CC No.878.2015

Filed on 07.05.2015

Disposed on.24.07.2018

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BENGALURU– 560 027.

DATED THIS THE 24^th DAY OF JULY 2018

CONSUMER COMPLAINT NO.878/2015

PRESENT:

Sri.  H.S.RAMAKRISHNA B.Sc., LL.B.

        PRESIDENT

             Smt.L.MAMATHA, B.A., (Law), LL.B.

                      MEMBER

                                     V/S

ORDER

BY SRI.H.S.RAMAKRISHNA, PRESIDENT

1. This Complaint was filed by the Complainant on 07.05.2015 U/s 12 of the Consumer Protection Act, 1986 and praying to pass an Order directing the Opposite Parties to reimbursement of medical expenses of 3,00,000/- (policy maximum coverage is 3 lakhs), Rs.50,000/- to compensate mental stress caused by the Opposite Parties by rejecting their claim, to pay cost of Legal Expenses of Rs.10,000/- and other reliefs.
2. The brief facts of the complaint can be stated as under:

In the Complaint, the Complainant alleges that the Complainant’s father Pranesh G.V was suffering from Diabetes, Hypertension and Metabolic Syndrome.  So as per the medical advice from the doctor his father had undergone surgery at Vikram Hospital, Bangalore on 04.09.2014.  The total expenditure of the surgery was Rs.3,60,000/-.  When he applied for reimbursement of the amount from Opposite Party No.1.  The Opposite Party No.1 rejected the claim stating their claim is not admissible under the Policy.  The policy is a Corporate Policy and Pre-Existing diseases are covered from the day one of the policy period as per the Policy Documents given to the Insurance Company.  Existing diseases are covered the TPA has rejected their claim.  Hence this complaint.

3. In response to the notice, the Opposite Party No.1 & 2 put their appearance through their counsel and filed their version.  In the version pleaded that the Complainant is an employee of M/s ABB Global Industries and Services Limited, Bangalore.  The employee has taken Group Health Insurance Policy-Floater from 2^nd Opposite Party.  The Opposite Party No.1 as the Third Party Administrator (TPA) and represents Opposite Party No.2.  The Complainant had opted for coverage of his parents under the above policy.  The benefits payable under the above policy are subject to the terms, conditions and exclusions contained in the contract of Insurance reflected by the policy. The father of the Complainant Mr.Pranesh G.V got admitted to Vikram Hospital, Bangalore for the period from 03.09.2014 to 06.09.2014.  The investigation reports reveals that the patient was weighing 110 Kgs and 172 Cms. in height and was a Known case of Hypertension(HTN) since last 15 years, dyslipidemic since 10 years & was suffering from diabetes mellitus since 20 years and was on insulin for the last 5 years and was recently detected to be obstructive sleep spnoea on CPAP.  The discharge summary of Vikram Hospital indicated that he was diagnosed as a case of Metabolic Syndrome and he underwent Laproscopic Banded Sleeve Gastrectomy+Liver Biopsy under GA on 04.09.2014.  This surgery was done for the reduction of obesity.  When the Complainant submitted the bill for Rs.3,60,000/- though the maximum coverage was Rs.3,00,000/-.  The Opposite Parties careful considered all the documents including hospital records furnished by the Complainant.  Thereafter on due application of mind took a bonafide decision to repudiate the claim on the ground that the treatment taken is excluded from the Insurance coverage as under the Exclusion Clause 4.10 and 4.19.   The Opposite Parties communicated the decision to repudiate the claim by a letter dtd.10.11.2014 giving detail reason and also specifically drawing the attention of the Complainant to the Exclusion Clauses.  Treatment for obesity or condition arising there from and any other weight control program.  The hospital records clearly shows that the investigations done was primarily for evaluation/diagnostic purposes and the treatment taken clearly shows the treatment for obesity and the condition, including Morbid obesity and other weight control programmes.  Therefore, in terms of the policy condition the Opposite Parties repudiated the claim.  The Complainant had not objected to any of the terms and conditions of the policy and also not stated in the complaint that how exclusion clause-4.10 and 4.19 will not apply to the treatment undergone by his father at Vikram Hospital.  It is specifically submitted that the rejection of the claim does not relate to any pre-existing disease.  The repudiation is for a specific treatment taken and excluded from coverage under Clause 4.10 and 4.19.  The repudiation of the claim after due application of mind and taking a bonafide decision will not amount to deficiency in service for invoking the Jurisdiction of the Hon’ble Forum.  Hence prays to dismissal of the complaint.
4. After filing the version by the Opposite Parties, the Complainant amended the complaint and by inserting two paras, Para No.3 & 4 reads as follows:-

It is submitted that, Complainant is an employee of              M/s ABB Global Industries and Services Limited, Bangalore, the Complainant has taken Group Life Insurance Policy Floater from National Insurance Company Limited.  It is submitted that, Medi Asst.India TPA Private Limited, is the third party Administrator (TPA) and represents National Insurance Company Limited, the Complainant has opted for coverage of his parents under the above said Policy.

