Punjab

Patiala

CC/15/8

Satish Singla - Complainant(s)

Versus

L I C - Opp.Party(s)

Smt Jaswinder kaur

27 May 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

 

                                      Complaint No. CC/15/8 of 6.1.2015

                                      Decided on:        27.05.2015

 

Satish Singla son of Sh.Tarsem Chand Singla C/o Singla Cloth House, Near Gandhi Ground, Samana, District Patiala 94170-92498.     

 

                                                                   …………...Complainant

                                      Versus

 

Life Insurance Corporation of India, Branch Office:Samana, District Patiala through its Manager.

                                                                   …………….Op

 

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

 

                                      QUORUM

 

                                      Sh.D.R.Arora, President

                                       Smt.Neelam Gupta, Member

                                      Smt.Sonia Bansal,Member

                                     

                                                                            

Present:

For the complainant:   Smt.Jaswinder Kaur, Advocate

For Op                           Sh.T.M.Sayal,Advoate

                                     

                                         ORDER

D.R.ARORA, PRESIDENT

1. The complainant purchased the mediclaim policy No.165323557 known as “Jeevan Arogya Health Plan” in the month of September,2012 for himself and his wife Smt.Veena Rani from the Op for a term of 37 years on payment of annual premium of Rs.9740/- for the insured amount of Rs.2lacs. At the time of the issuance of the policy, it was assured by the Op that all types of hospitalization expenses, medical expenses, and expenses on surgical treatment in any hospital in India will be disbursed by the Op.
2. Mrs.Veena Rani, wife of the complainant was diagnosed on 16.7.2017  with a complaint of Pituitary Macro Adenoma  and she was taken to The Medanta Medicity Hospital, Gurgaon, where she was admitted on 18.7.2013 vide No.MM00402654. She was operated upon on 19.7.2013 in the said hospital and she was discharged on 22.7.2013. The patient was charged Rs.3,29,270.64 by the said hospital.
3. The intimation regarding the admission of the patient was given to the insurance company well within time. The complainant requested the Op to make the payment of the bill but the Op lingered on the matter under one or the other pretext. The complainant had to pay the amount of the bill of Rs.3,29,670.64 under the compelling circumstances. The complainant approached the Op for the reimbursement of the amount of the bill or to pay the insured amount of Rs.2lacs. He also produced the relevant documents including the medical record with the Op. However, to the surprise of the complainant, the Op paid only Rs.24000/- despite the fact that the surgery falls under the category of Major Surgical Benefits and therefore, he was entitled to the payment of 100 times of the daily hospitalization benefit i.e. Rs.2lacs but the surgery of the patient was treated under the category of Other Surgical Benefits and thus, the complainant was denied the claim ignoring the policy terms and conditions.
4. Feeling aggrieved by the act of the Op, the complainant moved the Ombudsman of the insurance at Chandigarh on 4.3.2014 but the Ombudsman acted partially and dismissed the complaint of the complainant on 5.11.2014.
5. The failure on the part of the Op to disburse the claim of Rs.3,29,670.64 spent by the complainant on the treatment of his wife is said to be an unfair trade practice as also a deficiency in service, which resulted into the harassment and the mental agony experienced by the complainant. Accordingly the complainant has brought this complaint against the Op under Section 12 of the Consumer Protection Act,1986     (for short the Act) for a direction to the Op to pay him the remaining amount out of Rs.3,05,670/- spent on hospitalization of the wife of the complainant with interest @18% per annum from the date of the discharge; to pay him Rs.50,000/- by way of compensation on account of the harassment and the mental agony experienced by him and further to award him Rs.11000/-towards the costs of the complaint.
6. On notice, the Op appeared and filed the written version. The Op has not denied the complainant as also his wife being the holder of “Jeevan Arogya Health Plan” policy. It is denied that at the time of the inception of the policy, it was assured by the Op that all types of hospital expenses, medical expenses and expenses on surgical treatment in any hospital in India will be paid by the insurance company. In fact, there is no provision in the policy to make the payment of hospital bills. As per the terms and conditions, the claim amount is payable directly to the life assured instead of to the hospital. The health plan under the policy is a fixed benefit plan and the complainant/life assured are very much aware about the same.
7. It is further the plea taken up by the Op that as per observations of the TPA, the surgery performed on the patient was, “endoscopic endonasal transphenoidal excision of pituitary macrodenoma” and the same was done  via endoscopic procedure and no craniotomy was done and neither the pituitary adenoma was done. As per the terms and conditions of the policy, the surgery falls under OSB( Other Surgical Benefits).Therefore, the payment of Rs.24000/-was made to the complainant, which includes Rs.8000/- for hospital cash benefit and Rs.16000/- for other surgical benefits.
8. It is also the plea taken up by the Op that the complainant had filed the complaint before the Ombudsman, who dismissed the same with the following observations: “After going through the written submissions and verbal pleadings I am of a view that there appears to be no deficiency in service on the part of insurer as it had discharged the claim as per terms and condition of the policy. Actually the surgery does not come under the major surgical benefits and day care procedure benefits. Moreover the insurer did pay hospitalization cash benefit and  other surgical benefit as per the policy conditions. Keeping in view of this factual  position the complainant is dismissed”
