Chandigarh

DF-II

CC/354/2017

Harish Singhal - Complainant(s)

Versus

Apollo Munich Health Insurance Company Ltd., - Opp.Party(s)

Anirudh Kush Adv. & Varinder Sharma Adv.

01 Dec 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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1]  Harish Singhal son of Sh.Gopal Singhal, aged 46 years,

2]  Dhruv Singhal son of Sh.Harish Singhal, aged 20 years,

Both residents of H.No.315, Mahesh Nagar, Ambala Cantt.

             …..Complainants

Versus

1]  Apollo Munich Health Insurance Company Ltd., SCO No.50-51, 4^th Floor, Sector 34-A, Chandigarh through its Branch Manager.

2]  Apollo Munich Health Insurance Company Ltd., 2^nd & 3^rd Floor, ILABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon through its Authorised Signatory.

….. Opposite Parties

3]  Max Super Specialty Hospital, Saket, East Block, a Unit of Devki Devi Foundation, Registered Office at Press Enclave Road, Saket, New Delhi.

                      ….. Proforma Opposite Party

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

                                MRS.PRITI MALHOTRA        MEMBER

Argued by: Sh.Anirudh Kush, Adv. for Complainant

 Sh.Nitin Thatai, Adv. for OPs No.1 & 2.

 Sh.Swapan Shaorey, Adv. for OP No.3.

PER PRITI MALHOTRA, MEMBER

          The facts in issue are that complainant No.1 obtained a Medical Health Claim Policy – Optima Restore Insurance Policy vide No.110300/11121/AA0012804402 and it was got renewed from 2.9.2016 to 1.9.2017.  It is averred that under the said policy, Mrs.Poonam Singhal, wife of complainant NO.1, was also insured for Rs.10.00 lacs (Ann.C-1 to C-3) and it was a cashless facility policy. Unfortunately, Mrs.Poonam Singhal was diagnosed with Metastatic Adenocarcinoma Gall Bladder (poorly differentiated) with liver mets, Stage IVb (T4N2) by OP NO.3 on 6.7.2016 and was admitted on 11.7.2016 and given 1^st cycle D1 neoadjuvant chemotherapy with Gemcetabine + Carboplatin AUC5 and was discharged on the same day i.e. 11.7.2016.  It is also averred that Mrs.Poonam Singhal was also admitted on 18.7.2016, 2.8.2016, 22.8.2016, 29.8.2016, 11.11.2016 and 26.11.2016 in Opposite Party NO.3 Hospital where she was treated with chemotherapy & immunotherapy apart from conducting several tests (Ann.C-4 to C-17 Colly.).  It is averred that cashless request made by the complainant No.1 was declined by OPs NO.1 & 2 vide letter dated 25.11.2016 (Ann.C-20), as such the complainants had to pay the entire payment of Rs.3,73,851/- and Rs.3,81,425/- i.e. total Rs.7,55,276/- (Ann.C-11 & C-16) to Opposite Party No.3 Hospital from their own pocket.  Thereafter, a claim was lodged with Opposite Parties NO.1 & 2 for reimbursement of the amount of medical treatment bills and in the meanwhile, unluckily Smt.Poonam Singhal expired on 28.1.2017.  However, the Opposite Parties did not reimburse the medical expenses despite several reminders and visits.  Hence, alleging deficiency in service and unfair trade practice on the part of OPs, the present complaint has been filed.

2]       The OPs No.1 & 2 filed joint reply and while admitting the factual matrix of the case, stated that the cashless request was declined by answering OPs because prima-facie the treatment which was provided by Opposite Party No.3 to the policy holder was unproven and experimental only and was not approved by FDA (Food and Drug Administration) and such treatments aren’t covered/payable as per policy terms and conditions. It is stated that the justification provided to OPs NO.1 & 2 by the Hospital was not found to be satisfactory, hence only the cashless facility was denied.  It is submitted that after completion of the treatment, the policyholder or the complainants did not submit any reimbursement claim to Opposite Parties No.1 & 2 and hence, OPs No.1 & 2 was unable to process the same.  It is also submitted that since no claim has been filed by the complainants, hence there is no question of deficiency in service or unfair trade practice. Denying other allegations, the OPs No.1 & 2 have prayed for dismissal of the complaint.