The Complainant father (Pranesh G.V) was suffering from Diabetes, Hypertension and Metabolic Syndrome.

It is submitted that, the Complainant’s father by name Pranesh G.V, due to the consumption of dosage of the insulin as per advice of the Doctor, the condition of the Complainant’s father becomes critical and doctor Tulips of Vikram Hospital given opinion that, Complainant’s father Pranesh G.V, aged about 62 years, male, suffering from diabetes, hypertension and dyclipedimia.  He can live a life, free from the metabolic syndrome of quality of life will be improved. 

5. The Complainant, Sri.Pradeep G.P filed his affidavit by way of evidence and closed his side.  On behalf of the Opposite Party No.2, the affidavit of Sri.K.Sai Prakash has been filed.   Heard arguments of both parties.

6.      The points that arise for consideration are:-

1. Whether the Complainant has proved the alleged deficiency in service by the Opposite Parties ?
2. If so, to what relief the Complainant is entitled ?

7.     Our findings on the above points are:-

                  POINT (1)                  :-  Affirmative

     POINT (2)                          :-  As per the final order

REASONS

8. POINT NO.1:- As seen from the allegations of the complaint and also the version filed by the Opposite Parties, it is not in dispute that the Complainant is an employee of M/s ABB Global Industries and Services Limited, Bangalore, the Complainant has taken Group Life Insurance Policy Floater from National Insurance Company Limited.  It is submitted that, Medi Asst.India TPA Private Limited, is the third party Administrator (TPA) and represents National Insurance Company Limited, the Complainant has opted for coverage of his parents under the above said Policy.  To substantiate this fact, the Complainant has filed his affidavit, in his sworn testimony, he has reiterated the same and produced the copy of the policy.  By looking into this document, it is in the name of the National Insurance Company i.e., Opposite Party No.2 and as per this policy, the Policy Holder is name of ABB Global Industries and Services Limited and the policy is in the name of the Complainant Sri.Pradeep G.P.  This evidence of the Complainant is not been challenged by the Opposite Parties and also not disputed by the Opposite Parties.  To disbelieve the evidence of the Complainant, there is no contra evidence.  Therefore, it is proper to accept the contention of the Complainant that the Complainant is an employee of M/s ABB Global Industries and Services Limited, Bangalore, the Complainant has taken Group Life Insurance Policy Floater from National Insurance Company Limited and Medi Asst.India TPA Private Limited, is the third party Administrator (TPA) i.e., Opposite Party No.1.
9. It is further case of the Complainant that the Complainant’s father Pranesh G.V was suffering from Diabetes, Hypertension and Metabolic Syndrome, due to the consumption of dosage of the insulin as per advise of the Doctor, the condition of the Complainant’s father becomes critical and doctor Tulips of Vikram Hospital given opinion that, Complainant’s father Pranesh G.V, suffering from diabetes, hypertension and dyclipedimia i.e., Metrabolic Syndrome.  He will benefit in a major way if he undergoes metabolic surgery as he can get remission from diabetes, hypertension and dyclipedimia.   He can live a life, free from the metabolic syndrome of quality of life will be improved.   So far as per the medical advice from the doctor the Complainant’s father had undergone surgery at Vikram Hospital, Bangalore on 04.09.2014.  The total expenditure of the surgery was 3 Lakhs 60 thousand.  The Complainant then applied or reimbursement of the amount from Health Insurance Policy.  The Complainant had taken this Health Insurance Company Limited and the Third Party Assistant (TPA) is Media Assist India PTA Private Limited i.e., Opposite Party No.1.  The TPA rejected the Complainant claim stating that Complainant claim is not admissible under the Policy.  Further to substantiate this fact, the Complainant in his sworn testimony, he has reiterated the same and produced the Discharge Summary from Vikram Hospital.  As seen from this document, the Complainant’s father Pranesh G.V admitted to the Vikram Hospital on 03.09.2014 and Discharged on 06.09.2014 he was hospitalized for Metabolic Syndorme and conducted Laparoscopic Banded Sleeve Gastrectomy+Liver Biopsy under GA on 04.09.2014 and also produced the package price.  By looking into this, it is clear that the Complainant’s father Pranesh G.V was admitted under the care of Dr.Tulip on 03.09.2014, he underwent Laparoscopic Banded Sleeve Gastrectomy+Liver Biopsy Under GA and got discharged on 06.09.2014, the package price for the above surgery in semi-private category is Rs.3,00,000/- and also produced the bill issued by the Vikram Hospital and as per this bill dt.06.09.2014, the Complainant’s spent Rs.4,10,000/- towards the medical expenses of his father Pranesh G.V.  This evidence of the Complainant is also not been denied or disputed by the Opposite Parties.  Therefore, it is proper to accept the contention of the Complainant that the Complainant’s father Pranesh G.V suffering from diabetes, hypertension and dyclipedimia and Metabolic Syndrome.  On the advice of Dr.Tulip, Vikram Hospital, he was admitted to the Vikram Hospital on 03.09.2014 and on the advice of Dr.Tulip, the Complainant’s father undergone Metabolic Syndrome on 04.09.2014 the total expenditure of the surgery was Rs.3,60,000/-.  
10. The Complainant when applied for reimbursement of the amount from Opposite Party No.1.  The Opposite Party No.1 3^rd party Medi Asst.India TPA Private Limited rejected the Complainant claim stating that the Complainant claim is not admissible under the Policy.  This evidence of the Complainant is also not been denied or disputed by the Opposite Parties.  Therefore, it is proper to accept the contention of the Complainant.
11. It is further case of the Complainant that the policy is a Corporate Policy and Pre-Existing diseases are covered from the day one of the policy period as per the Policy Documents given to the Insurance Company.  Existing diseases are covered the TPA has rejected the Complainant’s claim.  Even to substantiate this also the Complainant in his sworn testimony, he has reiterated the same and produced Health Insurance-Benefit Manual.  By looking into this document, it is clear that the Insurer is Opposite Party No.2 National Insurance Company Service Provider is Medi Assist India TPA Private Limited and policy starts from 24.09.2014 and ends on 23.09.2015 and dependents coverage is spouse, parents and new born baby.  So from this evidence, it is clear that the Complainant’s father is also covered under this policy, eventhough the policy was covered to the parents.  Since the Complainant has taken Group Life Insurance Policy Floater from National Insurance Company Limited and Complainant’s father undergone surgery for Metabolic Syndrome in Vikram Hospital and the total expenses for that is about Rs.3,60,000/-.  For that reason, the Complainant submitted his Claim Form along with bills and necessary documents instead of honour the claim, the Opposite Party No.1 rejected the claim of the Complainant.

