.2019, wherein the complainant has mentioned that he has attached the consignment note and delivery report of this letter and again forwarded scanned copy of the signed and stamped sticker of the implant. The Artemis hospital had already stated to the complainant that the original sticker is a part of record of the Hospital file and in case, insurance company/OPs wants to verify the original sticker of implant, the OPs may contact Artemis Hospital, Gurugram. The OP No.3 through telephone on 25.05.2019 asked the complainant to submit a certificate from the Artemis Hospital in lieu of original sticker of implant. The complainant vide letter dated 05.06.2019 submitted the required certificate dated 03.06.2019 issued by attending Dr.Vipul Gupta. Even after receiving the desired certificate dated 03.06.2019 issued by the Artemis Hospital, Gurugram, as per their requirement, the OPs did not bother to reply and arbitrarily, illegally closed the file, which the complainant could know only through the website, which amounts to delay, deficiency and commission of unfair trade practices; hence the present complaint.

2.             Upon notice, OPs No.1 to 3 appeared through counsel and filed written statement raising preliminary objections qua complaint is not maintainable being baseless and false; the complainant does not fall within the definition of a consumer; not come with clean hands; suppressed the material facts and no territorial jurisdiction. On merits, it is stated that all claims under insurance policy are being settled strictly according to terms and conditions of the policy. The main clauses of the policy are mentioned as under:-

i)      Clause 1.2 Basic Cover sub clause-1.2 is defined as under:-

“In the event of any claim becoming admissible under this scheme, the company will pay to the Hospital/Nursing Home or insured person the amount of such expenses as would fall under different head mentioned below and as are reasonably and medically necessary incurred thereof by or on behalf of such insured person but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.” Further in clause 3 sub clauses 3.3 it has again been mentioned that Company’s Liability in respect of any/all insured person/s during the period of insurance shall not exceed the Sum insured stated in the  schedule.

ii)      Clause 5. Claim Procedure, Sub clause-B. Notification of claim there is following provision:-

Notification  of claim in case of cashless facility	TPA must be informed:
In the event of planned hospitalization	At least 72 hours prior to the insured person’s admission to network provider/PPN hospital
In the event of emergency hospitalization	At least 24 hours of the insured person’s admission to network provider/PPN hospital.
Notification of claim in case  of reimbursement	TPA must be informed:
In the event of planned hospitalization	At least 72 hours prior to the insured person’s admission to hospital
In the event of emergency hospitalization	At least 24 hours of the insured person’s admission to hospital

 

But in the present case, the complainant was admitted to hospital on 11.12.2018 and notification of claim was received by TPA on 25.02.2019 i.e. after delay of 76 days which is clearly breach of policy terms and conditions.

ii)      Clause 5. Claim Procedure, Sub clause-E Documents-(vii) Original invoice with payment receipt and implant stickers for all implants used during Surgeries i.e. Lens sticker and invoice in cataract surgery, stent invoice and sticker in Angoplasty Surgery. On 25.02.2019, the OP No.3 received claim of complainant for treatment with incomplete information and documents and the OP No.3 vide email dated 19.03.2019 requested the complainant to supply the following information:-

1. Provide, the claim intimation copy duly received by us or bank, if the same not yet reported, kindly clarify  the reason(intimation must be submitted within 72 hours in case of planned  hospitalization and within 24 hours in case of emergency from date of admission.
2. Provide the cause of delay submission of claim documents(claim documents related with hospitalization & pre hospitalization period expenses must be submitted within 15 days from date of discharge.
3. Provide the original breakup bill against the hospital bill for Rs.672256.05 from Artemis Hospital.
4. Provide the all original sticker of implant.
5. Provide the all original investigation reports from Artemis Hospital.

But despite repeated requests from OP No.3. On 17.04.2019, 06.05.2019, 25.05.2019, 19.06.2019 and 04.01.2020, the complainant failed to supply all the original stickers of implant whereas, these are the mandatory documents to settle the claim and is clearly mentioned in the policy document. Further, the complainant had failed to provide original stickers of implant which is pre-requisite to settle the claim despite demanding a number of times and hence his claim was closed. There is delay and deficiency on the part of complainant as well as proforma OP No.4 and the complainant should seek relief from OP No.4 who is not providing him the original implant stickers. So, there is no deficiency in service and unfair trade of practice on the part of OPs No.1 to 3 and prayed for dismissal of the present complaint.

