Versus
Oriental Insurance Company Limited, Divisional Office No.1, Gill Road, Opp. MC Zone C, Ludhiana through its Divisional Manager. …..Opposite party
Complaint Under Section 35 of the Consumer Protect Act, 2019.
QUORUM:
SH. SANJEEV BATRA, PRESIDENT
MS. MONIKA BHAGAT, MEMBER
COUNSEL FOR THE PARTIES:
For complainant : Sh. Mohit Verma, Advocate.
For OP : Sh. R.K. Chand, Advocate.
ORDER
PER SANJEEV BATRA, PRESIDENT
1. Shorn of unnecessary details, the facts of the case are that the complainant obtained Happy Family Floater Policy No.233400/48/2021/122 having validity from 30.04.2020 to 29.04.2021 from the OP and has been renewing from the last many years without any break. On 24.07.2020, the complainant got admitted in DMC Hospital for treatment of CNVM Rt eye (Choroidal Neo Vascular Membrace in Macular Region). According to the complainant this was not the first time that he got treatment for his eye. His previous claims regarding same complication were reimbursed by the OP. The complainant further stated that this treatment needs aseptic measures and injection is given in operation theatre under all aseptic conditions and is not OPD procedure. The complainant submitted the claim but the OP repudiated the same vide letter dated 18.12.2020 on the false ground that “It is not an OPD procedure and not covered under the policy terms and conditions. So the file close as NO CLAIM.” The complainant further stated that he is entitled to reimbursement of final bill of DMC Hospital amounting to Rs.24,434/-, Rs.244/- pharmacy bill, in all Rs.24,678/-. The complainant claimed to have suffered mental agony due to deficiency in service and unfair trade practice on the part of the OP for which he is entitled for compensation. In the end, the complainant has prayed for issuing direction to the OPs to pay a sum of Rs.24,678/- i.e. Rs.24,434/- as final bill of DMC Hospital and Rs.244/- as pharmacy bill along with compensation of Rs.50,000/- and litigation expenses of Rs.33,000/-
2. Upon notice, the OP appeared and filed written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; lack of jurisdiction; the complainant has not come with clean hands; suppression of material facts etc. The OP stated that the complainant lodged the claim regarding medical claim and immediately on receipt of claim, it was duly registered and entertained. The complainant was asked to submit the documents. Dr. Tarsem Lal Gupta was deputed for investigation and assessment of loss as per terms of the policy, who submitted his report dated 07.12.2020 and on receipt of which, the claim file was scrutinized by the competent authority of the OP and found the claim of the complainant to be not payable. As such, the same was repudiated vide letter dated 18.12.2020 as per terms and conditions of the policy.
On merits, the OP reiterated the crux of averments made in column brief facts of the case. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.
3. In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of RTI information dated 28.04.2022, Ex. C2 is the copy of repudiation letter dated 18.12.2020, Ex. C3 is the copy of report of investigator dated 07.12.2020, Ex C4 is the copy of claim form Part-A, Ex C5 is the copy of claim form Part-B, Ex C6 is the copy of In-Patient Final Bill dated 24.07.2020 of DMC Hospital, Ex C7 is the copy of discharge summary of DMC Hospital, Ex. C8 is the copy of bill of Rs.244/- dated 24.07.2020, Ex C9 is the copy of Tax Invoice dated 24.07.2020, Ex C10 is the copy of prescription slip, Ex. C11 is the copy of bill dated 24.07.2020 of Rs.2500/-, Ex C12 is the copy of Email dated 24.07.2020, Ex C13 is the copy of insurance policy, Ex. C14 is the copy of certificate issued by Civil Surgeon, Office, Ludhiana, Ex C15 is the copy of cashless authorization letter dated 31.01.2023 and closed the evidence.
4. On the other hand, the counsel for the OPs tendered affidavit Ex. RW1/A of Sh. Yash Paul, Sr. Divisional Manager of OP as well as affidavit Ex. RW2.B of Dr. Tarsem Lal Gupta, Ghumar Mandi Chowk, Civil Lines, Ludhiana along with documents i.e. Ex. R1 is the copy of repudiation letter dated 18.12.2020, Ex. R2 is the copy of report of investigator dated 07.12.2020, Ex R3 is the copy of claim form Part-A, Ex. R4 is the copy of Section A-Details of Primary Insured, Ex. R5 is the copy of claim form Part-B, Ex. R6 is the copy of In-Patient Final bill dated 24.07.2020, Ex. R7 is the copy of discharge summary dated 24.01.2020, Ex. R8 is the copy of bill dated 24.07.2020 of Rs.244/-, Ex. R9 is the copy of Tax Invoice dated 24.07.2020, Ex. R10 is the copy of prescription slip, Ex. R11 is the copy of bill dated 24.07.2020 of Rs.2500/-, Ex. R12 is the copy of Email dated 03.11.2020, Ex. R13 is the copy of Email dated 23.09.2020, Ex. R14 is the copy of insurance policy, Ex R15 is the copy of policy terms and conditions and closed the evidence.
5. We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statement, affidavits and documents produced on record by both parties.
