MS. NIPUR CHANDNA, MEMBER
- A complaint under Section 12 of Consumer Protect Act 1986 filed by Sh. Suresh Kumar (hereinafter referred to as complainant). The complainant is seeking grant of Rs.1,22,812/- alongwith interest @ 18% p.a for the claim of Medical Insurance and Rs.1,00,000/- for compensation for harassment from OP Insurance Co. The complainant has filed the present complaint alleging the deficiency in service on the part of OP. The brief facts of the case are that the complainant is the mediclaim policy holder of OP insurance company vide policy bearing No. 2817/54863745/03/000 w.e.f. 26.02.2018 to 25.02.2019.
- It is alleged by the complainant that the wife of the complainant Smt. Premlata was suffering with burning micturition with increased frequency of urine with body ache and fever. As such, she visited Ekansh Nursing Home on 24.04.2018 and consulted with Dr. R. Parashar, who advised three days medicine to her. After taking the medicine the wife of the complainant could not get relief and as such she again visited Ekansh Nursing Home on 26.04.2018. The treating doctor advised her for hospitalization and accordingly she was admitted in the hospital on 26.04.2018. The intimation of hospitalization was given to the OP on 27.04.2018 through email at the email of TPA i.e Health
- Notice of the complaint was sent to OP. Despite service none appeared on behalf of OP. As such OP was ordered to be proceeded ex-parte vide order dated 08.10.2018 by our Ld. Predecessor Bench. On 06.05.2019 the OP appeared and filed an application under Order IX Rule 7 of C.P.C praying for setting aside ex-parte order dated 08.10.2018 however same was also dismissed due to non prosecution vide order dated 23.08.2019.
- Complainant filed his evidence by way of affidavit and has also placed on record the copy of the policy document, copy of email dated 27.04.2018 regarding intimation of hospitalization to the TPA, claim submission letter dated 05.05.2012, copy of the medical records and bill, copy of repudiation letter dated 17.05.2018 and copy of clarification letter dated 21.05.2018 sent to the OP by complainant in support of his contention. Complainant has also placed on record written submission. We have heard the arguments advance at the bar and have perused the record.
- The sole question for our consideration in the present complaint case is whether the OP was justified in repudiating the claim of the complainant. We have gone through the repudiation letter filed on record by the complainant. The contents of which are reproduced as under:
Dear Sir/Madam,
This has reference to the above mentioned claim, on scrutiny of the claim documents submitted, we observe that:
The insured admitted from 26/04/2018 till 03/05/2018 with c/o burning micturition, increases frequency of urination 5-6 bodyache and fever and diagnosed with Acute urinary tract infection (E.Coll).
On scrutiny various discrepancies were observed as follows: 1. As per hospital records insured admitted with c/o recurrent vomiting but no such complaint noted in insured statement. 2. No entry of insured details for USG insured was sent out of the hospital. 3. Variation found in ICP’s Injection Alfakin 500mg given by hospital by 11:30 a.m on 27/04/2018 but, as per USG film, patient was admitted at Mittal diagnostic center between 11:00 am till 12:00 p.m. on same day. 4. As per lab report urine r/m dated 27/04/2018 pus cells in urine was WNL. Investigation team confirmed report is not submitted by hospital and not shown to us. Based on the discrepancies observed, claim stands repudiated as per policy guidelines.
In this regard, we regret to inform you that the claim is not admissible as per following Policy Clause:
10: Mis-description This Policy shall be void and premium paid shall be forfeited to Us in the event of Mis-representation, mis-description or non-disclosure of any materials facts to you. Non-disclosure shall include non intimation of any circumstances which may affect the insurance cover granted.
- The bare perusal of the aforesaid letter makes it clear that the OP insurance co. repudiate the claim of the complainant on mis-description for which OP company justified the repudiation on the basis of following discrepancies :
1.As per the hospital record insured admitted with the C/o recurrent vomiting but no such complaint noted in the insured statement.
Admittedly, as per the discharge summary the complainant got admitted in the hospital for recurrent vomiting, insured might have missed to inform the OP about the recurrent vomiting at the time of her statement during investigation. We do not find this a valid legal ground for repudiating the claim of the complainant when the discharge summary itself speaks about the recurrent vomiting episodes.
2. No entry of insured detail for USG insured was sent out of the hospital. As per the medical record the USG of the complainant was conducted at Mittal Diagnostic Center on 24.04.2018 as such there was no entry of the insured detail in the hospital record because the complainant was admitted in the hospital on 26.04.2018 ie. after USG test.
3. Variation found in ICP’s injection alfakin 500mg given by hospital by 11:30 a.m on 27.04.2018, but patient was admitted at Mittal Diagonistic center between 11 a.m till 12 p.m as per the USG film dated 27.04.2018. Perusal of the report shows that OP has misconstrued the schedule timings of giving the medicine to the complainant with actual time of giving the medicine to the patient. Moreover, during the hospitalization the patient was in the hands of the hospital. Hence, for the discrepancies in the medical record, the claim of the complainant should not be rejected.
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As regard the pus cells in urine was NIL, we have gone through the report of Mittal Diagonistic Center dated 27.04.2018, the conclusion of which is reproduced as under:
IMPRESSION: Mild hepatomegaly with fatty infiltration (Grade II).
Significant residual urine in bladder, may be due tU.T.I.
The bare perusal of the aforesaid report makes it clear that the patient is suffering from urinary tract infection and as per the discharge summary also the wife of the complainant was hospitalized and undergone treatment for urinary tract infection for which she incurred the medical expenses to the tune of Rs.1,22,812/-.
- In view of the above discussion we are of the considered view that the OP Ins. co. is not justified in repudiating the claim of the complainant rather they had taken the false stands to escape themselves from the liability. We therefore hold OP ins. Co guilty of deficiency in service and direct it as under:
i) Pay to complainant a sum of Rs.1,22,812/- alongwith interest @6% per annum from the date of filing of complaint i.e. 01.08.2012 till realization.
ii) Pay to complainant a sum of Rs.15,000/- as compensation for mental agony and harassment which will include the cost of litigation also.
- OP is directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.
- Copy of the order be sent to the parties free of cost. The orders be uploaded on www.confonet.nic.in.File be consigned to Record Room.
Announced in open Forum on 13.03.2023.
SANJAY KUMAR NIPUR CHANDNA
PRESIDENT MEMBER
