Delhi

East Delhi

CC/131/2022

VINOD KUMAR JAIN - Complainant(s)

Versus

NATIONAL INS. CO. - Opp.Party(s)

23 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No.131/2022

 

 

	Vinod Kumar Jain H-1, Siddh Appartment, 107, I.P. Extention, Delhi – 110092.	….Complainant
Versus
	National Insurance Co. Ltd. Division-XI, IInd Floor, National Insurance Building, 14, Jamshedji TATA Road, Churchgate, Mumbai, Maharashtra – 400020.	……OP

Date of Institution: 14.03.2022

Judgment Reserved on: 15.03.2023

Judgment Passed on: 23.03.2023

               

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

 

Order By: Shri Ravi Kumar (Member)

 

JUDGEMENT

        The Complainant, a Sr. Citizen, has alleged deficiency in service on the part of OP in not permitting cashless authorization and not approving medical bill of his wife Smt. Maya Jain of Rs.79476/- for Chemo Therapy despite of having Medical Policy.

        The complainant has stated in his complainant that he is having Group Medical Insurance Policy No.251100502010000329 from the OP for himself and his wife for Rs.9,00,000/- for the period 01.11.2020 to 31.10.2021. His wife Smt. Maya Jain is a Cancer patient and she was taking cashless Chemo Therapy treatment from one of the approved Hospital of the OP and cashless reimbursement for 11 cycles Chemo each was approved by the OP till 15.12.2020. The Chemo therapy of 12^th Cycle was given to the wife of the complainant on 06.01.2021 at Max Hospital, Vaishali and bill of Rs.79203/- was raised for which cashless approval was not given by the OP by stating that Monoclonal Antibody Chemo Therapy is done on OPD basis and as per the revised guidelines of IRDA the same is not permissible.

On account of refusal the complainant underwent mental stress as he had to arrange the payment of Rs.79203/-. The Chemo Therapy was completed at 01.00 p.m. in the Max Hospital Vaishali, however, on account of his arranging the amount to be paid to the hospital,  the complainant’s wife was discharged at 06.00 p.m. approximately and she was at risk of life due spread of Corona as there was large number of Corona patients in the Hospital. He has further stated that treating Dr. Vikas Goswami vide letter dated 07.01.2021 has confirmed that Chemo Therapy cannot be given on OPD basis and it is given intravenously however, despite of that and his having Insurance cover of Rs.9.00 lacs which was valid from 01.11.2020 to 31.10.21 his cashless request was disapproved by OP and so was his medical claim. The complainant has made following prayers in the complaint:

• OP to reimburse Chemo Therapy expenses paid by him at the Hospital amounting to Rs.79746/-.
• OP to pay compensation of Rs.100000/- for mental harassment and negligence.

Complainant has filed following documents alongwith his complaint:

• Copy of Letter dated 06.01.2021 of Heritage Health Insurance TPA Pvt. Ltd. rejecting the cashless hospitalization.
• Copy of letter dated 07.01.2021 of Dr. Vikas Goswami of Max Hospital, Vaishali.
• E-mail dated 13.01.2021 from Heritage Health Insurance TPA Pvt. Ltd.
• Discharge Summary dated 16.12.2020 of Max Hospital.
• Discharge Summary dated 06.01.2021 of Max Hospital.
• Detail revised guidelines issued by the OP.
• Print out of IRDA making changes in Health Insurance Guidelines.
• In-patient bill dated 06.01.2021 of 79203/- and bill dated of Ahinsa Jain Dharmarth Sansthan dated 27.01.2021 of Rs.544/-.

Notice was issued to OP and it has filed its Reply wherein it has stated that the complaint is not maintainable in view of the fact that treatment taken by the patient was not listed in Day Care and usually done on OPD basis. Smt. Maya Jain wife of the complainant was admitted for administration of Monoclonal Antibody on standalone basis in Max Hospital, Vaishali on 06.01.2021 and was discharged on the same day. This procedure is usually done on OPD basis. The claim was repudiated under the policy clause No. 2.19 and intimation dated 13.01.2021 was e-mailed by the TPA to the complainant that as per revised guideline the treatment of Monoclonal Antibody Chemo Therapy is done on  OPD basis and does not require hospitalization. This stand of the OP was also confirmed by the Insurance Ombudsman. The Group Medical Claim Policy was issued to Punjab National Bank Retirees subject to terms and conditions contained therein. The revised guideline made by IRDA became effective from 01.10.2020 and these changes were aimed at making the health insurance broader covering more treatments. The treatment for Monoclonal Antibody was to be given as an injection. As the said treatment was done on OPD basis, hence the claim was rejected by the TPA. OP has also stated that cashless benefit was given inadvertently earlier by TPA for the said treatment for which the OP is initiating recovery against the TPA. OP has enclosed Terms and Conditions of the policy alongwith his reply and copy of letter dated 06.01.2021 of the TPA and also orders dated 10.02.22 of the Insurance Ombudsman.

    The complainant has filed Rejoinder denying the contentions of the OP and has reiterated the complaint’s contents. In his Rejoinder the complainant has stated that OP has mentioned that the treatment ‘usually’ done on OPD basis, which means that treatment given is not compulsorily be given on OPD basis and it can be given in Day Care also. The patient was admitted in Max Hospital which is approved Hospital of OP where she was given the following treatment - inj. Trastuzumab +  inj. Docetaxel + Inj. Corboplatin (TCH) which have been mentioned in the Discharge Summary. Further regarding the revised guidelines the same were communicated only on 13.01.2021 whereas the treatment was given to the patient on 06.01.2021. As per the policy document clause No.3.3.13 given by the OP, expenses on hospitalization for minimum period of a day are permissible. However, this time limit is not applied for specific treatment as such Chemo Therapy. There is no distinction between Monoclonal Chemo and non-Monoclonal Antibody Chemo.

