IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM

Dated, the 22^nd day of July, 2024

Present: Sri. Manulal V.S. President

  Smt. Bindhu R.  Member

C C No. 77/2024 (Filed on 27.02.2024)

O R D E R

Sri. Manulal V.S. President

The complaint is filed under Section 35 of the Consumer Protection Act 2019.

The complainant is working at a firm, namely Wabtec India Industrial Private Limited, at Banglore. The opposite party issued a Corporate Policy in the name of the concern, which covers the employees and their dependent having policy No.421300/148/2024/410 for the period from 01.04.2023 to 31.03.2024, with Medi Assist ID 4049520145. Thus, the complainant is the primary beneficiary, having primary beneficiary Employee ID No.149797. The total sum insured is ₹ 7,00,000/- (Rupees seven lakhs only) out of which the policy premium for ₹ 4,00,000/- (Rupees four lakhs only) was remitted from her salary and for the additional ₹ 3,00,000/- (Rupees three lakhs only) the complainant remitted an additional amount of ₹ 16,000/- (Rupees sixteen thousand only). The policy also covers the parents of the complainant.

The father of the complainant, M.R. Saji, went for a comprehensive medical check up and it was found that the PSA value in the blood crossed the limit. After that he approached Dr. Suresh Bhat at Caritas Hospital, Thellakom on 16.10.2023. MRI was taken and a biopsy was done on 26.10.2023. Subsequently Malignant Neoplasm of the prostate, i.e., adenocarcinoma prostate was detected and he advised surgery. At that time it was advised that surgery should be conducted only 45 days after the biopsy. After detecting Malignant Neoplasm in the prostate, the doctor advised that it is better to undergo Robotic Surgery than Conservative Surgery.  An amount of ₹ 56,445/- (Rupees fifty six thousand four hundred and forty five only) is spent as pre-hospitalization expenses even though the complainant claimed it with the original bills before the opposite party as claim No.118481497 that was rejected by the opposite party.

The father of the complainant approached Dr. Balagopal Nair.T. at Rajagiri Hospital, Aluva and he also advised that surgery can only be conducted 45 days from the date of biopsy. Thus, on 14.12.2023, the father of the complainant was admitted and a Robotic-Assisted Radical Prostatectomy was conducted on 15.12.2023 and discharged on 20.12.2023. The Hospital authorities issued a bill for ₹ 4,74,133/- (Rupees four lakhs seventy four thousand one hundred and thirty three only) towards treatment expenses and all the bills were forwarded to the TPA and the claim is registered with No.540000/48/2024/00137235. On 24.11.2023, pre-authorization was for            ₹ 2,60,000/- (Rupees two lakhs sixty thousand only) and the opposite party approved only an amount of ₹ 70,000/- (Rupees seventy thousand only).

The hospital authorities gave a discount of ₹ 74,133/- (Rupees seventy four thousand one hundred and thirty three only). After that, the son of the complainant raised the balance of ₹ 3,00,000/- (Rupees three lakhs only) and paid it. At the time of the pre-authorization request, the opposite party was informed that the mode of surgery would be Robotic Surgery. The company informed that they will not pay the expense of Robotic Surgery. As per IRDA norms, the opposite party cannot repudiate the claim stating the reason for Robotic Surgery.

After that, the complainant sent mail to the TPA and they agreed to reconsider the claim. They demanded many papers, including certificates from the treating doctor, hospital and the complainant submitted all the documents. After that they released a further amount of ₹ 1,57,232 /- (Rupees one lakh fifty seven thousand two hundred and thirty two only) to the complainant on 19.02.2024. Hence, the balance payable to the complainant comes to                    ₹ 1,72,768/- (Rupees seventy two thousand seven hundred and sixty eight only). The opposite party deducted an amount of ₹ 42,415/- (Rupees forty two thousand four hundred and fifteen only) towards consumables from the total amount. So, after deducting this amount, an amount of ₹ 1,30,673/- (Rupees one lakh thirty thousand six hundred and seventy three only) (i.e.,₹ 1,72,768-             ₹ 42,415)/- is to be released apart from the pre-hospitalization expense of            ₹ 56,445/- (Rupees fifty six thousand four hundred and forty five only). The opposite party rejected the pre-hospitalization expense of  ₹ 56,445/- (Rupees fifty six thousand four hundred and forty five only) without any valid reasons. Thus, the complainant is entitled to a total amount of ₹ 1,87,118/- (Rupees one lakh eighty seven thousand one hundred and eighteen only) (i.e., ₹ 1,30,673+        ₹ 56,445) from the opposite party.

