CC No: 394/2015

 Filed on 26.02.2015

Disposed on 17.05.2016

BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM,

BENGALURU – 560 027

DATED THIS THE 17^th DAY OF MAY 2016

CONSUMER COMPLAINT NO.394/2015

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 is a complaint filed by the Complainant against the Opposite Party under Section-12 of the Consumer Protection Act, 1986, praying to pass an order directing the Opposite Party No.2 to reimburse an amount of Rs.64,483/- together with interest at 12% p.a., a sum of Rs.20,000/- as compensation for the mental agony and a sum of Rs.13,000/- towards legal notice charges and costs of this litigation.

2.         The brief facts of the Complaint can be stated as under:

In the complaint, the Complainant alleged that the Complainant is an employee with the 1^st Opposite Party, the 1^st Opposite Party provided medical insurance covered to the Complainant and his family members including parents.  Against the claim in the case of parents upto 25% is reimbursed.  The Complainant obtained policy for his father Sri Bal Krishna Prasad came to be diagnosed with Non Hodgkin lymphoma in March 2014.  He has been treated with Rituximab-Bendamustine Chemotherapy for a total of six cycles starting from May 2014 upto October 2014.  Ever since his treatment he has been on maintenance Rituximab therapy as per standard treatment protocol for low grade NHL.  All his claims during his period of treatment have been pre-authorized and claims submitted thereafter by the Complainant have been approved and payments have been made as per norm.  For the treatment undergone on 13.12.2014 a sum of Rs.60,000/-, the Complainant submitted the claim bearing No.90239621 on 13.12.2014 along with all necessary documents for the cashless claim, despite this the 2^nd Opposite Party has rejected the claim of the Complainant citing the following reasons “Rituximab is biological drug which is not admissible as treatment for cancer under policy conductions-hence denied”.  With these observations, this cashless claim put forth by the Complainant has been denied in total.  Thereafter, the Complainant had resubmitted the claim for reimbursement along with physical bills bearing No.90290981 dt.17.12.2014 for a sum of Rs.64,483/- which has been rejected on 05.01.2015 with the observation “on the perusal of the submitted claim documents it is noted that this claim petition pertains to a 70 years old male patient Mr. Bal Krishna Prasad with the complaints of Non Hodgkin’s Lymphoma.  During stay in hospital, patient received intravenous Rituximab which is a monoclonal antibody and will not be covered under the policy, hence, claim stands repudiated.  The Complainant got confirmation from the 2^nd Opposite Party that his claim for reimbursement as above was not entertained therefore, he got issued legal notice on 31.01.2015 through registered post for both the Opposite Parties.  The notice has been delivered personally and despite of service of notice, the Opposite Parties have neither sent reply nor have met the demands put forth by the Complainant.  Hence, this complaint.

            3.         Even though notice was served on the 1^st Opposite Party, the 1^st Opposite Party fails to put their appearance, hence, placed them exparte.  In response to the notice, the 2^nd Opposite Party put their appearance and filed their version.  In the version pleaded that the complaint is not maintainable either in law or on facts.  The Insurer-United India Insurance Company Ltd., has not been made as party to the proceedings who has issued the policy, therefore, the complaint is not maintainable for non-joinder and mis-joinder of proper and necessary parties to the proceedings.  The Opposite Party is licensed by IRDA is an independent organization and having separate entity.  This Opposite Party is a service provider of insurance companies and their job is processing the claims of the customers under health insurance policies issued by the Insurer.  As third party service provider, the Opposite Party shall process the claims and the decision for settlement/denial of claims rest with the insurance company.  Any communication regarding settlement or denial regarding settlement/denial of claims will be made through this Opposite Party which is based on the insurer concurrence and advice.  United India Insurance Company has issued the Group Mediclaim Policy in favour of the 1^st Opposite Party herein covering their employees.  The United India Insurance Company is engaged this Opposite Party as a service provider under the policy for adjudicating the health insurance claims subject to policy terms and conditions and guidelines of insurer.  The Complainant’s father Sri.Balakrishna Prasad, 70 years patient known case of Non-Hodgkin’s Lymphoma, he has received 6 cycles of thermotherapy with injection bendamustine and rituximab till 10.10.2014 and all the previous claims were considered till October 2014 as the treatment was with injection bendamustine and supportive care including retuximab.  Since bendamustine is a chemo drug and as chemotherapy is included under approved list of day care procedures previous claims were considered and now the present claim is disputed for non-hospitalization shown on 13.12.2014 for an outpatient day care treatment.  This treatment procedure of administration of the injection rituximab neither falls under the list of approved day care procedures nor requires 24 hours of inpatient hospitalization.  Hence, the claims stands repudiated under operative clause and 2.3 as hospitalization are mandatory under the policy.  The drug Rituximab is generally administered adjuvant during chemotherapy which this Opposite Party has paid as chemotherapy as listed under day care procedures.  It is submitted that this maintenance therapy along is not under the day care procedures list and does not consider the claim as the nature of treatment could have been done on OP basis and the same cannot be considered as chemotherapy to avail the benefit of chemotherapy exclusion for outpatient treatment under the policy conditions.  Hence, prays to dismiss this complaint.

