Chandigarh

DF-I

CC/23/2023

SHASHI GUPTA - Complainant(s)

Versus

NATIONAL INSURANCE COMPANY LTD - Opp.Party(s)

ARUN KUMAR & VARUN BHARDWAJ

03 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/23/2023
Date of Institution	:	10/01/2023
Date of Decision	:	03/04/2024

 

Shashi Gupta aged about 73 years wife of Late Sh. Vijay Gupta, r/o House No.5792-B, Sector 38 West, Chandigarh.

… Complainant

V E R S U S

1. National Insurance Company Ltd., through its Regional Manager, SCO No.332-334, Sector 34-A, Chandigarh.
2. The Regional Manager, National Insurance Company Ltd., SCO No.332-334, Sector 34-A, Chandigarh.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Varun Bhardwaj, Advocate for complainant
	:	Sh. Nitin Gupta, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Shashi Gupta, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that for the first time in the year 2009,  complainant had purchased a Mediclaim Policy (Ex.C-1) for herself from OP-1 on payment of requisite premium and got the same renewed from time to time without any break and the last policy (hereinafter referred to as “subject policy”) was issued by OP-1 in favour of the complainant which was valid w.e.f. 30.11.2021 to 29.11.2022 (Ex.C-2) on payment of premium of ₹52,990/- with sum assured of ₹7.00 lacs.  In the month of September 2022, complainant suffered from breathlessness and difficulty in breathing during sleep, as a result of which she visited the Kular Hospital, Ludhiana (hereinafter referred to as “Treating Hospital”) on 10.9.2022 for her medical check-up, where she was diagnosed to be suffering from Morbid Obesity with a BMI of 42.57 Kg/M² with co-morbidities, breathlessness on exertion, Severe Obstructive Sleep Apnea etc. Complainant was advised to get herself admitted for Laparoscopic Cholecystectomy (Gall Bladder Removal) with Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery). At that time the doctor informed that the cost of package for surgery would be ₹4,15,000/-.  Accordingly, on the advice of doctor, complainant got herself admitted in the Treating Hospital and underwent Laparoscopic Cholecystectomy (Gall Bladder Removal) with Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery) on 11.9.2022 and she was kept under observation.  As per direction of the doctor, complainant had deposited an amount of ₹4,15,000/- on 12.9.2022 and she was discharged from the hospital on 15.9.2022.  Copies of medical tests, bill, receipt and discharge summary are Ex.C-3 to C-6 respectively. Thereafter, complainant lodged claim with the OPs for reimbursement of total amount spent by her to the tune of ₹4,17,166/- on 26.9.2022 supported with all the documents.  However, the OPs vide letter dated 29.9.2022 demanded other documents, which were also supplied.  Complainant kept on waiting for reimbursement of the claim amount and visited the branch office of OPs various times, but, the matter was delayed on one pretext or the other.  However, complainant was shocked to receive a sum of ₹52,000/- only against the claim amount of ₹4,17,166/- regarding which Claim Settlement Voucher (Ex.C-13) was also issued.  OPs also informed the complainant that they have only paid amount for Laparoscopic Cholecystectomy (Gall Bladder Removal) that too after deduction of ₹43,000/- against claimed amount of ₹95,000/- and have not paid claim for other surgery and hospitalisation charges since four years waiting period has not lapsed.  As per certificates (Ex.C-14 & C-15) issued by the doctor, Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery) was medically required by the complainant.  Complainant had informed the OPs that the Mediclaim Policy is continuing without any break since the year 2009 and her case does not fall under exclusion clause, but, despite of that OPs have made aforesaid deduction from the claimed amount without any reason. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objection of maintainability. However, it is admitted that the subject policy was issued to the complainant by the OPs and the complainant has submitted total claim of ₹4,17,104/- out of which an amount of ₹52,000/- was paid to her and the remaining amount of ₹3,65,166/- was deducted on the ground that the obesity related treatment was not payable as there was waiting period of four years for Morbid Obesity under the insurance policy, which was revised w.e.f. October 2020 and the copies of the policy terms and conditions are Annexure R-1 and R-2 and the claim settlement voucher is Annexure R-3. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In replication, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant has been obtaining the Mediclaim policy from the OPs since the year 2009, which fact has also not been specifically denied by the OPs in their written version, and the said policy was continuously renewed by the complainant till the issuance of the subject policy (Ex.C-2), which was valid w.e.f. 30.11.2021 to 29.11.2022 and due to the breathing problem, complainant got herself checked at the Treating Hospital, where she was diagnosed with  Morbid Obesity and seeing the aforesaid ailment of the complainant as life threatening, doctors in the Treating Hospital advised her to undergo Laparoscopic Cholecystectomy (Gall Bladder Removal) with Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery) and the said surgery was conducted on 11.9.2022 and the Treating Hospital had charged an amount of ₹4,15,000/- from the complainant and thereafter she had lodged claim of ₹4,17,166/- with the OPs, out of which they have only settled the claim to the tune of ₹52,000/- and have deducted an amount of ₹3,65,166/- on the ground that the said treatment was not covered under the subject policy i.e. as per clause 3.9.7, there was waiting period of four years for Morbid Obesity treatment, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in not settling the claim of the complainant in totality, which amounts to deficiency in service and unfair trade practice on their part, and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs/insurers are justified in partially allowing the claim of complainant and the instant consumer complaint, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and the claim settlement voucher and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. As per the case of the complainant, she has been obtaining the Mediclaim policy from the OPs since the year 2009 and getting the same continuously renewed without any break.  On the other hand, since the defence of the OPs is that the subject policy was revised w.e.f. October 2020 and as per the revised terms & conditions, waiting period of four years for Morbid Obesity treatment has been provided under clause 3.9.7, it is to be determined if the claim of the complainant falls under the aforesaid clause and the same was rightly repudiated. For ready reference, clause 3.9.7 of subject policy is reproduced below :-