Both Complainant & OP have filed their Evidence by way of Affidavit.

This commission has heard the argument of both sides and has perused the documents on record.

Complainant was having Medical Insurance Policy No. 251100502010000329 with the OP which was valid from 01.11.2020 to 31.10.2021 wherein he and his wife were covered for insurance of Rs.9.00 lacs. The wife of the complainant is cancer patient and she was undergoing Chemo Therapy and she had already undergone 11 Chemo cycles till 16.12.2020 at Max Hospital, Vaishali and all cashless reimbursement were approved by the OP. She went for 12^th cycle of Chemo Therapy on 06.01.2021 at  Max Hospital, Vaishali where she was admitted at 11:12 a.m. and was administered medicines through intravenous injection. However, request for cashless hospitalization was rejected by the TPA on the ground that patient was admitted for Monoclonal Antibody Chemo Therapy which is taken on OPD basis and falls under exclusion clause 2.19 of the Policy. Since, the cashless hospitalization was refused the complainant had to arrange the funds from his own sources and made the payment and his wife got discharged from the Hospital at 6:29 p.m. on that day. In the Bill of Supply In-patient Bill (Summary) dated 06.01.2012 as well as Discharge Summary of Max Hospital  dated 06.01.2021, she is shown as in-patient

Para 2.19 of the policy is as follows:-

    Hospitalization:

Means admission in the Hospital/Nursing home for a minimum period of 24 in-patient care consecutive “In-patient care” hours except for the period specified day care procedures/treatments. Where such admission could be for a period of less than 24 consecutive hours.

OP has relied on the above clause as well as upon the revised guideline issued by the IRDA according to which Monoclonal Antibody Chemo Therapy is OPD based treatment does not require hospitalization and hence OP has rejected the cashless pre-authorization as well the claim of the complainant.

The primary question that arises before this Commission is that whether the revised guidelines were communicated to the complainant as policy holder by the OP and if so, when. As per the records available the 12^th Cycle Chemo Therapy was given to the patient on 06.01.2020 at Max Hospital, Vaishali and till that time there was no communication of such revised guideline of the IRDA by the OP to the complainant. OP is not been able to establish that it communicated about change in the Terms & Conditions of the Policy to the Complainant before 06.01.2021 and sent the modified Terms & Conditions of the Policy. This amounts to deficiency in service on the part of OP.

    It is to be further examined whether the treatment of Chemo Therapy given to the complainant could be given in OPD. The Doctor administering the treatment to the complainant i.e.  Dr. Vikas Goswami in his letter dated 07.01.2021 has stated that the treatment given to the patient was intravenous and cannot be given on OPD basis.

As per the Discharge Summary dated 06.01.2021, the treatment given by way of injection was inj. Trastuzumab +  inj. Docetaxel + Inj. Corboplatin (TCH) which cannot be given in OPD and patient was registered as ‘In-patient’ by the Max Hospital Vaishali vide registration No.VSLI230863. Treatment of Cancer by Chemo-therapy is a complicated treatment which require expert Doctor and the treating Doctor permitted her to be taken as ‘in-patient case’ then only she was admitted in the Hospital and in previous 11 Chemo therapies same procedure was followed  and OP/TPA had approved the expenses. Thus the stand of the OP that the Chemo Therapy treatment given to the wife of the Complainant was OPD case is neither convincing nor tenable. Further neither OP nor Insurance Ombudsman are expert in medical line and opinion of the treating doctor is of utmost importance as he is aware of the medical condition of his patient and the treating Doctor opined in his letter dated 07.01.2021 that it was not a case of OPD.

It is also strange to note that the OP who had earlier approved the Chemo therapy expenses is taking the stand that it is taking steps to recover the amount inadvertently approved, from TPA for previous 11 Chemo cycle but it is not indicating any steps it is contemplating for the recovery of this amount from the Complainant. If the Complainant had wrongly claimed the amount then OP should have taken steps to recover it from him and not from TPA and therefore, this establish that there was nothing wrong in approving Chemo Therapy expenses for 11 cycle and ‘Rule of Estoppel’ shall apply against the OP on account of the previous conduct and therefore approval of expenses for 12^th Chemo cycle on 06.01.2021 also should have been given by OP as there was no change in Terms and Conditions of the policy on that date nor anything with regard to any such change was communicated to the complainant.

We are also not losing sight of the fact that complainant is a retired Sr. Citizen and so is his wife and they had taken Group Medical Claim Policy to have the comfort of their medical needs taken care without any hassle for which good amount of premium was paid by them. However, conduct of the OP in the present complaint is not upto the mark in refusing the reimbursement of same medical treatment of 12^th Chemo Cycle on 06.01.2021 to the wife of the Complainant. This has caused unwarranted mental stress and agony to both these Senior Citizens without any fault of them.

For the reasons stated above deficiency in service is established against the OP and this Commission orders as follows:

• OP to pay Rs.79203/- to the Complainant being the Hospital expenses incurred on 06.01.2021 by him alongwith interest @7% p.a. within 30 days of receipt of this Order.
• OP to pay exemplary cost of Rs.25000/- towards mental agony and harassment caused to the Complainant.
• If the above order is not complied within 30 days from receipt of this order by OP then OP shall be liable to pay interest on all the above amounts @9% p.a. till the date of payment.

Copy of this Order be send to parties free of cost as per rules.

File be consigned to Record Room.

 Announced on 23^rd day of March, 2023.