Complaint filed on: 15-12-2012 Disposed on: 26-09-2013 BEFORE THE BANGALORE IV ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052 C.C.No.2449/2012 DATED THIS THE 26th SEPTEMBER 2013 PRESENT SRI.J.N.HAVANUR, PRESIDENT SRI.H.M.SHIVALINGAPPA, MEMBER Complainant: - Dr.Vijay Kumar Khoda, 857, 20th B Main, 8th Block, Koramangala, Bangalore - 95 V/s Opposite party: - The Manager, The Oriental Insurance Company Limited, 22 DVG Road, VC Plaza, Basavanagudi, Bangalore-04 ORDER SRI.J.N.HAVANUR, PRESIDENT This is a complaint filed by the complainant against the OP, praying to pass an order, directing the OP to pay Rs.21,060=00, compensation towards harassment and such other relief as deemed fit under the circumstance of the case. 2. The brief facts of the complaint can be stated as under. The complainant’s wife Rajni Khoda had a pancreatic cyst, and she went for investigations from time to time since 2007. During these years, the cyst was not removed as per the advice of doctors. In the year 2012 wife of the complainant experienced constant pain in the abdominal region and therefore went for consultation to Bangalore Institute of Oncology. The doctors advised detailed investigations which included checking for malignancy. During the investigation at Bangalore Institute of Oncology, it was found that the cyst had grown in size, and the doctors advised for removal of the cyst and accordingly the patient underwent USG guided FNAC procedure on 7-6-2012. The Cystic fluid was investigated for malignant cells. Thus after detailed investigation the patient i.e. wife of the complainant was treated by USG guided FNAC procedure to remove the cyst. As the wife of the complainant has a Mediclaim policy with the OP, the hospital expenses amounting to Rs.21,060=00 was submitted to Raksha TPA. Surprisingly, the said TPA informed vide their letter dated 30-6-2012 that the claim is rejected. The complainant sent an email on 12-7-2012 to the said TPA explaining why his claim came to be rejected. The said TPA did not respond to the complainant’s email, and he tried to contact them over phone a number of times but they did not even lift the telephone, then the complainant contacted Dr.Selva, Branch Manager of Basavanagudi branch of Oriental Insurance Co. by phone and email on 25-7-2012, but he did not respond, so he sent a mail to him, he did not give any response and the complainant again sent a mail. At last Dr.Selva sent a mail to Ms.Mary of Raksha TPA on 13-8-2012 to inform the status of the claim of complainant. After that, the complainant did not hear from him again, after waiting for another three weeks, he finally contacted the customer services department (CSD) of the insurance company in Delhi and sent a mail on 4-9-2012, and he received an email on 13-9-2012 from Mr.Suresh Chandra of CSD, Delhi informing that the concerned office is being advised to resolve the issue within 15 days and in the meantime the complainant shall be communicated a unique grievance number. The complainant did not receive the unique grievance number nor did not hear from the company, so he again sent a mail to Suresh Chandra. There was no response from him, and he finally contacted the chief grievance officer of the insurance company, finally he received a letter dated 5-12-2012 from Regional Manager informing that his claim is rejected. All along the insurance company has treated the complainant as a customer with indifferent and contempt. The insurance company is a service organization and they survive because of their customers, in this case all along the company officials’ right from branch manager, officials in regional office and chief grievance officer did not respond to the complainant, except one official Suresh Chandra of customer service department in Delhi. It is clear that this insurance company does not care about its customers and from their attitude they have only shown contempt for a customer. The complainant’s wife had undergone investigation for the pancreatic cyst before 2012 also since the investigation was not followed by removal of the cyst, he did not make any claim to the insurance company. However, in the present case the investigation were followed by removal of the cyst by the hospital and the patient was treated for removal of the abnormal growth. So he would like to submit that his wife and their children have been insuring with oriental insurance for the last 12 years, in this period of 12 years in just one claim. He has been very careful in making claims and he surprised by stand of the insurance company in rejecting his claim. So he has filed the present complaint, so he prays medical expenses of Rs.21,060=00 may kindly reimbursed by the insurance company and also to pay compensation and other relief as deemed fit, under the circumstance of the case. 3. After service of the notice, the OP has appeared through its counsel and filed version, contending interalia as under: The complaint of the complainant is not maintainable. The claim of the complainant has been suitably examined in