BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 13^TH DAY OF MAY 2024

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP for the following reliefs against the OP:-

1. Direct the OPs to look into the matter with foremost importance and to pay to the complainant a sum of INR 2,23,940/- which OP in the settlement letter says to be a non payable expense for which the OP dint provide any explanation and which is without any logic.
2. Direct the OPs to properly appropriate the discount which OP received from the hospital of Rs.32,000/- which legally belongs to the complainant.
3. Direct the OP to pay to the complainant a sum of INR 6,000/- as cost of litigation.
4. Direct the OP to pay a sum of INR 2,00,000/-towards compensation for the inconvenience, damage, mental trauma suffered by the complainant.
5. Any other relief as this Commission may deems fit.

2. The case set up by the complainant in brief is as under:-

The complainant’s mother Mrs.Babita Verma has taken family health optima insurance claim from the OPs herein for her family which covers her and family including her son the complainant herein, with Rs.10,00,000/- in case of hospitalization during the policy period. The OP is the Star Health and Alied Insurance an Indian Multinational Health Insurance Company, head quarter in Tamilnadu, Chennai and it provides services in health, personal accidents and overseas travel insurance directly as well as through various channels like agents, brokers and online.  The complainant had taken family health insurance from the Haldwani Branch of Star Health and Allied Insurance, feels grossly deceived by its concerned functionaries with whom he dealt with at the time of hospitalization in Vedantha Hospital, Gurugram for a period of 12 days from 10.03.2022 to 22.03.2022.

3. It is further case of the complainant that during discharge on 22.03.2022 he was billed an amount of Rs.6,23,940/-.  The OP on the discharge told the complainant that the payable expenses in the aforementioned bill was exceeding the sublimit associated with specific treatment of the ailment.   The alleged sub limit for the treatment being Rs.4,00,000/-.
4. It is further case of the complainant that the OP informed the complainant in the authorization letter that it would only pay a sum of Rs.4,00,000/- and the remaining amount of Rs.2,23,940/- to be borned by the complainant himself. Hence the complainant has paid the amount of Rs.2,23,940/- directly to the hospital at the time of discharge.  The complainant after getting the bill settlement letter from the OP on 19.04.2022 find out deficiency on the part of the OP committed to him.   The bill assessment received conveyed the following mall practice of the OP.

1. That opposite to as claimed by respondent during the time of discharge the complainant’s payable expenses hadn’t crossed the stated sub-limit of INR 400000.  In fact the non-payable expenses of the claim were summed upto INR 223940 the reason for which the respondent failed to provide even after the continued follow ups on the same from the complainant.

• Payable expenses being the amount the insurance company has to pay in case there is no sub-limit attached.
• Amount exceeding sub-limit is INR 0 as shown in Bill Settlement letter at Page No.33.

2. That the respondent received a network hospital discount of INR 32000 from the hospital which wasn’t passed onto the complainant which grossly violates the guidelines provided by IRDAI, specifically the circular passed by IRDAI on 23.06.2015 regarding discount on bills provided by network providers issued in terms of Section 14(2) of IRDA act, 1999.

• Bill settlement letter dated 19.04.2022 Page No.31-33.

5. It is further case of the complainant that the OP even in this wrongly created payable expenses was liable to pass the network discount of Rs.32000 to the complainant and to pay the alleged sublimit amount of Rs.4,00,000/- to the hospital but the OP somehow paid Rs.3,68,000/- to the hospital grossly receiving the complainant hiding the discount from the complainant.  The claim settlement letter dated 10.05.2022 showed the eligible amount of Rs.3,68,000/- as opposed to payable expenses of Rs.4,00,000/- shown in the bill settlement letter. The complainant has tried to get clear resolution to the issue but the respondent did not have any positive response to the complainant and seen reluctant to have a dialogue.   The complainant has also got issued legal notice. Inspite of service of notice the OP neither refund the amount nor comply the demands of the complainant. Hence this complaint is filed.

