Punjab

Ludhiana

CC/21/105

Mohinder Kumar - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

B.K.Rampal adv

14 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:  105 dated 04.03.2021.                                                       Date of decision: 14.03.2024. 

 

Sh. Mohinder Kumar Chopra Aged about 65 years S/o. Sh. Shiv Chander Lal Chopra, R/o. House No.6, Garden Enclave, South City, Ludhiana.                                                                                                     ..…Complainant

                                                Versus

1. United India Insurance Co. Ltd., B-17, Phase II, Focal Point, Ludhiana-141010 through its Divisional Manager.
2. Vipul Medcorp Insurance TPA Pvt. Ltd., SCO No.98, Ist Floor, Industrial Area, Phase II, Chandigarh-160002 through its Director/Authorized Person.                                                                                                                                                                        …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2020.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. B.K. Rampal, Advocate.

For OP1                         :         Sh. Rajeev Abhi, Advocate.

For OP2.                        :         Exparte.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

 

1.                Briefly stated, the facts of the case are that on the assurance of OP1 for providing cashless hassle free treatment, the complainant purchased Individual Health Insurance Policy Cashless from OP1  vide policy No.2014002819P109671528 w.e.f. 31.10.2019 to 30.10.2020 for sum insured of Rs.5,00,000/-. The complainant claimed to have been purchasing policy from OP1 since 2011 continuously without any break.

                   The complainant stated that he suffered Cancer problem for which he was admitted in Max Super Specialist Hospital, Mohali for treatment. The complainant raised the following bills with the OPs:-

Bill dated	Amount claimed	Amount reimbursed
26.06.2019	Rs.75,110/-	Rs.71,101/-
23.08.2019	Rs.74,429/-	Rs.63,325/-
22.10.2019	Rs.65,931/-	Rs.64,537/-
23.10.2019	Rs.71,104/-	Rs.68,854/-
25.02.2020	Rs.72,419/-	Rs.69,449/-

 

The complainant further stated that he got treatment on 04.05.2020 for Chemotherapy treatment for which he claimed Rs.71,353/- which was declined by the OPs vide letter dated 10.06.2020. Thereafter, the complainant again submitted claim of Rs.66,200/- regarding treatment of Chemotherapy got on 01.07.2020 and the OP paid Rs.64,139/-. The complainant was also admitted in Max Super Specialist Hospital, Mohali on 30.11.2020 for treatment of Chemotherapy and raised a claim of Rs.71,717/- which was declined by the OPs vide Email letter dated 30.11.2020. The complainant was further admitted in Max Super Specialist Hospital, Mohali on 25.01.2021 for Chemotherapy treatment for which the complainant raised a claim of Rs.72,730/- which was declined by the OPs on flimsy ground vide Email letter dated 25.01.2021. The complainant further stated that the OPs have arbitrarily and illegally declined his claims dated 04.05.2020, 30.11.2020 and 25.01.2021 which is a deficiency in service on their part due to which the complainant has suffered mental tension harassment, pain and agony, financial loss. The complainant sent a legal notice dated 22.10.2020 upon the OPs through counsel Sh. B.K. Rampal, Advocate but the OPs sent a false and frivolous reply. In the end, the complainant has prayed for issuing direction to the OPs to pay Rs.71,353/-, Rs.71,717/- and Rs.72,930/- i.e. total Rs.2,16,000/- along with interest and compensation of Rs.2,00,000/- besides litigation expenses.

2.                 Upon notice, none appeared on behalf of OP2 despite service and as such, OP2 was proceeded against exparte vide order dated 22.10.2021.

3.                However, OP1 filed written statement and assailed the complaint by taking preliminary objections that on the ground of maintainability of the complaint; suppression of material facts; the complaint being estopped by his own act and conduct from filing the present complaint etc. OP1 stated that immediately on receipt of claim, it was duly registered, entertained and processed. OP1 admitted the issuance of Individual Health Insurance Policy No.2014002818P1086673414 w.e.f. 31.10.2018 to 30.10.2019, policy No.2014002819P109671528 w.e.f. 31.10.2019 to 30.10.2020 and policy No.20140002820P107950572 w.e.f. 31.10.2020 to 30.10.2021 for sum assured of Rs.5,00,00/- as per the terms and conditions of the policy including condition under the head Modern Treatment Methods and Advancement in Technology with limits as per surgery that

5

Immunotherapy – Monoclonal Antibody to be given as injection

Up to 20% of sum insured subject to a maximum of Rs.2 lacs per policy period.

