Punjab

Ludhiana

CC/19/369

Sandeep Kaur - Complainant(s)

Versus

Max Bupa Health Ins.Co.Ltd - Opp.Party(s)

Dalip GargAdv/

08 Aug 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:369 dated 29.07.2019                   

                                      Date of decision: 08.08.2022.

 

Sandeep Kaur wife of Shri Inderjit Singh, resident of House No.315, Hambran Road, village Partap Singh Wala, Ludhiana.                                                                                                                                                 ..…Complainant

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1.Max Bupa Health Insurance Company Limited., B-1/1/-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi 110044 through its Vice President Claims.

2.Max Bupa Health Insurance Company Limited., Plot No.88, IInd Floor, Kunal Tower, Mall Road, Opposite Axis Bank, Ludhiana 141001 through its Branch Manager.                                                                                                                                                                                            …..Opposite parties

         

          Complaint under section 12 of the Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh.Dalip Garg, Advocate

For OPs                         :         Sh.V.S.Mand, Advocate

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                Briefly stated, the case of the complainant is that she along with her husband namely Inderjit Singh obtained a medi-claim insurance policy which was valid from 16.04.2019 to 15.04.2020. The basic sum insured in the policy was Rs.1 lac each for the complainant and her husband along with floater sum insured of Rs.3 lacs. During the currency of the policy, the complainant felt stomach pain for which she visited Dayanand Medical College & Hospital, Ludhiana where she was diagnosed with primarily infertility with ovarian cyst problem. A pre-authorization request was sent from the hospital to the OPs on 03.04.2019 which was approved for a sum of Rs.59,346/- vide letter of the same date. On 05.04.2019, another letter was received by Dayanand Medical College & Hospital, Ludhiana from the OPs following which the OPs approved the pre-authorization for a sum of Rs.68,846/-. The complainant remained admitted with Dayanand Medical College & Hospital, Ludhiana for 05.04.2019 to 11.04.2019. She was operated upon by the doctors and the said hospital raised a total bill of Rs.1,00,248/-. However, on 11.04.2019, the OPs denied the payment on the ground that as per policy terms and conditions clause 8.23(b), treatment to assist reproduction (infertility services including artificial insemination and advanced reproductive technology such as IVF, ZIFT, GIFT, ICSI, Gestational Surrogacy) was not covered. The repudiation of claim on the basis of clause 8.23 is illegal and arbitrary and amounts to deficiency of service on the part of the OPs. Hence the complaint whereby it has been requested that the OPs be directed to reimburse the claim of Rs.68,846/- along with interest @18% per annum from 11.04.2019 till payment. Further, OPs be directed to pay compensation of Rs.50,000/- and litigation expenses of Rs.11,000/- to the complainant.

2.                The complaint has been resisted by the OPs. In the written statement filed on behalf of OP1 and OP2, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, the complainant and her husband obtained the policy in question online on 17.04.2017 wherein the individual sum insured under the policy was Rs.1 lac and the floater sum insured was Rs.3 lacs. The OPs have further pleaded that the policy along with documents were supplied to the policy holder and the complainant would cancel the policy within the free look period of 15 days. The OPs have further pleaded that the complainant was admitted in Dayanand Medical College & Hospital, Ludhiana on 11.04.2019 for provisional diagnosis of infertility with ovarian cysts and had to undergo surgery of Laparoscopic Cystectomy. The pre-authorization was initially approved but later on denied under clause 8.23 (b) as the treatment related to infertility is permanently excluded as per the policy terms and conditions. Therefore, the claim has been rightly repudiated as no claim under clause 8.23(b). The complainant and her husband are bound by the terms and conditions of the contract of insurance and clauses of the policy. Thus, there has been no deficiency of service on the part of the OPs. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

3.                In evidence, complainant submitted her affidavit Ex.CA along with documents Ex.C1 to Ex.C9 and closed the evidence.

4.                On the other hand, OPs submitted affidavit Ex.RA of Ms.Chandrika Bhattacharya, Chief Manager-Legal of OPs along with documents Ex.OP1/1 to Ex.OP1/7 and closed the evidence. Further, he suffered statement that the written reply be also read as evidence of OP1 and OP2.

5.                We have heard the arguments advanced by the counsel for the parties as well as written arguments submitted by the OPs and have also gone through record.

6.                In this case, the claim in respect of the hospitalization of the complainant from 05.04.2019 to 11.04.2019 with Dayanand Medical College & Hospital, Ludhiana has been repudiated on the basis of clause 8.23(b) of the policy terms and conditions. As per discharge summary Ex.C3, the complainant was hospitalized/admitted for the reasons i.e. i)Infertility to conceive for 2 ½ years ii) pain in lower abdomen for about 4-5 months. It is further mentioned in the discharge summary Ex.C3 under the column of “Procedure Performed” that cystectomy was performed. In addition to the cystectomy, the procedure of chromopertubation and adhesiolysis was also performed. Cystectomy procedure is performed for removal of all or part of urinary bladder while chromopertubation is performed usually to determine the cause of someone’s difficulty in getting pregnant or to remove obstruction in fallopian tubes which could be one of common causes of suspected infertility. Adhesiolysis is a surgical procedure performed to remove or segregate adhesions in order to regain the normal anatomy and functionality of an organ which is commonly performed by way of laparoscopy. From a perusal of discharge summary, it is evident that primarily the complainant underwent laparoscopic cystectomy which is term or surgical removal of all or part of the urinary bladder, Cystectomy cannot be considered to be a treatment of infertility. Since primarily the complainant was treated by way of cystectomy, even if the procedure pertaining to chromopertubation was also performed, it cannot be said that the entire procedure was for the treatment of infertility. Therefore, in our considered view, the treatment of the complainant would not fall within the mischief of clause 8.23(b) of the policy terms and conditions which excludes any treatment pertaining to:-

a)Birth control:- Any type of contraception, sterilization, abortions, voluntary termination pregnancy (except under Maternity Expenses for Medical Termination of Pregancy (MTP) as governed by MTP Act 1971 under Section 2.7 above) or family planning.

b) Assisted Reproduction:- Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, Gestational Surrogacy.

c) Sexual disorder and Erectile Dysfunction:- Treatment of any sexual disorder including impotence (irrespective of the cause) and sex changes or gender reassignments or erectile dysfunction.

d)Any costs or expenses related to pregnancy, complications arising from pregnancy or medical termination of pregnancy except to the extent covered under Section 2.7(Maternity Benefit), if applicable.

Therefore, the repudiation of claim pertaining to the surgical cystectomy does not fall within the ambit of clause 8.23 of the policy. Therefore, in our considered view, the claim has been wrongly repudiated and it would be just and proper if the OPs are directed to consider and reimburse the claim in respect of hospitalization of complainant from 05.04.2019 to 11.04.2019 with Dayanand Medical College & Hospital, Ludhiana strictly as per terms and conditions of the policy along with composite costs of Rs.5,000/-.

7.                As a result of above discussion, the complaint is allowed with a direction to OPs to consider and reimburse the claim in respect of hospitalization of complainant from 05.04.2019 to 11.04.2019 with Dayanand Medical College & Hospital, Ludhiana strictly as per terms and conditions of the policy. OPs shall further pay composite cost of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.       

8.                Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:08.08.2022.

Gurpreet Sharma.