DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/243/2022

Date of Institution   : 30.11.2022

Date of Decision    : 15.03.2024

1.Anish Kumar Singla son of Sh. Sham Lal Singla;

2.Aparna Singla daughter of Sh. Anish Kumar Singla both residents of H.No. 131, Aashthaa Enclave, Barnala-148101, District Barnala.         

                          …Complainants Versus

M/s Care Health Insurance Ltd., 5th Floor, 19 Chawla House, Nehru Palace, New Delhi-110019 through its Manager. 

                             …Opposite Party

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. R.K. Singla counsel for complainant.

Sh. Dhiraj Kumar counsel for opposite party.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

3.Sh. Navdeep Kumar Garg : Member

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1. The present complaint has been filed under Section 35 of the Consumer Protection Act 2019, (amended upto date) against M/s Care Health Insurance Ltd. (hereinafter referred as opposite party).  

2. The facts leading to the present complaint are that the complainant purchased one Health Insurance Policy for three persons named Anish Singla, Nidhi Singla (wife) and Aparna Singla (daughter) bearing Insurance/certificate No. 31422176 for the period from 12.5.2021 to 11.5.2022 and thereafter purchased the said policy from 12.5.2022 to 11.5.2023 from the opposite party. It is alleged that the complainant Anish Singla paid the premium of Rs. 15,228/- on 22.4.2021 and thereafter Rs. 16,370/- on 11.5.2022 to the opposite party from his bank Account No. 0044000104244058 with Punjab National Bank, Barnala. The opposite party did not supply any copy of terms and conditions at the time of issuance of said insurance policy and assured that all types of medical treatment is covered under the said policy for the family of complainant. The complainant is purchasing the said policy from the opposite party for the last many years. It is further alleged that the complainant No. 2 developed problems like water falling, irritation, pain, unclear vision etc., in her eyes. The complainants visited many doctors for the removal of the said problems but all in vain. Ultimately as per advice of doctors the complainant No. 2 visited Grewal Eye Institute, Chandigarh on 20.12.2021 for her eyes for the rectification of said eye problems and the doctor at the Institute throughly checked the complainant No. 2 and did many tests and Diagnosis: Myopic Astignatism means the eye sight of the complainant No. 2 is extremely weak and will further go on weaking with the passage of time. The said doctor told the complainants that for the rectification of said eye problems the complainant No. 2 will have to go for surgery and if the procedure of surgery is not adopted/performed then it may lead to retinal disorder/retinal deattached/macular hole. The complainants got very much worried under the fear of warning of the doctor and feared even blindness at this young age and what will happen to the complainant No. 2 in life if doctor's advice comes true. It is further alleged that on the advice of doctor the complainant No. 2 decided to go for surgery to avoid further problems. The complainants approached the opposite party for cashless payment for the surgery to the tune of Rs. 1,20,000/- but the opposite party wrote a letter dated 3.3.2022 to the complainant telling that the complainants will get only Rs. 58,000/- for the purpose, on this the complainants told the opposite party that doctor's fee for the purpose is Rs. 1,20,000/-, so Rs. 58,000/- is very less. Then the opposite party vide letter dated 6.7.2022 said that the complainants will get only Rs. 40,000/- for the purpose. In the mean time when the said eye institute was again approached by the complainants for the purpose the doctor at the institute told that the complainants will have to pay Rs. 1,98,000/- as the problem has increased. On this the opposite party approved only Rs. 99,999/- vide letter dated 29.7.2022 with remarks that approved as per agreed package only conventional surgery covered in the policy benefit provide KYC document of Anish Singla. It is further alleged that on 3.8.2022 at 7 A.M. the complainant No. 2 was admitted in the Grewal Eye Institute for the surgery of her eyes as diagnosed as case of MYOPIC ASTIGMATISM in both eyes and was discharged on 3.8.2022 at 5 PM and the doctor raised a bill of Rs. 1,98,000/- after discount of Rs. 48,000/- the complainants were asked to pay a bill for Rs. 1,50,000/- but the opposite party refused to pay the said bill and on this the doctor wrote a Reconsider letter dated 4.8.2022 to the opposite party if the treatment was not payable then why the case was approved initially for Rs. 99,999/- but all in vain. The doctor told the complainants that the patient will be discharged only after full and final payment and under compelled circumstances the complainants had to pay the doctor's bill of Rs. 1,50,000/-. The complainants submitted claim form alongwith original bills for Rs. 1,50,000/- of the hospital with the opposite party for the settlement of the claim. But the opposite party issued denial letter dated 4.8.2022 alleging that benefit not covered in policy. The opposite party issued cashless authorization letters dated 3.3.2022, 6.7.2022 and 29.7.2022 after going through the said policy but issued denial letter against law and facts. It is further alleged that the complainants purchased the said mediclaim policy to secure them against the unknown future medical problems and the complainants did not went for surgery for the correction of eyesight/beautification of complainant No. 2, rather the surgery was got done to prevent blindness and other related problems as warned by the doctors. Even at the time of selling the policy the opposite party did not talk about such terms and conditions and opposite party repudiate the claim on one pretext or the other. Thus, the above said act and conduct of the opposite parties falls under the deficiency in service and unfair trade practice on the part of opposite party. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To pay a sum of Rs. 1,50,000/- medical expenses incurred by the complainant alongwith interest @ 18% per annum from the date of payment till realization. 

