Haryana

Karnal

CC/254/2021

Apaar Bedi - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Suresh Kumar Raheja

09 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 254 of 2021

                                                        Date of instt.19.05.2021

                                                        Date of Decision:09.08.2022

 

Apaar Bedi son of Shri Palwinder Singh Bedi, resident of House no.192, Sector-14, Part 2, Urban Estate, Karnal. Aadhar no.8241 9749 7399.

 

                                               …….Complainant.                  Versus

 

1.     Star Health and Allied Insurance Co. Ltd. New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034, through its authorized signatory.

 

2.     Star Health and Allied Insurance Co. Ltd. 930/8 RJ Tower, 2^nd Floor, G.T. Road, opposite IB College, Panipat-132103, through its Branch/Divisional Manager.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary……Member

          

 Argued by: Sh. S.K. Raheja, counsel for the complainant.

                   Shri Naveen Khetarpal, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:  

 

                

                The complainant has filed the present Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on averments that complainant obtained a cashless policy in year 2017 and regularly paying the Renewal amount from time to time and currently insurance policy bearing no.P/211112/01/2021/003634, product name Family Health Optima Insurance and the said policy was valid from 27.06.2020 to 26.06.2021. Smt. Ramneek Kaur who is wife of the complainant went to Dr. Aarti Kaushal Obstretics & Gynecology in Life Care Hospital, Sector-7, Karnal and Dr. has advised her for Ultrasound Abdomen and she came to know that she is suffering from PCOD, B/L Polycystic ovaries, fatty liver. Thereafter, on advice of Doctor she is taking regular medicine but due to PCOD her weight is regularly increasing and her disease PCOD is not treated. The wife of complainant to get the treatment of PCOD has visited on 13.04.2021 in Amritdhara I.T.I. Chowk Karnal and visited the Dr. Stuti Modi and Doctor after seeing the ailment and record of wife of complainant has diagnosed her as she is suffering from PCOD (amenorrhea) and Morbid Obesity i.e. disorder involving excessive body fat that increase the risk health problem such as diabetics, heart disease, Breathing difficulties and joint pain etc. and due to that her obesity level is increasing and to treat PCOD Doctor Stuti Modi has advised for weight loss through Bariatric Surgery and she referred the wife of the complainant to Dr. Nitin Bansal for further treatment of PCOD with Morbid Obesity through Bariatric Surgery for weight loss. On 13.04.2021, requested for pre approval cashless treatment was forwarded by the Amritdhara Hospital Karnal to OP as wife of complainant is to be admitted on 16.04.2021 of cashless treatment, but on same day query was raised by OPs that they required the following documents, since when the patient is obese i.e. provided all previous consultation papers, treatment records, thereafter on the query raised by OP the complainant submitted the treatment record of the wife of the complainant but on 14.04.2021 the complainant received the denial of preauthorization request for cashless treatment from the OPs on the ground that duration of ailment, height of customer, indication for surgery is not clear, hence cashless cannot be considered, revert with documents for reimbursement. Thereafter, complainant contacted the agent of OPs namely Abhishek Dhamija and narrated about the same, the agent told the complainant that cashless treatment is denied due to some technical and misunderstanding and further told the complainant to write the latter to OPs for treatment of PCOD through Bariatric surgery and it is to be forwarded through concerned hospital i.e. Amridhara Hospital, Karnal and sent a clarification letter dated  16.04.2021 with all treatment record and correct details. Complainant again received the denial of preauthorization request for cashless treatment. It is further averred that the cost of Bariatric surgery is approximately 3-4 lakhs and some amount after the surgery. As complainant has been regularly paying the premium/renewable amount for cashless of insurance policy so that in any health issue he and his family member can avail his insurance so that huge amount is difficult to pay at a time. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan covering Mr. Apaar Bedi (self), Mrs. Ramneek Kaur (spouse) and Parneek Bedi-Dependant child for sum inured Rs.5 lakhs, vide policy no. P/211112/01/2021/003634 for the from period 27.06.2020 to 26.06.2021. The policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The terms and conditions of the policy were explained to the complainant at the time of proposal of policy and the same was served to the complainant alongwith the Policy Schedule. It is further pleaded that insured raised cashless request for planned admission on 16.04.2021 at Amritdhara Hospital Pvt. Ltd. Karnal towards the treatment of Obesity. On scrutiny of the pre authorization documents it is noted that the OPs were unable to ascertain the duration of the disease based on the available documents/details in cashless level, and it requires further evaluation to ascertain whether the complainant is having pre existing disease. OPs therefore denied the approval for cashless treatment of the above diagnosed disease vide letter dated 16.04.2021, however called for reimbursement to find out the cause and duration of the ailment. However, the insured has not submitted the same and filed the present complaint. It is observed from the complaint that the complainant was not hospitalized till date and filed a complaint for Rs.3,00,000/- towards medical expenses. Thus, the complaint is premature. It is further pleaded that the claim of the complainant was not maintainable, so the claim of the complainant was repudiated and communicated to the complainant. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.CW1/A, affidavit of Ramneek Kaur Ex.CW2/A, copy of cover note of policy no. P/211112/01/2021/003634 Ex.C1, copy of OPD slip dated 27.06.2020 Ex.C2, copy of ultrasound report Ex.C3, copies of OPD slips dated 10.07.2020, 10.09.2020, 13.04.2021, 13.04.2021 Ex.C3 to Ex.C7, copy of denial of cashless treatment dated 14.04.2021 Ex.C8, copy of clarification letter dated 14.04.2021 Ex.C9, copy of denial of cashless treatment dated 16.04.2021 Ex.C10, copy of cover note of policy no. P/211112/01/2022/005822 Ex.C11, copy of cashless work flow regarding obesity Ex.C12 and closed the evidence on 29.09.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of terms and conditions of the insurance policy Ex.R1, copy of insurance policy Ex.R2, copy of letter for inclusion of new born baby Ex.R3, copy of renewal of health insurance policy Ex.R4, detail of insurance policy Ex.R5, request for cashless Ex.R6, copy of treatment detail Ex.R7, prescription slip Ex.R8, OPD slip Ex.R9, doctor certificates Ex.R10 and Ex.R11, copy of intimation by Amritdhara My Hospital, Karnal to OPs for cashless facility Ex.R12, copy of OPD slip Ex.R13, copy of denial of pre-authorization request Ex.R14, copy of 1^st reminder dated 28.05.2021 Ex.R15 and 2^nd reminder dated 12.06.2021 Ex.R16 regarding submission of claim form and hospital records, copy of letter dated 27.06.2021 regarding rejection of claim Ex.C17 and closed the evidence on 22.03.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant has obtained a health insurance policy from the OPs. Wife of complainant namely Ramneek Kaur went to Dr. Aarti Kaushal Obstretics & Gynecology in Life Care Hospital, Sector-7, Karnal and she came to know that she is suffering from PCOD, B/L Polycystic ovaries, fatty liver. Thereafter, on 13.04.2021 she visited to Amritdhara Hospital Karnal to get the treatment of PCOD where Doctor has advised for weight loss through Bariatric Surgery for further treatment of PCOD with Morbid Obesity. On 13.04.2021 request for pre approval cashless treatment was forwarded by the Amritdhara Hospital Karnal to OPs as wife of complainant is to be admitted on 16.04.2021 of cashless treatment, but OPs denied the preauthorization cashless request of complainant on the ground that duration of ailment, height of customer, indication for surgery is not clear, hence cashless cannot be considered. Thereafter, complainant again sent a letter dated 16.04.2021 with all treatment record and correct details for cashless facility but OPs again denied the preauthorization request of complainant and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that insured has availed Family Health Optima Insurance Plan for sum inured Rs.5 lakhs. The insured raised cashless request for planned admission on 16.04.2021 at Amritdhara Hospital, Karnal, towards the treatment of weight loss through Bariatric Surgery of his wife. On scrutiny of the pre authorization documents, it is noted that the OPs were unable to ascertain the duration of the disease based on the available documents/details in cashless level, and it requires further evaluation to ascertain whether the complainant is having pre existing disease. OPs therefore denied the approval for cashless treatment of the above diagnosed disease vide letter dated 16.04.2021, however called for reimbursement to find out the cause and duration of the ailment. However, the insured has not submitted the same and filed the present complaint. He further argued that the complainant was not hospitalized till date and filed a false complaint for Rs.3,00,000/- towards medical expenses. Thus, the complaint is premature and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the complainant purchased the Family Health Optima Insurance Policy from the OPs, which was valid from 27.06.2020 to 26.06.2021. It is also admitted that the wife of complainant wanted to take the treatment of weight loss through Bariatric Surgery from Amritdhara My Hospital, Karnal, during the subsistence of the insurance policy. It is also admitted that wife of complainant has not taken a treatment.  It is also admitted that the OPs have denied to provide the cashless facility.