“3.9.7 Morbid Obesity Treatment

The Company shall indemnify the Hospital or the Insured, the Medical Expenses (including Pre and Post Hospitalisation Expenses) incurred for surgical treatment of obesity that fulfils all the following conditions and subject to Waiting Period of four (04) years as per Section 4.2.f.iv:

1.     Treatment has been conducted is upon the advice of the Medical Practitioner, and

2.     The surgery/Procedure conducted should be supported by clinical protocols, and

3.     The Insured Person is 18 years of age or older, and

4.     Body Mass Index (BMI) is;

b) greater than or equal to 40 or

c) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:

i. Obesity-related cardiomyopathy

ii. Coronary heart disease

iii. Severe Sleep Apnea

iv. Uncontrolled Type 2 Diabetes”

4. Perusal of discharge summary (Ex.C-6) clearly indicates that the complainant was diagnosed by the Treating Hospital with Morbid Obesity with a BMI of 42.57 Kg/m², breathlessness on exertion and Severe Obstructive Sleep Apnea and was operated through Laparoscopic Cholecystectomy with Laparoscopic Gastric Bypass procedure and remained in the said hospital from 10.9.2022 to 15.9.2022.
5. Claim Settlement Voucher (Ex.C-3) clearly indicates that out of total claim of ₹4,17,166/-, OPs had deducted an amount of ₹3,65,166/- on the ground that the said claim was not covered under the terms & conditions of the subject policy.
6. The learned counsel for the complainant contended with vehemence that as the complainant has been obtaining Mediclaim policy from the OPs since the year 2009 and has undergone surgery for Laparoscopic Cholecystectomy (Gall Bladder Removal) with Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery)  in the Treating Hospital in the year 2022, the alleged one sided revision of terms & conditions of the subject policy, if any, by the OPs is not binding upon the complainant and she is entitled for the entire claimed amount.
7. On the other hand, learned counsel for the OPs contended with vehemence that as the terms & conditions were revised in the year 2020 and the complainant had taken treatment for Morbid Obesity before four years of the waiting period, claim of the complainant was disallowed partially. 
8. However, there is no force in the contention of the learned counsel for the OPs as it stands proved on record that the complainant had obtained the Mediclaim policy in the year 2009 and got the same renewed continuously without any break till the issuance of the subject policy (Ex.C-2) which was valid w.e.f. 30.11.2021 to 29.11.2022 and if there is any revision of the terms & conditions of the subject policy that it is one sided and has no binding effect upon the rights of the complainant, which she has been getting since the year 2009. Hence, it is unsafe to hold that OPs/insurers were justified in only partially allowing the claim of the complainant qua the subject policy and the present consumer complaint deserves to succeed. 
9. Now coming to the quantum of amount to be awarded in the instant case, since admittedly an amount of ₹3,65,166/- was deducted by the OPs from the total claim of ₹4,17,166/-, as is also evident from the claim settlement voucher (Ex.C-13), OPs/insurers are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment caused to the complainant.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹3,65,166/- to the complainant alongwith interest @ 9% per annum from the date of claim settlement voucher i.e. 1.11.2022 onwards.
2. to pay ₹40,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

03/04/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member