Punjab

Ludhiana

CC/20/37

Anil Aggarwal - Complainant(s)

Versus

United India Insurance Co.Ltd - Opp.Party(s)

Shekhar Gupta Adv.

20 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:37 dated 24.01.2020.                                                 Date of decision: 20.07.2023.

 

1. Anil Aggarwal son of Sh. Ramesh Chander Aggarwal,
2. Palak Aggarwal aged 28 years D/o. Anil Aggarwal, both residents of House No.8374/1, Chuharpur Road, Durgapuri, Haibowal Kalan, Ludhiana.                                                                                                                                                                              ..…Complainants

                                                Versus

1. United India Insurance Co. Ltd., Savitri Complex, Dholewal Chowk, Ludhiana through its Divisional Manager.
2.  United India Insurance Co. Ltd., Plot No.19, Nungambakkam High Road, IV Lane, Chennai-600034 through its Managing Director/General Manager.
3. Sat Guru Partap Singh Hospital, Sherpur Chowk, Ludhiana through its Director.                                                                                                                                                                      …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. Shekhar Gupta, Advocate.

For OP1 and OP2          :         Sh. Rajeev Abhi, Advocate.

For OP3                         :         Sh. R.K. Bhandari, Advocate.     

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the complaint are that complainant No.1 purchased Medi-claim Cashless Policy from the opposite party No.1 and 2 bearing No.2010002818 P113569257 having validity from 22.01.2019 to 21.01.2020 by covering the complainant himself, his wife and his unmarried daughter i.e. complainant No.2. The complainant had deposited one time premium of Rs.25,000/- approximately with opposite parties on assurance that a the medical charges of hospitalization and tests will be borne by the Insurance Company.

                   The complainants stated that complainant No.2 Palak Aggarwal had a complaint of Lipoma in her right arm and she was advised operation by concerned doctor for which she was admitted in SPS Hospital, Sherpur Chowk, Ludhiana on 17.09.2019 vide UID No.716786. The opposite parties gave their consent for initial deposit of Rs.50,000/- with the hospital vide Misc. authorization letter dated 19.09.2019 but later on withdrew the said consent on wrong information of hospital authorities that complainant No.2 was admitted for Liposuction i.e. reduction of fat and no money was deposited by them with hospital. Operation was performed and the complainants had to pay Rs.1,36,169/- to the hospital besides the complainant had to incurred operation expenses, tests, MRI by depositing Rs.6000/-, Rs.6000/- on 04.09.2019 and Rs.4000/- on 13.09.2019 with Mayo Imaging & Diagnostic Centre, Ludhiana to be payable by the opposite parties but the insurance company had not paid the same. Complainant visited office of opposite party No1. Number of times with request to release the entire amount of operation, various tests and MRI but they flatly refused to pay the same. A legal notice dated 24.10.2019 was issued to the opposite parties to which a fake reply dated 01.12.2019 was sent by the opposite parties by stating that complainant No.2 was admitted for Lipo Suction for reduction of fat which is a cosmetic procedure. However, it was made clear to the opposite parties that the treatment of complainant No.2 was on her right arm and not on both the arms and medical certificates/ reports were also provided to them but they refused to make the payment to the complainant which amounts to deficiency in service on the part of the opposite parties due to which the complainants suffered mental tension, harassment. In the end, the complainants prayed for issuing direction to pay an amount of Rs.1,52,169/- as treatment expenses etc. and to pay Rs.1,00,000/- as compensation besides Rs.15,000/- as litigation expenses.

2.                Upon notice, opposite party No.1 and 2 appeared and filed joint  written statement by taking preliminary objections that the complaint is not maintainable, the complainants are estopped by their own act and conduct from filing the complaint, the complainants have not come to court with clean hands and have suppressed the material facts, this Commission has no jurisdiction to entertain and try the complaint etc. Opposite party No.1 and 2 stated that  immediately on the receipt of the claim it was duly registered, entertained and processed. The complainants had obtained Family Medicare Policy 2014 bearing No.2010002818P113569257 valid from 22.01.2019 to 21.01.2020. According to opposite party No.1 and 2 the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. Nothing can be added or subtracted out of it. The insurance policy is issued on the basis of utmost good faith. It is one of the exclusion clause No.4.6 and 4.9 of the policy which reads as under:-

"The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:-

Exclusion clause 4.6.

a) Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident.

b) Vaccination or inoculation of any kind unless it is post animal bite, change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight, etc.

c) Plastic surgery other than as may be necessitated due to an accident or as a part of any illness.

Exclusion clause 4.9.