 

The complainant was admitted in Max Super Specialty Hospital, Mohali due to cancer where he took treatment during policy period w.e.f. 31.10.2019 to 30.10.2020 and lodged certain claims for chemotherapy, which were settled as per terms and conditions of the policy and same were accepted by the complainant as full and final settlement, the detail of which is reproduced as under:-

Sr. No.	Bill Dated	Amount	Status
1.	26.06.2019	75,100/-	Settled for Rs.71,101/-
2.	23.08.2019	74,419/-	Settled for Rs.63,325/-
3.	22.10.2019	65,931/-	Settled for Rs.64,537/-
4.	23.10.2019	71,104/-	Settled for Rs.68,854/-
5.	25.02.2020	72,419/-	Settled for Rs.69,449/-
6.	01.07.2020	66,200/-	Settled for Rs.64,139/-

 

OP1 further stated that the complainant lodged cashes authorization on 04.05.2020 for reimbursement of medical expenses incurred on his treatment on 04.05.2020 for Rs.71,353/- with OP2 which Max Hospital, Mohali, which was registered at file No.21CB04UIK0150 of OP2 for treatment with date of admission as 04.05.2020 and date of discharge as 04.05.2020 with diagnosis of "unspecified B Cell Lymphoma, unspecified site". The said cashless treatment was duly entertained, registered, processed as per terms and conditions of the policy. However, the said cashless treatment was not lodged for chemotherapy. After the receipt of the documents and after scrutinizing the same, the cashless authorization of the complainant was rejected as no claim by OP2 M/s. Vipul MediCorp Insurance TPA Pvt. Ltd. vide its Email dated 04.05.2020 on the grounds that the patient Sh. Mohinder Kumar Chopra 64Y/M was treated with INJECTION RITUXIMAB only during his admission with diagnosis of LOW GRADE B CELL LYMPHOMA. This injection does not require hospitalization for a period of 24 hours or more neither it is a day care procedure. According to OP1, the policy clause 2.18 deals with hospitalization and specified day care procedures/treatments. Item No.140 defines Cancer Chemotherapy - Item 140 as permissible in day care treatment. But the therapy through RITUXIMAB INJECTION is not Cancer Therapy but it is a type of monoclonal antibody therapy which attacks the cells where cancer starts. It works by showing or stopping the growth of Cancer Cells. As the claim was not admissible and as such same was repudiated as no claim as the said therapy is not included in the day care list of the policy terms and conditions. The cashless authorization of the complainant has rightly been repudiated as no claim on legal and valid grounds.

                   OP1 further stated that the complainant had lodged the claim under policy having validity from 31.10.2020 to 30.10.2021 for his treatment in Max Super Specialty Hospital, Mohali on 30.11.2020 for a sum of Rs.71,717/- with OP2 with date of admission as 30.11.2020 and date of discharge as 30.11.2020 with diagnosis of "unspecified B Cell Lymphoma, unspecified site". The said cashless authorization was registered at No. 21RBO4UKI1002 which was duly entertained, processed as per terms and conditions of the policy. The said claim was not lodged for chemotherapy. Further after the receipt of the documents and after scrutinizing the same, the cashless authorization of the complainant was rejected as no claim by them vide their Email dated 30.11.2020 on the similar grounds. Further the claim lodged by the complainant under policy No.2014002820P107950572 having validity from 31.10.2020 to 30.10.2021 for his treatment in Max Super Specialty Hospital, Mohali on 30.11.2020 for a sum of Rs.72,930/- with OP2 for treatment in Max Super Specialty Hospital with date of admission as 25.01.2021 and date of discharge as 25.01.2021 for chemotherapy cycle 9 on 25.01.2021 - lnj Rituximab (Ristova) 700 mg. IV, which was also registered at No. 21RBO04UK1K1198 and settled and paid for Rs.68,342/- on 15.02.2021 vide UT No.21126236494 in full and final settlement of the claim and accepted by the complainant in full and final settlement of the claim by the complainant voluntarily, unconditionally, without any protest, and without reserving any right to recover any further amount under claim. According to OP1, the said claim falls under new policy valid w.e.f. 31.10.2020 to 30.10.2021 under which intra vitreal injunctions are covered up to the maximum limit of Rs. 1 Lac per policy period. Hence the balance amount of Rs.31,658/- (Rs.1,00,000/- less Rs.68,342/-) can be considered in the subsequent claim for the said treatment. However, the amount of Rs.31,658/- has been credited to the account of the complainant by Vipul MedCorp Insurance TPA Pvt. Ltd. vide claim settlement voucher dated 16.08.2021 in claim No.21RBO4UIK1002 with hospitalization from 30.11.2020 to 30.11.2020. Thus OP1 had paid Rs.1 Lac to the complainant for the aforesaid treatment which was the maximum liability of OP under the policy in question for such treatment. The complainant had wrongly stated that the claim has been repudiated as no claim vide email dated 25.01.2021 by OP2. However, two claims of the complainant have rightly been repudiated as no claim on legal and valid grounds.