12. The defence of the Opposite Party is that the investigation reports reveals that the patient was weighing 110 Kgs and 172 Cms., in height and was a Known case of Hypertension(HTN) since last 15 years, dyslipidemic since 10 years & was suffering from diabetes mellitus since 20 years and was on insulin for the last 5 years and was recently detected to be obstructive sleep spnoea on CPAP.  The discharge summary of Vikram Hospital indicated that he was diagnosed as a case of Metabolic Syndrome and he underwent Laproscopic Banded Sleeve Gastrectomy+Liver Biopsy under GA on 04.09.2014.  This surgery was done for the reduction of obesity.  When the Complainant submitted the bill for Rs.3,60,000/- though the maximum coverage was Rs.3,00,000/-.  The Opposite Parties careful considered all the documents including hospital records furnished by the Complainant.  Thereafter on due application of mind took a bonafide decision to repudiate the claim on the ground that the treatment taken is excluded from the Insurance coverage as under the Exclusion Clause 4.10 and 4.19.   The Opposite Parties communicated the decision to repudiate the claim by a letter dtd.10.11.2014 giving detail reason and also specifically drawing the attention of the Complainant to the Exclusion Clauses.  In support of this defence,                                Sri.K.Sai Prakash filed his affidavit, on behalf of Opposite Parties and reiterated the same, but the Opposite Parties have not produced any document, eventhough in their version they have mentioned as EX.R1 to R3.  However the Complainant produced the Discharge Summary, as looking into this document, as stated earlier, it is clear that the Complainant’s father Pranesh G.V. is a known case of diabetic mellitus since 20 years and on insulin since five years, hypertensive since 15 years on treatment, dyslipidemic since 10 years and with recent history of detected obstructive sleep apnoea on CPAP was admitted for metabolic surgery.  Further the Opposite Parties have not furnished the Annexure R-2 i.e., exclusive Clause 4.10 & 4.19 as per that clauses the Complainant’s claim is not liable to be honoured. 
13. On the other hand, the Complainant in support of their case examined Dr.Ramesh, according to his evidence,  the Complainant’s father Pranesh G.V was admitted to their Hospital on 03.09.2014 and he was complained suffering from diabetes mellitus since 20 years and on insulin since five years, hypertensive since 15 years on treatment, dyslipidemic since 10 years and with recent history of detected obstructive sleep apnoea on CPAP.  On  examination noticed that the Complainant’s father will be benefited in a major way if he undergoes metabolic surgery as he can get remission from diabetes, hypertension and dyclipedimia.  He can live a life, free from the metabolic syndrome and he was operated Metabolic surgery on 04.09.2014.  During his cross-examination Doctor has clearly denied the suggestion that the Syndrome indicates pre-existence.  The Syndrome indicates symptoms of Medical complication and also advice that the Metabolic Syndrome is due to obesity and further advised that the Metabolic Syndrome is always having a sleep obstruction and further stated that the Metabolic Syndrome would be a Chronic.  From this evidence of Dr.M.Ramesh, it is very clear that the Metabolic Syndrome would be a Chronic but it is not due to obesity. 
14. As the defence taken by the Opposite Parties.  Further as stated earlier, the Opposite Parties have not produced any evidence.  To substantiate their defence, except the interested version of Sri.K.Sai Prakash and the Complainant also produced Certificate issued by Dr.Tulip, certifying that Mr.Pranesh G.V is suffering from diabetic, hypertension and dyslipidemic i.e., Metabolic.   He will be benefited in a major way if he undergoes metabolic surgery as he can get remission from diabetes, hypertension and dyclipedimia.   He can live a life, free from the metabolic syndrome of quality of life will be improved.  So from this evidence also it is clear that if the Complainant’s father undergone surgery i.e., he will be benefited and have a better life.  For that reason only, the Complainant’s father undergone surgery was contacted by Dr.Tulip himself and for surgery incurred expenses of Rs.3,60,000/-.  But when the Complainant submitted the claim form along with the medical record and bill the Opposite Party No.1 is rejected the claim of the Complainant without assigning proper reason i.e., expenses incurred primarily for evaluation/diagnostic purposes and treatment for obesity or condition arising there from and any other weight control program.  On the other hand, Dr.M.Ramesh in his evidence clearly stated that the Metabolic Syndrome is not obesity and Metabolic Syndrome is not weight reduced program.  As the defence taken by the Opposite Parties, thereby the Opposite Parties failed to substantiate their defence.  On the other hand, the Opposite Party No.1 bound to honour the claim.  Nodoubt, the policy coverage is only Rs.3,00,000/- but the Complainant claims Rs.3,60,000/- it is not permissible, thereby the Opposite Parties is bound to reimburse the medical expenses of Rs.3,00,000/-.    Hence, this point is held in Affirmative.