 

• Convalescence, general debility; run-down condition or rest cure, obesity treatment, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxication drugs/alcohol."

Opposite party No.1 and 2 stated that the complainants had lodged a cashless request for reimbursement of medical expenses incurred on the treatment of Palak Aggarwal, complainant No.2 from in Satguru Partap Singh Hospital, Ludhiana from 21.9.2019 to 23.9.2019 with diagnosis of - ? Lipoma Right arm (Post traumatic (?)) on account of post traumatic swelling right arm since last six months. Lipoma means: charbee kee raseelee). She was operated for Lepectomy Right Arm on 21.09.2019 as per the discharge summary. The hospital authorities have raised a cashless authorization of Rs.50,000/- vide cashless authorization letter with M/s Raksha Health Insurance TPA Pvt. Ltd. a third party administrator appointed under the policy in question with provisional diagnosis, of beginning lipomatous neoplasam (unspecified). After the receipt of cashless authorization letter from Satguru Partap Singh Hospital dated 16.09.2019 the same was approved for Rs.50,000/- vide cashless authorization letter dated 19.09.2019 with specific instructions that the same was valid for admission up to 17.09.2019. The complainant No.2 was admitted on 21.09.2019 and was discharged on 23.09.2019 and as such said cashless authorization letter automatically stands withdrawn. M/s Raksha Health Insurance TPA Pvt. Ltd. has raised a cashless query letter dated 17.09.2019, 22.09.2019, whereby the hospital authorities were called upon to provide OT notes i.e.

• Provide a letter from the treating doctor stating under which circumstances injury took place (hospital).
• Send PAN card of Sh Anil Aggarwal (hospital).
• Provide positive investigation report in support of diagnosis (hospital).

• Provide size of lipoma with supportive investigation report (hospital).
•  Provide the basis by which hospital decided that lipoma is complex in this case (hospital).
•  Provide detail narration of injury with date, time and place resulting lipoma with all supportive treatment record (hospital).

According to opposite party No.1 and 2 the hospital authorities have failed to provide all the necessary documents demanded vide aforesaid query letters. On the basis of the documents and information available M/s. Raksha Health Insurance TPA Pvt. Ltd. vide its letter dated 23.09.2019 has declined the cashless authorization request vide denial of cashless access on account of the reasons reproduced as under:-

• Discrepancy in the information provided by the insured and the hospital. As per the submitted documents it was mentioned that the case is of traumatic lipoma, but it is a case of liposuction for reduction of fat i.e. cosmetic procedure. Due to discrepancy and the non-coverage of the procedure, cashless facility is denied and earlier issued letter stands cancelled.
•  This is not the denial of treatment but only the denial of credit facility. Hospital is requested to collect the bill amount from the patient. Policy holder may submit the claim after discharge with complete set of documents for a possible review. The reimbursement claim will be processed subject to admissibility as per policy terms and conditions.

M/s. Raksha Health Insurance TPA Pvt. Ltd. also clearly stated in the denial of cashless access dated 23.09.2019 that the earlier issued authorization letter stands cancelled. Further, M/s. Raksha Health Insurance TPA Pvt. Ltd. vide their letter dated 30.11.2019 had informed the answering respondents that the claim is not tenable on account of the following reasons and as such the answering respondent should intimate the repudiation of the cashless authorization to the complainants:-

Observation and Opinion

Patient admitted with ?lipoma (swelling on rt arm) and underwent liposuction for reduction of fat which is a is a cosmetic procedure. 2 As per investigation, patient is obese and had over fat on shoulders. Thus patient underwent liposuction for removal of excess fat from shoulder and it was not traumatic swelling. Thus cosmetic surgery falls under permanent exclusion of the policy. Hence claim recommended to be non-payable as per clause 4.6.

a) Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident.

b) Vaccination or inoculation of any kind unless it is post animal bite, change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight, etc.

c) Plastic surgery other than as may be necessitated due to an accident or as a part of any illness.

Opposite party No.1 and further stated that after the receipt of the letter of M/s.Raksha Health Insurance TPA Pvt. Ltd. and after scrutinizing the documents placed in the claim file and after due application of mind by the officials of the respondents the claim of the complainants for the treatment of complainant No.2 was repudiated vide letter dated 26.10.2020 and 06.11.2020 on the ground that the claim is not tenable and that the claim falls under the permanent exclusion clause No.4.6 and 4.9 of the policy since as per the submitted documents it was mentioned that the case is of TRAUMATIC LIPOMA, but it is a case of LIPOSUCTION for reduction of fat i.e. cosmetic procedure and due to discrepancies referred above. The grounds of rejection of cashless authorization of the complainants for treatment of complainant No.2 are legal, valid, enforceable and are in accordance with the terms and conditions of the policy. As per opposite party No.1 and 2 no regular claim after discharge from the hospital has been lodged by the complainants for reimbursement of medical expenses incurred on the treatment of complainant No.2 Palak Aggarwal. 