                   On merits, OP1 reiterated the crux of averments made in the preliminary objections and facts of the case. OP1 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.      

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated his averments of the complaint. The complainant also placed on Ex. C1 copy of policy w.e.f. 31.10.2019 to 30.10.2020, Ex. C2 is the copy of policy schedule w.e.f. 31.10.2020 to 30.10.2021, Ex. C3 is the copy of claim/cashless history for member, Ex. C4 is the copy of settlement receipt dated 04.05.2020 as well as medical bills, Ex. C5 is the copy of Inpatient bill summary dated 01.12.2020, Ex. C6 is the copy of settlement receipt dated 25.01.2021 as well as medical bills, Ex. C7 is the copy of settlement receipt dated 23.08.2019, Ex. C8 is the copy of Inpatient bill summary dated 22.10.2019, Ex. C9 is the copy of settlement receipt, Ex. C10 is the copy of settlement receipt dated 24.02.2020, Ex. C11 is the copy of statement of account of the complainant, Ex. C12 is the copy of legal notice dated 22.12.2020, Ex. C13 and Ex. C14 are the copies of postal receipts,  Ex. C15 to Ex. C17 are the copies of claim forms and closed the evidence.

5.                On the other hand, the counsel for OP1 tendered affidavit Ex. RA of Ms. Sangeeta Kakkar, Senior Divisional Manager, United India Insurance Co. Ltd., DO-VI, B-17, Phase II, Focal Point, Ludhiana as well as affidavit Ex. RB of Dr. Rahul Verma, administrator of OP2 along with documents i.e. Ex. R1 is the copy of  insurance policy w.e.f. 31.10.2018 to 30.10.2019, Ex. R2 is the copy of insurance policy w.e.f. 31.10.2019 to 30.10.2020, Ex. R3 is the copy of insurance policy w.e.f. 31.10.2020 to 30.10.2021, Ex. R4 is the copy of Email dated 17.08.2021, Ex. R5 is the copy of claim settlement letter dated 16.08.2021, Ex. R6 is the copy of claim processing module Ex. R7 is the copy of claim processing sheet dated 20.07.2021, Ex. R8 is the copy of claim settlement letter 21.10.2020, Ex. R9 is the copy of query letter dated 29.12.2020, Ex. R10 is the copy of claim form dated 07.12.2020 Ex. R11 is the copy of claim form-Part B dated 07.12.2020, Ex. R12 is the copy of consent form dated 07.12.2020, Ex. R13 is the copy of discharge summary dated 30.11.2020, Ex. R14 is the copy of query letter dated 01.08.2020, Ex. R15 is the copy of claim processing sheet dated 20.08.2020, Ex. R16 is the copy of claim form dated 04.05.2020, Ex. R17 is the copy of consent form dated 11.05.2020, Ex. R18 is the copy of Claim Form-Part B dated 11.05.2020, Ex. R19 is the copy of discharge summary dated 04.05.2020 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavits and documents produced on record by both the parties.

7.                The complainant a cancer patient and subscriber of health insurance policies issued by OP1 invoked the jurisdiction of this Commission and has prayed for issuing direction to the OPs to pay Rs.71,353/-, Rs.71,717/- and Rs.72,930/- i.e. total Rs.2,16,000/- along with interest and compensation of Rs.2,00,000/- besides litigation expenses.

