Order by:
Smt.Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainants have been purchasing the ‘Family Health Optima Insurance Plan’ policy from the Opposite Parties from the so many years continuously, vide which the complainants namely Shivinder Singh (complainant no.1) self alongwith Mrs.Ranjeet Kaur (spouse) Ms.Komaldeep Kaur (complainant no.2), Rupinder Singh and Ravinder Singh (sons) are duly covered. The said policy was further renewed for the period 12.05.2021 to 11.05.2022 and thereafter for the period 13.05.2022 to 12.05.2023. During the policy period 12.05.2021 to 11.05.2022 complainant no.1 felt some uneasiness and became unconscious and due to emergency case, he was brought to the nearest hospital i.e. Harbans Nursing Home & Maternity Hospital, Dharamkot Road, Kot Ise khan District Moga, where he was completely diagnosed and found that he was suffering from Covid-19 and remained admitted in the hospital till 09.07.2021. During the hospitalization, the complainant no.1 spent Rs.5,50,202/- on his treatment. Similarly, complainant no.2 was also admitted in the said hospital due to Covid-19 for the period 17.06.2021 to 06.07.2021 and during the hospitalization, an amount of Rs.3,79,949/- was incurred on the treatment of complainant no.1. In this way, the complainants spent Rs.9,30,151/- in the said hospital. Further averred that Opposite Parties were duly informed before the aforesaid admission of complainant no.1 & 2 and Opposite Parties was asked for cashless treatment under the policy, but the officials of opposite parties told that there may occur some delay in sending the case of the complainant for cashless treatment to the higher authority and the complainant has to pay the expenses from his own pocket and after discharge, the medical treatment claim amount will definitely be reimbursed under the policy. In these circumstances, the complainant paid the amount of expenses from his own pocket. After discharge from the hospital, the complainants lodged the claim for the reimbursement of the medical expenses incurred by them in the said hospital and completed all the required formalities and submitted all the required documents with the opposite parties, but they did not pay any heed to the request of the complainant. Initially, the opposite party lingered on the matter on one pretext or the other and they sent the matter to their investigating agency i.e. Ombudsman, Chandigarh where said agency also required certain documents from complainants, which were duly provided. After that said agency advised the Opposite Parties to explore the possibility of review of the claim to arrive at an agreement. But the Opposite Parties reiterated their stand of SCN and stressed on remarks that bills are inflated very much. At last the Opposite Parties repudiated the claim of the complainants. The repudiation of the claim by the Opposite Parties is totally wrong and incorrect. Further alleged that at the time of issuing the policy in question, the opposite parties never issued any terms and conditions of the policy documents. As such, the alleged terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. Further alleged that complainants were got admitted in hospital in emergency conditions suffering from Covid-19 and it is quite natural at the time of emergency where there is threat to the life of patient, the patient or his attendants immediately will approach to the nearest hospital or doctors and not supposed to find the empanelled hospital or go for the treatment. As such, there is deficiency in service as well as unfair trade practice on the part of the Opposite Parties. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite parties may be directed to reimburse the medical claim of the complainant amounting to Rs.9,30,151/- alongwith future interest @ 12% p.a. from the date of payment to the treating hospital till its actual realization.
b) To pay an amount of Rs.2,00,000/- as compensation on account of damages, mental tension and harassment.
c) To pay an amount of Rs.51,000/- as cost of complaint.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that this Commission has got no jurisdiction to try and decide the present complaint as the alleged dispute needs voluminous evidence to decide the present complaint and thus, this Commission having limited jurisdiction, the present dispute cannot be adjudicated without the sufficient evidence and therefore, the alleged dispute may be referred to Civil Court as per the prescribed law. The alleged claim is highly suspicious and doubtful and requires thorough and proper investigation and enquiry which can only be conducted by way of huge evidence, witnesses and cross examinations of witnesses which is not possible in this Commission. Moreover, the present matter was referred to Ombudsman by the complainant himself and the matter was resolved with the directions to complainant that he would submit the required documents and clarify the queries raised by insurance company but the complainant himself has failed to do so. On this ground this Commission has got no jurisdiction to decide the present matter which has already been decided by the Ombudsman, Chandigarh, vide its order dated 28.07.2022. Further averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Policy- 2021’ bearing no.P/21122/01/2022/000993 valid from 12.05.2021 to 11.05.2022 covering the complainant self and his spouse Ranjit Kaur and Komaldeep Kaur and Rupinder Singh dependent children for a sum of Rs.20,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. Further averred that the insured submitted two claims for the reimbursement of alleged medical expenses incurred on both the complainants, towards the treatment of Covid-19 for hospitalization from 16.06.2021 to 09.07.2021 and 17.06.2021 to 06.07.2021 respectively at Harbans Nursing Home & Maternity Hospital, Kot Ise Khan, District Moga. The insured Shivinder Singh has reported the alleged claims on the 36th and 37th day after the issuance of insurance policy in question. On scrutiny of claim documents, the medical team of the answering company observed that
i) The insured patients Mr.Shivinder Singh and Ms.Komaldeep Kaur has taken treatment in the Harbans Nursing Home- Sanghera which is an excluded provided Hospital.