         The Opposite Party No.3 Hospital has also filed reply stating that the processing and disbursement of cashless facility and medical insurance claim is a matter between the patient and the insurance company and OP Hospital has no role either in the sanction or rejection of the cashless facility or approving the claim by the insurance companies. The Opposite Party No.3 Hospital while admitting the providing of medical treatment to the policyholder/patient and charging of bill amount, as alleged by the complainant, stated that the amount paid to it was in lieu of medical services provided by the Hospital.  It is submitted that answering Opposite Party treated the patient in accordance with the set medical protocols which was also clarified to Opposite Parties NO.1 & 2.  It is also submitted that the answering OP Hospital was fully committed towards the well-being of the wife of complainant No.1 and strived to save her life, but could not succeed. Further stated that due to decline of cashless facility by Opposite Parties No.1 & 2, the answering OP has no other option but to raise the bills and whatever amount paid by the complainants was towards the medical services availed/provided only and not otherwise. Pleading no deficiency in service, the OP No.3 has prayed for dismissal of the complaint qua it.

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of OPs No.1 & 2.

4]       Parties led evidence in support of their contentions.

5]       We have heard the ld.Counsel for the parties and have also gone through the entire record.

6]       It is duly proved on record that deceased Mrs.Poonam Singhal, wife of the Complainant No.1 was duly covered under the medical insurance policy i.e. Optima Restore Floater for an insured amount of Rs.10.00 lacs. The wife of the Complainant NO.1, when suffered ailment was got admitted in Max Super Specialty Hospital, New Delhi/OP No.3, where she was diagnosed as a case of Metastatic Adenocarcinoma Gall Bladder (poorly differentiated) with liver mets, Stage IVb (T4N2) and was given treatment accordingly from time to time.  The whole treatment for the above disease was provided within the coverage period of the policy.

7]       During the course of treatment, the complainant duly applied to Opposite Parties NO.1 & 2/Insurance Company for cashless benefit under the policy in question, which they declined.  The complainants filed the present complaint qua the rejection of the claim by the OPs and for non-payment of medical bills amount paid to OP No.3 (Hospital) by the complainants.

8]       At the onset of the arguments, the counsel for the OPs No.1 & 2 submitted that the present complaint is a pre-mature complaint as they have declined only the cashless request of the complainants and as per the letter of denial issued to the complainants, it was duly mentioned that the complainant is free to lodge claim for reimbursement afterwards and was informed that cashless denial is in no way indicate the denial of claim and the insured was requested to submit the claim documents after completion of treatment for review on admissibility, which the complainants failed to lodged afterwards.

9]       The perusal of Ann.C-20 i.e. Letter of Denial of Cashless Service by OP Insurance Company reveals that the request for the cashless facility was declined as the expenses for unproven and experimental treatment are not payable as per policy terms & conditions.

10]      The thorough perusal of the record reveals that undoubtedly the complainants did not formally lodge any claim with OP Insurance Company for the reimbursement, but the perusal of denial of pre-authorization letter (Ann.C-20) reveals that the OPs are decisive in their view to decline the claim of the complainants in case it is raised afterwards.  The further perusal of the record reveals that OP No.3 Max Hospital has duly issued a Certificate dated 12.11.2016 (Ann.C-18) to the effect as under:-

This is to certify that patient Mrs.Poonam, Singhal, 44/Fe-Male, is a diagnosed case of Metastatic Adeno-carcinoma of Gallbladder with Liver Mets IV.

She has received 3 cycles of chemotherapy with Inj. Gemcitabine (1GM) and Inj. Carboplatir AUC-5, which showed progressive disease, and then she was put on Oral chemotherapy, which also showed progressive disease.

Thereafter GENE SEQUENCING was done to assess the altered Genes & their therapy efficacy.  This revealed Inj.Nivolumab, showing improved efficacy in this patient.  In this era of personalized medicine, the Drugs chosen according to GENE SEQUENCING are appropriate and this being IMMUNO-THERAPEUTIC drug will improve the immune response to this tumor, which is not highly Chemo responsive.

