CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/304/17

          Date of Institution:-    02.06.2017

          Order Reserved on:- 03.05.2024

          Date of Decision:-      25.09.2024

IN THE MATTER OF:

Mrs.Anita Singhal

W/o Mr. Ashok Singhal

R/o G-39, SFS Flats, Saket,

New Delhi     

.….. Complainant No.1

Mr. Ashok Singhal

S/o Late Shri O.P. Singhal

R/o. G-39, SFS Flats,

New Delhi

                                                                         ……Complainant No.2

VERSUS

United India Insurance Company Ltd.

24, Whites Road

Chennai – 600014

Also at:

46, Community Center

BasantLok, VasantVihar,

South West Delhi,

New Delhi - 110057

          …..Opposite Party No.1

EMEDITEK

Plot No.577, UdyogVihar,

Phase-V Gurgaon

Haryana – 122016

…..Opposite Party No.2

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations thatthey have been insured under the Individual Health Policy-Gold for a sum assured Rs.5 lakh each with OP since 29.11.2000. The complainant no.1 is the owner of the policy which also covers complainant no.2. The policy is valid from 05.12.2016-04.12.2017. They have been continuously taking the policy from the OP since 2000.On 28.10.2016, the complainant no.2 was under treatment for urinary tract infection at Max Smart Super Speciality Hospital, New Delhi under Dr.AnupamBhargavwho advised admission to Hospital. The admission department of the hospital got in touch with OP-2 and submitted an estimate and prior approval of the treatment with an estimate of Rs.20,000/- was given by OP-2. On 01.11.2016, the complainant no.2 raised a claim which was rejected by OP-2 under exclusion clause 4.11 of the policy. The rejection is wrong as it is done without considering the letter dated 28.10.2016 issued by TPA. On 15.11.2016, complainant no.2 has raised a claim of Rs.75,045/- towards the treatment of Prostate Cancer as he remained hospitalized from 31.10.2016-01.11.2016.Firmagon injections were prescribed for the treatment of Prostate Cancer as it is complete treatment for the said disease. The certificate has been issued by Dr.AnupamBhargav to this effect. He is now advised to take an alternate treatment of Eligard as it is administered after every three months. The certificate is issued by Dr.AnupamBhargav to this effect. On 19.12.2016, a claim of Rs.52,164/- was raised with OP-1 in respect of Firmagon injections.
2. On 13.02.2017, the OPs have partly allowed the claim of Rs.56540/- as against Rs.75046/- raised vide letter dated 15.11.2016. The claim was rejected on pro-rata basis without any valid justification. The deductions were made on the ground that claims relate to hospitalization and pre-hospitalization charges. A cap of Rs.5000 has been placed on room rent without any explanation which is against clause 3.35 of the policy.The policy benefits under hospitalization and pre and post-hospitalization has been raised by IRDA vide notification no.IRDA/Reg./14/72/2013 dated 18.03.2013. The first claim pertains for the period 31.10.2016 – 01.11.2016 under the policy from 2015-16 which got renewed on 05.12.2016 so the amount available should have been 10 lakh as against Rs.5 lakh considered by the OP. The claim falls within the two policy periods and therefore claim should be paid by taking into consideration the available sum insured in two policy period.

3. On 17.02.2017, the OP-2 has partly allowed the claim raised vide letter dated 19.12.2016. The claim of Rs.10146/- as against Rs.52164/- was allowed on the ground that Firmagon injections are a mere post-hospitalization treatment and complainant no.2 is not insured for the same. The treatment was under the doctor so covered under clause 2.1 (29) of the health insurance policy so the part claim has been wrongly allowed. On 20.01.2017 and 16.02.2017, the complainant no.2 has filed the claim for a sum of Rs.30195.54/- and Rs.20506/- which are pending consideration with OP-1.The pro-rata rejection is without any basis which leads to the deficiency of service on the part of OPs. A notice was issued to the OPs on 07.03.2017 but without any result. Hence, this complaint.
4. The OP-1 has filed the WS with the averments that complainants have taken the policy valid from 05.12.2015 -04.12.2016 for a sum assured of Rs.5 lakh under Individual Health Policy. OP-2 is a TPA.The policy was got renewed on 05.12.2016 till 04.12.2017 for a sum assured of Rs.5 lakh. The complainant no.2 has submitted two claims which stand adjudicated whereas claim of Rs.30195/- and Rs.20506/- are pending for adjudication with OP-2. The injection administered to complainant no.2 does not fall under chemotherapthus day care treatment cannot be extended to cover the charges of Firmagon and Eligard. The charges incurred within 60 days from the date of discharge have been indemnified @10%of sum insured under post-hospitalization. The policies of two years cannot be clubbed together. The clause 1.1 refer to the scenario where hospitalization stretches to two policy periods then the benefit of both the policies during hospitalization will be available. The treatment documents indicate that admission was only for diagnostic purposes. The amounts of different heads have been disallowed which are as under:

1. Room rent to the Rs.6,500=00 had been disallowed against Rs.11,500/-.
2. Consultant charges to the extent of Rs.400=50 has been disallowed as against 2,000=00.
3. Surgeon charges to the extent of Rs.6,968=00 has been charged extra which stands disallowed as against 11,875=00.
4. Imaging Studies Blood 02 charges to the extent of Rs.1,822=00 has been charged extra which stands disallowed as against Rs.31,105=00.
5. Other medicines equipments charges to the extent of Rs.1,551=00 has been charged extra which stands disallowed as against Rs.1,661=00.
6. Investigations of Laboratory charges to the extent of Rs.416=00 has been charged extra which stands disallowed.
7. Misc. Charges to the extent of Rs.185=00 has been charged extra which stands disallowed as against Rs.3,171=00.
8. Pre Post Hospitalizational to the extent of Rs.1,080=00 has been charged extra which stands disallowed as against Rs.40,934=00.

The complainant is relying upon clause 3.35 of the policy which is strict to the sum insuredto the extent of Rs.500/- per day room rent and other medical expenses. The IRDA guidelines are for hospitalization period between the date of admission and date of discharge extending two policy period whereas in the instant case hospitalization falls under single policy. There is no deficiency of service.

5. The perusal of the order sheet dated 21.08.2017 shows that
   Sh. Gurmeet Singh Ahuja, Advocate appeared for OP-1 and filed the vakalatnama. The vakalatnama is only for OP-1. The reply was filed on 21.08.2017. The reply does not show it is for both the OPs. The reply is for OP-1 so it cannot be considered the reply for OP-2. There is no reply from OP-2.

6. The complainants have filed the replicationwherein they have denied the averments made in the written statement and reiterated the stand taken in the complaint.

7. The parties were directed to lead the evidence.

8. The Complainant no.1 has filed her ownaffidavit in evidence wherein she has corroborated the version of the complaint.
9. The OP-1 has filed the affidavit of Sh. Gaurav Kumar Papnai, Branch Manager, in evidence wherein he has corroborated the version of the written statement.

10. The OP-2 has led the evidence. The evidence filed by the OP-2 cannot be looked into because OP-2 has not filed the WS/reply.

11. We have heard the Ld. Counsel for the complainant as no one has appeared on behalf of the OP to address oral final arguments and perused the entire material on record.

12. The complainants have taken the plea that policy from 05.12.2015 -04.12.2016 which was got renewed on 05.12.2016 was valid till 04.12.2017. The sum assured was Rs.5 lakh for each complainant. The treatment was going on. The policy was in continuation so the claim should have been considered for Rs.10 lakh for each complainant rather than for Rs.5 lakh though this fact is controverted by OP-1 on the premise that the complainant no.2 has not remained admitted to hospital at the time of renewal of policy.

13. Annexure-P-4are the bills, invoices and inpatient summary issued by Max Smart Super Speciality Hospital, New Delhi. This shows that complainant no.2 has remained admitted to hospital from 31.10.2016 – 01.11.2016 i.e. during the continuation of the policy from 05.12.2015 – 04.12.2016. Complainants have not renewed the policy at the time of admission of complainants no.2 in the hospital. He has raised the bills for the period for which he has remained admitted to hospital. His admission was not continuous i.e. from 05.12.2015 – onwards. He has been discharged on 01.11.2016 i.e. before the lapse of the policy. The policy from 05.12.2015 – 04.12.2016 cannot be tagged with policy from 05.12.2016 – 04.12.2017 in order to claim together the benefit of sum assured in each policy. The benefit of sum assured of policy during which he remained admitted to hospital will be taken into consideration. The plea of the complainants that complainant no.2 is entitled for a sum assured of Rs.10 lakh under two policies does not hold water.

14. The perusal of the record shows that Annexure-P-4 contains the bills, invoices and discharge summary issued by Max Smart Super Speciality Hospital, New Delhi. The complainant no.2 has raised a  bill of Rs.75406/- as apparent from Annexure-P-7 and this fact is admitted by OP-1.

15. The OP-1 has passed the claim of Rs.56540/- as against Rs.75046/- by deducting the various charges by citing reasons. The dietician charges were not allowed. The glucometer report was not available so the bill of Rs.185/- was not paid. A sum of Rs.1822/- for Investigation-lab report charges were deducted by citing the reason of room rent + RMO opted for higher category so linking was applied. A sum of Rs.1550.76/- from pharmacy charges were deducted by citing the reason history assessment + RMO charges. A sum of Rs.6500/- were deducted from room rent at maximum room rent of Rs.5000/- per day was allowed. A sum of Rs.6968/- from surgeon charges were deducted on the premise of room rent + RMO opted for higher category so linking was applied. A sum of Rs.1080/- was deducted from consultation charges on the premise of duplicate receipt of date 28.10.2016 was not payable.

16. The question arises whether deduction was in accordance with terms of the terms and conditions of the insurance policy.

17. The perusal of the clause 1.2(A) of the insurance policy says that room, boarding and nursing expenses as provided by the hospital up to 1% of the sum insured per day. This also including nursing care, RMO charges, IV fluid/blood transfusion administration charges and other expenses.

