Smt. Amita Gupta w/o Sh.R.K. Gupta, r/o 113, Green Park, Civil Lines, Distt. Ludhiana.
….Complainant.
Versus

1- United India Insurance Co. Ltd. 818, Indl. Area-B, near Pratap Chowk, Ludhiana through authorized signatory.
2- Paramount Health Services Pvt. Ltd., 81, Barodawala Mansion, B-Wing, Gr. Floor, Dr. Annia Besant Road, Worli Naka, Mumbai- 400018 through Authorised Signatory.
….Opposite party.

COMPLAINT UNDER SECTION 12 OF THE CONSUMER PROTECTION ACT, 1986.
Quorum:
Sh. T.N. Vaidya, President.
Sh. Rajesh Kumar, Member.

Present: Sh. M.S. Sethi Adv. for complainant.
Sh. M.R. Saluja Adv. for opposite party no.1.
Complaint against opposite party no.2 withdrawn.

O R D E R

RAJESH KUMAR, MEMBER:

1- Complainant obtained individual mediclaim policy from opposite party for the period 14.12.2006 to 13.12.2007, by paying consideration of Rs.2209/-. Earlier for previous year, complainant hired services of other branch of opposite party. As there was delay of 7 days in renewal of present policy, opposite party specifically disclosed the factum of previous policy number/year and issuing office etc. and insured the complainant without any hesitation. Opposite party issued PHS Id card for cashless hospital treatement. During period of insurance, complainant visited first time CMC Hospital on 20.3.2007 with complaint of urine, where remained admitted from 1.5.2007 to 7.5.2007 for treatment of vaginal hysterectomy with pelvis floor repair. At CMC, she was given final diagnosis as complaint of cystonele and rectocele with 1* cervical descent (Status-vaginal hysterectomy with PFR). Complainant lodged claim of Rs.39,667.80 with opposite party alongwith hospital record, who forwarded claim to opposite party no.2. Opposite party under guidelines of opposite party, repudiated the claim vide letter dated 25.5.2007 addressed to opposite party no.1, as under:-
“On scrutiny of documents, it is observed that Mrs. Amita Gupta 48 years female admitted with complaints of cystocele and rectocele since last 5 months. The date of inception of policy is 14.12.2006. Although patient covered since 9.12.2004, but there is gap of 7 days in renewal of policy. As per policy clause 4.1, any disease/illness which are pre-existing, isn’t covered, hence the said claim could be repudiated”.


It is averred that earlier policy no.404502/48/04/8500590 for the period 9.12.2004 to 8.12.2005(of National Insurance) was obtained and another policy no.200700/48/05/01525 for the period 8.12.2005 to 7.12.2006 was taken from opposite party. Although there was gap of 7 days, but opposite party at the time of issuing the policy, had admitted it being renewal of earlier policy. No new proposal form was got signed at the time issuing this policy. No terms and conditions were supplied to the complainant. So, claiming this repudiation to be null and void, filed this complaint u/s 12 of the Consumer Protection Act, 1986, for claim amount of Rs.39,668/- with interest @ 18 alongwith compensation of Rs.50,000/- for mental tension and harassment and Rs.5500/- as litigation costs.


2- Opposite party no.1 in reply pleaded that complaint is not maintainable because there is no deficiency in service on their part. Claim has been repudiated after considering documents and applying mind by officials of the company. Claim is not payable under the policy in question, as complainant had pre-existing disease at the time of taking the policy. Under exclusion clause 4 and 4.1 of the policy, opposite party is not liable to pay the treatment expenses of pre-existing disease. The policy was taken on 14.12.2006 and complainant got admitted in CMC Hospital on 1.5.2007. The disease for which, complainant got herself admitted in the hospital, was pre existing and she was contracted before taking the policy on 14.12.2006. Even earlier policy was also renewed after some gap. Latest policy is considered to be a fresh policy, so complainant is not entitled to any claim. The discharge summary was prepared at the instance of the complainant and she had knowledge about her disease before taking the policy. Further averred that the claim was referred to the 3rd party administrator (TPA) namely Paramount Health Services Pvt. Ltd. Delhi, who after hearing the party and considering the documents and applying mind, repudiated the claim under clause 4.1 of the policy vide letter dated 20.6.2007. The said authority also previously made claim of cashless treatment expenses as “no claim” vide letter dated 27.4.2007. Admission of complainant in CMC Hospital, is admitted. It is denied that terms of policy were not supplied as alleged. Entitlement of complainant to the tune of Rs.39,668/- alongwith compensation is denied. All other assertions of complaint are denied and it is prayed that the complaint should be dismissed.