ii)To pay Rs. 1,00,000/- as mental agony and harassment and 11,000/- as litigation expenses.   

3. Upon notice of this complaint, the opposite party appeared and filed written version taking preliminary objections interalia on the grounds that the complaint is not maintainable. The present complaint is filed with malafide intention and has not come with clean hands. The complaint involves disputed question of facts which cannot be determined in summary jurisdiction. Further, the present complaint is false, frivolous and vexatious in nature. The complainant has tried to challenge the veracity of decision of the opposite party to repudiate the claim. The company has repudiated the claim under the said policy by a speaking order, which lists out the specific reasons for the decision. This Commission has no jurisdiction to entertain the present complaint and the complainant has sought relief on the basis of allegations which are not supported by any documentary evidence to substantiate the same. 

4. On merits, it is submitted that the replying opposite party had issued a Mediclaim Insurance Policy to Mr. Anish Singla under the plan name of “Group Care 360” bearing Policy No. 31422176 which was renewed from 12.5.2022 to 11.5.2023, covering the complainant his spouse and daughter for a sum of Rs. 5,00,000/- subject to policy terms and conditions. The copy of Schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly sent and delivered to Proposer. Further, no assurance was given to the complainant beyond the terms and conditions of the policy. It is further submitted that the policy kit containing all relevant documents was duly delivered to the complainant, thereby giving an opportunity to the complainant to verify and examine the benefits, terms and conditions of the policy taken by the complainant. It is further submitted that the daughter of the insured developed problems like water falling, irritation, pain, unclear vision etc., in her eyes. The insured visited hospital on 20.12.2021 where on undergoing several tests she was diagnosed with Myopic Astignatism. A cashless request was received from the Grewal Eye Institute for the surgery of Ms. Aparna Singla, complainant No. 2 and daughter of the insured for the ICL (Implantable Collamer Lens) surgery she underwent to treat her Myopic Astignatism on 3.8.2022. Upon receipt of the Pre-Authorization Form, We analysed the request and the same was denied on the grounds of: Benefit not covered in policy SMILE B/L Eyes, Benefit not covered. It is further submitted that the ideal approach the complainant should have taken was submission of a Reimbursement claim, however, instead the complainant approached the court without following the due procedure. The complainant actual amount spent on the surgery was Rs. 1,50,000/- and not Rs. 1,98,000/- as has been claimed. The opposite party in the Exclusion clause submitted that the company will pay for the reasonable and customary fees charged for corrective spectacle lenses (with frames) or contact lenses as prescribed by the ophthalmologist or optometrist. The benefit also pays for one time routine eye examination carried out by an ophthalmologist or optometrist per cover year. This benefit does not pay for tinted/reactive lenses, sunglasses, non-corrective contact lenses, lasik/Laser eye surgery, medical or surgical treatment of the eye (s) and/or similar, whether prescribed or not. Moreover, the initial sanction of pre-authorization amount is always conditional subject to the terms and conditions laid down in the said approval letter. While issuing of the Authorization letters, there are certain Terms and Conditions attached to it which gives the company right to deny the claim on certain mentioned grounds. It is further submitted that cashless authorization letter issued on the basis of information provided in Pre-Authorization form, in case misrepresentation/concealment of the facts, any material difference/deviation/discrepancy in information is observed in discharge summary/IPD records then cashless authorization shall stand null and void. At any point of claim processing insurer or TPA reserves right to raise queries for any other document to ascertain admissibility of claim. However, these terms and conditions are to be read with the policy terms and conditions, which though gives the company right to deny cashless on just file for reimbursement of the claim. Hence, the company alongwith the denial mentioned the reason for the same in line with the policy terms and conditions, thus acting within law. It is further submitted that the complainant till date no reimbursement claim ever lodged with the replying opposite party. The complainant till date not provide Discharge Summary, NEFT of Proposer, Detailed Final Bill, Payment Receipts. All reports and ICPS to the replying opposite party. Therefore, there is no deficiency in service on the part of opposite party and prayed for the dismissal of complaint with costs. 

