Delhi

North

CC/17/2019

RAKSHA SHARMA - Complainant(s)

Versus

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

SAURABH BHARGAVAN

19 Mar 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Phone: 011-23969372; 011-23912675 Email: confo-nt-dl@nic.in

Consumer Complaint No.17/2019

In the matter of

Raksha Sharma

W/o Late Shri Om Prakash Sharma

R/o A57A, Ganesh Nagar Complex

Pandav Nagar, New Hanuman Temple

Delhi-110092                                                                          …ComplainantNo.-1

 

Smt Neelam Sharma

W/o Sh. Bansi Lal

Office at –Chamber No.165A

Gate No.11, Patiala House Court

New Delhi                                                                            …Complainant No.-2

Versus

United India Insurance Co.Ltd            

Office at :  D-2, Ist floor, Kamla Nagar

Delhi-110007

(Through it Branch Manager)                                                     ...Opposite Party

ORDER
19/03/2024

Ms.Harpreet Kaur Charya, Member

Jurisdiction of this Commission has been invoked by Smt. Raksha Sharma, Complainant No.1 and Smt. Neelam Sharma, Complainant No.2 against United India Insurance Co.Ltd. as OP with the allegations of  deficiency in services and unfair trade practice. 
1. Facts as per the complaint are that the No.2 is an advocate by profession and complainant No.1 is the mother of the Complainant No.2. It has been stated by the complainant that the complainant alongwith other family members are covered under medi-claim insurance policy bearing No.0426002817P 108798146 issued by OP.  The said policy being a corporate policy through New Delhi Bar Association, New Delhi. 
2. On 27/03/2018, complainant No.1 was admitted in St. Stephen Hospital and discharged on 06/04/2018.  Claim for reimbursement was rejected by OP vide communication dated 08/08/2018 on the ground that complainant No.1 was hospitalized only for evaluation, which was in contravention to the policy terms and conditions. 
3. Legal notice dated 22/09/2018, was served upon OP calling them to settle the claim and also pay Rs.1,00,000/-  for mental agony and harassment.  The said legal notice was neither replied nor complied with by the OP. Hence the present complaint with the prayer for direction to OP to pay Rs.1,22,249/- being the medi-claim alongwith interest @18% from the date of filing of complaint till realization; Rs,1,00,000/- as compensation for mental agony and pain and Rs.50,000/- as the cost of litigation. 
4. The complainants have annexed the Group Health Insurance policy; medi-claim reimbursement claim form, copy of legal notice dated 22/09/2018 and letter issued by OP dated 08/08/2018 with the complaint.
5. Notice of the present complaint was served upon OP.  Written statement was filed on its behalf.  Preliminary objections such as the complainants have not approached the Commission (erstwhile Forum) with clean hand; the claim was not payable as per Exclusion Clause 4.11 of policy terms and conditions; claim was repudiated on the recommendation of Third Party Administrator (TPA) and the s No.1 was hospitalized only for investigation and evaluation of the ailment which is not admissible under the Exclusion Clause 4.11.  
6. It has been admitted that the complainants are holding a tailor-made group Health Policy bearing No.0426002817P108798146 for the period from 30/08/2017 to 29/08/2018.  It has been submitted that on the recommendations of the TPA, the claim of the complainants was repudiated.  TPA being a professional agency and is  engaged for a fee/remuneration by the Insurance company  for the provision of Health services under an agreement and governed by the provisions of IRDA Regulation (Third Party Administrator-Health Services) 2001.
7. The claim of the complainants was rejected as it was not admissible under Exclusion Clause 4.11:
“Charges incurred at Hospital or Nursing Home primarily for diagnosis, X-ray or laboratory examination or other diagnosis studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at the hospital/Nursing home”.
8. It has been denied that there is deficiency in services or unfair trade practice on their part.  The contract of Health Insurance is just like any other contract subject to terms and conditions and the complainant is bound by the policy terms and conditions as it has been signed by the Complainant No.-2.  Rest of the contents of the complaint have been denied with the prayer to dismiss the complaint with heavy cost. 
9. OP has annexed the copy of the Group Health Policy alongwith terms and conditions as Annexure-B.
10. Rejoinder to the written statement of the OP has been filed by the complainants.  It has been stated that the policy terms and conditions including the alleged Exclusion clause and the repudiation letter were not supplied to the Complainants.  It has been denied that the hospitalization was only for investigation and evaluation. The discharge summary of St. Stephen Hospital explained the treatment undergone.   Rest of the contents of the complaint have been reaffirmed and those of the written statement have been denied.
11. Evidence by way of affidavit has been filed by both the complainants reiterating the contents of the complaint.   They have relied upon the document annexed with the complaint and have got them exhibited as follows:- 