ii) No Govt. approved RT-PCR report has been submitted.
iii) The TPR (Temperature, Pulse and Respiration) chart is stereotyped.
iv) The Final bill and receipt are submitted as printout taken in the prescription- which reads “not for medico legal purpose”.
v) As per the payment receipt full amount have been paid on day of discharge- The mode of payment is not mentioned. If it was a cash payment, it cannot be made for Rs.5 lakh as per rules (Sec 269 IT Act).
vi) As per final bill, the insured Mr.Shivinder Singh was admitted in ICU and was hospitalized there for 24 days without being stepped down to normal room. The insured was discharged directly from ICU, which is medically incorrect.
v) As per the TPR chart, the case was projected as a severe disease but CT scan test of chest not taken to ascertain the same.
vi) There is no positive investigation reports supporting life threatening situation.
vii) As per the final bill unwarranted drugs for Covid-19 are billed (Inj. Bryxta 400 mgs and Inj. Adalimumab- cancer drugs) without proper indication or bill receipt.
Further averred that the insured patients Ms.Shavinder Singh Ms.Komaldeep Kaur have taken treatment in excluded provided hospital (i.e. Harbans Nursing Home-Sanghera) which is not payable as per Exclusions no.(11) Excluded Providers – Code Excl-11 of the policy. As per 3. Exclusions No.(11). Excluded Providers – Code Excl 11 of the policy, the expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the insurer and disclosed in its website/notified to the policyholders are not admissible. However, in case of life threatening situations following an accident, expenses upto the stage of stabilization are payable but not the complete claim. Hence, claim was repudiated and communicated to the insured vide letter dated 09.09.2021. Further averred that in the above referred case, the insured approached the Ombudsman vide complaint CHD-H-044-2223-0298 filed by insured and subsequently the Ombudsman, Chandigarh has passed a Award, wherein the complainant is directed to clarify the issues raised by the Insurance Company for enabling the insurer to process both the claim as per the terms and conditions of the policy. In order to comply the directions of Ombudsman, the insured sent representation to review the claims. The Opposite Parties medical team has perused insured representation and has noted the following contents. The team which re-examined the claim records and observed that
i) That the complete ICP (Increased Intracranial Pressure) for the hospitalization period is still not provided.
ii) The submitted treating doctor clarification is without date.
iii) Further, in the treating doctor clarification, it is mentioned that full payment was done only at the time of discharge but the mode of payment with proof for digital payment nor provided; however as per your email the mode of payment is cash (Cash payment above 2 lakhs is not allowed.
iv) The Final bill and receipt submitted are not in proper format, rather printed in the prescription.
v) As per the clarification there is no GST certificate for hospital, however the medicine bills in both the hospitalization does not bear any Batch number, Expiry date and GST number.
vi) As per the TPR chart, the case is projected as a severe disease with SPO2 from 79% but why no CT Chest and X-rays are taken to ascertain the condition and its progress.
vii) As per the submitted documents in claim intimation number CIR/2022/211222/2909362, patient was administered with unwarranted drugs i.e. Inj. Bryxta 400mg and Inj. Adalimumab (anti-cancer drugs without proper indication also no purchase invoice submitted and the submitted doctor letter states that the drug was administered as an experimental therapy which is not payable.
viii) The submitted video of hospitalization is not authentic as there is no mention of date and time in the same; moreover the patient is shown wearing a mask in the video when the records shows his oxygen saturation was less. Thus, there is discrepancy noted in the records which amounts to misrepresentation of facts.
As per condition no.1 of the policy issued, if there is an misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make by payment in respect of any claim which is very doubtful and suspicious.
As such, in terms of the said provision of the insurance policy, the insurance company have repudiated the claim of complainant in proper manner, after due application of mind. The instant complaint is neither maintainable in law nor on facts. No deficient services has been rendered by the answering Opposite Parties. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
4. In order to prove his case, complainant has placed on record his affidavit Ex.C1/A alongwith copies of documents Ex.C1 to Ex.C21.
5. To rebut the evidence of complainant, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Ins. Co. Ltd. Ex.OP1,2/A, Power of Attorney Ex.OP1,2/B alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/12, Ex.OP1,2/12A & Ex.OP1,2/12B.
