Chandigarh

DF-I

CC/26/2024

KAMAL RAJ SINGH THIND - Complainant(s)

Versus

CARE HEALTH INSURNACE LTD. - Opp.Party(s)

VIKRAM TANDON

04 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/26/2024
Date of Institution	:	04/01/2024
Date of Decision	:	04/09/2024

 

Kamal Raj Singh Thind son of Sh. Harbhajan Singh Thind, aged about 57 years, resident of H.No.2368, Pushpak-I, Sector 48-C, Chandigarh 160047

… Complainant

V E R S U S

1. Care Health Insurance Limited, Regd. Office, #19, Chawla House, 5^th Floor, Nehru Place, New Delhi-110019 through its Managing Director/Director/General Manager/Manager/ Authorised Representative.
2. Care Health Insurance Limited, Service Branch Office, SCO No.56-58, 2^nd Floor, Madhya Marg, Sector 9-D, Chandigarh 160017 through its Branch Manager/Manager/ Authorised Representative.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Gaurav Bhardwaj, Advocate for complainant
	:	Sh. Raj Kumar, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Kamal Raj Thind, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the complainant has been regularly taking the cashless health insurance policy from the OPs since the year 2013 and had also obtained the subject policy namely “Care Shield Floater Policy” valid w.e.f. 28.3.2023 to 27.3.2024 (Annexure C-1) on payment of premium of ₹40,202/- with basic sum insured of ₹5.00 lacs, covering the complainant, his wife Smt. Parvinder Kaur Thind and son Agamjyot Singh Thind.  On 16.6.2023, wife of the complainant (hereinafter referred to as “insured patient”) was admitted in the Fortis Hospital, Mohali (hereinafter referred to as “treating hospital”) with complaint of Abnormal Uterine Bleeding (AUB) for which hysteroscopy polypectomy was done under general anaesthesia and she was discharged on 17.6.2023.  At that time, hospital authorities had raised bill of ₹36,123/-. The doctors had also done biopsy and other tests and had also conducted CT scan for which an amount of ₹20,000/- was charged.  After investigation and tests the treating hospital had raised bills (Annexure C-2 to C-4).  On 5.7.2023, the insured patient was again admitted in the treating hospital for post coital bleeding and for further evaluation and she was operated with Robotic Radical Hysterectomy with Bilateral Salpingo-Opherectomy on 5.7.2023.  Thereafter on 7.7.2023 the treating hospital had raised bill of ₹4,16,665/- and discharged the insured patient on 7.7.2023. Copies of discharge summary, bill and receipt are Annexure C-5 to C-7.  Out of the aforesaid amount, OPs vide their claim approval letter dated 7.8.2023 (Annexure C-8) passed the claim of ₹2,54,710/- only and balance claim of ₹1,45,300/- was denied as non payable item (Robotic charges), non medical expenses (admission and registration charges) being not payable.  On 18.7.2023, complainant sent claim form of balance amount to the tune of ₹2,11,983/- to the OPs alongwith documents and bill for reimbursement, out of which OPs have only cleared the amount of ₹79,222/- vide their letters dated 23.8.2023 and 24.8.2023 (Annexure C-9 & C-10) whereas an amount of ₹1,32,761/- was not paid by the OPs with the remarks that non payable items and non medical expenses.  Even the treating doctor vide letter dated 7.7.2023 (Annexure C-11) has mentioned that Robotic surgery is required for higher magnification and better precision with less chances of recurrence etc.  Moreover, when the robotic surgery is also covered under the terms and conditions of the subject policy, OPs have wrongly repudiated the partial claim of the complainant. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and jurisdiction. However, it is admitted that the subject policy was issued by the OPs to the complainant covering the insured patient and other family members and the same was valid at the relevant time. It is further admitted that the insured patient was admitted in the treating hospital w.e.f. 16.6.2023 to 17.6.2023 and the complainant had raised claim with the OPs.  It is further alleged that, in fact, few queries were put to the complainant with respect to the bills vide letter (Annexure 4) and thereafter the partial claim of the complainant was processed and the amount of ₹2,54,710/- was accordingly transferred on 8.8.2023, but, the claim, which was not covered under the subject policy, was denied to the complainant and he was accordingly intimated about the same.  Moreover, OPs are not liable to pay an amount of ₹1,32,761/- to the complainant being not covered under the policy.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the insured patient was admitted in the treating hospital firstly on 16.6.2023 and was discharged on 17.6.2023 and thereafter again she was admitted in the treating hospital on 5.7.2023 and was discharged on 7.7.2023 where she was operated with Robotic Radical Hysterectomy with Bilateral Salpingo-Opherectomy and the treating hospital had raised a bill of ₹4,16,665/- on 7.7.2023 out of which OPs have only sanctioned/paid an amount of ₹2,54,710/- and have partially repudiated the claim of the complainant vide letter dated 27.8.2023 (Annexure C-13) on the ground that the benefit is not covered under the policy i.e. Robotic Surgery is not covered under the policy, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in partially repudiating the genuine mediclaim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly partially repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the medical record as well as the terms and conditions of the subject policy and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Annexure C-5 is the discharge summary dated 5.7.2023 which clearly indicates that the insured patient was diagnosed with past history of hysteroscopy polypectomy done on 16.6.2023 i.e. when the insured patient was first time admitted in the treating hospital and known case of hypertension and treatment was given to her. Relevant portion of the discharge summary is reproduced below for ready reference :-