3- Both parties adduced evidence in support of their claims and stood heard through their respective counsels.


4- From the above facts and figures, it is clear that the complainant visited for the first time on
20.3.2007(Ex.C3) with the complaint of urine and got herself admitted in the CMC Hospital for the period 1.5.2007 to 7.5.2007(Ex.R2) for treatement of vaginal hysterectomy with the pelvic floor repair and CMC diagnosed this disease as cystonele and rectocele with cervical descent(status-vaginal hysterectomy with PFR) (Ex.R2). It is established fact that the complaint had earlier policy no.404502/48/04/8500590 for the period 9.12.2004 to 8.12.2005 (of National Insurance Co.) and another policy no.200700/48/05/01525 for the period from 8.12.2005 to 7.12.2006(United India Ins. Co.)(Ex.C1) and there was a gap of 7 days in getting the policy valid from 14.12.2006 to 13.12.2007 from opposite party. Policy no.201003/48/06/20/00000486 (Ex.R1).


5- Complaint argued that no new proposal form was got signed at the time of getting insurance for the period 14.12.2006 to 13.12.2007 and no terms and conditions of policy was supplied for the period in question. As the complaint was hospitalized at CMC from 1.5.2007 to 7.5.2007 for getting medical treatement and claim for Rs.39,667/- under the policy was submitted to opposite party(Ex.C5).


6- Opposite party argued that the claim under the said policy was not payable as the complainant was suffering from pre-existing disease of vaginal hysterectomy before taking the policy in question. Opposite party further argued that the complaint took the policy Ex.R1 after a gap of 7 days and due to this break, the renewal of the policy can not be considered to be a continuing policy and earlier policy taken by the complainant has no effect on the subsequent policy. Opposite party argued that the claim filed by the complainant was referred to Paramount Health Services (Pvt.) Ltd. , Delhi which is licensed by Insurance Regulatory Dev. Authority(India) and the claim of the complainant was repudiated vide letter dated 20.6.2007 Ex.R4 on the ground that the disease was pre-existing. In the repudiation letter, it was mentioned that although the patient was covered since 9.12.2004, but there is a gap of 7 days in renewal of policy from 14.12.2006 to 13.12.2007 and earlier policy was valid from 8.12.2005 to 7.12.2006.


7- As per case reported in Oriental Ins. Co. Ltd. Vs Madan Kumar Dutta, 2008(3)CPC-46(NC), when there is break of 14 days in renewal of policy, this break is no ground to repudiate the claim by invoking the exclusion clause which was initially given for first year.


8- Therefore, break of 7 days in renewal of earlier policy is no ground to repudiate the claim by invoking the exclusion clause which was initially given for the first year. Repudiation of claim of complainant by opposite party vide letter Ex.R4 is illegal and arbitrary. Therefore, complaint is allowed and opposite is directed to pay the medi claim for Rs.39,667.80 for which complainant got treatement in CMC Hospital, Ludhiana from 1.5.2007 to 7.5.2007. They are also directed to pay compensation of Rs.2000/- for harassment and Rs.1000/- as litigation costs to the complainant. All these amounts should be given to complainant within 45 days of receipt of copy of order, and if not paid within the prescribed period, then 9% interest is to be given to the complainant on total amount.

Shri Manuj Doegar son of

Shri K.K. Sood,

R/O Krishan Kunj,

Sanjauli, Shimla-171006.
… Complainant.
Versus
1. M/S Paramount Health Services

B-2, 3rd Floor, Greater Kailsah Enclave-II

New Delhi 110048

Through its Managing Director.

