3. Lalgarhia Hospital, Dabwali Road, Sirsa, through its Incharge/ responsible person.
4. Dr. Sanjay Garg, Lalgarhia Hospital, Dabwali Road, Sirsa.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. A.S. Kalra, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties no.1 and 2.
Sh. Sanjay Goyal, Advocate for opposite parties no.3 and 4.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant is consumer of ops no.1 and 2 as policy bearing no. P/211121/01/2021/004047 from 08.08.2020 to 07.08.2021 for covering the risk of medical insurance for all the family members to the extent of sum insured with further additions of the benefits of enhancement of sum insured and other features were purchased. That during the first year of policy, complainant after being affected with the fever etc. was hospitalized at Lalgarhia Hospital, Sirsa where complainant was diagnosed with COVID and treated accordingly and she remained admitted there from 24.04.2021 to 28.04.2021. It is further averred that before discharge complainant was asked to deposit Rs.50,000/- as ops no.1 and 2 did not pay this amount incurred on treatment in addition to medicine and test reports charges of Rs.12,177/- prescribed by doctors of op no.3 during the hospitalization period. As such complainant was forced to pay hospital charges of Rs.50,000/- and Rs.12,177/- from her own pocket due to non reimbursement of treatment expenses by ops no.1 and 2 to ops no.3 and 4. That thereafter complainant lodged the claim with ops no.1 and 2 and submitted all the required documents, but ops no.1 and 2 repudiated the claim of complainant vide letter dated 01.07.2021 mentioning therein that “it has been observed from the submitted medical records that the patient’s clinical picture and vital charts indicate that the patient falls under category of BI of AIIMS protocol. Our medical team is of the opinion that the insured patient could have been managed under home quarantine”. It is further averred that if contention of ops no.1 and 2 is correct and accepted, in that eventuality, ops no.3 and 4 both should be held liable for the wrong committed with the complainant as being patient was at the mercy of ops for financial assistance and ethical treatment. That repudiation of claim by ops no.1 and 2 is either wrong, against law, facts or the doctor and hospital are liable for acting deficiently against the ethics of practice and complainant has been harassed by the ops. Hence, this complaint.
3. On notice, ops appeared. Ops no.1 and 2 filed written version raising certain preliminary objections. It is submitted that complainant took family health optima insurance commencing from 08.08.2020 to 07.08.2021 with limit of coverage of Rs. five lacs. The complainant after accepting the policy and being fully aware of terms and conditions executed the proposal form with free will and consent. It is further submitted that complainant lodged the claim before the company and submitted the documents for reimbursement towards treatment of Covid-19. The patient was shown to be admitted in Lalgarhia Hospital Musaibwala on 24.04.2021 and discharged on 28.04.2021. In discharge summary it is observed from the submitted medical report that the patient’s clinical picture and vital chart indicate that the patient falls under category B1 of AIIMS protocol. The insured patient could have been managed under home quarantine. It is further informed to the patient that as per the guidelines from AIIMS New Delhi and Ministry of Health and Family Welfare, Govt. of India, wherein the patient needs only self isolation by home quarantine and not advised for admission and treatment. So, the claim was repudiated vide letter dated 01.07.2021. That thereafter, the insured again requested for reconsideration, after due analyzing of the facts the matter was reinvestigated and observed that as per RVO report the final bill copy not provided by the Hospital, patient was admitted before Covid RT PCR report is done, no payment receipt available for laboratory done, and there was no Covid patient in that area as per the neighboring admitted patient, multiple discrepancies of facts, documents fabricated for claim purpose only. Thus, there is a discrepancy in the record, which amounts to misrepresentation of the facts. As per terms and conditions of the policy issued by the company, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to pay any payment in respect of any claim. So, the claim is hereby again repudiated as per letter dated 30.09.2021 and claimant has been duly informed through proper communication but complainant has intentionally not disclosed about second repudiation letter dated 30.09.2021 for the reason best known to him. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. Ops no.3 and 4 also filed written version raising certain preliminary objections. It is submitted that answering ops have given best treatment to the patient. The patient came to the hospital with fever and cough and difficulty in breathing. She earlier took treatment from Dr. Poonia Hospital on OPD basis. But she did not get respond and her condition was worsened. When she came to this hospital, her SPO2 was 90% on room air. Her HRCT chest done, CT score was 9/25 i.e. moderate in severity. She had fever. All parameter indicated that she needs admission which all indicate and found it suitable to admit the complainant/ patient in the ops’ hospital. Hence, the answering ops admitted the complainant/ patient with due care and to avoid any mis-happening or further deterioration of health. On merits, it is submitted that policy of complainant was not cashless policy and as such complainant was bound to pay the medical expenses to the hospital and to claim her rights from health insurance company, if any. The condition of complainant was alarming and there were many indications which may result into any serious problem as earlier she took OPD treatment from Dr. Poonia and after that also she could not be cured and due to this reason she was admitted in the hospital of answering op and there she was provided with best treatment during her hospitalization because as per her medical condition hospitalization was very necessary. So on that basis the answering ops have taken due care and considering the health condition of complainant/ patient admitted her in the hospital and provided best treatment. It is further submitted that even the claim of complainant against answering ops is totally false, frivolous and concocted one. The answering ops have been impleaded as party to the complainant unnecessarily because the answering ops have admitted the complainant after conducting tests of complainant which showed that condition of complainant was alarming and could be fatal in case she was not admitted in the hospital of answering ops. With these averments, dismissal of complaint qua ops no.3 and 4 prayed for.