18. The sum insured is Rs.5 lakh so complainant no.2 is entitled only for a room rent of Rs.5,000/- per day i.e. 1% of the sum insured. The Annexure-P-4 (page no.77) shows that complainant no.2 has claimed room rent of Rs.11,500/- so a sum of Rs.6,500/- has been rightly deducted. The dietician charges are not payable in terms of the policy so dietician charges of Rs.400/- has been rightly deducted. The glucometer report was not supplied by the complainant no.2 to the OPs so a sum of Rs.185/- has been rightly deducted.

19. The charges for duplicate receipt amounting to Rs.1080/- was not paid. The duplicate receipt is only issued when original is misplaced for any reason. There is nothing in the Annexure-P-7 that this fact was verified from the hospital. There is nothing on the record that this receipt was not issued by the hospital. No investigation to this effect was made so deduction was not rightly done.

20. The OPs have deducted Rs.1822/-, Rs.6968/- by plying the linking principal with room rent and RMO opted for higher category. A sum of Rs.1550.76/- was deducted from pharmacy charges due to history assessment and RMO charges which are not payable.
21. The insurer should define ‘associate medical expenses’ when a policy holder choses to have a room of higher category. To our mind pharmacy charges, medical devices charges and diagnostic charges are not covered under associate medical expenses. The terms and conditions of the insurance policy does not show what are the associate medical expenses when the insured has taken a room of higher category beyond his entitlement. Furthermore, the hospital has not followed the differential billing based upon room category. There is nothing in the terms and conditions of the policy that proportionate deduction would be applied wherein hospital follows differential billing practice based upon room category or not.

22. The clause 1.2 (A) of the terms and conditions of the insurance policy says that nursing care, RMO charges and blood transfusion charges are included in the room, boarding and nursing expenses up to 1% of the sum insured per day. It shows that nursing care, RMO charges and blood transfusion charges cannot be segregated and remain the part of 1% of the sum insured.

23. All this show that the OP has wrongly deducted the charges amount to Rs.1822/-, Rs.155.76/-, Rs.6968/- and Rs.1080/- from the bill raised by the complainant no.2 and these charges should be paid to the complainant no.2.

24. The complainant no.2 has submitted another bill of Rs.52,164/- and a sum of Rs.10,146/- was cleared. The Annexure-P-8 at page 100 shows that a sum of Rs.3,060/- was deducted with the reason of pre-post claim paid 10% of sum insured, a sum of Rs.2,458/- was deducted in pre-post claim maximum paid 10% of SI and a sum of Rs.36500/- out of pharmacy charges by the reason of pre-post claim paid 10% of SI.

25. The complainant no.2 has annexed the certificate Annexure-P-5 issued by treating Dr.AnupamBhargav that Firmagon injection is a complete treatment in itself of curing prostate cancer. Eligard is administered as a single subcutaneous injection every three months. The therapy of advance prostate cancer with Eligard entails long term treatment and therapy should not be discontinued when remission or improvement occurs. It is a complete treatment in itself for curing prostate cancer.

26. The OPs have decided as to which expenses are not necessary or how much maximum amount can be paid for the treatment. The complainant no.2 has borne the expenses for the necessary treatment for prostate cancer. The treating doctor has issued the certificate that injections Firmagon and Eligard are necessary for the treatment of prostate cancer. The OPs should have filed contrary document that both these injections are not absolute necessary for curing the disease of prostate cancer. There is nothing on the record expenses were not necessary for the treatment of prostate cancer. The insurance firm cannot decide on the kind of expenses to be met by the insurer on the prescription of the doctor. The injections were necessary for treatment so the deduction was not justified. The OPs are liable to pay the expenses of Rs.36,500/- to the complainant no.2.

27. The OPs have wrongly deducted investigation and consultation charges and restricted it to 10% of the sum assured. The complainant no.2 has incurred the actual expenses towards the medical treatment so these charges have wrongly deducted.

28. The two bills submitted by the complainant no.2 for the reimbursement have been pending clearance. The OPs have taken too long a time to clear the bill which has caused mental harassment and agony to the complainant no.2.

29. In view of our discussion, we are of the view that some of expenses borne by the complainant no.2 for the treatment of prostate cancer has been wrongly deducted and OPs are liable to pay.

30. The deductions made by the OP are without any reasonable basis which tantamounts to deficiency of service.

31. Hence, the complaint of the complainant is allowed to the effect that OPs shall jointly or severally pay a sum of Rs.10,025.76/- (from the bill of Rs.75,046/- submitted by complainant no.2) and sum of Rs.42,018/- (from the claim of Rs.52,164/- submitted by complainant no.2) from the date of 11.04.2017 with interest @7% p.a. till its realization. The OPs shall further decide the claims of Rs.30195.54/- and Rs.20,506/- filed by the complainant no.2 within one month from the date of receipt of this order if not already decided. The complainants have undue mental harassment and they were forced to go for litigation so they are entitled for compensation of Rs.50,000/- on this score.The OPs are directed to comply with the order within 30 days from the receipt of the order failing which complainants will be entitled for interest @7% p.a. on the amount of mental harassment and litigation charges i.e. from the date of order till its realization.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 25.09.2024.