CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

Udyog Sadan, C – 22 & 23, Institutional Area

(Behind Qutub Hotel)

New Delhi – 110016

Case No.83/2020

Apoorva Vashishta

D/o Mr. Narender Vashisthta.

R/o E-393, G.F., G.K-II

New Delhi.                                                           …..COMPLAINANT

Vs.

1. The New India Assurance Company Ltd.

(Through its Divisional Manager)

89, Hemkunt Chambers, 2^nd Floor

Office-202-204, Nehru Place,

New Delhi-19

2. Health Insurance TPA of India Ltd.

(Through its Managing Director)

NBCC Centre, Office No.301, Maa Anand Mai Marg

Okhla Industrial Area, Phase-I

New Delhi-11000                                                    …..RESPONDENTS

                                                                                       Date of Institution-   23.02.2024

   Date of Order- 19.07.2024

                                                O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on the part of OP in making part payment of the claim of the complaint.

2. The complainant’s father had obtained a medi-claim policy bearing No.31250034182800000913 for himself and his family members from OP1 since 2004-05 and also earned no claim bonus. This is the first claim filed by the complainant with OP.

3. On 16.02.2019, the complainant felt a sharp lower abdominal pain. Since the complainant was attending a lecture in a Medical College Hospital & Research Centre at Bharati Vidyapeeth University, she was referred to Dr. Priscilla Joshi.  The complainant was found to have an oval mass on the right adnexal region extending up to midline which appeared to be posterior acoustic enhancement, which is called endometriotic cyst.

4. On 18.02.2019, the complainant was examined by Doctor Alka  Kriplani at Paras Hospital and was recommended various tests.  It was confirmed through an investigation that she has an ovarian cyst measuring 9*5.230*0.6 cm, requiring an immediate surgery.  The complainant was immediately admitted and OPs were intimated for processing cashless approval.  As the surgery was urgent and the TPA approval was not received by 3.00 p.m. on 18.02.2019, the complainant deposited Rs.25,000/- with the hospital.  OP-2 on behalf of OP-1 issued the preauthorisation approval  letter bearing reference No.181200215401010201 dated 19.02.2019 for Rs.1,00,000/- despite receipt of estimated bill for surgery to the  tune of Rs.1,37,182/-. 

5. The complainant was discharged on 19.03.2019.  It is stated that the hospital submitted a bill of Rs.1,41,075/-, but OP-2 paid Rs.89,939/-. The complainant had to pay the remaining amount of Rs.51,136/-. The complainant incurred a post operation expense of Rs.2,630/-.  The complainant prays for reimbursement of Rs.53,766/- along with interest @ 12%, and Rs.72,000/- towards harassment and legal expenses.

6. OP-1 in its reply states that a cashless claim was received from the complainant’s hospital.  A pre-authorization amount on the basis of provisional diagnosis of right ovarian torsion was requested and approval was given for a sum of Rs.1,00,000/- which was 80%  of the estimated amount.  This pre-authorisation amount was increased up to Rs.1,28,643/- subject to furnishing of final bill and discharge summary as per tariff.  OP-1 submits that OP-2 stated in the final approval letter that  charge for non-medical items can be collected from the patient which would be deducted at the time of final settlement.  Hence, the deduction was as per tariff plan.

7. OP-1 states that as per OP-2,  the total billed amount was Rs.1,28,644/- out of which an amount of Rs.38,705/- was deducted towards discount and advance taken by the hospital.  Hence, OP-2 on behalf of OP-1 approved the claim for the amount of Rs.89,939/- and the same was duly reimbursed to hospital.

8. It is further stated that the complainant had paid an amount of Rs.21,256/- directly to the hospital without waiting for approval. Hence, this amount was not raised by the hospital. Accordingly, the hospital had requested for Rs.1,04,618/-.  Some of the bills for Rs.2,630/- were not received by the OP-2 for the reimbursement, hence it was deducted.

9. Notice was issued to OP-2 who were duly served on 14.09.2020.  However, no reply was filed by OP-2.

10. Complainant in its rejoinder submitted that OP had arbitrarily deducted the medical bill payment. The deductions include:“Tegaderm” which is a transparent medical dressings used to cover and protect wounds/catheter sites, other consumable items which are directly associated with the treatment of the complainant such as Gillette presto, hand rub, visi bath bed bath, clave connector, gloves examination, band aid round, bandage roll, ECG Electrode, vaccu suction set, sponge large, camera cover, trolley cover foley catheter, laparoscopic sealer blunt tip, dietician visits and consultancy of histopath/pericardial fluid for malignant cells on account of non-receipt of report from the hospital.

