| Final Order / Judgement | CONSUMER DISPUTES REDRESSAL COMMISSION-VII DISTRICT: SOUTH-WEST GOVERNMENT OF NCT OF DELHI FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN SECTOR-20, DWARKA, NEW DELHI-110077 CASE NO.CC/661/14 Date of Institution:- 29.09.2014 Order Reserved on:- 11.01.2024 Date of Decision:- 14.05.2024 IN THE MATTER OF: SurajBhan R/o House No.1/446, DakshinpuriExtn., New Delhi-110062 .….. Complainant VERSUS - National Insurance Company Ltd.
Through Its Manager/A.R Division No.XXIII, 106, PalikaBhawan, R.K. Puram, New Delhi – 110066 - Batra Hospital and Research centre
1, Tughlakabad Institutional Area, M.B. Road, PS-Dr.Ambedkar New Delhi – 110062 - Medi Assist India TPA Pvt. Ltd.
B-20, Sector-2, Noida, Near: Sec-15 Metro Station Opp. HCL Comnet Building Noida U.P. - 201301 .…..Opposite Parties Per Dr.HarshaliKaur, Member - The Complainant, covered undera National Mediclaim Policy of OP-1 since 2007, renewed his Policy continuously. His wife was also covered under the Policy since 2007, along with his two wards, namely, Arun Singhal and Sumit Singhal, since 2013-2014. His current Mediclaim Policy, No. 360900/48/14/8500000008,was issued on 01.04.2014 and valid until 31.03.2015. The Complainant states that he did not take any claim fromthe inception of his Policy in 2007 till 2014.
- In 2014, the Complainant suffered from knee pain and backache along with difficulty in standing and walking. He visited OP-2 for a checkup and was advised by Dr. D.K. Gupta, Senior Joint Replacement Surgeon and head of Orthopedic Surgery, on 28.04.14 for immediate admission.
- After admission to OP-2 Hospital, the Complainant sent the estimated cost of treatment to the tune of Rs. 45,000/- to OP-3, the TPA Department of OP-1, through the hospital and received the approval for the tentative amount of Rs. 10,000/-. The Complainant has annexed the copy of the authorised amount of Rs.10,000/- as Annexure-3 with the Complainant.
- Dr. D.K. Gupta and his team conducted several tests like MRI, Serology Test, Clinical Biochemistry Test, and Hematology at OP-2 Hospital. Copies of the reports have been annexed as Annexure-4 to Annexure-6with the complaint. After four days in OP-2, the Complainant was discharged on 02.05.2014. Annexure- 7 is the discharge summary issued by OP-2, along with the final Bill for the total amount of Rs.47,222/-(Annexure- 8).
- The Complainant alleges that when his family went to pay the Bill, OP-2 staff informed his family members that the cashless claim had not been approved, and the pre-authorised amount of Rs.10,000/- was also recalled by OP-3.
- After discharge from OP-2, the Complainant sent all the requisite documents for the claimed amount of Rs. 42,143/- to OP-3 via courier on 07.05.14. Annexure-9 is the copy of the courier receipt annexed with the complaint towards the same. Despite fulfilling the terms and conditions of the OP-1 policy, his claim was not processed, and OP-1 rejectedhisgenuine claim via a registered letter (Annexure-10).
- Upon receipt of the repudiation letter for his claim, the Complainant met with Dr. D.K. Gupta, who had allegedly assured him at the time of admission that his disease was covered under the Mediclaim Policy. Dr. D.K. Gupta issued a certificate (Annexure-11)regarding the Complainant’s illness and the treatment given at the OP-2 hospital to no avail. Despite visiting the office of OP-3 several times and numerous calls, the Complainant’s claim was not passed. With no other option, the Complainant issued a letter dated28.05.14 (Annexure-13) to OP-1 towards reimbursement of his claim duly received by OP-1. However, no action was taken by OP-1 to process his claim in his favour.
- Aggrieved, the Complainant filed the present complaint under Section 12 of the Consumer Protection Act, 1986, alleging deficiency in service on the part of the OPs. He has prayed for directing the OPs to refund the total amount of Rs. 47,222 /- with interest, Rs. 40,000/- towards compensation for mental agony, pain and torture and Rs. 10,000/- towards litigation costs.
- On notice, OP-1 and OP-2 filed their respective replies. OP-3 was proceeded ex-parte vide order dated 10.03.16 when the Complainant filed adequate proof of service qua OP-3.
- OP-1, in their reply, stated that admittedly, OP-1 had issued a Mediclaim Policy in favour of the Complainant from the period of 01.04.14 till 31.03.15 (Annexure A1). The liability of OP-1 was subject to the terms and conditions of the said insurance policy. On receiving the claim filed by the Complainant and scrutinising the documents submitted towards the claim, it was found that the Complainant’s claim was not payable under Exclusion Clause 4.13, which lays down - Hospitalisation for the purpose of diagnosis and evaluation and irrelevant investigation charges.
- The Complainant was admitted to OP-2 hospital on 28.04.14 and diagnosed with a case of polyarthralgia with patellofemoral osteoarthritis in the right knee with acute low back ache. The Complainant had the same complaint for the last three months, and the pain in the knees had increased in the last 15 days with no other abnormal variations seen.
- Further, the hospital bill was found to be mainly for investigations and medication that could have been taken on an OPD basis. Hence, it was clear that the Complainant’s admission was only for diagnostic and evaluation purposes since no active line of treatment warranting continuous hospitalisation was required. Thus, the same treatment could have been given in the OPD. The Complainant’s claim was repudiated vide letter dated 05.08.14 (Annexure A2) based onthe terms and conditions of the insurance policy that the Complainant had agreed upon. Hence, no deficiency in service can be made out against OP-1, and the complaint deserves to be dismissed.