9. It is further averred that the complainant is not entitled to the amount of Rs.3,29,670.64. There is no relation of the amount of the bill paid by the complainant with the terms and conditions of the policy. It is denied that there was any unfair trade practice adopted by the Op or there was any deficiency of service on their part. Ultimately after denouncing the other averments of the complaint, going against the Op, it was prayed to dismiss the complaint.
10. In support of his complaint, the complainant produced in evidence Ex.CA, his sworn affidavit, Ex.CB, the sworn affidavit of Smt.Veena Rani, Ex.CC, the sworn affidavit of Sh.Naresh Kumar, the neighbor of the complainant alongwith documents Exs.C1 to C5 and his counsel closed the evidence.
11. On the other hand, on behalf of the Op, it’s counsel tendered in evidence Ex.OPA, the sworn affidavit of Mrs.Hemlata,Manager(Legal) of the Op in the Divisional Office at Chandigarh alongwith documents Exs.OP1 to Op6 and closed its evidence.
12. The parties failed to file the written arguments. We have heard the learned counsel for the parties and gone through the evidence on record.
13. It is the case of the complainant that his wife Smt.Veena Rani, also covered under the Jeewan Arogya Health Plan policy No.165323557 issued by the Op, had under gone the surgery in respect of pituitary Macro Adenoma in The Medanta Medicity Hospital, Gurgaon and the complainant having lodged the claim with the Op for the disbursement of the expenses of Rs.3,29,670.64 spent on her treatment or the insured amount of Rs.2lacs, the Op paid only Rs.24,000/- treating the surgery under the heading “Other Surgical Benefits” and not under the heading ‘Major Surgical Benefits’.
14. The complainant has produced ,Ex.C2, the medical record of the patient Smt.Veena Rani consisting of the MRI of Delta MRI & CT Scan Centre, Patiala and the medical record prepared by Medanta Global Health Private Limited in respect of the patient Mrs.Veena Rani under UHID, MM00402654.The same also includes discharge summary–Neuro showing the date of admission as 18.7.2013 and date of discharge as 22.7.2013.Under the heading procedure or surgery, it is recorded: “Endoscopic Endonasal Transphenoidal Excision of Pitutary Macroadenoma Done under GA with Image Guidence was done on 20.7.2013”
15. Ex.C1 is the copy of the comprehensive health plan known as Jeevan Arogya  and under the heading List Of Major Surgeries at serial No.20, it is recorded: “Excision of the Pituitary  Gland” and the percentage of the Major Surgical Benefits SA has been recorded as 100%.
16. In the heading Other Operations, following items have been provided : “Coronary Angiography, Bronchoscopic treatment of bleeding lesion, Bronchoscopic treatment of fistula/stenting, Bronchoalveolar lavage and biopsy, Pericaediocentesis, Insertion of filter in interior Vena Cava, Insertion of gel foam in artery or vein,Carotid angioplasty,Renal angioplasty,Tumor Embolisation, Endoscopic drainage of pseudo pancreatic cyst, Varicose vain stripping or ligation, Excision of dupuytren’s constructure, Carpal tunnel Decompression, PCNS(Percutaneous neprostomy), PCNL(Percutaneous nephro lithetomy) Nail bed deformity/resection and reconstruction”. Apparently the same does not cover excision of pituitary gland.
17. It is the plea taken up by the Op that it was observed by the TPA that in this case the surgery performed is:“endoscopic endonasal transphenoidal excision of pituitary macrodenoma”  and the same was done via endoscopic procedure and no craniotomy was done and neither the pituitary excision was done. The observation made by the TPA does not carry any value in the eyes of the procedure of surgery noted in the discharge summary as : “Eendoscopic Endonasal Transphenoidal Excision of Pitutary Macroadenoma Done under GA with Image Guidence was done on 20.7.2013. ”Whether the excision of Pituitary Macroadenoma was done under GA with image guidance or through an open surgery will not make any difference because the net result would remain that the excision of the pituitary was done and the same is covered under the list of Major Surgeries at Sr.No.20 of Comprehensive Health Plan namely ‘Jeewan Arogya’.Apparently the treatment was not done with a radiation therapy using high-dose-x-rays/proton beams to kill tumor cells or medication therapy  to shrink or eradicate the tumor. The Op has just innovated a way to deny the legitimate claim of the complainant simply by way of having obtained an opinion from the TPA that the excision of the pituitary was done via endoscopic procedure and no craniotomy was done. No exception has been taken in the list of the major surgeries in respect of excision of the pituitary gland that in case the same is not done  through open surgery, the claim is not to be covered under the list of major surgeries. When the Op has made a list of 140 surgeries under the heading Major Surgical Benefits (MSB) and the excision of the pituitary gland being covered under the same and not being covered under the heading Other Surgical Benefits (OSB), the Op was not justified in having settled the claim of the complainant under the heading OSB. This certainly amounts to an unfair trade practice on the part of the Op. The complainant is certainly entitled to the insured amount payable under the policy, which as per the averments made in the complaint is Rs.2lac, a fact not denied by the Op in its written version or even by the learned counsel for the Op during the argument at bar. Therefore, the complainant cannot claim more than the assured amount of Rs.2,00,000/- even though he spent Rs.3,29,670.64 as per the hospital bill,Ex.C3 issued by The  Medanta Medicity Global Health Pvt.Ltd. The complainant has already been disbursed a sum of Rs.24000/- and now he is entitled to the balance amount of Rs.1,76,000/. We accordingly accept the complaint and direct the Op to make the payment of Rs.1,76,000/- to the complainant with interest @9% per annum from the date of the disbursement of the partial claim amount of Rs.24000/- till final payment. In view of the facts and circumstances of the case, the complaint is accepted with costs assessed at Rs.5000/-. The order of the Forum be complied by the Op within one month on receipt of the certified copy of the order.

Pronounced

Dated:27.5 .2015

 

                   Sonia Bansal                Neelam Gupta                        D.R.Arora

          Member                        Member                                  President