5. To prove their case the complainants tendered into evidence affidavit of complainant No. 1 Ex.C-1, copy of statement of account Ex.C-2 (containing 2 pages), copy of policy Ex.C-3 (containing 2 pages), copy of renewal certificate Ex.C-4 (containing 7 pages), copy of Diagnose certificate Ex.C-5 copy of authorization letters Ex.C-6 to Ex.C-8, copy of advice follow up Ex.C-9, copy of prescription for glasses Ex.C-10 (containing 2 pages), copies of prescription slips Ex.C-11 to Ex.C-13, copy of Brief Case Summary Ex.C-14, copy of discharge certificate Ex.C-15, copy of reconsideration letter Ex.C-16, copies of bills and receipts Ex.C-17 & Ex.C-18, copies of Denial letters Ex.C-19 & Ex.C-20 and closed the evidence. Ld. Counsel for the complainant has made statement on 14.3.2023 that I do not want to file any rejoinder on behalf of complainant. 

6. To rebut the case the opposite party tendered into evidence affidavit of Shruti Saxena Ex.O.P-1, copy of policy Ex.O.P-2 (containing 7 pages), copy of terms and conditions Ex.O.P-3 (containing 42 pages), copy of authorization letter Ex.O.P-4 (containing 4 pages), copy of pre-authorization form Ex.O.P-5 (containing 2 pages), copy of denial letter dated 4.3.2022 Ex.O.P-6 (containing 2 pages), copy of pre authorization form Ex.O.P-7, copy of denial letter dated 4.8.2022 Ex.O.P-8, copy of pre authorization form Ex.O.P-9 (containing 2 pages), copy of letter dated 4.3.2022 Ex.O.P-10 (containing 2 pages), copy of cashless authorization letter Ex.O.P-11, copy of denial letter dated 4.8.2022 Ex.O.P-12 and closed the evidence. 

7. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by the parties.

8. Ld. Counsel for the complainants argued that the complainant purchased one Health Insurance Policy for three persons named Anish Singla, Nidhi Singla (wife) and Aparna Singla (daughter) bearing Insurance/certificate No. 31422176 for the period from 12.5.2021 to 11.5.2022 (Ex.C-3) and thereafter purchased the said policy from 12.5.2022 to 11.5.2023 (Ex.C-4) from the opposite party. It is further argued that the complainant Anish Singla paid the premium of Rs. 15,228/- on 22.4.2021 and thereafter Rs. 16,370/- on 11.5.2022 to the opposite party from his bank Account No. 0044000104244058 with Punjab National Bank, Barnala (Ex.C-2). It is also argued that the opposite party did not supply any copy of terms and conditions at the time of issuance of said insurance policy and assured that all types of medical treatment is covered under the said policy for the family of complainant. It is further argued that the complainant No. 2 developed problems like water falling, irritation, pain, unclear vision etc., in her eyes and the complainants visited many doctors for the removal of the said problems but all in vain and as per advice of doctors the complainant No. 2 visited Grewal Eye Institute, Chandigarh on 20.12.2021 (Ex.C-5) for her eyes for the rectification of said eye problems and the doctor at the Institute throughly checked the complainant No. 2 and did many tests and Diagnosis: Myopic Astignatism means the eye sight of the complainant No. 2 is extremely weak and will further go on weaking with the passage of time and the said doctor told the complainants that for the rectification of said eye problems the complainant No. 2 will have to go for surgery and if the procedure of surgery is not adopted/performed then it may lead to retinal disorder/retinal deattached/macular hole and the complainants got very much worried under the fear of warning of the doctor and feared even blindness at this young age and what will happen to the complainant No. 2 in life if doctor's advice comes true. It is further argued that on the advice of doctor the complainant No. 2 decided to go for surgery to avoid further problems and the complainants approached the opposite party for cashless payment for the surgery to the tune of Rs. 1,20,000/- but the opposite party wrote a letter dated 3.3.2022 (Ex.C-6) to the complainant telling that the complainants will get only Rs. 58,000/- for the purpose, on this the complainants told the opposite party that doctor's fee for the purpose is Rs. 1,20,000/-, so Rs. 58,000/- is very less and then the opposite party vide letter dated 6.7.2022 (Ex.C-7) said that the complainants will get only Rs. 40,000/- for the purpose. It is also argued that when the said eye institute was again approached by the complainants for the purpose the doctor at the institute told that the complainants will have to pay Rs. 1,98,000/- as the problem has increased and on this the opposite party approved only Rs. 99,999/- vide letter dated 29.7.2022 (Ex.C-8) with remarks that approved as per agreed package only conventional surgery covered in the policy benefit provide KYC document of Anish Singla. It is further argued that on 3.8.2022 at 7 A.M. the complainant No. 2 was admitted in the Grewal Eye Institute for the surgery of her eyes as diagnosed as case of MYOPIC ASTIGMATISM in both eyes and was discharged on 3.8.2022 at 5 PM (which proves from Ex.C-14 & Ex.C-15) and the doctor raised a bill of Rs. 1,98,000/- after discount of Rs. 48,000/- the complainants were asked to pay a bill for Rs. 1,50,000/- (as per Ex.C-18), but the opposite party refused to pay the said bill and on this the doctor wrote a Reconsideration letter dated 4.8.2022 (Ex.C-16) to the opposite party if the treatment was not payable then why the case was approved initially for Rs. 99,999/- but all in vain. It is further argued that the doctor told the complainants that the patient will be discharged only after full and final payment and under compelled circumstances the complainants had to pay the doctor's bill of Rs. 1,50,000/- and the complainants submitted claim form alongwith original bills for Rs. 1,50,000/- of the hospital with the opposite party for the settlement of the claim but the opposite party issued denial letter dated 4.8.2022 (Ex.C-20) alleging that benefit not covered in policy. The opposite party issued cashless authorization letters dated 3.3.2022, 6.7.2022 and 29.7.2022 (Ex.C-6 to Ex.C-8) after going through the said policy, but issued denial letter against law and facts. It is further argued that the complainants purchased the said mediclaim policy to secure them against the unknown future medical problems and the complainants did not went for surgery for the correction of eyesight/beautification of complainant No. 2, rather the surgery was got done to prevent blindness and other related problems as warned by the doctors. It is also argued that at the time of selling the policy the opposite party did not talk about such terms and conditions and opposite party repudiated the claim on one pretext or the other and the above said act and conduct of the opposite parties falls under the deficiency in service and unfair trade practice on the part of opposite party. 