“Diagnosis

• ATYPICAL ENDOMETRIAL HYPERPLASIA ON HPE WITH H/O POST COITAL BLEEDING
• SURGERY - ROBOTIC RADICAL HYSTERECTOMY WITH BILATERAL SALPINGO-OOPHERECTOMY WITH ROBOTIC BILATERAL PELVIC LYMPH NODE DISSECTION AND SENTINEL LYMPH NODE DISSECTION AND REMOVAL DONE ON 5/7/23

Presenting Complaints

Patient came to FHM with the complaint of post coital bleeding (1 episode). Endometrial study was done. Patient had hysteroscopy on 16/6/23 which was s/o malignant changes in HPE. BIOPSY done on 16/6/23 s/o endometrial polyp with atypical endometrial hyperplasia. PET CT SCAN done on 27/6/23 s/o non hypermetabolic uterine fibroid. Sub pleural pulmonary nodule - benign. Hypermetabolic foci in the region of sigmoid colon Now admitted here for further evaluation and management.

Past History/Comorbidities

• H/O HYSTEROSCOPY POLYPECTOMY DONE ON 16/6/23
• K/C/O HYPERTENSION

Physical Examination

On admission, Conscious, oriented. No pallor, No icterus, No clubbing, No lymphadenopathy, No pedal edema BP-130/80 mmHg, Temp- 98.4F, Pulse rate-82/min, RR- 24/min, SpO2 96% on room air CNS-NAD. Chest-b/l air entry present. cvs-s1 s2 normal. Abdomen-soft, non-tender.

Course In The Hospital 

Patient was admitted for surgery. All routine investigations were done. PAC was done and clearance was done and patient was taken for ROBOTIC RADICAL HYSTERECTOMY WITH BILATERAL SALPINGO OOPHECTOMY WITH ROBOTIC BILATERAL PELVIC LYMPH NODE DISSECTION AND SENTINEL LYMPH NODE DISSECTION AND REMOVAL DONE ON 5/7/23.”

Thus, one thing is clear on record that the Robotic Surgery was conducted on the insured patient by the treating hospital.

4. Repudiation letter (Annexure C-13) clearly indicates that the claim of the complainant was partially denied by the OPs on the simple ground that benefit not covered under policy without mentioning why it is not covered under the policy.  However, at the time of argument, it has been submitted by the learned counsel for the OPs that, in fact, Robotic surgery was not covered under the subject policy.
5. Pertinently, perusal of terms and conditions of the subject policy (Annexure A-9) clearly indicates that treatment through robotic surgery to the insured patient was also covered as per clause 3.1.1 (iv) and the said clause is reproduced below for ready reference :-

“(iv)   Advance Technology Methods :

          The Company will indemnify the Insured Person up to Sum Insured for expenses incurred under Benefit I (Hospitalization Expenses) for treatment taken through following advance technology methods :

                          xxx           xxx           xxx

          G. Robotic surgeries.

xxx           xxx           xxx”

 

6. Perusal of the claim approval and settlement letter dated 9.8.2023 (Annexure A-9) clearly indicates that the claim of the complainant was allowed only to the extent of ₹2,54,710/- by the OPs. As it is an admitted case of the parties that the partial claim of the complainant was repudiated by the OPs only on the ground that robotic surgery was not covered under the subject policy whereas the terms and conditions of the subject policy squarely cover even the treatment through robotic surgery, it is clear that the OPs have wrongly denied the claim of the complainant and the said act certainly amounts to deficiency in service on their part.
7. So far as the earlier treatment given to the insured patient on 16.6.2023 when she was admitted in the treating hospital is concerned, as the discharge summary (Annexure A-3) clearly indicates that nothing significant was found in her past history, it is clear that the OPs have wrongly repudiated the claim of the complainant by holding that the benefit not covered under the policy and it is unsafe to hold that OPs/insurers were justified in partially repudiating the claim of the complainant and the present consumer complaint deserves to succeed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹1,32,761/- to the complainant alongwith interest @ 9% per annum (simple) from the date of partial repudiation of the claim i.e. 27.8.2023 onwards.
2. to pay ₹15,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs, jointly and severally, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

04/09/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member