Haryana

Ambala

CC/12/2020

Dr. Arun Bala Bedi - Complainant(s)

Versus

New India Assurance Co Ltd - Opp.Party(s)

06 Oct 2022

ORDER

 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                          Complaint case no.         :     12 of 2020

                                                          Date of Institution           :     07.01.2020

                                                          Date of decision    :     06.10.2022.

Dr. Arun Bala Bedi aged about 71 years, W/o Dr. N.K.Bedi R/o # 07, Vikas Vihar, Ambala City         

                                                                             ……. Complainant.

                                                Versus

New India Assurance Company Ltd, through its Divisional Manager, Division Office, Ambala Cantt.                                                                                 

                                                                             ….…. Opposite Party.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.

 

Present:       Shri Pardeep Kumar Batra, Advocate, counsel for the complainant.

Shri Shubham Aggarwal, Advocate, counsel for the OP.

 

Order:        Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’) praying for issuance of direction to it, to pay compensation of Rs 5 lacs along with actual expenses incurred by the complainant on her treatment to the tune of Rs.3,20,532/- alongwith interest from the due date till realization.

2.             Brief facts of the case are that the complainant purchased medi claim policy no.35350234179500000025 from the OP for her as well as for her husband- Dr. Naresh Bedi, for the sum insured of Rs.3,00,000/- each. The said policy has been continued for the last more than 14 years and on account of this fact, she also earned a cumulative bonus buffer of Rs.90,000/ each. The present policy which is in dispute was valid for the period from 10.10.2017 to 09.10.2018. The complainant had to go for the treatment of age related Osteo Arthritis of Both knees in the month of April 2018. The prospectus of New India Medi Claim policy 2016-17 which was prevailing during that period laid down three important conditions for getting cash less treatment are as follows:

a) The hospital should be net worked hospital with cash less facility.

b) Pre-approval should be obtained from RAKSHA TPA PVT. LTD. The Ancillary/Assisting body of the OP.

c) There should be continuous coverage of more than 48 months in the treatment of age related Osteo Arthritis (as per Clause 3. (Subclaluse-2) of prospectus.

