Delhi

East Delhi

CC/212/2017

RAVINDER KUMAR - Complainant(s)

Versus

RELIGARE HEALTH INS. - Opp.Party(s)

13 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110092

 

C.C. NO. 212/2017

 

	Ravinder Kumar, S/o Sh. Hari Chand, R/o B 111, G.D. colony, Mayur Vihar, Phase-III, Delhi-110096	….Complainant
Versus
1.           2.	Rashmi Kumar, Deputy Manager-Customer Service, Religare Health Insurance Company Ltd., Office:- 03, P3B, District Centre, Saket, New Delhi-110017.   Anuj Gulathi, Religare Health Insurance Company Ltd., Office No. 206, 2nd Floor, Roots Tower, Plot No. 7, District Center, Laxmi Nagar, New Delhi-110092.	…OP1                                                                                   …OP2

 

 

Date of Institution: 30.05.2017

Order Reserved on: 12.04.2023

 Order Passed on: 13.04.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms.Rashmi Bansal (Member)

 

 

Judgment by : Sh. S.S. Malhotra (President)

 

 

 

 

 

 

 

JUDGMENT

 

1. By this order the Commission shall dispose off the claim of the complainant with respect to deficiency in not reimbursing the medical bill of the complainant to the tune of Rs. 50,747/-.
2. Brief facts as stated by the complainant in the complaint are that complainant had a policy with OP1 w.e.f. 13.09.2016. He was feeling uncomfortable due to severe chest pain, breathlessness, cough and fever & then he was rushed to Metro Hospital Sector-11, Noida, U.P. which is adjacent to his house and consulted with Dr. Deepak and on his advice he was admitted in hospital. The information to this effect was given to OPs and even hospital authority also sent an e-mails to the insurer for pre-authorisation of cashless hospitalization for estimate expenditure of 99,000/- but instead of providing the cashless, the OPs demanded information w.r.t. investigation report, OPD Prescription and admission paper which were sent & when the complainant called again to clear pre-authorisation, the OPs told that they will send their official to the hospital to check the parameters of the complainant and thereafter would take necessary steps.
3. The representative of the OPs accordingly visited the hospital, took reports and status of the health of complainant along with declaration from the complainant that he was not suffering from any disease prior to that or was not having any habit of taking drugs or alcohol and thereafter all the report were secured with the insurer for pre-authorisation but the cashless was denied by OPs by alleging that claim is not payable as all the vitals of complainant were found normal and investigation were within the normal limits. After the recovery, the hospital raised bill of Rs. 50,747/- towards discharge and this amount was claimed from OPs by filing all the documents but his complaint was not redressed and as such the present case has been filed before the Commission thereby seeking direction to the OPs, to reimburse the amount of Rs. 50,747/- with interest @12 p.a., compensation of Rs. 1,00,000/- and Legal expense of Rs. 2298/-.
4. The OPs has filed its written statement taking preliminary objection that complaint of the complainant is not maintainable on various grounds interalia that policy no. 16073457 was issued from 04.06.2016 to 03.06.2017 alongwith the terms & conditions and one of the terms & conditions was that reimbursing w.r.t. investigation would be payable only when the parameters would not normal and in this case all the parameters/vitals were normal and therefore there is no deficiency on the part of the OPs in repudiating the claim & in fact there was no need to undergo for lever & kidney test in the absence of any symptoms.
5. It is further submitted that OPs had also sent Medico Legal Opinion(MLO) and Dr. C.H. Asrani who concluded that complainant were hospitalized mainly for investigation and diagnose purposes & therefore keeping in view the fact and the Report of MLO, the claim was rejected being not payable as per the Clause 4.3(a)(1) i.e. Annexure ‘C’ (71). It is stated that facts mentioned in preliminary objection be treated as correct. Fact of the policy, and complainant’s visit in the hospital is not denied and it is reiterated that complainant was admitted only for investigation and evolution purposes and even otherwise all the concluded reports were found normal & since there was no necessity of admission in the hospital, complaint of the complainant is liable to be dismissed.
6. The complainant has filed the rejoinder & his evidence and OP has filed its evidence through Ms. Shreya Chansoria, Manager-Legal Religare Health Insurance Company Ltd.
7. The Commission has heard the arguments and perused the record. The sole question in dispute is that, as to whether the complainant was actually suffering from some ailments or was required hospitalization after admission i.e. IPD, or whether there was no requirement of the complainant for getting admitted in the hospital or the treatment could have been on the OPD basis. The discharge summary of the complainant is the basic documents to appreciate the contention of both the parties. It reads that complainant was hospitalized in 13.09.2016 with the complaint of chest emergency and complainant was having breathlessness & suffering from cough & fever for last 5 or 6 days. The discharge summary further reads as follows ‘Patient was admitted with chief complaint of breathlessness, cough & fever for last 3-5 days. On admission Respiratory rate was 28/min, Temp-101F and bilateral wheeze was present. Therefore, admitted for the stabilization’

“He was started on IV antibiotics, inhaled and oral bronchodilators, oxygen enriched air and other supportive treatment”… In view of CXR findings, HRCT thorax was done(report awaited)’.