                Upon notice, OP No.4 appeared through counsel and filed written statement raising preliminary objections qua complaint is not maintainable being baseless and false; no territorial jurisdiction; no cause of action. On merits, it is stated that the complainant was admitted in the hospital of OP No.4 on 14.12.2018 for the treatment of Cerebral Venous Thrombosis, the complainant remained admitted for 9 days and he was discharged on 22.12.2018. It is also submitted that the complainant has specifically mentioned in his complaint that the OP No.4 is proforma party. So, there is no deficiency in service and unfair trade of practice on the part of OP No.4 and prayed for dismissal of the present complaint.

3.             To prove his case, the learned counsel for the complainant has tendered affidavit as Annexure C/A along with documents Annexure C-1 to C-16 in evidence and closed the evidence by making a separate statement. On the other hand, the learned counsel for the OPs No.1 to 3 has tendered affidavits Annexure RA & Annexure RB alongwith document Annexure R-1 & R-2 and closed the evidence. The learned counsel for OP No.4 has tendered affidavit as Annexure R4/A and close the evidence.

4.             We have heard learned counsels for the complainant as well as OPs No.1 to 3 & OP No.4 and gone through the entire record available on record including written arguments & additional written arguments filed by the learned counsel on behalf of the complainant, OPs No.1 to 3 and OP No.4, minutely and carefully.

5.             It is not in dispute that the complainant, during the validity period of insurance policy no.5001002818P109953495, was, initially hospitalized in the Alchemist Hospital Panchkula w.e.f. 11.12.2018 to 14.12.2018 and thereafter, in the Artemis Hospital, Gurugram(OP No.4) w.e.f. 14.12.2018 to 22.12.2018, in connection with treatment relating to the ailment of cerebral venous Thrombosis. It is also not in dispute that the Alchemist Hospital, Panchkula charged a sum of Rs. Rs.85,245/- from the complainant vide bill dated 14.12.2018 (Annexure C-3) and that the Artemis Hospital, Gurugram(OP No.4) charged a sum of Rs.6,72,256/- from the complainant vide bill dated 22.12.2018 (Annexure C-5). Further, the lodging of claim no.HH871959136(AnnexureC-6(colly)) by the complainant with OP No.3 i.e. M/s Heritage Health TPA Private Limited claiming the reimbursement of the amount as spent during the treatment is also not disputed. The OP No.3. i.e. M/s Heritage Health TPA Private Limited, after seeking certain documents and clarifications from the complainant, closed the claim on 23.11.2019 mainly on the ground of non submission of original sticker of implants by the complainant. As per version of the complainant, he had sent the photocopy of relevant sticker of implant on 03.04.2019 to OP No.3 and thereafter, sent the signed and stamped copy of implant on 11.04.2019, followed by scanned copy of signed and stamped implant alongwith consignment implant description Neuro DSA Lab(Annexure C-12) and finally, the copy of certificate issued by treating Doctor(Annexure C-14) on 05.06.2019 to OP No.3 but the claim was, ultimately, closed by OP No.3 on the ground of non submission of original sticker of implant by the complainant.

6.             The present complaint has been contested by OPs No.1 to 3, apart from merits, by raising preliminary objection qua maintainability of the complaint stating that this Commission lacks territorial jurisdiction to entertain and decide the present complaint. This objection is rejected in view of the fact that, undisputedly, the complainant was initially hospitalized for his treatment in Alchemist Hospital Panchkula w.e.f. 11.12.2018 to 14.12.2018, which is within the jurisdiction of this Commission.

                The next objection is that the complainant does not fall under the category of a consumer. This objection is also rejected being baseless and meritless as the complainant was duly insured, on the basis of premium paid by him, vide Group Health Insurance Policy No.5001002818P109953495 with its validity w.e.f. 01.10.2018 to 30.09.2019.

                On merits, the complaint has been contested on two separate objections. The first objection is that the claim was not lodged within the stipulated period as required vide clause 5(b) of the terms and condition of the insurance policy. No doubt, the claim was lodged on 25.02.2019 with a delay of 76 days but the delay was duly explained and justified by the complainant vide his reply(Annexure C-8(colly)) sent to the OP No.3 on 03.04.2019 mentioning that at the time of hospitalization, he was not conscious and thereafter, he was under heavy medication and in trauma and thus, his mental state was not normal. It is relevant to mention here that the OP No.3, after the receipt of said reply from the complainant, wherein delay in lodging the claim was duly clarified and justified, did not seek any further clarification from the complainant on this count and thus, the objection pertaining to the delayed lodging of the claim was deemed to have been dropped by the OP No.3 itself. Even otherwise, it is pertinent to mention here that OPs No.1 to 3 have not disputed or doubted the health condition of the complainant, which prevented him to lodge the claim with the OP No.3 in stipulated period and thus, the plea of delay in lodging of the claim as taken in the written statement of OPs No.1 to 3 is of no avail to them.