GENE SEQUENCING REPORT IS ENCLOSED.”

11]      Thereafter, the Hospital concerned i.e. OP No.3 also duly issued an e-mail to OP Insurance Company on 12.11.2016 (Ann.C-19) at

“This is in regards Patient Mrs.Poonam Singhal UHID No.10007463135, rejection under Clause “Unproven and Experimental Treatment” as per policy terms and conditions.

          Please be informed, as per Doctor treatment is not an Unproven or Experimental, as the disease was progressive after Intravenous and Oral chemotherapy.  Thereafter, investigation GENE SEQUENCING was done to assess altered genes and their therapy. 

Kindly acknowledge this letter as Medical Justification for consideration of Treatment under Medical Policy.”

12]      From the above two documents i.e. Certificate issued by the treating doctor as well the clarification sent by the Hospital Authorities to the OP Insurance Company, it establishes that the treatment given to the wife of the Complainant NO.1 (insured under the policy) was not unproven or experimental treatment, as alleged by OP Insurance Company.

13]      The OPs No.1 & 2 has not placed on record any expert evidence/medical opinion  controverting the certificate issued by the treating doctor (Ann.C-18) whereby it is specifically disclosed that the treatment given to the patient/insured Mrs.Poonam Singhal is not an unproven and experimental treatment as the disease was progressive after Intravenous and Oral Chemotherapy and the investigation Gene Sequencing was done to assess altered genes and their therapy. Thus, it is beyond doubt clear that the claim of the complainants is genuine and is not excluded under any of the terms & conditions of the policy as claimed by the insurance company i.e. OPs No.1 & 2.  The plea of the insurance company that the treatment in question was not approved by FDA (Food & Drug Administration) is irrelevant when once it is certified by the competent doctor concerned that the correct line of action was followed in this era of personalized medicine and the drugs chosen according to Gene Sequencing are appropriate and this being IMMUNO-THERAPEUTIC drug will improve the immune response to this tumor, which is not highly Chemo responsive.  No judgmental error is found at the part of the treating doctor.     

14]      From the reply filed by the OPs No.1 & 2, it is gathered that even after receiving the  email dated 12.11.2016 (Ann.C-19) sent by the Max Hospital/OP No.3 justifying the treatment given to the patient/insured concerned, the OPs No.1 & 2 stated that the justification submitted by OP No.3 to them was not found to be satisfactory and therefore, earlier decision which was communicated vide email dated 12.11.2016 was repeated by email dated 25.11.2016.  This fact clearly establishes that the OPs No.1 & 2 are reluctant  to consider the genuine claim of the complainants and are inclined & adamant in their turn to reject the claim of the complainant in case a claim is lodged.  In such scenario, we are of the view that it is not appropriate to direct the complainants to lodge the claim with OP Insurance Company giving the OP Insurance Company an opportunity to delay and again deny the genuine claim. Therefore, the deficiency in service on the part of Opposite Parties No.1 & 2 is writ large. 

15]      Keeping in view the above findings, we are of the opinion that the deficiency in service on part of OPs NO.1 & 2 is proved.  Therefore, the complaint is allowed with directions to OP NO.1 & 2 – Apollo Munich Health Insurance Company to reimburse an amount of Rs.7,55,276/-, being the medical treatment bills, to the complainants along with interest @9% p.a. from the date of filing this complaint till payment, along with compensation of Rs.25,000/- for causing mental & physical harassment and litigation cost of Rs.10,000/-, within a period of 30 days from the date of receipt of certified copy of this order.

         In case the Opposite Party No.1 & 2 failed to comply with the order within the above stipulated period, then they shall also be liable to pay additional compensatory cost of Rs.10,000/- to the complainants apart from the above relief.

16]      However, the complaint qua OP NO.3/Max Hospital stands dismissed.

         Certified copy of this order be forwarded to the parties, free of charge. After compliance, file be consigned to record room.

Announced

1^st December, 2017                                                      

                                                                                      Sd/-  

                                                                   (RAJAN DEWAN)

PRESIDENT

Sd/-

 (PRITI MALHOTRA)

MEMBER