6. In response to the notice, OP appears and files version stating that the complainant has availed the family health optima insurance for a sum insured of Rs.10,00,000/- and further admitted that the complainant took policy vide policy NO.P/161312/01/2021/013344  for the period from 18.02.2022 to 1702.2023. The complainant reported the claim in the second year of the medical insurance policy.  The complainant was raised request for cashless treatment for the said hospitalization. As per the request this OP has initially approved an amount of Rs.1,00,000/- on 13.03.2022 towards cashless, subsequently Rs.75,000/- was settled and after that Rs.2,00,660/-  and Rs.24,340/- and the same was settled and the hospital was given discount of Rs.32,000/- and total Rs.4,00,000/- was settled by the OP.

7. The complainant has submitted request for enhancement of the amount for cashless treatment, this OP was earlier approved Rs.4,00,000/- and hence the request of the complainant was rejected for the said reason and intimated to the hospital. Therefore this OP was unable to settle the balance claimed under the above policy terms and conditions and the same was repudiated and intimated to the insured.  As per the policy terms and conditions Rs.4,00,000/- is sublimit for Rs.10,00,000/- sum insured to the above said hospitalization.  The companies liability in respect of all the claims admitted within the period of insurance shall not exceed the sum insured per family mentioned in the schedule.  The various relief sought by the complainant is not payable as per the terms of the policy.  The amount claimed by the complainant towards mental agony harassment, stress inconvenience are highly exaggerated and without any basis. There is no cause of action. Therefore the OP prayed for dismissal of the complaint.

8. The complainant has filed his affidavit evidence and relies on 13 documents.  Affidavit evidence of official of OP has been filed and OP relies on 09 documents.