                The second objection is that original sticker of implants has not been submitted by the complainant for the processing as well as settlement of the claim in question. In this regard, the learned counsel for the Ops No.1 to 3 contended that the submission of original sticker of implants was a pre-requisite as per clause 5(E) of the terms and conditions of the Insurance Policy. It is contended that all claims are settled as per terms and conditions of the Policy and thus, OPs No.1 to 3 cannot settle the claim in violation of the terms and condition of the Insurance Policy. Concluding the arguments, it is contended that OP No.4 i.e. Artemis Hospital, Gurugram can retain the photocopy of stickers of implant and provide original stickers to the complainant for onward transmission of the same to OPs No.1 to 3 for the settlement of the claim.

7.             The core issue in the present complaint is the non submission of original sticker of implants with the OPs No.1 to 3. As per version of OP no.4, the original stickers of implants were duly delivered to the complainant, while he was discharged from the hospital on 22.12.2018. It is contended by the ld. counsel for the OP No.4 that the complainant had paid the entire treatment charges amounting to Rs.6,72,256/- at his own level at the time of his discharge and thus, as per the policy of hospital, original implants were handed over to him.

                Although, as per version of OP No.4, the complainant was handed over the original stickers of implants alongwith original bills, discharge summary, Lab and Radiology report etc. at the time of his discharge on 22.12.2018 as per policy of the hospital but no documentary proof qua the receipt of original stickers by the complainant from the hospital as alleged has been submitted on record by OP No.4. Moreover, no such policy of hospital as alleged by OP No.4 regarding delivery of the original implants to its patient has been placed on record. On the other hand, as per the complainant, the original stickers were not handed over to him and thus, there is a serious dispute between the complainant and OP No.4 with regard to the custody of original sticker of implants in question.  

8.             We need not to go into the controversy as to where the original stickers are lying, keeping in view, the facts that the complainant has, admittedly, submitted the signed and stamped copy of stickers with the OP No.3, apart from consignment implant description Neuro DSA Lab (Annexure C-12) and certificate dated 03.06.2019(Annexure C-14) issued by the treating Doctor, namely, Dr.Vipul Gupta. A perusal of consignment implant description Neuro DSA Lab (Annexure C-12) shows that it contains the details of the implants, challan numbers as well as the name of the complainant alongwith the name of treating Doctor. The recitals contained in the said consignment implant description Neuro DSA Lab(Annexure C-12) completely match with the details of implants as given in the certificate(Annexure C-14) issued by Dr.Vipul Gupta. For the sake of convenience and clarity, we deem it expedient to reproduce the contents of the said certificate as under:-

                                      Artemis  Hospital                                                                                                                  Dated 03.06.2019

                             TO WHOMSOEVER IT MAY CONCERN

          This is to certify that Mr. Sukhwinder Singh Sidhu(GN0000571187) was admitted in Artemis Hospital from 14.12.2018 to 22.12.2018 with diagnosis of cerebral venous thrombosis superior saggital sinus, left transverse sinus  and left IJV).

          He underwent procedure Mechanical Thrombectomy for cerebral venous thrombosis on 14.12.2018(implants  used during the procedure).

Implant details:-

1. Traxcess 14

Lot No – 180727

2. Rebar 27

Lot No –A678921

3. ACE 68

Lot No – F84642

4. Neuron Max

Lot No – F82982

 

Dr.Vipul Gupta

 

9.             After the receipt of signed and stamped copy of implants followed by consignment implant description Neuro DSA Lab(Annexure C-12) as well as the certificate (Annexure C-14), from the complainant, the OP No.3 i.e. M/s Heritage Health TPA Private Limited ought to have depute someone to verify the correctness as well as the genuineness of the aforementioned documents. The OP No.3 neither deputed anyone to contact the OP No.4 to ascertain the genuineness of the aforementioned documents, namely, signed and stamped copy of implants, consignment implant description Neuro DSA Lab (Annexure C-12) and certificate (Annexure C-14) nor made any correspondence with OP No.4 to ascertain the correctness and genuineness of the said documents. Rather, the OP No.3, instead of making any correspondence with OP No.4 to ascertain the genuineness of the aforesaid documents, preferred to close the claim in question, which tantamounts to repudiation/rejection of the claim.