6. We have heard the counsel for the parties and also gone through the documents placed on record.
7. There is no dispute that complainant no.1 has purchased the health insurance policy bearing No. P/211222/01/2022/000993 for the period 12.05.2021 to 11.05.2022 covering himself, his spouse Ranjit Kaur and dependent children Komaldeep Kaur, Rupinder Singh and Ravinder Singh. During the policy period complainant no.1 suffered from Covid-19 and got admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga for the period 16.06.2021 to 09.07.2021. Similarly, complainant no.2 was also admitted in the said hospital due to Covid-19 for the period 17.06.2021 to 06.07.2021 is also not disputed. The main dispute between the parties arises, when the claim lodged by the complainants regarding the expenses incurred by them on their treatment was repudiated. The main plea taken by the Opposite Parties is that complainants got treatment from Excluded Provider Hospital that’s why they are not entitled for the amount so claimed. It is not the case of the Opposite Party that the treating hospital from where the complainants took treatment has charged more than the empanelled hospital.
8. However, the plea taken by the Opposite Parties that policy holders got the treatment from excluded provider hospital is totally arbitrary. Sometime it is not possible for the policy holder to approach the listed hospitals due to any reasons. On this point, we are well guided by the judgement of Hon’ble Supreme Court of India in case titled Shiva Kant Jha Vs. Union of India in Civil Writ Petition No. 694 of 2015, decided on 13.04.201, in which it is held that:-
Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned.
In the facts of the present case, it cannot be denied that complainants were admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga in emergency conditions due to Covid-19. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the Opposite Parties have denied the grant of medical reimbursement to the complainants and forcing them to approach this District Commission.
9. Opposite Parties have also taken the plea that the complainant also filed a complaint before Ombudsman Chandigarh and the matter was resolved with a directions to the complainant that he would submit the required documents and clarify the queries raised by insurance company, but the complainant failed to do so. However, it is also transpires from the order dated 28.07.2022 of the Ombudsman that they admitted that the claim of the complainants is fair and reasonable and vide this order complainant was also directed to clarify the issues raised by the insurer. Now, we come to the issue raised by the Opposite Party i.e. company. The perusal of the issues so raised by the Opposite Parties in its written reply shows that they raised the said issues regarding the doctor’s clarification, proof of mode of payment, final bill submitted is not proper, medicine bills does not bear any Batch number, Expiry date and GST number, but we are of the view that there is no necessity of these documents for the settlement of the claim. They also raised the issues stating that no CT Chest and X-rays are taken to ascertain the condition and its progress, patient was administered with unwarranted drugs and there is discrepancy noted in the records, but there is no affidavit of any other doctor to prove this fact that there is need of CT chest and X-ray to ascertain the condition and the patient was administered with unwarranted drugs. Opposite Parties also taken the plea that the complete ICP (Increased Intracranial Pressure) for the hospitalization period is still not provided. The plea taken by the Opposite Parties is not sustainable, as if the complainant failed to submit the same, they get it from the hospital at their own. In view of the above, we are of the view that the issues raised by the Opposite Parties not appears to be genuine and raised only to repudiate the claim of the complainant.
10. Now come to the quantum of amount to be awarded to the complainants. Vide instant complaint, the complainants have claimed the amount of Rs.9,30,151/- i.e. Rs.5,50,202/- spent on the treatment of complainant no.1 and Rs.3,79,949/- spent on the treatment of complainant no.2, whereas the bills produced on record does not clear the amount so claimed to be spent by the complainants. There is no clear cut bifurcation of the medical bills and expenses placed on record. However, vide Bill Assessment Sheet Ex.OP1, 2/12, the Opposite Parties assessed the final admissible amount to tune of Rs.3,50,380/- against the amount of Rs.5,50,202/- for complainant no.1 and Rs.2,87,419/- against the amount of Rs.3,79,949/- for complainant no.2. Hence we allow the same.
11. It is pertinent to mention here that at the stage of final arguments, complainant no.1 expired and the ld. Counsel for the complainant has moved an application for substitute the LRs of Shivinder Singh, which was allowed and LRs of complainant no.1 i.e. Ranjit Kaur (wife), Ravinder Singh (minor son), Komaldeep Kaur daughter (already impleaded as complainant no.2) and Rupinder Singh (son) have substituted in place of complainant no.1.
12. From the discussion above, we partly allow the complaint of the complainants and directed the Opposite Parties to pay Rs.3,50,380/- with regard to the mediclaim of complainant no.1 to his LRs in equal shares and to pay an amount of Rs.2,87,419/- to complainant no.2. Opposite Parties are also directed to pay compository costs of Rs.8,000/-(Rupees Eight Thousand only) for thrusting avoidable litigation as well as harassment suffered by the complainant. This amount is to be paid to the LRs of the complainant no.1 in equal shares. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the LRs of the complainant no.1 for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