3.           The complainant decided to take the treatment under the policy for age related Osteo Arthritis of Both Knee from the Sahaj Hospital, Indore, which is networked hospital of the OP for cash less hospitalization. Resultantly, on 12.04.2018, the said hospital sent a request alongwith necessary documents to the OP for cash less hospitalization. Thereafter, the RAKSHA TPA PTV.LTD ancillary unit of the OP made some queries and demanded some more documents, which were supplied by the said hospital. After thorough investigation of the said documents supplied by the hospital, the RAKSHA TPA PVT.LTD. granted approval for the said treatment on 17.04.2018. After receipt of the said approval/pre-authorization, the said hospital performed surgery of the complainant on 17.04.2018. On 18.04.2018 the hospital sent discharge summary and the final bill for payment to RAKSHA TPA PVT. LTD.  However, RAKSHA TPA PVT.LTD. cancelled the pre authorization on the ground that the said procedures is not payable as per technical manual (Prospectus of medi-claim policy) of New India Assurance Company, hence cash less denied. Previously approved amount of Rs.50,000/- was also withdrawn by the OP. It was also stated that there was no emergency and the treatment underwent by the complainant was  elective and complainant opted to go for treatment only after the approval. The RAKSHA TPA PTV. LTD. took five days i.e. from 12.04.2018 to 17.04.2018 to give the pre-approval and on 18.04.2018 i.e. on the very next day after granting pre authorization and day after the surgical procedure was over, the OP withdrew the pre-authorization and also invalidated the previously approved amount of Rs.50,000/-. While denying the cash less facility to the complainant, the OP took shelter of prospectus of medi claim policy which itself states under Para 25 thereof that cashless hospitalization is provided by the TPA on behalf  of the OP.  It is mentioned in the comprehensive medical opinion dated 4.05.2018, Annexure C-11 under the heading RECOMMENDATIONS PATIENTS/RELATIVES/GUARDIANS/POLICYHOLDERS/INSURED that if patients/relatives/guardians/policyholders/insured intended to claim the cost of treatment under the Insurance Policies they should insist on cash less hospitalization, so that apart from getting inherent benefits of cashless claim facility, not only the experimental/un approval nature can also be evaluated but also admissibility of treatment under the Insurance policy could be ascertained in advance. There is no clause contained in the policy in question, under which claim can be denied after approval from the TPA and certainly not after the patient has taken treatment. The complainant was fully eligible in terms of clause 3.2(2) of prospectus of company i.e. continuous under coverage of more than 48 months and in choosing Sahaj Hospital, Indore (MP) a company networked hospital for her treatment. However, despite that the complainant was made to run from pillar to post for redressal of her grievance but all her efforts proved futile. Ultimately the complainant filed her claim before the New India Assurance Ombudsman but it rejected the same vide order dated 22.11.2019.Due to repudiation of her genuine claim the complainant has suffered a lot of mental agony and physical harassment. Hence, the present complaint.
4.           Upon notice, the OP appeared and filed written version and raised preliminary objections with regard to cause of action, jurisdiction etc. On merits, while admitting factual matrix of the case with regard  to issuance of the policy in question and also treatment taken by the complainant in the said hospital during subsistence of the said policy, it has been stated that  the OP had approved an amount of Rs.50,000/-, i.e. the eligible amount of claim under the policy in question.  The complainant applied for cashless hospitalization for the treatment on 12.04.2018. The approval for hospitalization and treatment was accorded to the complainant through Raksha TPA vide pre-authorization letter dated 17.04.2018. But as a matter of fact, the complainant had taken admission in Sahaj Hospital Indore; the date of admission of the complainant is 16.04.2018 at 3.15 PM and initial approval was given on 17-04-2018 at 10.30 AM for the surgery of Osteo Arthritis  in Both knees. In final bill and discharge summary of the complainant it was mentioned that she was treated with 'Autologus adipose tissue derived from 'stromal vascular fraction'. However, since the procedure was not being a common procedure for the treatment of Osteo Arthritis  knee, the case was re-discussed and reference of all the technical Manuals and Addendums were taken by the senior Doctor. It was found that the treatment is a type of stem Cell Therapy and also it is an experimental treatment, which fell under the exclusion clause of the policy. Hence, the cashless facility was denied and initial approval of Rs.50,000/- already given was also withdrawn before the discharge of patient from the hospital. The complainant has stated that she has taken the treatment only after approval from TPA, but it is a clear fact that she is a resident of Ambala and has taken treatment from Indore for a procedure that was pre-planned. Therefore, it is clear that the neither the hospital nor the complainant had waited for the insurance company's approval. The claim of the complainant was thus rightly rejected by the OP. The complainant had also approached the insurance ombudsman Chandigarh and had filed a complaint having Reference No. CHD/G/049/1819/0766 for her grievance, which was dismissed vide order dated 22.11.2019. Rest of the averments of the complainant were denied by the OP and prayed for dismissal of the present complaint with costs.
5.           Complainant tendered her affidavit as Annexure CW1/A alongwith documents as Annexure C-1 to C-14 and closed the evidence of the complainant. On the other hand, learned counsel for the OP tendered affidavit of Mona Bagga, Senior Divisional Manager, New India Assurance Co. Ltd. as Annexure OP-A  alongwith documents Annexure OP-1 to OP-11 and closed the evidence on behalf of OP.
6.           We have heard the learned counsel for the parties and carefully gone through the case file.
7.           Learned counsel for the complainant submitted that since it was only after the approval having been granted by the Raksha TPA, ancillary of the OP that the complainant took treatment from the said hospital for age related Osteo Arthritis of Both Knees, yet, her genuine claim has been repudiated by the OP on flimsy grounds, which act amounts to deficiency in providing service.   
8.           On the contrary, the learned counsel for the OP submitted that since the disease for which the complainant took treatment fell under the exclusion clause of the policy in question, as has been suggested by the senior Doctor of the OP, when her case was reviewed by him, as such, the claim of the complainant was rightly rejected by the OP, strictly as per terms and conditions of the insurance policy.
9.           Admittedly, the claim of the complainant was repudiated by the OP vide email dated 23.04.2018, Annexure C-12, relevant contents of which are extracted below:-

“…Apropos to the trail mail, this is to apprise you that the claim has been denied as per the instructions in Health Manual. The same is attached herewith for your ready reference. Kindly refer to the point "c" which reads as follows:

 

c) Admissibility of procedure-Ossron: Ossron is an autologous biological therapy containing patient's own cultured osteoblasts for autologous bone implantation. It is a new therapy for treating Arthritis, bone necrosis, non-union fractures etc.

 

Resolution: It is a type of stem cell therapy, hence not admissible as stem cell therapy is exclusion in the policy."

 

Even this treatment is not approved in USA "It is addressing a growing stem cell clinic industry that markets what seem to be unapproved biological drugs without any FDA approval. The clinics also most often lack rigorous data from properly controlled studies to back up what they are selling".

 

On the basis of the above facts, the cashless was denied to the insured. Hope you will find the above information in order.. ….”

