CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

  Udyog Sadan, C – 22 & 23, Institutional Area

          (Behind Qutub Hotel)

   New Delhi – 110016

    Case No.84/2020

Mrs. Jyoti Singh

W/o Dr. Saumil Gaur

R/o E-1602, Brigade Metropolis

Mahadevura ITPL Main Road Bengaluru

Through Authorised Representative

Dr. Saumil Gaur…..COMPLAINANT

Vs.

 Max Bupa Health Insurance Company Limited

 B-1/I-2, Mohan Co-operative Industrial Estate

 Mathura Road, New Delhi-110044.                                          ..RESPONDENTS

Date of Institution-07.08.2020

Date of Order-  22.03.2024

                                                O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on part of OP in repudiating the claim of complainant.

2. The complainant had a availed a health plan from OP namely Health Companion Variant 2 bearing No.30749741201800.

3. The complainant states that her husband experienced a sudden severe pain in abdomen and was admitted under Dr. Manish Joshi of Apollo Spectra Hospital on 30.1.2019.  The complainant was advised blood test, scan and a surgery was conducted on the same day due to acute medical emergency.

4. The husband of the complainant underwent emergency Laparoscopic Cholecystectomy and the gall bladder was removed and sent for pathological diagnosis and examination to Onequest Laboratories Ltd. The said pathological diagnosis and examination report included ultrasound report, blood test, biopsy report and histopathology reports of the husband of the complainant.

5. In the ultrasound report, the findings included presence of stone in gall Bladder of the complainant’s husband.  However, the biopsy report does not state that the inflammation of gall bladder was due to the presence of stone in the gall bladder of the complainant’s husband.  It is submitted that the acute inflammation of gall bladder can be caused because of several reasons such as bile duct problem, tumors, serious illness, gallstones and certain infections.

6. The complainant’s husband filed a claim for emergency surgery done for acute cholecystitis on 23.3.2019.  The claim was denied by OP vide letter dated 24.3.2019 on grounds of clause 5.3 of policy terms and condition which stipulates that the complainant’s illness have a waiting period of 24 months.  The complainant sent a legal notice dated 18.4.2019. 

7. The complainant prays for reimbursement of expenditure incurred i.e., Rs.1,04,730.00 with 18% interest and Rs.1,00,000/- towards mental agony.

8. OP in its reply submits that the complainant had opted for a health insurance policy namely Health Companion Variant 2 for sum assured of Rs.7,50,000/-. The policy commenced on 10.3.2018 and was renewed again on 9.3.2019.

9. A cashless claim was received from Apollo Spectra Hospital for the husband of the complainant.  It is submitted that he was suffering from biliary colic, provisionally diagnosed as Cholecystisis, and Laparoscopic Cholecystectomy was planned to be conducted.  The cashless claim was denied vide letter dated 29.1.19 stating that the claim is repudiated in accordance with Clause 5.3(a).

10. The complainant filed a claim for the reimbursement of expenses of Rs.1,04,730/- incurred during hospitalization wherein he was diagnosed as Acute Cholecystitis.  OP appointed an investigator.  On receipt of investigation report and investigation documents, OP rejected the claim.  It is alleged that Laparoscopic Cholecystectomy is performed when patient have stones in gall bladder.

11. The complainant in its rejoinder has re-iterated the averments made in the complaint.  The complainant emphasizes that the biopsy report did not find any stone in the gall bladder.

12. The complainant has filed the evidence by way of affidavit and exhibited the following documents:

1. Copy of Authorisation issued by the complainant is exhibited as Exhibit-C1.
2.  Copy of Policy and Customer ID allotted by OP is exhibited as Exhibit-C2.
3. Copy of prescription of doctor is exhibited as Exhibit-C3.
4. Copy of pathological diagnosis and examination reports are exhibited as Exhibit-C4.
5. Copy of  relevant extract from renowned medical Journal  is exhibited as Exhibit-C5 & 6

13. The OP has filed the evidence by way of affidavit and exhibited the following documents:

1. Copy of Authorisation letter is exhibited as Ex.OP-1/1.
2. Copy of information summary sheet is exhibited as Ex.OP-1/2.
3. Copy of Policy’s certificate alongwith terms and conditions are exhibited as Ex.OP-1/3 and Ex.OP-1/4.
4. Copy of preauthorisation form is exhibited as Ex.OP-1/5.
5. Copy of preauthorisation denial letter is exhibited as Ex.OP-1/6.
6. Copy of claim form and medical documents are exhibited as Ex.OP-1/7.
7. Copy of investigation report is exhibited as Ex.OP-1/8.
8. Copy of claim repudiation letter is exhibited as Ex.OP-1/9.
9. Copy of reply to the Legal Notice is exhibited as Ex.OP-1/10.

14.  The commission has considered the pleadings and material on record.  It is admitted by both parties that the complainant was covered under a health plan namely Health Companion Variant 2 bearing No.30749741201800.  It is undisputed that the complainant has been admitted in Apollo Hospital on 30.01.2019.

15. A claim was filed. The claim was repudiated in March, 2019.  The relevant portion is as follows:   

Claim Details

16. Clause 5.3 of the terms & conditions of the policy is as follows:

The medical conditions and/or surgical treatment listed below will be subject to a Waiting Period of 24 months unless the condition is directly caused by Cancer or an Accident and will be covered in the third Policy Year as long as the Insured Person has been insured continuously under the Policy without any break:

1.  Pancreatitis and Stones in Biliary and urinary System.

17.  The discharge summery shows that the complainant was admitted on 30.1.2019 and discharged on 31.1.2019.  Relevant portion is as follows:

     FINAL DIAGNOSIS:

     Acute Cholecystitis

CHIEF COMPLAINTS:

Pain Abdomen in the upper outer quadrant

SURGERY DETAILS:

LAPAROSCOPIC CHOLECSTECTOMY

18. The ultrasound report dated 29.01.2019 is as follows:

ULTRASOUND ABSOMEN

GALL BLADDER

Dilated and shows a calculus measuring 1.5 cm obstructing the neck with multiple small calculi clustered together in the fundus – There is significant wall thickening.Common bile duct appears normal.