5. The complainant in evidence has tendered her affidavit Ex.P1 and documents Ex.P2 to Ex.P33.
6. Ops no.3 and 4 have tendered affidavit of Dr. Sanjay Garg as Ex. RW1/A and copy of indoor file Ex.R1. Ops no.1 and 2 have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A, affidavit of Ms. Indu Singh, Investigator as Ex.RW2/A and documents Ex.R1/1 to Ex.R1/13.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. From the policy document Ex.R1/2 produced on file by ops no.1 and 2 themselves, it is proved on record that husband of complainant namely Sh. Subhash Chander had purchased family health optima insurance plan from ops no.1 and 2 from 08.08.2020 to 07.08.2021 for himself, for wife i.e. complainant and son Himank for the sum insured amount of Rs.5,00,000/- with bonus of Rs.1,25,000/-. There is also no dispute of the fact that insured Smt. Sarita during the period of policy remained admitted in Lalgarhia Hospital, Sirsa i.e. hospital of ops no.3 and 4 from 24.04.2021 to 28.04.2021 and was treated for COVID-19 and the complainant claims that she spent an amount of Rs.62,177/- on her treatment in the said hospital. But, however, the claim lodged by complainant with ops no.1 and 2 has been repudiated by them vide repudiation letter dated 01.07.2021 on the ground that patient needed only self isolation by home quarantine and her admission was not needed. The ops no.1 and 2 have wrongly and illegally repudiated the genuine claim of complainant on the said ground because as per guidelines of AIIMS, New Delhi relied upon by ops no.1 and 2 as Ex.R1/13, it falls under severe disease if Respiratory rate > 30/ min or SpO2 < 90% on room air and patient needs to be admitted in ICU. In this regard, ops no.3 and 4 have submitted that when complainant came to their hospital, her SpO2 was 90% on room air and said fact is also proved from the discharge card of complainant from which it is evident that at the time of her admission in the Lalgarhia Hospital, Sirsa on 24.04.2021, her SpO2 was 90%. The complainant was already taking treatment from Poonia Hospital but as there was no improvement in her health rather her condition deteriorated, so keeping in view her health condition, the ops no.3 and 4 admitted her in the hospital. So the complainant was admitted in the hospital by the doctor in view of her condition and even as per guidelines of AIIMS, New Delhi her admission was necessary. So it is proved on record that ops no.1 and 2 have wrongly and illegally repudiated the claim of complainant and even the second letter of repudiation dated 30.09.2021 issued by ops no.1 and 2 is also not tenable in the eyes of law, baseless and groundless. It is proved on record from bill dated 28.04.2021 and receipt dated 28.04.2021 of ops no.3 and 4’ hospital that an amount of Rs.50,000/- was charged by hospital from complainant for her treatment and besides this she also spent another amount of Rs.12,177/- on medicines and test reports etc. as is evident from bills/ receipts Ex.P23 to Ex.P30 and as such complainant was entitled to claim amount of Rs.62,177/- from ops no.1 and 2 and non payment of this amount clearly amounts to deficiency in service on the part of ops no.1 and 2. However, no liability of remaining ops no.3 and 4 is made out because doctor of the hospital admitted the complainant in the hospital as per poor health condition of the complainant which was necessary at that time.
9. In view of our above discussion, we allow the present complaint qua opposite parties no.1 and 2 insurance company and direct the ops no.1 and 2 to pay the insurance claim amount of Rs.62,177/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of this complaint i.e. 04.10.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops no.1 and 2 to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. However, complaint qua ops no.3 and 4 stands dismissed. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 08.05.2024. District Consumer Disputes
Redressal Commission, Sirsa.