9. Heard the arguments of both counsels and perused the written arguments and documents filed by both the parties.

10. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

11. Our answers to the above points are as under:

Point No.1:  Affirmative

Point No.2: Affirmative in part

Point No.3: As per final orders

REASONS

12. Point No.1 AND 2: These two points are inter related and hence they have taken for common discussion.  We have perused the allegations made in the complaint, version, affidavit evidence of both the parties, written arguments and documents.
13. There is no dispute that the complainant took policy NO.P/161312/01/2021/013344  and it was in force from 18.02.2022 to 17.02.2023.  The mother of the complainant namely Smt.Babita Verma has availed Family Health Optima Insurance Policy Plan through OP covering the mother of the complainant and the complainant and his wife and his son for the sum assured Rs.10,00,000/-.   
14. It is also not in dispute that the complainant was admitted to Medantha Hospital Gurgoav and he was taken treatment for Transverse Mellitus and discharged on 22.02.2022.  The complainant has incurred total expenses of Rs.6,23,940/- for which the complainant has raised the claim to the OP.  The OP has informed to the complainant during the discharge that there is a sub limit of Rs.4,00,000/- associated with the treatment the complainant was claimed. This OP was liable to pay a sum of Rs.4,00,000/- and the rest of the amount has to be paid by the complainant. The complainant has directly paid the balance amount of Rs.2,23,940/- at the time of discharge. After that he has received the bill settlement letter from the OP on 19.04.2022.
15. After received the bill settlement letter the complainant came to know that during the time of discharge his payable expenses had not crossed the stated sub limit of Rs.4,00,000/-. In fact the non payable expenses of the claim were sum upto Rs.2,23,940/-. The segregation for which the OP failed to provide even after the continued follow-ups. The OP has also received a network hospital discount of Rs.32,000/- from the hospital that was not passed on to the complainant which grossly violated the guidelines provided by IRDAI, the circular passed by IRDAI on 23.06.2015 regarding discount on bills provided by network providers issued in terms of sec14(2) of IRDAI Act 1999.  Hence the OP has only paid Rs.3,68,000/-.
16. It is further grievance of the complainant that Rs.4,00,000/- is the sub limit for Rs.10,00,000/- as per the policy terms and conditions.  The sum insured for immunotherapy-Monoclonal Antibody to be given as injunction. The complainant was admitted for treatment for disease transverse myelitius for which the complainant was administered injections of Rituxirel 500mg and the two injection costs Rs.78,956.90 ps., and were the sole injection that comes under the alleged components of sub limit.  The complainant also underwent other forms of diagnosis and treatment. There were several blood tests and radiology tests along with treatments like plasma transfusion along with other medications involved in the treatment which do not classify as imuneo therapy and do not fit the criteria of sub-limit.
17. In support of his contention the complainant has relied on 12 documents. The complainant has mainly relied on policy documents, cashless authorization letter, marked as Ex.P1, Bills, marked as Ex.P2,  bill settlement letter, marked as Ex.P3, claim settlement letter, marked as Ex.P4, email conversations, marked as Ex.P5 & P6, copy of the legal notice, marked as Ex.P7 & P8,  copy of the policy renewal letter, marked as Ex.P9.
18. On the other hand, the main contention taken by the OPs is that the total bill was settled for Rs.4,00,000/- and the hospital has given discount of Rs.32,000/-. The request made by the complainant for enhancement of the amount for cashless treatment was rejected since this OP has earlier approved the sub limit of Rs.4,00,000/-.  Hence they have repudiated the claim made by the complainant. The coverage for modern treatment i.e., uterine artery embolization and HIFU, Balloon Sinuplasty, EP brain stimulation, oral chemotherapy, immunotherapy-monoclonal antibody to be given as injection, intra vitreal injections.  For the above said expenses are payable during the policy period for the treatment/procedure is limited to the amount mentioned in the table.  These OPs have taken the decision as per the terms of the policy of policy No.2.
19. The complainant is claiming the refund of Rs.2,23,940/- which was rejected by the OP and also claim the Rs.32,000/- which was discount given by the network hospital. In support of his contention that complainant has clearly relied on the circular issued by the IRDAI on 23.06.2016 as per clause 4 of the said circular “the insurer and the TPAs shall ensure that every discount received or agreed to be received from the hospital is passed on to the policyholder or the claimant in respect of the undergoing claim only in absolute monitory terms.” And further held that “the above procedures shall be applicable with immediate effect for both i.e., cashless services and reimbursements of all the claims on health insurance policies.”
20. Further the complainant has incurred Rs.78,956.90 ps., towards injections of RITUXIREL 500 mg., that classifies as monoclonal antibody and they are the sole injections that comes under the alleged component of sub limit prescribed by the OP.
21. Under these circumstances, the complainant is entitled for the balance medical expenses of Rs.2,23,940/- and also the discount given by the network hospital Rs.32,000/-,  even though the complainant is entitle for the aforesaid amount the OPs without considering the request of the complainant have simply repudiated the claim of the complainant.  Even though the complainant is having the sub limit of Rs.4,00,000/- towards hospital expenses and also entitled for the discount given by the hospital i.e., Rs.32,000/- and the policy was in force the conduct of the OP in repudiating the claim clearly discloses their deficiency in service, negligence and unfair trade practice. In view of the rejection of the claim the complainant has suffered mental agony, financial loss. If the OPs have settled the claim as per the terms and conditions of the policy and also as per the norms of the IRDAI, the complainant would not have filed this complaint by approaching this commission. Under these circumstances the complainant is entitled for compensation of Rs.1,00,000/-  with litigation expenses of Rs.6,000/-.  Hence we answer point No.1 in affirmative and point No.2 partly in affirmative.
22. Point No.3:- In view the discussion referred above we proceed to pass the following;

O R D E R

1. The complaint is allowed in part.
2. OPs are hereby directed to pay the balance medical expenses of Rs.2,23,940/- and also the discount given by the network hospital Rs.32,000/- with interest at 8% p.a., from the date of discharge till realisation to the complainant.
3. OPs are further directed to pay Rs.1,00,000/- towards mental agony along with litigation expenses of Rs.6,000/- to the complainant.
4. The OP shall comply this order within 60 days from this date, failing which the OP shall pay interest at 10% p.a. after expiry of 60 days on Rs.2,23,940/- and Rs.32,000/-  till final payment.
5. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 13^TH day of MAY 2024)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;