4.         In support of the complaint, the complainant has filed affidavit by way of evidence.  For the Opposite Party one Sri S.R. Bhat, CAO of the Opposite Party has filed his affidavit by way of evidence.  Heard the arguments of both the parties.

5.         Now 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?

6.         Our findings on the above points are:-

                        POINT (1):- Accordingly

                        POINT (2):- As per the final Order

REASONS

7.         POINT NO. 1:-         It is the case of the Complainant that he obtained a policy for his father Sri Bal Krishna Prasad came to be diagnosed with Non Hodgkin lymphoma in March 2014.  He has been treated with Rituximab-Bendamustine Chemotherapy for a total of six cycles starting from May 2014 upto October 2014.  Ever since his treatment he has been on maintenance Rituximab therapy as per standard treatment protocol for low grade NHL.  All his claims during his period of treatment have been pre-authorized and claims submitted thereafter by the Complainant have been approved and payments have been made as per norm.  This fact has not been denied.  Further to substantiate this fact, the Complainant filed his affidavit and in the sworn testimony he reiterated the same and also produced claims information.  As looking into this document, it reveals that the Complainant’s father Sri Balakrishna Prasad and his treatment on 13.12.2014 for the abovesaid treatment.  As looking into this document, the Complainant presented the claim application and the said claim was honoured by the 2^nd Opposite Party from July 2014 to October 2014.  This evidence of the Complainant remains unchallenged.  So to disbelieve this version of the Complainant, there is no contra evidence.  Therefore, it is proper to accept the contention of the Complainant that the Complainant’s father Sri Balakrishna Prasad was diagnosed with Non Hodgkin lymphoma in March 2014.  He has been treated with Rituximab-Bendamustine Chemotherapy for a total of six cycles starting from May 2014 upto October 2014.  Ever since his treatment he has been on maintenance Rituximab therapy as per standard treatment protocol for low grade NHL.  All his claims during his period of treatment have been pre-authorized and claims submitted thereafter by the Complainant have been approved.