10.            At this stage, it is pertinent to highlight here that the OPs No. 1 to 3 have not expressed any doubt with regard to the genuineness or correctness of the aforementioned documents, namely, signed and stamped copy of implants, consignment implant description Neuro DSA Lab (Annexure C-12) and certificate (Annexure C-14). It is also not the case of the OPs No.1 to 3 that the said documents were/are fake or bogus or have been obtained by the complainant fraudulently adopting foul and unfair means. It is also not the case of the OPs No.1 to 3 that the claim in question falls under the category of Fraudulent Claims. Needless to mention here that the objective to be achieved by insisting upon the submission of original implants is to rule out the possibility of sanctioning or clearing of fake/bogus or false claims. In the present case, we find no foul play in the non submission of original implants. Further, we have no doubt with regard to the correctness or genuineness of the claim in question. Therefore, the decision of the OP No.3 to close the claim in question is neither valid nor justified. As per well settled legal proposition, the insurers’ decision to reject a claim should be based on sound logic and valid grounds and the clause in policy requiring the submission of original papers/documents i.e. the original implants in the present case does not work in isolation and is not absolute; One needs to see the merit and good spirit of clause, without compromising the bad claims; Rejection of claims on purely technical grounds in mechanical fashion is bound to result in policyholders losing confidence in the insurance industry giving rise to  excessive litigation. 

11.            Apart from above, the rejection of the claim by OP No.3 i.e. M/s Heritage Health TPA Private Limited is not found valid being contrary to the provisions contained in Clause 3(2) of the Insurance Regulatory and Development Authority of India(Third Party Administrators–Health Services) Regulations, 2016(hereinafter referred as to IRDAI), wherein it is specifically mentioned that a TPA  shall not reject or repudiate any of the claims directly. In the present case, the TPA i.e. OP No.3 has closed the claim in question at his own level, which is in violation of above mentioned provisions. The another infirmity found in the decision of the OP No.3 while closing the claim in question, is that, in case of rejection of claims, as per the Clause 5(I) of the Insurance policy, the claim was liable to be referred to a committee comprising of the Bank, TPA and United Insurance Company but the OP No.3 took the decision at his own level in utter violation of the policy provisions.

12.            In view of the aforementioned discussion, we find no merit in the contentions of the OPs No.1 to 3 and therefore, we conclude that there has been lapse and deficiency in service on the part of Ops No.1 to 3 while rendering services to the complainant. The present complaint is dismissed qua OP No.4 being a proforma party.

13.            Adverting to the relief, it is found that the complainant was insured for a sum of Rs.4,00,000/- and  accordingly, he is entitled to the reimbursement of  said  insured sum of Rs.4,00,000/-. Apart from insured sum of Rs.4,00,000/-, the complainant has claimed the benefit of Rs.1,00,000/- under the critical illness category. Though, the OPs No.1 to 3, has opposed the said claim under the critical illness category but on perusal of the policy, it is found that the benefit under the critical illness is over and above the base sum insured. As per relevant clause, evidence of permanent neurological deficit lasting for at least 3 months has to be produced. In the present case, the complainant has placed on record his joining report as well as the treatment record showing that he remained under permanent neurological deficit lasting for 3 months and thus, he is entitled to the benefit of Rs.1,00,000/- under the critical illness category in addition to insured sum of Rs.4,00,000/-.

14.            As a sequel to the above discussion, we partly allow the present complaint with the following directions to the OPs No.1 to 3:-

1. To pay a total sum of Rs.5,00,000/-i.e. 400000+100000 to the complainant, along with interest @ 9% per annum w.e.f. the date of filing of the complaint till its realization.
2. To pay an amount of Rs.25,000/- to the complainant on account of mental agony and harassment.
3. To pay an amount of Rs.5,500/- to the complainant on account litigation charges.

 

15.            The OPs No.1 to 3 shall comply with the order within a period of 45 days from the date of communication of copy of this order failing which the complainant shall be at liberty to approach this Commission for initiation of proceedings under Section 71 of CP Act, 2019 against the OPs No.1 to 3. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance.

Announced on: 08.04.2022

 

Dr.Sushma Garg          Dr. Pawan Kumar Saini         Satpal          

        Member                           Member                       President

 

Note: Each and every page of this order has been duly signed by me.

 

                                         Satpal                               

                                    President