11. The Complainant  has filed the evidence by way of affidavit and exhibited the following documents:

1. Copy of Identity Card is exhibited as ExCw-1/A.
2. Copy of Medi-Claim Policy and pre-authorization letter dated 19.0.2019 is exhibited as ExCw-1/B & C.
3. Copy of bill No. OCGG/19/207466 along with clinical test report is exhibited as ExCw-1/D-1 to D-4.
4. Copy of receipt of amount deposited is exhibited as ExCw-1/-E
5. Copy of estimated expenditure and pre-authorization approval letter is exhibited as ExCw-1/F-1 & F-2.
6. Copy of bills are exhibited as ExCw-1/G-1 to G-7.
7. Copy of emails are exhibited as ExCw-1/-H-1 & H-2.
8. Copy of legal notice and its reply is exhibited as ExCw-1/I-1 to I-4.

12. OP-1 has filed evidence by way of affidavit of Mr. Pradeep, Divisional Manager and has relied on claim processing sheet as annexure-A.  However, no such sheet has been placed on record.

13. The Commission has considered the pleadings and material on record.  Admittedly, the complainant is covered under insurance namely New India Floater medi-claim for sum insured of Rs.5,00,000/- in the disputed period.  The complainant was hospitalised on 18.02.2019 and was discharged on 19.02.2019.

14. The preauthorisation approval letter approved an amount of Rs.1,00,000/-  on 19.02.2019 on an estimated  amount of Rs.1,26,282/- sent by the treating hospital.  There is another pre-authorisation approval letter dated 19.02.2019 where the amount has been enhanced to Rs.1,28,644/-. The hospital bills dated 19.02.2019 amounts to Rs.1,28,644/-.  The pharmacy bill dated 19.02.2019 amounts to Rs.888/-.  Follow up consultation receipt amounting to Rs.1000/- each dated 22.03.2019 and 23.0.2019 and biopsy report bill dated 01.03.2019 amounting to Rs.210/- has been placed on record.

15. The first pre-authorisation letter dated 19.02.2019 shows that Rs.1,00,000/- was approved on the authorisation request forwarded by the hospital on 18.02.2019. The hospital had sent a request of Rs.1,26,283/- for double bed occupancy and Rs.1,37,182/- for single bed occupancy.

16.  The second pre-authorisation letter dated 19.02.2019 shows that an amount of Rs.1,28,600/- was approved on the authorisation request forwarded by the hospital on 19.02.2019. 

17. OP-1 in its reply to legal notice has explained the payment and deductions as follows:
18.  
19.  

Reason (deducted amount)

-1815/- Lab reports not attached (pericardial fluid analysis & histopath report).38/- razor, 175/- handrub, 359/- wet towel, 2/-swab, 4/-band aid, 30/- face mask, 30/- surgeon’scap, 96/-apron, 364/- sponge, 32/- jar, 127/- handrub, 220/- urobag, 75/- camera cover, 130/- trolley cover, 390/- abd drain kit, 50/- gloves.

21,256/- paid by patient.

• 48/- others, 600/- history assessment.

……

It is to be noted that we had not received any claim from the insured related to the deducted amount of Rs.21,256/- in reimbursement.”

18. The OPD prescription indicates that the patient was experiencing excruciating pain. She was admitted and paid an advance of Rs. 24,026/-. It is acknowledged that OP has paid Rs. 89,939/- to the hospital for the complainant’s bill, despite authorization for Rs. 1,28,600/- as per letter dated 19.02.2019. OP-1 in its submissions before the Commission mentions that Rs. 38,705/- was deducted towards the advance and a discount was provided by the hospital. The deductions are explained in the legal notice. It is difficult to understand the reasons for OP’s refusal to reimburse medical consumables such as hand rub, sponges, and gloves. Moreover, there was no justification for penalizing the complainant for the hospital's failure to submit lab reports.  Additionally, OP has not provided any explanation as to the reasons for not reimbursing the advance paid by the complainant, who was in severe pain and needed immediate admission.

19. Hence we find OP-1 guilty of deficiency in service and unfair trade practice in non-reimbursement of the hospitalisation expenses of the complainant and direct it to pay-

1. Rs.41,803/-{(1,28,644-89,939)+888+2000+210} with 9% interest from date of authorisation i.e. 19.2.2019 till realisation.
2. Rs.5,000/- towards compensation
3. Rs.5,000/- towards litigation.

20. Order to be uploaded and complied with within 30 days.  File to be consigned to record room.