DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.17/2023

Girish Chandra Agarwal

K-24-D Hauz Khas Enclave,

New Delhi 110016

….Complainant

Versus

National Insurance Company Ltd

30-31 A, Jeevan Vikas Building,

IInd Floor, Asaf Ali Road

Delhi 110002

        ….Opposite Party

 Date of Institution    :  18.01.2023     

 Date of Order            :  25.06.2024     

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Present: None for complainant.

Adv. Vibhu Anshuman, proxy counsel on behalf of Adv. Abhinav Mukhi for OP.

ORDER

Member: Ms. Kiran Kaushal

1.       Facts of the complaint as stated by the complainant are that complainant purchased Mediclaim Insurance Policy from National Insurance Company Ltd. for period of 28.03.2021 to 27.03.2022.

2.       It is stated that complainant is a senior citizen and due to diabetes, the complainant had advance cataract in his both eyes. Doctor advised high end cataract surgery in the right eye of the complainant, therefore, Femto Laser Cataract Surgery with ‘ACRYSOF’ IQ VIVITY IOL was performed, in contrast to conventional MICS Surgery in the right eye, at Medanta Mediclinic Hospital on 14.01.2022.

3.       It is stated that OP has a tie up for Cashless Package with hospital for conventional surgery but does not provide the same for high end cataract surgery to increase its profits. It is next stated that the hospital raised a detailed bill totaling to Rs.1,44,000/-  on 14.01.2022. The hospital bill is annexed as Annexure C. The complainant raised a reimbursement claim with OP on 27.01.2022 for pre and post hospital expenses amounting to Rs.3,551/- and further claimed reimbursement of Rs.1,44,000/- towards hospital bill for cataract surgery. It is stated  that OP has reimbursed Rs.3,551/- and has arbitrarily deducted  Rs.1,10,000/- from all the five items  of the hospital bill and reimbursed only Rs.34,000/-  on 23.02.2022. The claim settlement voucher is annexed as Annexure D.

4.       It is stated that since there is no signed PPN  cashless package pricing for High End Cataract Surgery ,the signed PPN Cashless Package for cheaper conventional surgery cannot be applied to a case of  high end advance cataract surgery. In such case the advance surgery will be have to be reimbursed in full in the same way as any other procedure for which there is no PPN Cashless Package. It is further stated that the advance cataract procedure undergone by the complainant was not for any cosmetic reason but was a medical necessity. Hence, OP is liable to pay the claim.

5.       It is further stated that complainant had purchased an indemnity health insurance policy and as per Clause 1.1 of the National Mediclaim Policy prospectus, the complainant/insured is to be indemnified for actual treatment.

6.       Alleging deficiency of service, complainant prays for direction to OP to pay the deducted amount from the hospital bill i.e Rs.1,10,000/- with interest  and also compensation of harassment, mental agony and cost of litigation.

7.       OP resisted the complaint stating inter alia that complaint is liable to be dismissed on the sole ground that the complainant has concealed material facts from the Commission and is guilty of supressio veri suggestio falsi .

8.       It is stated that prior to the admission and surgery complainant had been specifically informed about the concerned PPN Network Hospital. The complainant had opted  for an advance cataract surgery, as opposed to conventional surgery, which is not covered under the PPN pricing. Complainant was fully aware of the fact that the PPN Pricing and his Mediclaim Policy only covered Conventional Cataract Surgery and in case he wanted to undergo an advanced cataract surgery the additional amount over and above the prescribed amount shall have to be borne by the complainant. True copy of the declaration/consent letter dated 08.01.2022 is marked as Annexure R-3.

9.       It is next stated that in Health insurance, unlike other insurance, common pool is created by collection of premiums from multiple policy holders to pay the reasonable costs of treatments. This pool cannot be utilized for paying all claims using advanced or high end technology and is therefore restricted in the terms and conditions up to the reasonable, customary and necessary costs.

