ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT.

1.     This is the Complaint filed by the Complainant under Section 35 of Consumer Protection Act 2019, against the Opposite Party (herein referred in short as O.P) alleging the deficiency in service in not honouring the insurance claim in respect of the hospital expenses incurred regarding the treatment given to the wife of the complainant and the claim of Rs.7,77,000/- with interest at 18% per annum  contending that the bill amount the interest paid on the loan suffering mental agony for refusing to provide cash less facility, payment of interest on the pledged gold ornaments to raise loan to pay the hospital charges, the cost of legal expenses and for other reliefs as the Commission deems fit.

2.     The brief facts of the complaint are that; the complainant obtained insurance with OP-1 under the scheme Manipal Cigna Pro Health insurance by paying Rs.33,888/- as annual premium from 31.05.2017 onwards and has been renewing the same.  The said policy covers his wife Sowmya GR and his mother Mangalamma to the extent of Rs.10,00,000/- each (sum assured). It is contended that his wife Sowmya GR was having some breathing difficulty and was taken to Shankar Cardiac Center on 06.04.2021 wherein several tests were conducted and she was suggested to go to Apollo hospital heart institute at Bannerghatta Road, Bangalore.  On 09.04.2021 she was examined by one Dr. Lakshmikanth in the said hospital and advised to implant pace maker for the heart function.  The cost of the operation was intimated as approximately Rs.4,50,000/- . Since the medical policy was in force till 2.5.2021 he intimated the hospital authorities for cash less claim with OP-2. OP2 by sending an email requested the complainant/hospital to furnish the past medical/surgical history of the patient with relevant first and subsequent consultation paper on 10.04.2021. The same was provided to him and after going through the same on 13.04.2021 OP gave a consent for pre-approval authorization valid till 02.05.2021. It was also mentioned that the total bill amount of Rs.4,50,000/-, other deduction Rs.3,60,000/-, authorized amount Rs.90,000/-, amount to be paid by insured upon receipt of final bill and discharge summary Rs.3,60,000/-.

3.     The complainant got confirmed the above authorization by making calls to the OP and the OP also assured that further amount would be paid after the final bill. Hence he got admitted his wife to the hospital on 18.04.2021 for implanting pace maker. The surgery was done on 19.04.2021 successfully and she was discharged on 21.04.2021. On the said date, he was shocked to receive a mail from the OP that the cashless facility has been rejected. 

4.     He belongs to a middle class family and was not in a position to pay a that much of amount in cash. He was put to lot of mental torture mental agony and financial hardship he was compelled to borrow loan by pledging the gold ornaments of his sister in law.  Had the OP informed that the insurance amount is not payable, and did not approve the pre-approval for admission, and had they rejected his request he would not have ventured to get the operation done in respect of his wife’s problem. He would have postponed the operation in order to arrange the finance.  The act of insurer amounts to deficiency in service in rejecting the preapproval after giving approval of the same and that too after the surgery.   He had to pay Rs.3,92,000/- to the hospital regarding the pace maker charges and the surgery and other charges. The same is liable to be reimbursed by the OP Since OP did not reimburse the claim and as he had to obtain loan by pledging the gold ornaments by paying interest and had to suffer mental agony and to obtain loan and refusing the cashless entry without default on the part of the complainant amounts to deficiency in service and unfair trade practice. A legal notice was also issued to the OPs. After receipt of the same, they informed that the matter will be looked and the decision would be intimated. Inspite of it, they have not replied informing their decision and did not pay the amount. Hence there is deficiency in service and unfair trade practice on the part of the OPs and prayed to allot the complaint.

5.     Upon the service of notice, OP-1  appeared before the commission  through its advocate and filed the version.  Whereas, OP-2 though served with notice, remained absent and hence placed exparte. OP.2 is a 3^rd party administrator of the insurance claim made against OP-1. 

6.     In the version filed by OP-1 it is contended that, the complainant obtained insurance policy from it for a period of one year and policy issued date was 02.06.2021 and the sum insured is Rs.10,00,000/- each for the complainant for his wife Sowmy and for his mother Mangalamma. It has also admitted that it received the request for pre-authorization form for a cash less claim along with medical documents from the Apollo hospital heart institute, wherein, Smt. Sowmya underwent heart surgery for pacemaker. The cash less claim was for an estimate for Rs.3,02,694/- On perusing the discharge summary dated 21.04.2021, the surgery on account congenital complete heart block.  As per the policy terms and conditions for such a type of surgery, a waiting period of 24 months is applicable. As per section V(3) of the terms and conditions specified disease/procedure weighting period–Code–Excl.02:

“a. Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.

f. List of specific diseases/procedures:

i. Cataract,

ii. Hysterectomy for Menorrhagia or Fibromyoma or prolapse of Uterus unless necessitated by malignancy myomectomy for fibroids.

iii. Knee Replacement Surgery  (other than cused by an Accident), Noninfectiuous Arthritis, Gout, Rheumatism, Oestoarthritis and Osteoposrosis.