The partial rejection of the claim of the complainant was illegal, fraudulent and deliberate to deprive the right of the complainant, resulting in mental agony, hardship and financial loss to the complainant, which amounts to deficiency in service by the opposite party. Hence, this complaint is filed by the complainant praying for an order to direct the opposite party to pay the sum insured of ₹ 1,87,118/- (Rupees one lakh eighty seven thousand one hundred and eighteen only) with interest and to pay ₹ 20,000/- (Rupees twenty thousand only) towards compensation for mental agony and financial loss caused by the complainant due to deficiency of service and unfair trade practice, to the complainant along with ₹ 10,000/- (Rupees ten thousand only) as cost of this proceedings.

On admission of the complaint, notice was duly served to the opposite party. Though the notice was received by the opposite party on 11.03.2024 and appeared before this commission on 27.03.2024, they did not file a version within the statutory period.

The authorized agent of the complainant filed proof affidavit in lieu of chef examination and marked Exhibit A1 to A6.

On evaluation of complaint and evidence on record we would like to consider the following points.

1. Whether the complainant had succeeded to prove deficiency in service or unfair trade practice on the part of the opposite party?
2. If so, what are the reliefs and costs?

Point Nos. 1 & 2

The specific case of the complainant is that she is an employee of the Wabtec India Industrial Private Limited company in Bangalore and the opposite party issued a Corporate Policy in the name of the company which covers the employees and their dependents for the coverage of some insured of ₹ 7,00,000/-(Rupees seven lakhs only). According to the complainant being a primary beneficiary, the premium of ₹ 4,00,000/- (Rupees four lakhs only) was deducted from her salary and for the additional ₹ 3,00,000/- (Rupees three lakhs only) she paid an amount of ₹ 1,60,000/- (Rupees one lakh sixty thousand only). On perusal of Exhibit A4, we can see that the policyholder is Wabtec, India Industrial Pvt.Ltd., and the complainant is the primary insured vide member ID No. 28664903 and vide employee code No. 149797. On scrutiny of Exhibit A3, which is the claim repudiation letter issued by the Medi Assist to the complainant, we can see that Wabtec India International Pvt. Ltd., is the master policyholder of policy No. 421300/148/2024/410, which is issued by the opposite party and the complainant is the primary beneficiary of the said policy. Therefore, we are of the opinion that the complainant is a consumer of the opposite party.

It is proved by Exhibit A5, which is the discharge bills issued from Carita's Hospital Kottayam, that the father of the complainant, M.R Saji, was admitted there on 25.10.2023 and discharged on 27.10.2023 and the complainant spent an amount of ₹ 56,445 (Rupees fifty six thousand four hundred and forty five only) for his treatment at Caritas Hospital. Exhibit A5 further proves that a prostate biopsy was done at Caritas Hospital during that admission. Exhibit A6 is the certificate issued by Dr.Balagopal Nair, who is a Senior Consultant and Head of the Department of Urology at Rajagiri Hospital. On going through Exhibit A6, we can see that the father of the complainant was found to have elevated S.PSA, for which he underwent a prostate biopsy in Caritas Hospital on 26.10.2023 and was diagnosed with adenocarcinoma prostate. Exhibit A6 further proves that he was advised to undergo a Robotic-Assisted Radical Prostatectomy after 45 days with effect from the day of prostate biopsy. It is further stated in Exhibit A6 that the complainant’s preferred admission date for the surgery has been scheduled for 14.12.2023 and surgery on 16.12.2023. Exhibit A3 proves that the complainant had lodged a claim for the reimbursement for the treatment expenses of ₹ 4,74,134/- (Rupees four lakhs seventy four thousand one hundred and thirty four only) for the treatment of her father for a Malignant Neoplasm of the Prostate at Rajagiri Hospital. The opposite party settled the claim for an amount of ₹ 1,57,232/- (Rupees one lakh fifty seven thousand two hundred and thirty two only) against the claim of ₹ 4,74,134 (Rupees four lakhs seventy four one hundred and thirty four only).

On going through Exhibit A3, we see that the opposite party deducted       ₹ 42,415/- (Rupees four two thousand four hundred and fifteen only) towards the consumables from the total amount. On going through Exhibit A3, we can see that the opposite party has deducted ₹ 14,417/- (Rupees fourteen thousand four hundred and seventeen only) under the head of deductible amount and         ₹ 1,90,340/- (Rupees one lakh ninety thousand three hundred and forty only) as an excess of the defined ailment limit.