9. Ld. Counsel for the opposite party argued that the copy of Schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly sent and delivered to Proposer. It is further argued that no assurance was given to the complainant beyond the terms and conditions of the policy. It is further argued that the daughter of the insured developed problems like water falling, irritation, pain, unclear vision etc., in her eyes and the insured visited hospital on 20.12.2021 where on undergoing several tests and she was diagnosed with Myopic Astigmatism. It is also argued that a cashless request was received from the Grewal Eye Institute for the surgery of Ms. Aparna Singla, complainant No. 2 and daughter of the insured for the ICL (Implantable Collamer Lens) surgery she underwent to treat her Myopic Astigmatism on 3.8.2022 and upon receipt of the Pre-Authorization Form, the opposite party analyzed the request and the same was denied on the grounds of “Benefit not covered in policy SMILE B/L Eyes, Benefit not covered” (as per Ex.O.P-12). It is further argued that the complainant actual amount spent on the surgery was Rs. 1,50,000/- and not Rs. 1,98,000/- as has been claimed and the opposite party as per the Exclusion clause the company will pay for the reasonable and customary fees charged for corrective spectacle lenses (with frames) or contact lenses as prescribed by the ophthalmologist or optometrist and the benefit also pays for one time routine eye examination carried out by an ophthalmologist or optometrist per cover year and this benefit does not pay for tinted/reactive lenses, sunglasses, non-corrective contact lenses, lasik/Laser eye surgery, medical or surgical treatment of the eye (s) and/or similar, whether prescribed or not. It is further argued that the initial sanction of pre-authorization amount is always conditional subject to the terms and conditions laid down in the said approval letter and while issuing of the Authorization letters, there are certain Terms and Conditions attached to it which gives the company right to deny the claim on certain mentioned grounds. It is further argued that cashless authorization letter issued on the basis of information provided in Pre-Authorization form, in case misrepresentation/concealment of the facts, any material difference/deviation/discrepancy in information is observed in discharge summary/IPD records, then cashless authorization shall stand null and void and at any point of claim processing insurer or TPA reserves right to raise queries for any other document to ascertain admissibility of claim, hence the company alongwith the denial mentioned the reason for the same in line with the policy terms and conditions, thus acting within law. It is further argued that the complainant till date no reimbursement claim ever lodged with the opposite party and the complainant till date not provide Discharge Summary, NEFT of Proposer, Detailed Final Bill, Payment Receipts and all reports and ICPS to the opposite party, so there is no deficiency in service on the part of opposite party and prayed for the dismissal of complaint with costs.