Joint Replacement Surgery (other than cause by Accident), prolapse of Intervertibral discs (other than caused by Accident), all Vertibrae Disorders, including but not limited to Spondylitis, Spondylosis, Spondylolisthesis, Congenital Internal,

iv. Varicose Veins and Varicose Ulcers,

v. Stones in the urinary uro-genital and biliary systems incuding calculus diseases.

vi. Benign Prostate Hypertophy, all types of Hydrocele,

vii. Fissure, Fistula in anus, piles, all types of Hernia, Pilonidal sinus,

viii.  Chronic Suppurative Otitis Media (CSOM), Deviated Nasal Septum, Sinusitis and related disorders, Surgery on tonsils/Adenoids, Tympanoplasty and any other benign ear, nose and throat disorder or surgery.

ix. Gastric and duodenal ulcer, any type of Cysts/Nodules/Polyps/internal tumors/skin tumors, and any type of Breast lumps (unless Malignant,

Polycystic Ovarian Diseases,

x. Any surgery of the genito-urinary system unless necessitated by malignancy.”

7.     After the complainant requested for cashless entry, it obtained the relevant medical papers from the Apollo hospital on 10.04.2021 wherein complainant has been diagnosed having congenital heart disease. After a thorough scrutiny of the documents, it came to the knowledge of the Op that the heart surgery, permanent pace maker implantation fell under two years waiting period and hence claim was rejected vide letter dated 21.04.2021. Further the complainant has not submitted the document for a possible reimbursement of the claim subject to the policy terms and conditions. Hence this claim through this complaint, is premature and deserves to be dismissed. There is no cause of action for the complainant to file the complaint and hence prayed to dismiss the complaint. It has also denied all the allegations made against it in each and every para of the complaint and prayed the forum to dismiss the same.

8.     In order to prove the case, both parties have filed their affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1) Whether the complainant has proved deficiency in service on the part of the Opposite Parties?

2) Whether the complainant is entitled to the relief prayed for in the complaint?

9.     Our answers to the above points are:-

POINT NO.1:            In the Affirmative

POINT NO.2:            Partly in the affirmative.

                                For the following:

REASONS

POINT No.1:-

10.     Perused the complaint, version, affidavit evidence and the documents produced by respective parties. It is a n admitted fact by the OP.1 that the complainant obtained insurance for himself, for his wife Sowmya and his mother Mangalamma for an insured sum of Rs.10 lakhs each. Ex P1 is the insurence policy in this regard which OP do not dispute. It is also not in dispute that the OP gave permission for cash less entry as per Ex.P6. This is on 13.04.2021.  The procedure / treatment is implantation of Titanium  fixture. The period of policy is mentioned as 02.06.2020 to 01.06.2021 as per the discharge summary she was operated for pace maker on 19.04.2021 and discharged on 21.04.2021 and permanent pace maker implantation was done on 19.04.2021. Ex  P8 is the crucial letter written by OP-1 to the administrator /medical superintendent of Apollo hospital Bangalore regarding cashless claim for patient Sowmya it is mentioned that “we regreat to inform you that we are unable to extend the cash less facility for this scheme due to the following reasons.  On perusing the same, no reasons have been mentioned in the said document at Ex.P8. Receipt of legal notice is admitted by the OP.

11.   Only in the version filed OP, has taken a defense that the waiting period of 24 months from the date of issuance of policy is not yet over to cover the treatment of congenital internal. Nowhere in the letter written on 21.04.2021 refusing the cash less entry after giving approval, the said fact of 24 months period not covered to provide the treatment is mentioned.  It is to be seen here that, on perusing the OP.1 the insurance produced by the complainant, the complainant had obtained the insurance of similar nature from Max Bupa Health Insurance company on 31.5.2017 and it is mentioned therein that 3 years waiting period has been waived. That means the complainant had obtained the insurance for himself , for his wife and for his mother in the year 2017 itself and further the waiting period is waived.  This leads to the presumption the present insurance policy is a continuation of the earlier policy. Otherwise the information regarding previous insurance policy would not have been mentioned.   Hence the contention of the OP that the reimbursement claim and the congenital internal has taken place within 24 months after issuance the insurance policy as a reason to deny the benefits under the policy is cannot be accepted. 