11.           The preauthorization cashless request of complainant has been denied by the OPs, vide letter Ex.C8 dated 14.04.2021 on the ground that the duration of the ailment, height of the customer, indication of surgery is not clear, hence cashless cannot be considered, revert with documents for reimbursement.

12.           The moot question for consideration is whether the denial of preauthorization request for cashless facility by the OPs on the ground of duration of ailment, height of the customer and indication of surgery is not clear, is justified or not?

13.           It is evident from the OPD slip Ex.C2/Ex.R13 that on the advice of the doctor, ultrasound was conducted on 09.07.2021 of the wife of the complainant. The report of ultrasound Ex.C3 wherein it has been mentioned that she is suffering from PCOD, B/L Polycystic ovaries, fatty liver. It is also evident from the OPD slip Ex.C4, on the advice of the doctor, she has taken three months medicines. It is also evident from the OPD slip Ex.C5, the doctor has again advised to take three months medicines but due to PCOD her weight has been regularly increasing. It is also evident from the OPD slip Ex.C6/Ex.R8 the wife of complainant has been diagnosed as suffering from PCOD (amenorrhea) and Morbid Obesity.

14.           On 13.04.2021 the request for pre approval cashless treatment was forwarded by the Amritdhara Hospital, Karnal to the OPs and same was denied by the OPs with reason that duration of ailment, height of the customer, indication of surgery is not clear, hence cashless cannot be considered, revert with documents for reimbursement.

15.           It is evident from insurance policy Ex.R5 that at the time of purchasing the policy, the weight of wife of complainant was 65Kgs and her height was 176” which is approximately 5.7 ft. It is also evident from the clarification letter Ex.C9 dated 14.04.2021 that her weight was 101kg and her BMI was 40.46. Hence, it has been proved on the record that at the time of purchasing the policy in question, the wife of complainant was not suffering from Obesity and this disease occurred after purchasing the policy in question. Hence, in view of the above the act of the OPs while denial of preauthorization request amounts to deficiency in service and unfair trade practice.

16.           In view of the above discussion, it would be justified if the complaint is dispose of with the direction to OPs to provide the cashless facility to the wife of complainant at the time of taking the treatment for abovementioned disease, as per sum insured. Order accordingly. No order as to costs. Parties concerned be communicated of the order accordingly and file be consigned to the record room.

Announced
Dated: 09.08.2022

    President,     

District Consumer Disputes                               

Redressal Commission, Karnal.

 

 

                      (Vineet Kaushik)          (Dr. Rekha Chaudhary)           

                          Member                           Member