BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 20^TH DAY OF MAY 2024

ORDER

SMT.M.SHOBHA, PRESIDENT

1. The complaint has been filed under Section 35 of C.P.Act (hereinafter referred as an Act) against the OP to pay a sum of Rs.83,162/- being the global compensation along with interest and cost of this proceedings in the interest of justice and equity.
2. The case set up by the complainant in brief is as under:-

The complainant working in Syngene International Limited as a Senior Associate Scientist. The complainant have medical insurance specialties from OP insurance company bearing policy No.5018148009.

3. The main grievance of the complainant is that she gave birth to the second baby on 10.06.2017. The complainant’s daughter fell ill and was suffering from fever on 02.01.2018 and she was immediately admitted at SK hospital near Nagarabhavi circle.  Then after the advice of one Dr.Mahesh the complainant daughter was shifted to People Tree hospital, Goraguntepalya, wherein the complainant’s daughter was treated as inpatient from 02.01.2018 to 09.01.2018 and she was discharged from the hospital.  The complainant had paid medical bill of Rs.83,162/- and further she has paid Rs.5,000/- on 02.01.2018.
4. Thereafter since the complainant having a medical policy of the OP company she had claimed the medical reimbursement of Rs.83,162/- and the OP company had reimbursed the first medical bill for Rs.5,000/- on 02.01.2018 and the second reimbursement bill for Rs.83,162/- was rejected on 08.03.2018 for the reason that “congenital anomaly means a condition which is present since birth and anomaly which is on the visible and assessable parts of the body.” As per symptomatic seizure with pink mark on the face since birth.  The conditions congenital external disorders which are not covered under the policy.  In respect of these issues the complainant got issued legal notice to the OP on 15.02.2020 and it was duly served on the OP. the OP2 has given a evasive reply stating that they are the service provider to the National Insurance Company Limited and they are admitted that the complainant having a sensuality of the group mediclaim policy which value from 01.03.2017 to 28.02.2018 for the sum insured for Rs.3,00,000/-.
5. It is further case of the complainant that as per the medical opinion of Dr.Mahesh and Dr.Umashankar, Radiologist at the Padmashree Diagnostics that “neurosonogram Study Shows no definite abnormality” over the mark on the face of the complainant daughter, though the OP company intentionally by assigning self medical reasons, denied the medical reimbursement of the complainant. Hence the complainant has suffered mentally physically and monetarily due to the negligence and deficiency of service on the part of the OP. The OP dealing in Human Health Insurance and they are suppose to protect the policy holder health by paying health insurance amount under the health insurance policy, but the OP have not do so to the complainant.  The OP have committed cheating fraud and misappropriation and deficiency of service. Hence they are liable to make good the loss and damage caused to the complainant due to their negligent act. Hence this complaint.

6. In response to the notice, OP appears and files version. It is pertinent to note here that the complainant has only made the OP1 i.e., Medi Assist India Ltd., as party in this complaint.  After filing of the version by the OP1, this commission has directed the complainant to implead the OP2.  Hence the OP2 was impleaded and both have filed their version.