12.   If the above is true then what made OP-1 at the 1^st instance on 13.04.2021 to give consent/authorization for cashless facility /treatment with the hospital has not been explained.  If the contention of OP-1 that the period has not been elapsed, then OP-1 would have stated so in the letter dated 13.04.2021 and would have mentioned the same in the said letter and would have rejected then and there approval for cash less treatment.  Hence for the above reasons we answer POINT NO.1 IN THE AFFIRMATIVE holding that the repudiation and rejection of reimbursement of the hospital expenses insured by the complainant on behalf of his wife amounts to deficiency in service and further unfair trade practice when Rs.33,880/- was received towards the insurance premium for the complainant, his wife and his mother.

POINT NO.2

13.   Complainant has sought Rs.7,77000/- under all heads as compensation to be paid by the OP-1 OP has not at all stated anything regarding the hospital expenses which the complainant incurred on behalf of his wife’s treatment. In the final bill given by the hospital which is marked as  Ex.P9 the total cost is Rs.4,05,250/- a sum of Rs.10,000/- has been given as discount and complainant has to pay Rs.3,92,550/- towards the said treatment for his wife.  OP at the time of approving for cash less treatment has obtained the estimate of total bills for a sum of Rs.4,50,000/. It is also mentioned that total authorized amount for cash less amount of Rs.90,000/- and the amount to be paid by the insured would determine upon receipt of final bill and discharge summary. When this is taken into consideration, it becomes clear that the charge for the treatment has to be reimbursed by the OPs.  Hence the complainant is entitle for reimbursement of Rs.3,92,550/- paid to the Apollo hospital.  Complainant is also entitle for interest at 12% per annum on the said amount from 21.04.2021 the date of discharge from the hospital as the said amount ought to have been paid to the Apollo hospital at the time to discharge of the wife of the complainant. 

14.   Complainant has also sought Rs.1,00,000/- as interest on the borrowed amount stating that the gold ornaments belonging to wife’s sister was pledged with the credit co-operative society. He has produced two receipts dated 22.04.2021 pledging 2 gold chains of different weight to raise Rs.1,02.900/- and Rs.1,35,000/- in order to pay the hospital charges besides he has also paid credit card bills to the extent of Rs.2,00,000/- which he had to repay the monthly installments with agreed interest. By considering all the hassles and inconvenience and hardship caused to the complainant, we direct OPs to pay a sum of Rs.50,000/- towards the interest to be paid on account the above borrowings and further Rs.50,000/- towards damages for causing mental agony and physical hardship and further Rs.20,000/- litigation expenses and other expenses, which in our view is just  and reasonable. Hence we answer POINT NO.2 PARTLY IN THE AFFIRMATIVE and pass the following;

ORDER

1. Complaint is allowed in part with cost.
2. OP-1 and 2 are jointly and severally are hereby directed to pay Rs.3,92,550/- to the Complainant along with interest at 12% per annum on the said amount from 21.04.2021 the date of discharge from the hospital till payment of the entire amount.
3. OP-1 and 2 further directed to pay Rs.50,000/- towards the interest to be paid on account the above borrowings and further Rs.50,000/- towards damages for causing mental agony and physical hardship and further Rs.20,000/- litigation expenses.
4. OPs are directed comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
5. Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order failing which the same will be weeded out/destroyed.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 18^TH DAY OF JUNE 2022)

MEMBER                 MEMBER                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Copy of the Health Insurance Policy issued by OP-1

Ex P2: Copy of the  documents.

Ex. P3: Copy of the request for cashless facility

Ex P4: Copy of the Application form.

Ex P5: Certificate issued by Dr.Lakshmikanth

Ex P6: Copy of the authorization letter by OP.

Ex P7: Copy of the Discharge summary.

Ex P8: Copy of the letter written by OP

Ex P9: Copy of the final bill issued by Apollo Hospital.

Ex P10: Email correspondences/legal notice.

Ex P11: Copy of the legal notice.

Ex P12: Copy of the delivery notice.

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Sri Purushotham. N. Authorized representative of OPO company

Copies of Documents produced on behalf of Opposite Party/s

- Nil –

MEMBER                 MEMBER               PRESIDENT

RAK*