            8.         It is the further case of the Complainant that his father has undergone treatment on 13.12.2014, for that a sum of Rs.60,000/- was incurred.  The Complainant submitted a claim bearing No.90239621 on 13.12.2014 along with necessary documents for insurance claim.  Inspite of this, the 2^nd Opposite Party rejected the claim of the Complainant citing “Rituximab is biological drug which is not admissible as treatment for cancer under policy conductions-hence denied”.  Thereafter, the Complainant resubmitted the claim for reimbursement along with the bill bearing No.90290981 dt.17.12.2014 for a sum of Rs.64,483/- which has been rejected on 05.01.2015 with the observation “on the perusal of the submitted claim documents it is noted that this claim petition pertains to a 70 years old male patient Mr. Bal Krishna Prasad with the complaints of Non Hodgkin’s Lymphoma.  During stay in hospital, patient received intravenous Rituximab which is a monoclonal antibody and will not be covered under the policy.  In support of this contention, the Complainant in his sworn testimony reiterated the same and produced the letter addressed by the 2^nd Opposite Party to the Medical Superintendent of Manipal Hospital in respect of the cashless claim No.90239621. This document is with respect to Sri Balakrishna Prasad, father of the Complainant about submission of cashless claim request dt.12.12.2014.  The said claim was rejected by the 2^nd Opposite Party stating that “Rituximab is biological drug which is not admissible as treatment for cancer under policy conductions” and also produced the certificate issued by Dr. Ashish Dixit of Manipal Hospital dt.13.12.2014 certified that Sri Balakrishna Prasad has been diagnosed as Non Hodgkin’s Lymphoma since March 2014 and he has been treated with Rituximab-Bendamustine Chemotherapy for a total of six cycles starting from May 2014 upto October 2014.  Ever since his treatment he has been on maintenance Rituximab therapy as per standard treatment protocol for low grade NHL.  He was admitted on 13.12.2014 for maintenance of Rituximab-Bendamustine Chemotherapy.  The said claim was denied by the 2^nd Opposite Party.  This evidence has not been denied by the Opposite Party and also 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 claim bearing No.90239621 dt.13.12.2014 for a sum of Rs.60,000/- cashless claim is rejected as well as claim bearing No.90290981 for a sum of Rs.64,483/- was also rejected by the 2^nd Opposite Party on the ground that “Rituximab is biological drug which is not admissible as treatment for cancer under policy conductions”.  But as looking into the terms and conditions of the policy, it is not so.  If at all the claim of the petition is not admissible since Rituximab is biological drug which is not admissible as treatment for cancer under policy conductions, while earlier claim of the Complainant for the same disease was approved and honoured by the 2^nd Opposite Party.  Therefore, the 2^nd Opposite Party ought to have honoured the claim bearing No.90290981 submitted by the Complainant, but without considering in proper manner and assigning untenable reasons rejected the claim of the Complainant.  Thereby, the act of the 2^nd Opposite Party for rejecting the claim of the Complainant amounts to deficiency in service.  If at all 2^nd Opposite Party acted in a proper manner and by applying proper mind ought to have allow his claim of the Complainant.  On the other hand, it is not so, but unfortunately without proper application and assigning untenable reasons rejected the claim of the Complainant, thereby it amounts to deficiency in service on the part of the 2^nd Opposite Party.  Hence, this point is held accordingly.

9.         POINT NO.2:-          In view of the finding on Point No.1, we proceed to pass the following;

ORDER

The complaint against Opposite Party No.1 is dismissed.  The Complaint is allowed holding that there is deficiency in service by the Opposite Party No.2.  The Opposite Party No.2 is directed to pay a sum of Rs.64,483/- to the Complainant.  The Opposite Party No.2 is further directed to pay a sum of Rs.10,000/- as compensation for the mental agony and Rs.5,000/- as costs of this litigation to the Complainant.  The Opposite Party No.2 is granted 30 days time from this date to comply this Order.  Failing which, the aforesaid amount shall carry interest at 18% p.a. from the date of this Order, till the date of payment.

Supply free copy of this order to both the parties. 

(Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 17^th day of May 2016).

       MEMBER                                                                               PRESIDENT

CC. NO.394/2015

LIST OF WITNESSES AND DOCUMENTS

Witnesses not examined, but affidavit of the witnesses is filed, as follows;

1. Sri Pankaj Kumar has filed his affidavit for Complainant.
2. Sri S.R. Bhat, working as CAO has filed his affidavit for the Opposite Party.

List of documents filed by the Complainant :

1. Copy of the medical insurance policy.
2. Copy of the claims summary.
3. Copy of the cashless claim dt.13.12.2014.
4. Copy of the legal notice dt.31.01.2015.
5. Copy of the postal receipts and acknowledgements.

List of documents filed by the Opposite Party :

NIL

MEMBER                                                                               PRESIDENT