19. The Biopsy report dated 1.2.2019 is as follows:

NATURE OF SPECIMEN: Gall Bladder

GROSS EXAMINATION:

Specimen of gall bladder measuring 7 X 2.5 cm.External surface is unremarkable.Mucosal surface shows yellowish specks.Three bits in one block.

Section shows wall of gallbladder with a mild transmural lymphocytic infiltrate alongwith a few eosinophils.The lamina propria shows collections of foamy histiocytic.

•  
• cholecystitis with cholesterolosis.

20. As per terms and condition of policy, there was a waiting period of 24 months for pancreatitis and stone in biliary and urinary system. The Policy commenced on 10.3.2018 and the complainant was hospitalised on 30.1.2019.Undisputedly, the complainant was hospitalised within 24 months of the commencement of the policy. 

21. Perusal of the ultrasound report shows that there was a calculus measuring 1.5 cms and multiple small calculi in the gall bladder.

22. As per website of Betterhealth, (www.betterhealth.vic.gov.au/ health/conditionsandtreatments/gallbladder-gallstones-and-surgery#). Calculus means “Gallstones (biniary calculi) are small stones made from cholesterol, bile pigment and calcium salts, usually in a mixture that forms in the gallbladder.  They are a common disorder of the digestive system, and affect around 15% of people aged 50 years and over.”

23. The complainant was admitted to Apollo Spectra Hospital on 30.1.2019 and gall bladder was removed through a procedure called Laproscopic Cholesystectomy. As per Website Statpearls (www.ncbi.nlm.nih.gov/ books/NBK448145/)

24. The final diagnosis in discharge summery shows that the complainant had Acute Cholecystitis.  As per website: MedlinePlus (www.medlineplus.gov/ ency/article/ 000264.htm)

“Acute cholecystitis is sudden swelling and irritation of the gallbladder. It causes severe belly pain.

Causes

The gallbladder is an organ that sits below the liver. It stores bile, which is produced in the liver. Your body uses bile to digest fats in the small intestine.

Acute cholecystitis occurs when 

25. As per the biopsy report, the impression was chronic cholecystitis with cholesterolosis.

26. As per website : Healthline (www.healthline.com/ health/chronic-cholecystitis)

“What is chronic cholecystitis?

Cholecystitis is the sudden inflammation of your 

The gallbladder is a small, pear-shaped organ located on the underside of your liver. It stores bile made by the liver and sends it to the small intestine via the  (CBD) to aid in the digestion of fats. The CBD connects the liver, the gallbladder, and the pancreas to the small intestine.  are the leading cause of cholecystitis. This blockage causes bile to build up in the gallbladder, and that build-up causes the gallbladder to become inflamed.”

27. As per website : Healthline (www.healthline.com/ health/ cholesterolosis):
28.  that looks like a pear-shaped sac. It’s located under the liver.

The gallbladder stores bile and helps turn cholesterol and fats into cholesteryl esters to aid in digestion. These cholesteryl esters allow cholesterol and fatty acids to be transported through the body in the bloodstream. Cholesterolosis occurs when there’s a buildup of cholesteryl esters and they stick to the wall of the gallbladder forming  

28. As per website : Healthline As per website: National Library of Medicine:  (pubmed.ncbi.nlm.nih.gov/14719768/#:~:text=Cholesterolosis%20and%20adenomyomatosis%20of%20the,cholesterol%20esters%20within%20epithelial%20macrophages)
    •  

The documents and medical literature has been perused.The ultrasound report shows stones in gall bladder.The organ was removed through a procedure called Laparoscopic Cholecystectomy.The final diagnosis shows that the complainant was suffering from Acute Cholecystitis which means that bile has been trapped in gall bladder, often but not always due to gall stones.Thereafter the organ was sent for biopsy.The conclusion of biopsy result was chronic cholecystitis with cholesterolosis.  The medical literature defines cholesterolosis as a build-up of Cholesteryl esters which stick to the wall of gall bladder farming polyps.The polyps are defines as tissue growth.The medical literature further shows that cholesterolosis is clinically silent and cannot be reliably detected vide ultrasound report.It appears that cholecstectomy is usually done when there are stones in gall bladder.In rare cases, there is build-up of cholesteryl esters which may not be detected in ultrasound sonography.Hence the biopsy report shows that the gall bladder of the husband of the complainant became infected due to build-up of cholesteryl esters which does not fall within the exclusions specified in the terms and conditions of the policy.

30.  Complainant has filed bills for current hospitalisation wherein the complainant has paid Rs.1,02,000/-.  Complainant has also annexed bills of Rainbow Children Medical Pvt. Ltd. dated 29.01.2019 for Rs.800/- and Rs.1,530/-.

31. Thus we hold OP guilty of deficiency in service in repudiating the claim of complainant and direct OP to pay-

1. Rs. 1,04,330.00(1,02,00+800+1530)  with 9% interest from date of complaint i.e. 07.08.2020 till realisation.
2. Rs.20,000 for mental harassment and physical inconvenience.
3. Rs.5,000/- for litigation charges

32. File be consigned to record room. Order be uploaded and complied with 30 days.