                   On merits, opposite party No.1 and 2 reiterated the crux of averments made in the preliminary objections. Opposite party No.1 and 2 have denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                Opposite party No.3 filed separate written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability, lack of cause of action, suppression of material facts by the complainants, the compliant bad for mis-joinder of necessary parties.  Opposite party No.3 denied any deficiency in service on its part by claiming that it has been unnecessarily dragged into false complaint by the complainants.

                   On merits, opposite party No.3 admitted the factum of admission and treatment of complainant No.2 Palak Aggarwal given by their hospital. Before admission and operation, the complainants told that they are covered vide policy in question and nature of the policy is cashless. Opposite party No.3 further stated that after the operation of complainant No.1, it contacted opposite party No.1 and 2 for payment of hospital charges/operation cost but they denied the payment despite the fact that no wrong information was provided by opposite party No.3 to opposite party No.1 and 2. Opposite party No.3 further stated that due to denial of payment by opposite party No.1 and 2, it requested the complainant to pay the hospital charges and operation costs which they paid and now no matter in issue is between the complainants and opposite party No.1 and 2. Moreover, the complainants have no complaint against opposite party No.3 on account of any deficiency in service or negligence in treatment provided to complainant No.2 and opposite party No.3 is not liable either for payment of any amount or for any kind of act as complained in the complaint.

                   Opposite party No.3 further stated that as per the case history of complainant No.2 and course of treatment adopted by opposite party No.3, complainant No.2 Palak Aggarwal was got admitted in their hospital on 21.09.2020 and gave history of fall at home x6 months ago and complaint of swelling in right arm since then. Clinically gross discrepancy in grith/diameter of right and left arms was present at the time of examination. MRI reported excessive adipose tissue in right arm as compared to left arm. Plan to surgically exercise under GA (General Anesthesia) and was removed by Liposuction to prevent excessive scarring in a young female over right arm to correct the discrepancy between the two arms. Lipectomy was done via liposuction under GA. Patient discharged on 23.09.2020 in satisfactory condition. As per opposite party No.3 no wrong information was provided  to opposite party No.1 and 2 while obtaining their consent for operation and their assurance for payment. Further, opposite party No.3 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

4.                In support of their claim, complainant No.1 Sh. Anil Aggarwal tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy insurance policy, Ex. C2 is the copy of cashless authorization letter dated 19.09.2019,  Ex. C3 is the copy of denial of cashes access dated 23.09.2019, Ex. C4 is the copy of cash bill OPD, Ex. C5 is the copy of in-patient bill, Ex. C5/A is the copy of advance receipt, Ex. C6 is the copy of discharge summary dated 23.09.2019, Ex. C7 is the copy of legal notice dated 24.10.2019, Ex. C8 is the copy of reply to legal notice dated 01.11.2019 and closed the evidence.

5.                On the other hand, counsel for opposite party No.1 and 2 tendered affidavit Ex. RA of Sh. Inderjit Singh, Divisional Manager, United India Insurance Co. Ltd., DO-IV, Savitri Complex, Ludhiana as well as affidavit ex. RB  of Sh. Suneet Chopra of M/s. Raksha Health Insurance TPA Pvt. Ltd., 2^nd Floor, SCO 181, Sector 7-C, Chandigarh along with documents Ex. R1 is the copy of insurance documents, Ex. R2 is the copy of cashless authorization letter dated 19.09.2019, Ex. R3 is the copy of cashless query letter dated 17.09.2019, Ex. R4 is the copy of cashless authorization letter dated 19.09.2019, Ex. R5 is the copy of cashes query letter dated 17.09.2019, Ex. R6 is the copy of cashless query letter dated 22.09.2019, Ex. R7 is the copy of denial of cashless access dated 23.02.2019, Ex. R8 is the copy of discharge summary dated 23.09.2019, Ex. R9 is the copy of in-patient history and physical record etc., Ex. R10 is the copy of recommendation for non-payable of TPA, Ex. R11 is the copy of repudiation letter dated 26.10.2020, Ex. R12 is the copy of postal receipt, Ex. R13 is the copy of dispatch register, Ex. R14 is the copy of letter dated 06.11.2020 of insurance company to the complainants, Ex. R15 is the copy of postal receipt, Ex. R16 is the copy of dispatch register and closed the evidence.

