Chandigarh

DF-II

CC/851/2019

Amritpal Singh Sekhon - Complainant(s)

Versus

Religare Health Insurance Company Limited - Opp.Party(s)

In Person

22 Jun 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	851 of 2019
Date  of  Institution	:	29.09.2019
Date   of   Decision	:	22.06.2020

 

 

 

 

 

Amritpal Singh Sekhon age 35 years, R/o House No.217, Shiwalik City, Sector 127, Greater Mohali, SAS Nagar.

             …..Complainant

 

Versus

 

1]  Religare Health Insurance Company Limited, SCO 56-57-58, 2^nd Floor, Sector 9D, Chandigarh 160017, through Area Operation Manager / Authorized Signatory / Principal Officer.

 

2]  Religare Health Insurance Company Limited, Vipul Tech Square, Tower C, 3^rd Floor, Sector 43, Golf Course Road, Gurgaon 1220098, through National Head.

 

    ….. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN              PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER 

                    SH.B.M.SHARMA                      MEMBER

                               

Argued by :-    None for complainant.

Sh.Gaurav Bhardwaj, Advocate

 

 

PER PRITI MALHOTRA, MEMBER

          The case of the complainant, in brief, is that he obtained a Health Insurance Policy No.13044503 (Ann.C-1) with plan name ‘CARE’ from the OP in Sept., 2018, having health cover for sum assured of Rs.5 lacs and it was effective from 23.9.2018 to 22.9.2019.  It is averred that the complainant’s son namely Sahibdeep Singh, aged 4 years, was admitted to Max Superspecility Hospital, Phase-6, Mohali on 9.8.2019 under emergency condition with Urinary Tract Infection (UTI) along with retention of urine as illness.  It is also averred that complainant’s son remained admitted in the said hospital from 9.8.2019 to 14.8.2019 and surgery was conducted on 13.8.2019.  The OPs issued Cashless authorization letter on 10.8.2019 (Ann.C-2).  However, on the date of discharge of the patient i.e. 14.98.2019, the OPs rejected the claim of the complainant on the ground that there is 2 years waiting period for the surgery of Genito Urinary System unless necessitated by malignancy.  It is submitted that the said clause is not valid for the surgery of circumcision as circumcision comes under the Permanent Exclusions clause 4.2. Ultimately, the complainant had to make the payment of bill from his own pocket to the tune of Rs.99,533/- to Max Super Speciality Hospital, Mohali (Ann.C-6 Page 31). Thereafter, the complainant also represented the OPs through email (Ann.5), but to no avail.  Hence, this complaint has been filed alleging deficiency in service. 

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the cashless authorization approval for Rs.20,000/- was only for conservative management. It is stated that later on 14.8.2019, the Hospital sent Discharge Summary to the Company wherein it was mentioned that insured had Circumcision on 13.8.2019.  It is also stated that on further evaluation of the request, the OPs rejected the request vide letter dated 14.8.2019 (Ann.OP-4) as it was found that the request was for Surgical Management.  It is submitted that circumcision is a genitourinary procedure and as per policy Terms & Conditions, there is a 2 year waiting period for treatment of Genito Urinary Surgery unless necessitated by malignancy, therefore, the Cashless Facility Request of complainant was rejected.  It is also submitted that the OPs cannot ascertain the liability as no bills or reimbursement claim was filed by the complainant. Denying all other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the OP and have perused the entire record.   

 

5]       It is well proved on record that the complainant availed Health Insurance Policy No.13044503 (Ann.C-1) with plan name ‘CARE’ from the OPs vide which his son Sahibdeep Singh was also covered and the policy was effective from 23.9.2018 to 22.9.2019.  Admittedly the complainant’s son namely Sahibdeep Singh got admitted on 9.8.2019 in Max Superspecility Hospital, Phase-6, Mohali having Urinary Tract Infection (UTI) along with retention of urine as illness. The OPs initially approved Cashless authorization of Rs.20,000/- vide letter 10.8.2019 (Ann.C-2), but later on declined the claim of complainant for reimbursement of medical expenses incurred on the treatment of his insured son. 

 

6]       Contrarily, the OPs submitted that pre -authorization for cashless treatment of Rs.20,000/- was approved for the conservative management only and the procedure/surgery underwent by the son of the complainant falls under the exclusion clause of 2 years awaiting period, thus, claimed to have repudiated the claim rightly.  The OPs vide letter dated 14.8.2019 (Ann.C-3) conveyed the rejection of the claim and also informed that the initial approval granted stands null and void as there is two years waiting period for genitor urinary surgery.  It is explained  that surgery of genitor urinary system i.e. circumcision is payable only if it is necessitated by any malignancy or for treatment of an illness.

 

7]       In the present case also, the complainant’s son was admitted for the problem of Urinary Tract Infection and when the problem could not be treated with conservative method, then circumcision surgery was planned and conducted to cure the illness suffered by the son of complainant.  The surgery i.e. circumcision underwent by the son of the complainant was not an elective surgery and it was performed only to cure the illness, which the son of the complainant suffered.  It was only the treating doctor, an expert in the field, who advised and performed the surgery to cure the disease suffered by the complainant’s son.  Thus, it is right that the surgery was performed only to treat a particular illness and not otherwise.

 

         In the circumstances, as explained above, the exclusion clause as made applicable by the OPs, is held to be unjustified & untenable, and as such, the claim of the complainant has wrongly been rejected by the OPs. The Permanent Exclusion Clause (16) suggest a provision for honoring the claim for circumcision if it is necessary for treatment of an illness or as may necessitated due to accident.  The complainant’s son case is duly payable under permanent exclusion clause as circumcision has been conducted only to cure the illness as suffered by the son of the complainant.  The said Exclusion Clause 16 is reproduced as under:-

 

“Circumcision unless necessary for treatment of an illness or as may be necessitated due to an Accident.”

 

8]       It is also taken into consideration that the OPs when were contacted for cashless authorization also, after having gone through the pre-authorization request, approved an amount of Rs.20,000/-, which later on was declined.  The OPs have not put forth any reason for declining the pre-authorization approval for conservative management, which the son of the complainant was given.  No reasons or explanation has been given for rejecting the claim in toto, which as per the terms & conditions of the policy, is payable to the complainant in toto. 

 

9]       From the above discussion and findings, we are of the opinion that the OPs have wrongly rejected/repudiated the genuine claim of the complainant and thereby rendered deficient services. Therefore, the present complaint is allowed with directions to the Opposite Parties to reimburse an amount of Rs.99,533/- (Discharge Summary page-31), subject to the bills submitted by him along with formal claim form. The OPs are also directed to pay composite amount of Rs.10,000/- to the complainant towards compensation and litigation expenses.

         This order shall be complied with by the OPs within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay additional cost of Rs.20,000/-apart from above relief.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.   

Announced

22^nd June, 2020                                                                                                                                                            sd/-   

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(B.M.SHARMA)

MEMBER