10. It is admitted by the opposite party that they had issued a Mediclaim Insurance Policy to Mr. Anish Singla under the plan name of “Group Care 360” bearing Policy No. 31422176 which was renewed from 12.5.2022 to 11.5.2023, covering the complainant his spouse and daughter for a sum of Rs. 5,00,000/- subject to policy terms and conditions (as per Ex.C-3 & Ex.O.P-2). It is also not disputed between the parties that the complainant No. 2 has diagnosed as a case of MYOPIC ASTIGMATISM from Grewal Eye Institute Pvt. Ltd. It is also not disputed that the patient was admitted on 3.8.2022 at 7.00am and discharged on 3.8.2022 at 5:00pm and the above said Institute/Hospital has charged an amount of Rs. 1,50,000/- from the complainant. 

11. We have gone through the Discharge Certificate of Ms. Aparna Singla dated 4.8.2022 Ex.C-15 vide which it is mentioned that “she had been diagnosed as a case of MYOPIC ASTIGMATISM in Both Eyes and advised surgery: ICL (Per Eye), which was carried out on August 03,2022. She was admitted on August 03,2022 at 7:00am and discharged on August 03,2022 at 5:00pm” and this document is not disputed between the parties. We have further gone through the cashless authorization letter dated 3.8.2022 Ex.C-6 placed on record by the complainant, vide which the claim amount shows as Rs. 1,20,000/- and the approved amount shows as Rs. 58,000/-. We have also gone through the another cashless authorization letter dated 6.7.2022 Ex.C-7 placed on record by the complainant, in which the claim amount also shows as Rs. 1,20,000/- and the approved amount shows as Rs. 40,000/-. We have further gone through the another cashless authorization letter dated 29.7.2022 Ex.C-8 placed on record by the complainant, vide which the claim amount shows as Rs. 1,98,000/- and the approved amount shows as Rs. 99,999/-. But the opposite party has denied the claim of the complainants vide denial letter dated 4.8.2022 Ex.O.P-12, vide which it is mentioned that “we have reviewed your request, and hereby inform you that the cashless hospitalization cannot be approved as per the terms and conditions of the policy as “Benefit not covered in policy smile B/L Eyes, Benefit not covered in policy”. On this the complainant has also placed on record Reconsideration Letter of Grewal Eye Institute Pvt. Ltd., dated 4.8.2022 Ex.C-16 vide which it is mentioned that “This is in reference to your denial letter vide Claim No. 80767227 of patient Aparna Singla underwent ICL (Implantable Collamar Lens surgery in both eyes on August 03, 2022. Patient admitted on behalf of initial approval of Rs. 99,999/- vide claim No. 80767227. After the completion of her treatment we have sent the final bill and discharge but the case got denied. We have  reviewed the denied letter as “smile is not payable in policy” but patient didn't underwent smile sugery even we have sent the discharge summary for ICL surgery. If the treatment was not payable they why the case was approved initially for Rs. 99,999/-. Kindly look into the matter and process the case on priority basis. 

12. However, in the written arguments the complainants submitted/written that during the pendency of the arguments the opposite party paid the relief amount of Rs. 1,50,000/- vide letter dated 2.1.2024 and now the complainants are entitled to get interest @ 18% per annum from the date of deposit till realization. During arguments Ld. Counsel for the complainants has produced copy of letter dated 2.1.2024 of “claim approval letter” vide which the opposite party has approved the medical expenses of Aparna Singla to the tune of Rs. 1,50,000/-. Ld. Counsel for complainants also produced on record copy of account statement of Mr. Anish Kumar Singla, which shows that an amount of Rs. 1,50,000/- has been transferred through NEFT on 4.1.2024 by the opposite party in the account of complainant. Ld. Counsel for the complainant submitted that  as the complainant has received the claimed amount from the opposite party, he prayed that the complainants are entitled for the interest and compensation because the opposite party has paid the above said claimed amount to the complainants after filing of the present complaint on 30.11.2022 at the stage of arguments i.e. on 4.1.2024. Therefore, it proves that the claim was genuine one and there was clear cut deficiency in service on the part of the opposite party. 

13. The present complaint is partly allowed against the opposite party. Since the claimed amount of Rs. 1,50,000/- has been already paid, therefore the opposite party is directed to pay only the interest @ 7% per annum on the above said amount of Rs. 1,50,000/- from the date of filing the present complaint i.e. 30.11.2022 till realization i.e. 4.1.2024. The opposite party is further directed to pay Rs. 10,000/- on the account of consolidated amount of compensation alongwith litigation expenses to the complainant. 

14. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

15. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       15th Day of March, 2024

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member