                   The counsel for opposite party No.3 tendered affidavit Ex. RA of Sh. Jatinder Arora, C.E.O. of opposite party No.3 along with documents Ex. R1 is the copy of in-patient bill summary, Ex. Is the copy of cash bi (OPD), Ex. R3 is the copy of discharge summary of complainant No.2 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written replies along with affidavits and documents produced on record by the parties.

7.                Ms. Palak Aggarwal, complainant No.2, daughter of Sh. Anil Aggasrwal, complainant No.1 who is the holder of Family Medicare Policy 2014 Ex. C1=R1 having a validity from period 22.01.2019 to 21.01.2020, was admitted in opposite party No.3 hospital on 19.09.2019 with history of Post Traumatic Swelling Right Arm since last 6 months. She was clinically evaluated and thorough investigation was conducted and thereafter, she underwent Lipectomy Right Arm on 21.09.2019. She was discharged on 23.09.2019 vide discharge summary Ex. C6=R8. During the course of her admission, pre-authorization amount of Rs.50,000/- was approved by opposite party No.1 and 2 vide letter dated 19.09.2019 but later on the same was revoked/cancelled on 23.09.2019 vide letter Ex. R7 on the premise that it is case of Lipo Suction for reduction of fat and it is a cosmetic procedure . Complainant No.1 incurred an amount of Rs.1,36,169/- on the treatment of complainant No.2 with opposite party No.3. The reimbursement claim was also denied on 26.10.2019 vide repudiation letter Ex. R11 whereby opposite party No.1 and 2 invoked exclusion clause 4.6 of the policy. Even on 06.11.2020 vide letter Ex. R14, opposite party No.1 and 2 declined to pay the amount and additionally invoked the clause 4.9 of the policy.

8.                The first and foremost point of consideration arises before this Commission as whether it was a case of Traumatic Lipectomy or a case of Lipo Suction, a cosmetic procedure?

9.                Ex. R9 is the in-patient history recorded by the concerned doctor at the time of admission of complainant No.2 wherein it has been observed that there is a swelling of right arm for the last 6 months which is due to fall at home. This fact has also been mentioned in the discharge summary Ex. C6=R8 as well. In its written statement, opposite party No.3 hospital has chronologically elaborated the diagnosis, treatment and procedure done at the hospital. It has been categorically8 stated that Lipoctomy was done via Lipo suction under GA and have specifically denied it being a cosmetic surgery. On the other hand, opposite party No.1 and 2 have not examined any expert witness or placed on record any medical evidence to substantiate their assertion that the procedure adopted by opposite party No.3 hospital was for cosmetic purpose only. The opinion of opposite party No.1 and 2 appears to have been based on conjectures and surmises.

10.              So in these circumstances, opposite party No.1 and 2 were not justified in invoking cause 4.6 and 4.9 of the policy and revoking/cancelling the pre-authorization approval of Rs.50,00/- and thereafter, repudiating the claim of the complainants. In the facts and circumstances of the case, it would be just and appropriate if opposite party No.1 and 2 are directed to settle and reimburse the claim of the complainants in strictly in accordance to the terms and conditions of the policy along with composite costs of Rs.10,000/-.

11.              As a sequel of above discussion, the complaint is partly allowed with direction to opposite party No.1 and 2 to settle and reimburse the claim of the complainants strictly in accordance to the terms and conditions of the policy within 30 days from the date of receipt of copy of order. Opposite party No.1 and 2 shall further pay a composite costs of Rs.10,000/- (Rupees Ten Thousand ony0 to the complainant. Compliance of the order be made within 30 day8s from the date of receipt of copy of order. However, the complaint as against opposite party No.3 is hereby dismissed. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:20.07.2023.

Gobind Ram.

 

 

Anil Aggarwal Vs United India Insurance Co. Ltd.                   CC/20/37

Present:       Sh. Shekhar Gupta, Advocate for complainants.

                   Sh. Rajeev Abhi, Advocate for OP1 and OP2.

                   Sh. R.K. Bhandari, Advocate for OP3.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to opposite party No.1 and 2 to settle and reimburse the claim of the complainants strictly in accordance to the terms and conditions of the policy within 30 days from the date of receipt of copy of order. Opposite party No.1 and 2 shall further pay a composite costs of Rs.10,000/- (Rupees Ten Thousand ony0 to the complainant. Compliance of the order be made within 30 day8s from the date of receipt of copy of order. However, the complaint as against opposite party No.3 is hereby dismissed. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:20.07.2023.

Gobind Ram.