2. M/S Oriental Insurance Company Ltd.

Regd. Office at Oriental House,

Post Box No.7037, A-25/27, Asf Alit Road, New Delhi, having its Divisional Office at Mythe Estate Kaithu, Shimla-3 through its Divisional Manager, Shimla.
…Opposite Parties
O R D E R:
Sureshwar Thakur (District Judge) President:- The instant complaint has been filed by the complainant by invoking the provisions of Section 12 of the Consumer Protection Act, 1986. The complainant avers that he insured himself and his family members under the Good Health Insurances Policy, with the OP No.2 through OP No.1 vide policy bearing No.263100/48/06/00231 commencing from 18.05.2006 to 17.05.2006. It is averred that the complaint was hospitalized from 17.01.2006 to 18.01.2006 at Indus Hospital Shimla with the symptoms giddiness, dizziness and weakness. The complainant further proceed to aver that he submitted the claim to the OP No.1 vide letter dated 30.03.2006 Annexure C-2 for reimbursement of the expenses incurred by him on his treatment. However, the OP No.1 instead of indemnifying him, repudiated his claim vide Annexure C-2. Hence, it is averred that there is apparent deficiency in service on the part of the OPs and accordingly relief to the extent as detailed in the relief clause be awarded in her favour.

2. The OP No.2 in its reply raised preliminary objections vis-à-vis the claim is not covered under the policy and that the complainant has deliberately not disclosed the true facts of his health condition before taking the policy. On merits, it is contended that the complainant was hospitalized only for investigation for less than 24 hours and as per exclusion clause 1.4 and 2.1.10 of the policy, he is not entitled for re-imbursement of the expenses incurred by him on his treatment. Hence, it is denied that there is any deficiency in service on the part of the OP No.2. However, the OP No.1 did not contest the complaint.

3. We have heard the learned counsel for the parties at length and have also thoroughly scanned the entire record of the case meticulously.

4. The claim for reimbursement by the OP No.2 of the various expenses incurred towards test and laboratory examination necessary for the diagnosis/investigation, as well, as, for the treatment of the ailment entailed upon the complainant, as, comprised in various annexures appended to this complaint, have, been, sought to be repulsed by the OP-Company on exclusion clause 4.1 and 4.10 of Annexure R-2/1.

5. On the strength of the aforesaid exclusion clause, more particularly 4.10 of Annexure R1/1, the counsel for the OP No.2 contends, that, since the expenses claimed under the various annexures appended with the complaint, were not, in, consistent with or incidental for diagnosis/investigation or for the treatment of the positive existence or presence of any ailment, sickness or injury, nor did the complaint subsequent to such tests while theirs revealing the existence of an ailment/sickness underwent confinement in a, hospital/Nursing home, as enjoined in clause 4.10, therefore, the claim of the complainant, is, hence, sought to be repudiated.

6. The above condition, necessitating confinement of the complainant in a hospital/Nursing home subsequent to the tests revealing his having incurred any severe sickness/ailment, hence, necessitating his confinement in a hospital/nursing home, on, a, reading of the exclusionary clause 4.10 in Annexure R-2/1, as relied upon by the learned counsel for the OP, for, exculpating the claim of the complainant for the expenses incurred by him for pre confinement/tests, examination, is palpably so, revealed by it.

The exclusionary clause on its bare reading, necessitates that the pre-confinement tests/lab examinations, which bring to the surface the existence of any ailment or sickness, ordain, his, subsequent confinement in hospital/Nursing Home for their treatment. Obviously, the expenses incurred by him on such laboratory examinations, as well as, tests, on a date prior to confinement in a hospital/Nursing home as revealed, by, Annexure C-4 would be construable, to be, consistent with the treatment of the existence of the presence of any ailment, as, brought to the surface by test/laboratory examinations for whose treatment, he, ultimately had remained confined in a hospital for one day.

Any expenses incurred by the complainant on test/laboratory examinations, test subsequent, to, his period of hospitalization when, as, a matter of fact, such tests/laboratory examinations have, not, resulted, in, the treatment of the sickness or ailment as revealed by the said tests or laboratory examinations, by way of his confinement in a hospital/nursing home would, not, be reimbursable to him, for, the reason that the exclusionary clause comes to exculpate the liability of the insurer, when, the aforesaid indispensable requirement of his being subsequent to such tests coming to be confined in a hospital/Nursing home, is not, shown to be satisfied. Hence, expenses towards such tests/laboratory examinations are construable to be advisory in nature or are to be construed to be advised/undergone as a measure of self assurance to the complainant.