accordance with the conditions of the policy issued in his favour and as per the clause no.4.10, the claim of the complainant is not entitled, and hence the claim has been rejected. The rejection of the claim is in accordance with law, there is no illegality committed by the OP. The complaint of complainant has been examined and suitably replied within the stipulated period. The claim of the complainant that, the cyst was removed during the year 2012 at Bangalore Institute of Oncology is denied as false. There is no material, discharge summary, Hospital records produced by the complainant to show that the procedure followed by the hospital authorities for removal of the cyst is a hospitalization procedure. None of the documents were produced by the complainant to substantiate the said claim, records not related to removal of the cyst. There is no hospitalization for 24 hours as required by the policy condition and FNAL procedure done is an out patient treatment. No doctor certificate has been enclosed or any of the doctors from the hospital has certified about the procedure adopted and repudiation of claim of the complainant by TPA is in accordance with the terms and conditions of the policy, the complainant having not satisfied with the reply of the OP has complained to the head office alleging that the claim is still pending, so the head office in turn has referred the matter to the OP for examination. The OP once again has examined the same the complainant had approached the regional office at Bangalore and once again went through the claim of the complainant and after having satisfied the reasons assigned for rejection of the claim have closed the file. The records, bills produced by the complainant only refer to the investigation and outpatient treatment done in respect of the complaint of the complainant. No hospitalization treatment was followed pursuant to the said investigation, so the complaint is not maintainable; there is no deficiency of service on the part of the OPs. Hence the complaint be dismissed with cost. 4. So from the averments of the complaint of the complainant and objection of the OP, the following points arise for our consideration. 1. Whether the complainant proves that, the OP is negligent and there is deficiency of service on the part of the OP in rejecting his claim as prayed in the complaint? 2. If point no.1 is answered in the affirmative, what relief, the complainant is entitled to? 3. What order? 5. Our findings on the above points are; Point no.1: In the affirmative Point no.2: The complainant is entitled to refund of Rs.21,060=00 from the OP being the Evaluation and treatment of pancreatic cysts of his wife, within 30 days from the date of this order, failing which, the OP shall pay the said amount to the complainant alongwith 8% interest per annum on the said amount from date of this order to till the date of realization and Rs.3,000=00 and Rs.2,000=00 to the complainant towards compensation and cost of litigation respectively. Point no.3: For the following order REASONS 6. So as to prove the case, the complainant has filed his affidavit by way of evidence and produced nine copies of documents which were marked as annexure-1 to 9 and one certificate of Dr.Venkatachala.K, alongwith one letter of complainant dated 12-6-2013 filed. On the other hand, one Dr.B.Selvanayagam, who being the Sr. Divisional Manager of OP has filed his affidavit by way of evidence on behalf of the OP and produced 14 copies of documents. We have heard the arguments of both parties and we have gone through the oral and documentary evidence of both sides meticulously. 7. One Dr.Vijay Kumar Khoda who being the complainant has stated in his affidavit that, his wife Mrs.Rajni Kodha underwent USG guided FNAC procedure on 7-6-2012 for treatment of pancreatic cyst at Bangalore Institute of Oncology. He submitted a claim of Rs.21,060=00 to the OP which was rejected on the grounds that, as per the clause 4.10 of the insurance policy which says quote expenses incurred at hospital or nursing home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalization period. FNAC procedure in addition to being a diagnostic tool is also used as a therapy for cysts or abscesses. This is clearly supported by the several reports/research papers; these reports clearly mention that FNAC technique for simple cysts of pancreas is an ideal therapy. This is what the specialist at Bangalore Institute of Oncology did. FNAC can also be therapeutic for some lesions such as cysts or abscesses and in many instances will alleviate the need for an open surgical biopsy. The OP seems to be unaware that FNAC is also used as a therapy for simple cysts and is therefore making it a ground for rejection of his claim. FNAC was used in the present case both for diagnosis and treatment as it was the most suitable one for this type of cyst. FNAC technique does not require any hospitalization; fine needle aspiration cytology is used for aspiration of fluid from the cyst. Since FNAC is cost effective has lower risk than