It is pertinent to note that the complainant did not produce the terms and conditions of the policy before us. The opposite party failed to file their version within the statutory period and contest the case. Due to the negligence of the opposite party to contest the case, we cannot find out that relying upon which condition the opposite party deducted ₹ 14,417/- (Rupees fourteen thousand four hundred and seventeen only) as deductible amount and ₹ 1,90,340/-(Rupees one lakh ninety thousand three hundred and forty only)  as excess of defined ailment limits.

IRDAI guidelines dated 27^th September 2019 were effective from                  1^st October 2020 onwards.  As per the IRDAI guidelines for coverage for modern treatment or procedure guidelines, Robotic Surgeries shall be covered (wherever medically indicated) either as an in-patient or as part of domiciliary hospitalization or as day care treatment in a hospital. Therefore, we are of the opinion that the opposite party, without any authority, deducted ₹ 2,04,757/- (Rupees two lakhs four thousand seven hundred and fifty seven only) from the treatment expenses of the father of the complainant. Thus, the opposite party is liable to pay ₹ 4,31,729/- (Rupees four lakhs thirty one thousand seven hundred and twenty nine only) to the complainant after deducting amounts for the consumables.

Admittedly, the opposite party approved an amount of ₹ 70,000/- (Rupees seventy thousand only) when the request for the pre-authorization of an amount of ₹ 2,60,000/- (Rupees two lakh sixty thousand only) was submitted to the opposite party. The complainant admitted that the Hospital authorities gave him a discount of ₹ 74,133/- (Rupees seventy four thousand one hundred and thirty three only). Thus, according to her, the opposite party is bound to pay                  ₹ 2,87,596/- (Rupees two lakhs eighty seven thousand five hundred and ninety six only). As discussed earlier, the opposite party reimbursed only ₹ 1,57,232/- (Rupees one lakh fifty seven thousand two hundred and thirty two only) to the complainant for the treatment of her father.

Therefore, we are of the opinion that the opposite party is under a contractual obligation to pay the balance amount of ₹ 1,30,364/- (Rupees one lakh thirty thousand three hundred and sixty four only) to the complainant under the contract of insurance. The partial repudiation of the genuine claim of the complainant for which she is entitled to get indemnified by the opposite party under the contract of insurance amounts to imperfection and inadequacy on the part of the opposite party as a service provider of the insurance coverage under the contract of the insurance they are obligated to do.

Regarding the claim of the complainant for the pre-hospitalization expense of ₹ 56,445/- (Rupees fifty six thousand four hundred and forty four only) she did not adduce any evidence to prove that she had lodged a claim for the said amount, which the opposite party repudiated. Therefore, we are not inclined to allow the claim of the complainant for ₹ 56,445/- (Rupees fifty six thousand four hundred and forty four only) for pre hospitalization expenses.

Based on above discussions and the evidence on record we are of the opinion that the complainant had succeeded to prove deficiency in service on the part of the opposite party. As a result, we allow this complaint and pass the following order.

1. We hereby direct the opposite party to pay ₹ 1,30,364/- (Rupees one lakh thirty thousand three hundred and sixty four only) to the complainant together with interest @ 9% per annum from 20.02.2024. i.e., the date on which the opposite party repudiated the complainant's claim until realization.
2. We hereby direct the opposite party to pay ₹ 25,000/- (Rupees twenty five thousand only) as compensation to the complainant for the deficiency in service on the part of the opposite party.
3. We hereby direct the opposite party to pay ₹ 3,000/- (Rupees three thousand only) as the cost of this litigation.

Order shall be complied with in 30 days from receipt of the copy of this order, failing in which the compensation amount shall interest @ 9% per annum from the date of this order till realization.

 Pronounced in the Open Commission on this the 22^nd day of July, 2024

Sri. Manulal V.S, President   Sd/-

       Smt. Bindhu R.  Member        Sd/-

APPENDIX :

Exhibits from the side of the Complainant :

A1     -        Authorization dated 09.06.2024.

A2     -        Copy of receipt for ₹ 3,30,000/-

A3     -        Copy of letter dated 20.02.2023.

A4     -        Copy of ID card.

A5     -        Copy of bills from Carithas Hospital.

A6     -        Copy of certificate issued by Dr. Balagopal Nair T.

Exhibits from the side of the Opposite Parties : Nil

By Order,

     Sd/-

                                                                                                   Assistant Registrar