7. The OP1 has filed version stating that they are only a TPA which has been appointed by the insurance company through a valid contract and has been assigned with the task of managing the insurance policies and processing the claims raised by the concerned insured members on behalf of the respective insurance companies which issue the insurance policies. These TPA is not authorized to pay the claim amount directly to the insured person and they can only verify the validity of the insurance claim receive the claim papers from the respective insurance person, scrutinize the same for speedy settlement and effective disbursement of legitimate claim being bound by the terms of the insurance policy and submit the report to the insurance company. Then the respective insurance companies pay the amount to the insured person directly. Hence this OP does not have powers or authority to pay any claim amount under the insurance policy. There is no privity of contract between the complainant and this OP1.  The complainant has to make the insurer i.e., the National Insurance Company Ltd., as OP in this complaint. Hence the OP1 prayed for dismissal of the complaint.
8. The OP2 has filed their version and the preliminary objection raised by them is that the complaint is barred by limitation since the claim of the complainant is pertaining to 08.02.2018 and the complainant has brought this OP2 on record don 09.08.2023 i.e., after lapse of five years from the date of the claim.
9. It is further case of the OP2 that the complainant’s male child i.e., son was treated for Sturge Weber Syndrome with remote symptomatic seizures and not daughter as mentioned in the complaint. The same is clear from the discharge the document NO.1 produced by the complainant. Since the aforesaid syndrome is a congenital anomaly and the same is not covered under the insurance policy.  Hence the claim made by the complainant for reimbursement of Rs.83,162/- was rejected by this OP as per the terms and conditions of the group mediclaim policy exclusion clause 4 r/w clause 3.7.  
10. The OP2 have admitted about the policy taken by the complainant and the coverage of the policy for the complainant’s son and the treatment taken by the complainant’s son on 02.01.2018 as an inpatient.
11. The OP2 further denied all the other allegations made in the complaint. It is also the contention taken by the OP2 that the complainant is not entitle for the amount of Rs.83,162/- together with interest and cost of litigation. There is no statement alleging deficiency of service by this OP has been made by the complainant and thus in the absence of the same the complainant has failed to made out a case for deficiency of service on the part of this OP2. Therefore the OP2 prayed for dismissal of the complaint.

12. The complainant has filed her affidavit evidence and relies on 14 documents.  Affidavit evidence of official of OP2 has been filed and OP2 relies on 03 documents.

13. Heard the arguments of advocate for the both the parties.    Perused the written arguments filed by the complainant and OP2.
14. The following points arise for our consideration as are:-

1. Whether the complainant proves deficiency of service on the part of OP?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