surgery has minimal physical and psychological discomfort for the patient, it was adopted as the preferred method for treatment of the cyst. The doctor is not bound to explain for satisfaction of insurance company. Since the procedure was completed within a day there is no discharge summary, hospital records etc. as demanded by the OP. All the records of the procedures the patient underwent at the hospital have been submitted to the OP. It needs mention here that the doctor decides the course of treatment which is most suitable for the patient and not to satisfy the terms and conditions of insurance company. However, as per clause 2.3 of the insurance policy the time limit of 24 hours does not apply to surgery of gall bladder, pancreas and bile duct. Thus the present case also meets the insurance policy conditions as patent’s pancreas was involved. FNAC was the most suitable treatment in the present case and was therefore used by the hospital. He contacted Raksha TPA after they rejected his claim. They did not respond to his email on 12-7-2012 and phone calls, he contacted Dr.Selva of Basavanagudi branch of oriental insurance company by phone and emails. But he did not even acknowledge his phone calls and emails. He contacted the customer services department (CSD) at the head office of the insurance company in Delhi by email and he received an email from Mr.Suresh Chandra of CSD, Delhi informing that the concerned office is being advised to resolve the issue within 15 days, finally he received a letter dated 5-12-2012 from OP rejecting his claim without giving any reasons. He has insured his family members for the last 12 years with the OP, during these 12 years he has submitted only one claim for the whole family. He has suffered physically and mentally on account of deficiency of service on the part of the OP, so he has field the present complaint, so the complaint be allowed and pass an order as prayed for. 8. Let us have a look at the relevant documents of the complainant. Annexure-1 is a letter of TPA of OP rejecting the claim of complainant as per clause 4.10 of the policy as expenses incurred at hospital or nursing home primarily for evaluation proposes which is excluded from the policy. Annexure-2 and 3 are the biochemistry report and CT scan of whole body of the complainant’s wife dated 4-6-2012 and 5-6-2012 and as per the said reports, it is made clear that, blood sugar of wife of the complainant is normal and CT scan shows no evidence of pancreatic malignancy. Annexure-4 is Hematology report of the complainant wife. Annexure-5 is Cytology report of the complainant’s wife dated 8-6-2012 wherein it is stated that, in clinical information column that, simple cyst, pancreatic head. Annexur-6 is case summary issued by the Bangalore Institute of Oncology dated 9-6-2012 of complainant’s wife, wherein in the history of presenting illness column, it is stated that, the complainant’s wife having pancreatic cyst of last 4 years which is gradually increasing in size and recently she is having pain in right side of upper abdomen since 3-4 days and in the procedure column it is stated that, patient underwent USG guided FNAC by Dr.Sudhakar on 7-6-2012 and patient tolerated the procedure well and follow up column it is stated that, review after three months with USG report. Annexure-7 and 8 consisted of copies of emails correspondences between the complainant and OP with regard to making settlement of the claim of complainant as early as possible. Annexure-9 is the copy of letter of OP dated 5-12-2012 addressed to the complainant stating that, the committee has called for the file from TPA and pursued the file and it does not have any merit to reconsider the decision taken by the TPA, so they are treating the grievance as closed. The complainant has produced one certificate of Dr.Venkatachala.K which goes to show that the said certificate was issued by the said doctor stating that, the complainant’s wife a known case of chronic pancreatic cyst underwent ultrasound guided aspiration of the pancreatic cyst on 9-6-2012 which turned out to be inflammatory pathology, this procedure was diagnostic as well as therapeutic. The evidence of the complainant that, his wife underwent FNAC in Bangalore Institute of Oncology in the first week of June 2012 and this procedure was diagnostic as well as therapeutic stands corroborated by certificate issued by Dr.Venkatachala.K various test reports, cytology report and other reports produced by the complainant. 