10.     It is further stated that OP out of the final bill has paid Rs.37,551/-. The claim of the complainant had been settled as per the PPN Package of the cataract MICS which is Rs.27,000/- along with the cost of lens which is restricted to Rs.7,000/-. The said amount was approved as per Clause 7.44 i.e  reasonable and customary charges clause of the policy terms and conditions. The charges  were in line with prevalent charges notified by government authority in all states  on pan India basis.

11.     It is stated that OP has fulfilled its obligations in terms of the policy, as per the PPN Prices and the remaining cost so incurred by the complainant for advanced/high end procedure has to be borne by the complainant. It is thus prayed  that complaint be dismissed with exemplary costs being baseless  and flagrant abuse of the process of law.

12.     Rejoinder has been filed by the complainant wherein it is stated that no one had informed the complainant that PPN Pricing applies to conventional surgery. Complainant was sure that whatever is charged by the hospital will be reimbursed to the complainant under the Indemnity Clause of the policy. It is stated that on the recommendation of the surgeon the complainant opted for advanced cataract surgery and contacted the TPA staff at the hospital to obtain cashless policy wherein the TPA asked the hospital to revise the bill for conventional surgery. The hospital’s reply was that the estimate could not be revised as the doctor has advised the advanced cataract surgery. TPA did not pass the cashless requests. In such circumstances the cashless claim became redundant and the consent letter dated 08.01.2022 became nonest.

13.     Evidence by way of affidavit and written arguments  have been filed on behalf of parties.  Submissions made on behalf of parties are heard. Material placed on record is perused.

14.     Admittedly, complainant had purchased a National Mediclaim Policy with the currency period from 28.03.2021 to 27.03.2022 and complainant had undergone a cataract surgery  at Medanta (PPN Network Hospital) on 14.01.2022.

15.     The only point for consideration before this Commission is whether the complainant is entitled  to reimbursement of the Total bill amount towards his claim or not.

16.     It is not disputed that the complainant had undergone his cataract surgery in Medanta Medicity Hospital( PPN Network Hospital). It is seen that it was in the knowledge of the complainant that the said policy covers only conventional cataract surgery and charges as per applicable PPN pricing shall be paid, which is evidenced from the declaration signed by the complainant.

17.     The relevant extract of PPN Network declaration is reproduced as under-

Name of Additional Facility/Provision/Procedure/Treatment…….which costs 144000/- (in words): One Lakh Forty Four Thousand Only…

On my own option, I wish to avail above better facility and I hereby agree to pay on my free will, after being explained in detail by the Hospital authority in my own and understandable language about the abovementioned Additional Facility/Procedure/Treatment and associated cost of it, which is over and the above the agreed PPN Tariff. Further, I opt to go for the final bill reimbursement with insurance company. The respective insurance company will reimburse only as per the agreed PPN tariff rates and balance amount will be borne by myself  or patient only….

18.     Having signed the declaration without any coercion and out of his free will, complainant is bound by the terms and conditions therein. Complainant cannot deny the fact that he was aware that he would be paid only for conventional cataract surgery and if he opts for High End surgery rest of the charges would be borne by him.

19.     It is further seen that as per the PPN Pricing, complainant was entitled for Rs.27,000/- for conventional surgery along with the cost of the lens which was restricted to Rs.7,000/- total being Rs.34,000/- and the same  was paid to the complainant by OP.  No substantive evidence has been filed by the complainant to show that OP was liable to pay the claim for High End Surgery which was performed on the complainant.

20.     As per clause 7.44 of the Policy-

 ‘The policy covers expenses incurred due to hospitalization for impatient care or day care treatment, reasonably and customarily incurred for treatment of an illness contracted/injury sustained during the policy period.’

21.     In light of the fact that complainant was aware that he would be paid only the conventional rates for cataract surgery and in case he opts for High End surgery the remaining expenses would be borne by the complainant and also as per clause 7.44 of the policy, we are of the view that OP has rightly paid the claim in accordance with the terms and conditions of the policy, at the package rates settled with the approved hospitals.

22.     The complaint fails and is dismissed with no order as to costs.

Parties be provided copy of the judgment as per rules. File be consigned to the record room. Order be uploaded on the website.