(i) Copy of policy as Ex.CW1/1
(ii) Copy of all medical papers as Ex.CW1/2
(iii) Copy of repudiation letter as Ex.CW1/3.
(iv) Copy of legal notice dated 22/09/2018 as Ex.CW1/4
12. OP has got examined Sh. P.S.Arora, Sr. Divisional Manager and Authorised Representative of OP.  He has also repeated the content of their written statement and have got exhibited the repudiation letter as Ex.DW1/1. 
13. We have heard the arguments for the Ld. Counsel for the Complainants and Ld. Counsel for OP.  We have also perused the material placed on record.  The complainants have assailed the rejection of their claim for reimbursement vide letter dated 08/08/2018(Ex.CW1/3 and Ex.DW1/1)                                                                   on the ground that “charges incurred at hospital, nursing home primarily for diagnosis, X-ray or lab examinations not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at the hospital.” 
14. It is seen that the Cashless Service was denied by OP vide letter dated 06/04/2018 issued by the TPA to the St. Stephens Hospital.  On the basis of Doctors note that the present hospitalization is related to anxiety disorder, need of hospitalization not justified and case is mainly for investigation and evaluation only, the cashless service was denied.
15. On the other hand, the complainants have filed a certificate dated 06/04/2018 issued by the doctor of St. Stephens Hospital , it also bears stamp of  the doctor in-charge, Dr. Sachin Suresh Babu, Neurology, which states:
“To whomsoever it may concern
This is to clarify that this patient had a chronic vascular headache and also had an infection component as the CT report mentions as well. Rt. Maxillary sinusitis for which she was started on IV antibiotics. Anxiety-depression is nearly a component of her final diagnosis as is not the sole purpose of admission.”
16. OP has not disputed the certificate dated 06/04/2018 or its contents thereof. The doctor is the best person to judge if hospitalisation is required or not. As per this certificate the complainant No. 1 had infection and was started with Intravenous antibiotics .OP has placed nothing on record as such any literature that hospitalisation is not required for administration of IV antibiotics or certificate of the doctor of TPA who had recommended the cashless denial, in rebuttal of this certificate. 
17. As per discharge summary (Ex.CW-1/2) the Complainant No.1 was diagnosed with chronic daily headache with mixed anxiety depression; CAD post PTCA; HTN and right Maxillary sinusitis with follow up advice. The course in the hospital was:
“65 year old female k/c/o HTN, CAD post PTCA presented with c/o right sided headache.  Relevant blood investigations were done, CEMRI was done which was normal, MR venography +Angiography was done which was reported as normal.  Temporal artritis was thought as a differential USG Doppler was done to rule out. Cardiology consultation was sought for palpitation and advised followed ECG and 24hrs holter monitoring was done.
Rheumatology consultation of sought in view of polyarthralgia DEXA scan was done which was reported as above and advise followed.  Dermatology consultation was sought in view of left foot itching and advise followed.  Psychiatry consultation was sought in view of vague pain an advice followed. Respiratory medicine consultation was sought in view of dry cough and PFT done which showed normal study rest advised followed, ENT consultation done in view of discomfort in throat, dry cough, NCCT PNS was done which report right maxillary chronic sinusitis with deviated nasal septum, advised followed.
Patient was managed conservatively and showed improvement hence being discharge with the following advice.
 
18. Thus, it can be inferred from the documents that complainants are entitled to reimbursement of their claim and OP by rejecting the claim for reimbursement without any basis and reasoning, has indulged in deficiency in service and unfair trade practice.  These acts/omission on part of OP has caused mental agony and harassment to the complainants.
19. Therefore,  in the facts and circumstance of the present case and in the interest of justice , we direct OP to pay :
(a) Rs.1,22,249/- as reimbursement for the expenses incurred by the complainants.
(b) Interest @7% p.a. from the date of filing of the present case (24/01/2019) till realization.
(c) Rs.15,000/- as compensation for mental agony and pain.
(d) Rs.11,000/- as cost of litigation.
 
The order be complied with in 30 days from the date of receipt of order.Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website.  Thereafter, file be consigned to the record room.
 
 
  (Harpreet Kaur Charya)                                                     (Ashwani Kumar Mehta)
 
                   Member                                                                         Member
                                                                                                                                                                         
 
                                              (Divya Jyoti Jaipuriar)
                                                             President
 

 

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