15. Our answers to the above points are as under:

Point No.1:  In the Negative

Point No.2: In the Negative

Point No.3: As per final orders

REASONS

16. Point No.1 AND 2: These two points are inter related and hence they have taken for common discussion.  We have perused the allegations made in the complaint, version, affidavit evidence of both the parties, written arguments and citations.
17. It is undisputed fact that the complainant working as a senior associate scientist in Syngene International Limited, has obtained the medical insurance specialties in the OP company under policy No.5018148009. It is evident from the affidavit and documents that the complainant gave birth to a second baby girl on 10.06.2017 at G.M.Hospital. The complainant’s daughter fell ill and reported vomiting then immediately the complainant got admitted her daughter at the S.K.Hospital near Nagarabhavi Circle. Then as per the advise of Dr.Mahesh the complainant shifted her daughter the People Tree hospital, Goraguntepalya, Bangalore, wherein the complainant’s daughter was taken treatment as inpatient from 02.01.2018 to 09.01.2018 and then she has been discharged.  The complainant has paid the medical bill of Rs.83,162/- and another amount of Rs.5,000/- paid on 02.01.2018.
18.  Then the complainant having the medical policy with the OP company has claimed reimbursement of Rs.83,162/- from the OP company. The OP reimbursed the first medical bill of Rs.5,000/- dated 02.01.2018 and rejected the medical reimbursement of Rs.83,162/- on the ground that “Congential anomaly means a condition which is present since birth and anomaly which is on the visible and accessible parts of the body, as per symptomatic seizure with pink mark on fact since birth.  The conditions congenital external disorders which are not covered under the policy.”  The complainant has also got issued legal notice on 15.02.2020 the OP company have given a evasive reply even though the policy was in force from 01.03.2017 to 28.02.2018 and the sum insured was Rs.3,00,000/-.  
19. As per the terms and conditions of the policy the complainant and her family members are entitled for medical reimbursement without any conditions upto the insured sum three lakhs, but surprisingly the OP company rejected the medical reimbursement of Rs.83,162/-.
20. In support of her contention the complainant has relied on 14 documents. Ex.P1 is the ID card, Ex.P2 is the email communications, Ex.P3 is the Discharge summary Ex.P4 is the medical bills, Ex.P5 is the Copy of legal notice dated 15.02.2020, Ex.P6 is the Bunch of two postal receipts, Ex.P7 is the Unserved postal cover addressed to OP, Ex.P8 is the Reply notice dated 03.03.2020, Ex.P9 is the Copy of the opinion of the OP doctor dated 18.01.2018, Ex.P11 is the Copy of the policy terms and conditions issued by OP, Ex.P12 is the Copy of ID card of family member, Ex.P13 is the Copy of the insurance benefit manual of 2022-23 and Ex.P14 is the email.
21. On the other hand, the contention taken by the OP1 is that they have no power or authority to pay any amount under the policy to the complainant. They are only TPA. They can only verify the validity of the insurance claim receive the claim papers and scrutinize the same and send the same to the insurance company.  There is no privity of contract between them and the complainant and it is only between the complainant and OP2.
22. On the other hand, the main contention taken by the OP2 is that the complaint is barred by time and the complainant has filed this complaint after lapse of five years from the date of claim.  The complainant has not instituted the complaint against this OP and later this OP was impleaded.  According to the OP2 the complainant’s son was treated in the hospital. The medical papers i.e., the document NO.2 discharge summary reveals that the diagnosis of the doctors mentioned therein was Sturge Weber Syndrome with remote symptomatic seizures.
23. It is further case of the OP2 that the doctors have clearly stated that “MRI brain was done which was suggestive of congenital cerebral malformation – Sturge Weber Syndrome.” The child was admitted for fever vomiting and seizure arising out of and as a symptom of the said congenital anamol. Sturge weber syndrome with remote symptomatic seizure with pink mark on the fact at the time of birth falls within the exclusions contained in clause 4.5 of the insurance policy.  The condition of the complainant child is excluded from the application of insurance policy and hence the claim of the complainant was rightly repudiated. They have reimbursed part of the mediclaim.
24. In support of their contention the authorized representative of the OP2 has filed his affidavit evidence and relied on three documents. Ex.R1 is the Copy of the discharge summary, Ex.R2 is the Copy of the group mediclaim insurance policy and Ex.R3 is the Copy of the authorization letter.
25. There is no dispute about the policy and the validity of the policy at the time of taking treatment by the complainant to his child. The dispute is only regarding the claim made by the complainant. The OPs are depending on the Ex.R1 the discharge summary issued by the People Tree hospital, at the time of discharge of the complainant’s child on 09.01.2018.  Admittedly the diagnosis of the complainant’s child by the hospital is Sturge Weber Syndrome with Remote Symptomatic Seizures.  The complainant has not at all given any explanation to show that the child was not suffering from the said disease. 
26. The contention taken by the complainant is that as per the opinion of Dr.D.Umashankar, Radiologist of Padmashree diagnostics, there is no definite abnormality as per the neurosonogram study. Admittedly Ex.P2 was issued on 26.06.2017 when the complainant’s baby was 10 days old.  Later when the complainant’s child fell ill and admitted to hospital when the baby was six months old the doctors have diagnosed that the complainant’s baby is suffering from Sturge Weber Syndrome with Remote Symptomatic Seizures. 
27. The OP2 has also relied on the terms and conditions of the policy i.e., Ex.R2.  as per the terms and conditions of the policy condition No.4.5 r/w clause 3.7; General Debility, congenital external anomaly; General debility, run down condition or rest cure, congenital external disease or defects or anomaly. As per clause 3.7 Congenital anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position. i) Internal congenital anomaly means congenital anomaly which is not on the visible and accessible parts of the body, ii)         Internal congenital anomaly means congenital anomaly which is on the visible and accessible parts of the body. 
28. When the condition of the child of the complainant is excluded from the application of insurance policy the OP2 have repudiated the claim.  The complainant has not at all produced any medical reports to show that the said disease is not a congenital anomaly in support of her contention.  Under these circumstances this commission cannot direct the OP2 to pay the claim made by the complainant. Under these circumstances the complainant has failed to establish any deficiency of service or negligence on the part of the OPs in repudiating her claim.  There is no ground made by the complainant to entertain the claim made by her from the OP2. Hence we answer point No.1 and point No.2 in the Negative.
29. Point No.3:- In view the discussion referred above we proceed to pass the following;

O R D E R

1. The complaint is Dismissed. No costs.
2. Furnish the copy of this order and return the extra pleadings and documents to the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 20^TH day of MAY 2024)

Documents produced by the Complainant-P.W.1 are as follows:

Documents produced by the representative of opposite party – R.W.1;