8.                 During the course of arguments considering the settlement of other claims, adjudication was confined to non-reimbursement of claim of Rs.71,353/- (as per claim form Ex. C16) incurred by the complainant on his treatment on 04.05.2020 at Max Specialist Hospital, Mohali. The cashless authorization was declined by the OPs and its particulars were curled out from Ex. R4 Email on dated 17.08.2021, which is reproduced as under:-

 

Policy No./Claim File No./Amount Claimed	Hospitalization Period	Treatment	Status
No.2014002819P109671528 for the period: 31 Oct. 2019 to 30 Oct. 2020   21RB04UIK0091 for 71353/-	May 04 2020 at Max Super Specialty Hospital	Chemotherapy Cycle 6 on 04/05/2020-Inj. Rituxumab (Ritsova) 700 mg IV	Rejected   The patient Sh. Mohinder Kumar Chopra 64Y/M was treated with INJECTION RITUXIMAB for his diagnosis- LOW GRADE B CELL LYMPHOMA. This injection does not require hospitalization for a period of 24 hours or more neither it is a day care procedure. Policy clause 2.18 deals with Hospitalization and specified day care procedures/treatments are listed in Annexure-1 attached to the policy. Item no.140 in this annexure defines Cancer Chemotherapy- Item 140 as permissible in day care treatment. But the therapy through RITUXIMAB INJECTION is not Cancer Therapy but it is a type of monoclonal antibody therapy which attacks the cells where cancer starts. It works by slowing or stopping the growth of Cancer Cells.          The claim was therefore not admissible and as such our opinion/ recommendation on non-admissibility of the claim was sent to UW office who agreed with our opinion. The insured had also applied for cashless facilities under our file numbers 21CB04UIK0150 through Max Hospital, Mohali which was also rejected as per policy terms & conditions.

 It can be borne from the record that the complainant being a cancer patient had already undergone for chemotherapy treatment in cycles and its cashless reimbursement/facilities availed by him on previous occasions are tabulated as under:-

Sr. No.	Bill Dated	Amount	Status
1.	26.06.2019	75,100/-	Settled for Rs.71,101/-
2.	23.08.2019	74,419/-	Settled for Rs.63,325/-
3.	22.10.2019	65,931/-	Settled for Rs.64,537/-
4.	23.10.2019	71,104/-	Settled for Rs.68,854/-
5.	25.02.2020	72,419/-	Settled for Rs.69,449/-

 

Period of claim in quesiton fall during subsistence period of insurance policy Ex. C1 = Ex. R2. Its clause 2.18 defines the hospitalization as under:-

                   “2.18. Hospitalization

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

Further perusal of Annexure-I shows that a specified day care procedure has been mentioned as “139. Radiotherapy for Cancer and 140. Cancer Chemotherapy.”

9.                A close scrutiny of the column treatment of Ex. R4 pertaining to this claim finds mentioned Chemotherapy Cycle-6 on 04.05.2020 Injection Rituximab (Ristova) 700 mg. IV. So when it is abundantly clear that the treatment given to the complainant was in continuation of earlier chemotherapy process/cycle and thereby labeling it as monoclonal antibody therapy is devoid of any logic. It appears that the complainant was discharged within 24 hours because he did not suffer any probable side effect of the injection. Day Care Treatment defines that a day care treatment procedure involves medical operations, treatments and surgeries that require less than 24-hour hospitalization. Few examples of day care procedures are cancer chemotherapy, appendectomy, angiography, radiotherapy and more. So the said definition is to be construed liberally and not technically so to deny the claim of the complainant. Since the OP1 has invoked the exclusion clause at the recommendations of OP2 whereby it has been mentioned that Injection Rituximab is not used in cancer therapy. However, no medical expert has been examined by the OPs nor placed any opinion, literature on record to bolster its contentions. It is the settled law that whenever OPs invokes exclusion clause, the burden of proving the same also lies upon the OPs. In the given facts and circumstances, it would be just and appropriate if the OPs are directed to settle and reimburse the claim of the complainant regarding his hospitalization on 04.05.2020 at Max Super Specialist Hospital, Mohali amounting to Rs.71,353/- as per bill Ex. C4 to the complainant as per terms and conditions and also to pay composite costs of Rs.10,000/- to the complainant.

10.              As a result of above discussion, the complaint is partly allowed with an order that the opposite parties shall jointly and severally settle and reimburse the claim of the complainant regarding his hospitalization on 04.05.2020 at Max Super Specialist Hospital, Mohali amounting to Rs.71,353/- as per bill Ex. C4 to the complainant as per terms and conditions within 30 days from the date of receipt of copy of order failing which the complainant shall be entitled to interest @8% per annum  on the settled amount from date of order till date of actual payment to the complainant within 30 days from the date of receipt of copy of order. The opposite parties shall further pay a composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of the order. Copies of order be supplied to 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:14.03.2024.

Gobind Ram.