 

10.           From the afore-extracted contents of repudiation letter, it is evident that the insurance company repudiated the claim of the complainant, mainly on the ground that  the disease  for which the complainant took treatment from the said hospital is an autologous biological therapy containing patient's own cultured osteoblasts for autologous bone implantation and the same being a new therapy for treating Arthritis, bone necrosis, non-union fractures etc. and that being a type of stem cell therapy, was not admissible as stem cell therapy falls under the exclusion clause  in the policy.
11.           Thus, under above circumstances, the moot question which falls for consideration is, as to whether the OP was justified in repudiating the claim of the complainant or not?  It may be stated here that admittedly, in the first instance, on 12.04.2018, when the complainant sought approval from Raksha TPA Pvt. Ltd., the  ancillary unit of the OP, for treatment of age related Osteo Arthritis of Both Knee from Sahaj Hospital, Indore i.e. networked hospital for cashless treatment under the policy in question, the same was admittedly sanctioned and approved vide letter dated 17.04.2018. The fact that the complainant had obtained approval from Raksha TPA Pvt. Ltd., ancillary unit of the OP before treatment for age related Osteo Arthriits of Both Knee from Sahaj Hospital, Indore has also been fairly admitted by the OP in para no.5 of its written reply. Relevant part of the said admission of OP in para no.5 of its reply, to this effect is reproduced hereunder:-

“…..That the contents of Para No. 5 of the Complaint are admitted to the extent that the Complainant applied for cashless hospitalization for the treatment on 12.04.2018. It is also rightly mentioned in the corresponding para of the Complaint that the approval for hospitalization and treatment was accorded to the Complainant through Raksha TPA vide pre-authorization letter dated 17.04.2018….”

12.           Thus, once it has been proved on record that prior approval was taken by the complainant from the OP, through Raksha TPA, vide letter dated 17.04.2018, for taking treatment of age related Osteo Arthriits of Both Knees from Sahaj Hospital, Indore, as such, now the OP cannot wriggle out of the same, later on.

However, to wriggle out of the situation, learned counsel for the OP has contended with vehemence that the complainant had taken admission in Sahaj Hospital Indore; on 16-04 2018 at 3.15 PM and initial approval for the surgery of Osteoarthritis in Both knees was given only on 17-04-2018 at 10.30 AM; that when on 18-04-2018, final bill and discharge summary of the complainant was gone through, it was found that she was treated for 'Autologus adipose tissue derived from 'stromal vascular fraction' which was the not the common procedure; that the case was re-discussed and reference of all the technicalManuals and Addendums were taken by the senior Doctor and since it was found that the treatment is a type of stem Cell Therapy and also it is an experimental treatment, which fell within the exclusion clause of the policy, therefore the claim of the complainant was rightly rejected by the OP.

13.           In our considered opinion, irrespective of the fact that the complainant was admitted in the said hospital for treatment on 16.04.2018 or any other date, once the OP, through its Raksha TPA has admittedly approved her case for taking treatment of the said disease and based on that approval, the complainant took treatment thereof, therefore, later on, the OP cannot wriggle out of the same by stating that when the case of the complainant was discussed with senior Doctor it was found that the same fell under the exclusion clause of the policy in question. It has not been clarified by the OP as to why such an exercise of referring the case of the complainant, to the alleged senior Doctor (for which she moved request for approval of the said treatment), was not carried out by the OP before giving approval to the complainant. Thus, once it has been admitted by the OP itself, that approval was accorded to the complainant, on 17.04.2018 for taking the said treatment in the hospital referred to above which was under its network, then there is no occasion for the OP to deny the claim of the complainant. Had the OP denied the approval to the complainant sought by her on 12.04.2018 itself i.e. 5 days before treatment, she would have certainly thought twice in the matter to take such treatment and in those circumstances, the OP would have justified in its action but it is not so the case of the OP. 
14.           Furthermore, even the affidavit of the said senior Doctor, with whom the case of the complainant was discussed by the OP has not been placed on record. By not placing on record the affidavit of the said senior Doctor, the OP has attracted an adverse inference that nothing has been obtained by the OP in that regard from any doctor. Thus, by repudiating the claim of the complainant after giving approval, the OP has committed deficiency in providing service.
15.            Since, it has already been held above that by repudiating the claim of the complainant, the OP has committed deficiency in service, as such. this complaint very well falls under the purview of  Consumer Protection Act and there is no need to relegate it to the civil court. Thus, objection taken by the OP in this regard stands rejected.
16.           Since, we have already concluded that OP was not justified in repudiating the claim of the complainant, therefore, it is liable to reimburse/pay the amount incurred by the complainant on her treatment. It may be stated here that complainant has averred that she paid Rs.3,20,532/-, to the Sahah Hospital for her treatment but in the payment advice cum claim discharge voucher Annexure C-9, in the coloum, amount paid to hospital, an amount of Rs.3,14,349/-, has been mentioned, as such, the OP is liable to reimburse/pay the amount of Rs.3,14,349/-, alongwith interest. It is also liable to compensate the complainant for the mental agony and physical harassment. It is also liable to pay the litigation expenses.
17.           In view of the aforesaid discussion, we hereby partly allow the present complaint and direct the OP, in the following manner:-
    1. To reimburse/pay claim amount to the tune of Rs.3,14,349/- the complainant alongwith interest @4% p.a. from the date of repudiation of the claim i.e. from 23.04.2018 onwards.
    2. To pay Rs.5,000/- as compensation for causing mental agony and physical harassment to the complainant.
    3. To pay Rs.3,000/- as cost of litigation.

                   The OP is further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 06.10.2022.

 

 

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

              Member                         Member                       President