15. POINT NO.2:-  In the result, for the foregoing reasons, we proceed to pass the following order:

ORDER

The complaint is allowed holding that there is deficiency of service on the part of the Opposite Party No.1 & 2.

The Opposite Party No.1 & 2 are directed to reimburse the medical expenses of Rs.3,00,000/- to the Complainant.

The Opposite Party No.1 & 2 are further directed to pay sum of Rs.50,000/- as compensation for causing mental agony to the Complainant.

The Opposite Party No.1 & 2 are also liable to pay Rs.5,000/- as cost to the Complainant.

The Opposite Party N.1 & 2 are directed to pay aforesaid amount within 45 days from the date of receipt of this order.  Failing which the aforesaid amount will carry interest at 12% p.a. from the date of order, till the date of payment.

Supply free copy of this order to both the parties. 

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Forum on this, dt.24^th day of July 2018).

MEMBER                                            PRESIDENT

LIST OF WITNESSES AND DOCUMENTS

 Witness examined on behalf of the Complainant:

1. Sri.Pradeep G.P, who being the Complainant has filed his affidavit.

 List of documents filed by the Complainant:

1. Policy copy
2. Opinion issued by hospital
3. Discharge Summary.
4. MOU dtd.31.08.2015
5. Legal Notice
6. Postal Receipts
7. RPAD returned Covers.
8. Claims document List
9. Contact Details-Mediclaim
10. Scanned and ECG copies
11. Endoscopy report
12. Haematology report
13. Clinical pathology report transfusion medicine report
14. Serology report
15. Biochemistry report
16. Certificate of doctor Tulip
17. Surgical pathology report
18. Health questionnaire
19. Bill Receipts
20. Exercise Stress Test Report
21. Echo Cardiograph Report
22. Oral Gastrograffin Study
23. Ultrasound Scan of Abdomen and Pelvis
24. Diagnostic PSG Report
25. Respiratory Summary
26. Limb Movement Summary
27. Pre-operative orders for Bariatric(Obesity)Surgery

Witness examined on behalf of the Opposite Parties:

1. Sri.K.Sai Prakash, on behalf of the Opposite Party No.2 by way of affidavit.

List of documents filed by the Opposite Party:

                             -NIL-

MEMBER                                                                 PRESIDENT