7. The complainant has also incurred expenses on various medicines. The expenses incurred on medicines by the complainant, as, reflected in the various bills has been placed on record, which have been asserted by the complainant to be necessary for his recuperation from the ailment for which underwent hospitalization, for a day, at, Indus Hospital, Shimla.

When have not been demonstrated by the OP, by, adducing the evidence of medical expert, revealing, the fact that the medicines as comprised in the various bills whose expenses the complainant claims reimbursement from the OP were not required for the treatment of the ailment which was enjoined upon the complainant, hence, in the absence of the above cogent evidence, the, inference, to be drawn is that the expenses, as, incurred by the complainant, in, purchasing medicines as detailed in varies annexures were necessary for his recuperation for the ailment which was entailed upon. Therefore, the total expenses incurred by the complainant in purchasing the medicines is liable to be reimbursed to him. Hence, to the above extent, the complaint is allowed.

8. Resultantly, the complaint is allowed. The OP No.2-Company is directed to indemnify the complainant to the extent of Rs.2,773.95 alongwith interest at the rate of 9% per annum from the date of filing of the complaint, i.e. 13.10.2006, till actual payment is made. The litigation cost is quantified at Rs.1,000/- payable by the OP No.2-Company to the complainant. The ordered amount shall be defrayed by the OP No.2 to the complainant within a period of forty five days after the date of receipt of copy of this order.

Mediclaim rejected for Hospitalization of my Mother.
Hi,

I work with Freescale Semiconductor and we have a Mediclaim Policy with HDFCergo through Paramount Health Services(PHS) as TPA.I would like to register my complaint against PHS and HDFC Ergo.

PHS ID :- 2501197
Patient Name : Radha Devi


My Mother Complained of acute gidiness,headache and difficulty in walking in Early mroning Hours.I took her in Emergency to the Fortis Hospital Faridabad at 6AM in the morning.The doctor on duty tried to make her stable by some Injection and other treamtent but didn't find any improvement in her condition.She was not able to even sit on her seat.
As a result the Doctor advised us to admit her.

she was admitted and again examined by the Neurologist doctor for Cerebeller signs such as Tendom Walking, Knee heal etc.The Doctor informed us that she may be suffering from Acute Virtigo(Posterior Circulation TIA) and adviced us to get the tests like MRI,CT Scan,Blood and Urine tests.All of the tests done were incidental to the problem which my mother reported.Her MRI reports were normal.The Doctor Suggested to keep her under observation for some time.She was kept on antivertigo treatment along with other Symptomatic treatment.

After observing her condition to be stable and after 28 Hours of hospitalization,we opted to Discharge her.She was discharged on request with follow up Medical Prescription advice(such as Ecosprin) for 5 days and again consult the doctor.

The Insurance company rejected the hospitalization with a note that "Hospitalization was primarily for Investigation
and hence can't be compensated.The Investigations could have been done as per OPD".

How can they say that we went primarliy for investigation and these could be done as a part of OPD?

1)I had to admit my mother in Critical Condition.She was in no condition to even sit and So how can the insurance comapany expect me to wait for the day to get her diagnosed in the OPD for the same.

2)Secondly I took her to the Emergency ward where she was given some basic treatment, but her condition didn't show any improvemt even after one hour.As a result,only on the advice of the Doctor,I admitted her in to the Hospital.

3)All the tests that were carried out were incidental to the ailing condition of my mother and were conducted on the advice of the Doctor.

4)Also note that FORTIS is a listed hospital by the Insurance Provider.


Please suggest me how can I take this battle forward through the Consumer Court platform.The whole process has been a mental torture for me.Even during the hospitalization of my mother,I spent crucial hours hanging around the TPA guys to get a cashless claim for the same.I was working like a co-ordinator and messenger between TPA and Hospital Staff.
These guys are trying to prove a genuine hospitalization to a false claim of mainly for Investigation.

Regards,
Rajeev Sharma
9910036241