7. Undisputably, the complainant had obtained Happy Family Floater Policy-2015 Ex. C13 = Ex. R14 from the OP covering himself and his family members under Gold Plan for a sum insured of Rs.10,00,000/-. On 24.07.2020, the complainant got treatment of CNVM Rt eye (Choroidal Neo Vascular Membrane in Macular Region) after getting admission in Dayanand Medical College and Hospital, Ludhiana by way of taking Injection Accentrix given intra vitreal and was discharged on 24.07.2020 vide discharge summary Ex. C7 = Ex. R7. In-Patient Final Bill dated 24.07.2020 Ex. C6 = Ex R6 of Rs.24,434/- and Pharmacy bill dated 24.07.2020 Ex. C8 = Ex. R8 of Rs.244/- were raised by DMC Hospital. The complainant submitted the claim form Ex. C4, Ex. C5 = Ex. R3, Ex. R5 with the OP. The OP appointed Dr. Tarsem Lal Gupta for investigating the claim of the complainant who submitted his report dated 07.12.2020 Ex. C3 = Ex. R2, the operative part of which is reproduced as under:-
“Ref. to the file given to me for Prof. Opinion I have observed that he was admitted at DMCH Ldh on 24/7/2- 10:57:59 under treatment Dr. Sumit Chopra.
Diagnosis-CNVM Rt Eye (Choroidal Neo Vascular Membrane in Macular Region) Injection Accentrix given intra vitreal in Rt. Eye in operation theatre under Topical Anesthesia and was discharged on 24/7/2020 12:54:19 Medicines prescribed .
On discussion with yourself regarding the coverage of this procedure under Happy Family Floater Policy 2015 and further consultation with Mr. Balwinder Dhiman at Regional Office Chandigarh on 3/12/20 it is an OPD Procedure and Not Covered under the policy
Keeping the above facts in mind claim does not fall under the scope of policy and may accordingly be treated as No Claim.”
After scrutinizing the report, the OP repudiated the claim vide repudiation letter dated 18.12.2020 Ex. C2 = Ex. R1. The operative part of Ex. C2 = Ex. R1 is reproduced as under:-
“This is with reference to your claim reported on dated 24.07.2020.
On going through the claim file we observed that the treatment of CNVM Rt Eye (Choroidal Neo Vascular Membrane in Macular Region) taken by you from DMC Hospital, on dt. 24.07.2020. In this connection we have discussed with our Regional Health Officer and opinion of our company’s investigator, it is an OPD procedure and not covered under the policy terms and conditions. So, the file close as NO CLAIM”
8. The complainant being aggrieved of rejection of his medical claim has challenged the said repudiation letter Ex. C2 = Ex. R1. In this regard, the relevant clauses of terms and conditions of the policy Ex. R15 are reproduced as under:-
“DAY CARE CENTRE: means any institution established for day care treatment of illness and/or injuries or a medical set-up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:-
- has qualified nursing staff under its employment.
- has qualified Medical Practitioner(s) in charge.
- has a fully equipped operation theatre of its own where surgical procedures are carried out.
- maintains daily records of patients and will make these accessible to the insurance Company’s authorized personnel.
DAY CARE TREATMENT: means the medical treatment and/or surgical procedure which is-
i) undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement and
ii) which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an outpatient basis is not included in the scope of this definition.
DOMICILIARY HOSPITALIZATION BENEFIT means medical treatment for a period exceeding 3 days for such an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:-
i) the condition of the patient is such that he/she is not in a condition to he removed to a hospital or
ii) the patient takes treatment at home on account of non-availability of room in hospital.
OPD TREATMENT: is one in which the Insured visits a clinic/Hospital or associated facilities like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.”
9. Dayanand Medical College and Hospital, Ludhiana qualifies to be a ‘Day Care Centre’ and is equipped to provide ‘Day Care Treatment’ as stipulated in the terms and conditions of policy. Further in this regard, the complainant has placed on record a certificate Ex. C14 issued by Dr. Manu Vij, MBBS (MS) Eye) SMO and Eye Mobile Incharge, Civil Surgeon Office, Ludhiana, which is reproduced as under:-
“This is to certify that Injection Intravitreal Lucentis are not given in OPD This process needs complete asceptic measures and it is given in operation theatre under all aspectic conditions.”
Further the injection was administered in operation theatre under “Topical Anesthesia” and Ex. C6 is a ‘In-Patient Final Bill’ wherein admission of one day has been mentioned. The OP while deciding the claim of the complainant, has not given any weightage to this certificate Ex. C14 and has totally ignored the same and had become too technical and harsh in dealing with the reimbursement claim of the complainant. Moreover, the Ericson Insurance TPA Pvt. Limited on behalf of the OP Insurance Company approved the cashless claim of the complainant of Rs.25,636/- vide Cashless Authorization Letter dated 31.01.2023 Ex. C15 with respect to same treatment regarding which the claim of the complainant under present complaint was repudiated. Now the OP is estopped by its act and conduct and is blowing hot and cold in same breath by not allowing the claim with respect to his treatment dated 24.07.2020. In the given facts and circumstances, it cannot be said that the repudiation of the claim is justified and as such, it would be just and appropriate if the OP is directed to pay the medical expenses of Rs.24,434/- along with interest @8% per annum from the date of taking treatment i.e. 24.07.2020 till date of actual payment along with composite costs of Rs.5,000/-.
10. As a result of above discussion, the complaint is partly allowed with an order that the OP is directed to pay the medical expenses of Rs.24,434/- along with interest @8% per annum from the date of taking treatment i.e. 24.07.2020 within 30 days from the date of receipt of copy of order. The OP shall further pay a 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 the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.
11. Due to huge pendency of cases, the complaint could not be decided within statutory period.
(Monika Bhagat) (Sanjeev Batra) Member President
Announced in Open Commission.
Dated:11.12.2024.
Gobind Ram.