8. On the other hand the OP has filed report of Dr. C.H. Asrani exhibit ‘C’ and after placing all the documents before him, his opinion was sought & he has given opinion. His opinion reads as under “There were no clinical features (symptoms or signs) that necessitated hospitalization. The patient presented to the hospital with complaint of breathlessness, cough & fever for last 5-7 days”
9.  The issue therefore now is as to whose opinion is at better footing. It is settled principle of law that the dispute w.r.t. civil liabilities are based on preponderance of probabilities & not on strict proof beyond reasonable doubt. Here is a patient who had some pain in the chest, visited the hospital, treating doctors advised him admission in hospital, patient got admitted in the hospital on the base of, opinion & observation of the treating doctor that complainant is requiring hospitalization & in fact he remained for three days in hospital and this complainant was admitted on the advice of doctor who is his treating doctor.
10. On the other hand the opinion which is sought by OP from Dr. C.H. Asrani and admittedly his opinion only on the basis of documents. In fact Dr. C.H. Asrani had never an opportunity to see the patient in the hospital nor was able to see panic in the minds of complainant or his family member and he has given the report based on the papers brought before him. It cannot be anticipated that the complainant who is having chest pain would first reach to the panel doctor of the insurance company and would take his opinion firstly and then he would visit his treating doctor for the purpose of treatment. If this is being expected by the Insurance Company then such expectation cannot be said to legally sound. In such facts & under such panic, complainant would be visited his treating doctor first for the treatment. By just having an insurance policy, the complainant cannot be put to unimagined stress of all such technicalities to think about the reimbursement first. It would always be the effort of complainant that he would go to hospital first & therein hospital the doctor who is treating the insurer would be best person to advise clinically & in case, the complainant is got admitted on the advice of doctor, he can be said in safe hands.
11. No doubt, sometime the hospital or the doctor concerned may be, on account of greedy nature admit the patients and may make money out of it but if that is the opinion of OPs then defence of OPs should have been worded accordingly that this is bad hospital or is not a reputed hospital. In the entire written statement the OPs has not labeled any allegation either w.r.t. reputation of the doctor or bad reputation of hospital. It is not the case of the OPs at all that the doctor had admitted the patient in order to make money. Had there been any ill intention on the part of doctor, it should have been reflected in the written statement of OPs. Admittedly there is no allegation either against hospital or against the doctor.
12. Secondly another glaring issue is that who would decide that whether insurer should be admitted in the hospital or should not have been admitted in the hospital. In the considered opinion of this Commission, the insurance officials have no concern rather have no knowledge on this aspect to justify as to the whether the patient requires hospitalization or not, as they are not expert in the field. The OP initially rejected the cashless claim without taking any opinion of the expert and even the person who visited the hospital admittedly was not an expert or a qualified doctor who could have given report w.r.t. the health and standard parameters of the complainant. Once the cashless was rejected and complainant filed the claim before the OP then OP in order to conceal his malafide in rejecting the cashless pre-authorisation then decided to take the opinion from a doctor who admittedly cannot visualize the position of patient suffering from chest pain or w.r.t. requirement of his admission in the hospital at that particular time.
13. The Commission is of the opinion that insurance official or the surveyor should refrain from giving their opinion as an expert on the medical side and particulars for those who are admitted in hospital, until & unless they have some documentary evidence on record w.r.t. the bad reputation of that hospital either to the effect that such hospital are minting money by wrongly admitting the patient in order to cheat insurance company and then they should be able to prove that defence but otherwise they should not deny the claim of the insurer who is in the hospital on the obtained opinion of the doctor. Therefore in absence of any malafide allegation against treating hospital, the Commission is of the opinion there is deficiency in providing insurance claim to the complainant by OP.
14. The complainant has stated in the claim of Rs. 50747/- but the bill which are attached of Rs. 47,492/-, and another bill of Rs. 2,000/- and another bill of Rs. 1225/-. The total amount of all bills of Rs. 50717/-.

• Accordingly OPs are directed to pay (jointly & severally) an amount of Rs.50717/- to the complainant alongwith interest @9% p.a. from the date of filing the claim.
• Rs.10,000/- to the Complainant including compensation and towards mental agony and legal expenses of Rs. 2298/-as claim.
• It is further ordered that OPs would pay the amount within a period of 30 days from the date of order, failing which, the OPs would pay the interest on Rs.60717/- i.e. including compensation @12% p.a. from the date filing the claim till actual payment.  

Copy of the order be supplied/sent to both the parties free of cost as per rules.

File be consigned to Record Room.

Announced on 13.04.2023.