- OP-2, in their reply, simply stated that they had no role in the payment of the Complainant’s claim. The Complainant was treated and paid the Bill at OP-2 Hospital; thus, the present complaint is not maintainable against OP-2. Further, OP-2 had been made a party in the present complaint without reason and justification, misusing the process of law. OP-2, therefore, prayed for rejection of the complaint against OP-2.
- OP-3 is ex-parte.
- The Complainant filed the rejoinder to the reply of OP-1 and OP-2 and his affidavit in evidence reiterating his averments as made in his complaint. OP-1 filed the affidavit of Mr. Ravi Satija, AO/Manager of OP-1, and OP-2 filed the affidavit of Shri. Rajiva Bhargava, GH- HR of OP-2,is to be read as evidence, echoing what OP-1 and OP-2 had stated in their respective replies. OP-1 and OP-2 also filed their written arguments. The Complainant neither appeared before this forum thereafter nor filed written arguments.OP-1 and OP-2 addressed oral final arguments.The other parties were given the liberty to address oral arguments within seven days. None appeared to do the needful and hence, the order was reserved.
- We have carefully gone through the material on record and have perused the documents filed by the contesting parties to corroborate their testimonies. We find that the Complainant had the Mediclaim Policy of OP-1, which also covered his family members since 2007. The Complainant renewed the Policy again on 01.04.14, valid until 31.03.15.
- On 28.04.14, while the Policy was active, the Complainant, suffering from knee and back pain, visited OP-2 and consulted with Orthopedic Surgeon Dr. D.K. Gupta, who allegedly advised immediate admission to the OP-2 hospital. After admission, the Complainant, through the doctor, sent the estimated cost of treatment of rupees 45,000 along with necessary documents to OP-3, the TPA of OP-1, on 28.04.14. OP-3 sent Rs. 10,000/- to OP-2 as a pre-authorised tentative amount towards the Complainant’s treatment.
- Thereafter, the Complainant got several tests like MRI, Serology Test, Clinical Biochemistry Test, and Hematology from OP-2 and was discharged on 02.05.14 from OP-2 Hospital. When the Complainant’s cashless claim was rejected, OP-2 staff informed him that his pre-authorised amount had also been recalled by OP-3, and his cashless claim was disapproved. Despite running from pillar to post, the Complainant could not get his claim approved, hence this complaint.
- OP-1, in their reply, stated that the Complainant’s claim was repudiated based on ExclusionClause 4.13, a copy of which they have proved on record along with their affidavit filed to be read as evidence, which is reproduced below-
4.13- Hospitalisation for the purpose of diagnosis and evaluation, irrelevant investigation charges. Expenses incurred at the hospital primarily for diagnostic, x-ray, laboratory examinations or other diagnostic studies not consistent with nor incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury for which confinement is required at the hospital. The rejection of the Complainant’s claim was duly intimated to the Complainant via letter dated 05.08.14 (RW 1/B). - OP-2, in their reply, denied any deficiency in service or unfair trade practice on their part, as OP-2is only the hospital where the Complainant took the treatment and was later discharged after he paid the Bill for the said treatment. OP-3 is ex-parte.
- In our considered view, a bare perusal of the discharged summary issued by OP-2 dated 02.05.14 clarifies that the Treatment Givento the Complainant was conservative management done. Conservative Management, as per the International Online Medical Council Journal, is defined as: -
- management is an approach to treating back pain, neck pain and related spinal conditions utilising non-surgical treatment options, such as physical therapy, medication and injections.
National Library of Medicine in its Journal Conservative treatment of knee osteoarthritis: A review of the literature clarifies thatKnee osteoarthritis (KOA) is a common chronic debilitating disease with an estimated prevalence of 23.9% in the general adult population. Management for KOA can generally be divided into conservative (non-operative) and surgical (operative) measures. Conservative management broadly compromises pharmacological and non-pharmacological options and is conventionally the first-line treatment to avoid or delay the need for surgical management. The aim and treatment options included in conservative treatment modality is to provide symptomatic relief of the disease and slow its progression to avoid or forestall end-stage surgical options (i.e. total knee placement). The various conservative treatment options include exercise, weight loss, pharmacological agents and orthotics. - OP-1 further stated that theDischarge Summary issued by OP-2 also clarified that the course in the hospital was mainly for diagnostic purposes, and no active line of treatment was given to the Complainant in OP-2 Hospital. The Complainant has annexed the copy of the IPD final bill details as Annexure-8 with his complaint. The Bill raised by OP-2 is divided into room rent, investigation charges and medicines without any charges levied for any active treatment.
- The veracity of Annexure-11, which is Dr. D.K. Gupta’s handwritten note stating that the Complainant was admitted with difficulty in standing and walking for further management,cannot be determined in the absence of the treatment detail that Dr. D.K. Gupta chose not to mention in the note for reasons best known to him. The Complainant also did not file Dr. D.K. Gupta’s affidavit on record to substantiate his claim.
- Hence, no cogent evidence has been filed by the Complainant to show that his admission to the hospital could not have been avoided and was mandated by his treated doctor as no active line of treatment was given to the Complainant during his stay in the Hospital, which is duly noted in the discharge summary itself which mentions that the Treatment given was Conservative in nature. Thus, in our considered view, the Complainant was admitted to the OP-2 Hospital mainly for diagnostic and evaluation purposes, and his claim squarely falls under the Exclusion Clause 4.13 of the terms and conditions of the Policy opted for by the Complainant based on the treatment history, documents and bills filed by the Complainant himself.
- In light of the above discussion, the present complaint is dismissed without costs.
- A copy of this order is to be sent to all the parties as per rule.
- File be consigned to record room.
- Announced in the open court on 14.05.2024.
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