9. Let us have a cursory glance at the material evidence of the OP. One Dr.B.Selvanayagam, who being the Sr. Divisional Manager working in the OP office has stated in his affidavit that, the claim of the complainant has been examined in accordance with the conditions of the policy issued and as per the clause no.4.10, the claim of the complainant is not entitled, and hence the claim has been rejected. The rejection of the claim is in accordance with law, there is no illegality committed by the OP in repudiating the claim of the complainant, the cyst was removed during the year 2012 at Bangalore Institute of Oncology is denied as false. There is no material, discharge summary, Hospital records produced by the complainant to show that the procedure followed by the hospital authorities for removal of the cyst is a hospitalization procedure. There is no hospitalization for 24 hours as required by the policy condition and FNAL procedure done is an out patient treatment. No doctor certificate has been enclosed about the procedure adopted. The records, bills produced by the complainant only refer to the investigation and outpatient treatment done, so the complaint is not maintainable, and the same has been rejected and there is no deficiency of service on the part of the OPs. So the complaint be dismissed with cost. 10. The OP has produced copy of the claim form given by the complainant’s wife dated 14-6-2012 claiming expenses of Rs.21,060=00 alongwith investigation report bills, copies of slip issued by the department of Molecular Imaging and Radiology showing pancreas cyst, Cytology report, Whole body scanning report, case summary and terms and conditions of the policy. In the case summary copy produced by the OP, it is stated by Dr.Venkatachala.K, who being the consultant surgical oncologist, under the heading of procedure that, patient underwent USG guided FNAC by Dr.Sudhakar on 7-6-20112 and she tolerated the procedure well and she was asked to come for review after three months with USG report. Further in the terms and conditions under clause no.2.3 of the policy it is stated that, expenses on hospitalization as admissible only if hospitalization is for a minimum period of 24 hours, however this limit will not apply to following treatments : . . …. Xii. Surgery of gal bladder, pancreas and bile duct. Under clause 4.10 of the policy issued in the name of complainant, it is stated that, expenses incurred by hospital or nursing home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period. Since, investigation and treatment taken by the complainant wife in Bangalore Institute of Oncology was relating to pancreas, so we hold that the complainant wife has complied both clause no.2.3 and 4.10 of the policy conditions very well. In fact, the OP has not understood the meaning of FNAC procedure being new technique followed by the Bangalore Institute of Oncology for removal of cyst in pancreas instead of doing open surgery, so the rejection of the complainant’s wife’s claim by the TPA is totally incorrect and it is against the terms and the conditions of the policy. Taking the oral and documentary evidence of the complainant and compare the same with the material evidence of the OP, it is made manifest that, the complainant wife underwent investigation and treatment procedure for removal of pancreas cyst by FNAC procedure in the Bangalore Institute of Oncology and she has complied the terms and conditions of the policy, and accordingly, we hold that, the oral and documentary evidence of the complainant are more believable trustworthy and acted upon than the material evidence of the OP, and as such, we are inclined to come straight conclusion that, the complainant who comes to forum seeking relief has proved this point with believable material evidence that, the OP is negligent and there is deficiency of service on the part of the OP in rejecting the claim of the complainant wife, and accordingly, we answer this point in a affirmative. 11. In view of our affirmative finding on the point no.1, the complainant is entitled to reimbursement of Rs.21,060=00 from the OP, so the OP is directed to pay Rs.21,060=00 to the complainant being the evaluation and treatment of pancreatic Cyst of his wife, within 30 days from the date of this order, failing which, the OP shall pay the said amount to the complainant alongwith 8% interest per annum on the said amount from date of this order to till the date of realization. Since the claim of complainant was rejected by the OP without following the terms and conditions of the policy, so the complainant is entitled to nominal compensation, so the OP is further directed to pay Rs.3,000=00 and Rs.2,000=00 to the complainant towards compensation and cost of litigation respectively, and accordingly, we answer this point. In the result, for the foregoing reasons, we proceed to pass the following order. ORDER The complaint of the complainant is allowed. The OP is directed to pay Rs.21,060=00 to the complainant being the evaluation and treatment of pancreatic Cyst of his wife, within 30 days from the date of this order, failing which, the OP shall pay the said amount to the complainant alongwith 8% interest per annum on the said amount from date of this order to till the date of realization. The OP is further directed to pay Rs.3,000=00 and Rs.2,000=00 to the complainant towards compensation and cost of litigation respectively. Supply free copy of this order to both parties. (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open forum on this, the 26th day of September 2013). MEMBER PRESIDENT |
