PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                             CONSUMER COMPLAINT NO.32/2022

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Abinas Agrawal,

S/O- Ratan Lal Agrawal, R/O/Po/Ps-Sason,

Dist-Sambalpur.                                                                      ……..Complainant

Versus

1. Divisional Manager, Oriental Insurance Co. Ltd,

Uil Building, 4^th floor, 4, Esplanade, Chennai-600108,

Represented by Divisional Manager, Oriental Insurance Co. Ltd,

VSS Marg, Sambalpur-768001.

2. Claims Manager-Medi Assist India Pvt. Ltd,

Having its registered office at-Tower D, 4^th Floor, IBC Knowledge Park,

4/1 Bannerghatta Road, Bangalore-560029.

3. Claims Manager-Medi Assist India Pvt. Ltd,

2^nd floor, RWD Atlantis building, 24, Nelson Manickam Road,

Opp. ShobhanBabu Statue, Aminjikarai, Chennai-600029

4. Claims Manager-Medi Assist India Pvt. Ltd,

656, 2^nd Floor, Saheed Nagar, Bhubaneswar-751007    …...Opp.Parties

Counsels:-

1. For the Complainant          :-      Sri. R.L. Agrawal & Associates
2. For the O.P.No.1                             :-      Sri. R.P. Nanda
3. For the O.P. No.2 to 4         :-      Ex-parte

Date of Filing:09.05.2023,Date of Hearing :24.07.2023,Date of Judgement : 25.09.2023

  Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complainant is that as an employee of the Cholamandalam Investment and finance Co. Ltd. the Complainant was insured for Rs. 2,00,000/- for the period 01.10.2020 to 30.09.2021 vide policy No. 41200/48/2021/6307. The Complainant also paid Rs. 4425/- to-wards top-up of Rs. 2.00 lakhs extra vide policy NO. 411200/48/2021/9145 for the period 01.11.2020 to 31.10.2021. Mrs Puspalata Agrawal, mother of the Complainant diagnosed breast Cancer on 05.052020 and treatment continued at Bhubaneswar, Rourkela and Sambalpur due to Covid-Pandemic Situation. Operation was done on 28.05.2020 at SUM Ultimate Medicare Hospital, Bhubaneswar and Chemotherapy started at Bhubaneswar on 17.06.2020. As per doctor advice in every 21 days interval for one year with initial six sessions with three forms of Chemo in each session and thereafter 12 sessions only one form of chemo. For Covid situation under supervision on Dr. Sanjay at JPH. Hospital Rourlkela 4 sessions completed. Due to Covid infection she undertook six session at DHH, Jharsuguda. In 7^th session medicine changed, the patient took the same at SUM Medicare, Bhubaneswar. Medical expenses of operation and 7 initial chemo sessions claimed under different Health policy. From 8^th sessions onwards when Covid was peak Dr. Biswa Ranjan Routray V.S.S. MCH, Burla helped in inducing Chemotherapy with transportation of medicines from Bhubaneswar.

After three Session claim No. 23876619, 23876625 & 23876627 were made amounting to Rs. 18,465/- Rs, 16,705/- and Rs. 17,707/- respectively. Thereafter 8 sessions continued under Dr. Biswa Ranjan Routray home and claim sent to the O.Ps. The claim of the complainant was rejected after a year and rejection letter was shared in January and April 2022 with ground that the place of Chemotherapy sessions are not registered.

The O.Ps not rejected or approved the sessions 11^th to 15^th for more than one year for which the Complainant not able to send the last three claims in time and sent in March-2022, which are pending again for want of hospital registration certificate. Number of correspondences made but the O.Ps raised different objections.

Being aggrieved this complaint has been filed alleging deficiency in service of the O.Ps.

2. The O.P. No.1 admitted the execution of the policies. The answering O.P. denied the chemo sessions of Dr. Biswa Ranjan Routray. Claim No. 23876619, 23876625 and 23876627 are admitted. The TPA due to Covid Pandemic situation could not conduct manual investigation. Claim No. 24292868, 24294924 and 24309540 were registered and asked for hospital registration but complainant failed to do so. Accordingly claim was rejected.

The O.P. admitted the receipt of tracking ID No. CHE-011-36531, claim No. 24309540,24595867,27646609,27646537 and 27646476 and rejection due to non-submission of Hospital Registration certificate. Several request letters were made to the Complainant to submit documents but for non-submission claims were rejected. The allegation of sessions 11 to 15 claim in March 22 are denied. There is no any deficiency on the part of the O.Ps and rejection of claims are proper.

3. The O.P. NO.2 to 4 submitted their version but TPA have not submitted their version and hence set ex-parte.
4. Perused the documents filed by the Complainant. The O.Ps heve not filed any documents except copy of IRDA regulation on TPA., condition No. 3.47. Against Claim No. 23876619, 23876625 and Rs. 23876627 for Rs. 18,495/-, 16705/- and Rs. 17,707/- respectively the O.Ps paid Rs. 16,648/-, Rs. 14,400/- and Rs. 15,937/- as treatment continued under Dr. Biswaa Ranjan Routray, Burla.

The O.Ps rejected the claim No. 24292868, 24294924 and 24309540 referring clause No. 5.5. “Final claim along with hospital receipted original bill/cash memos/reports, claim form and list of documents should be submitted to the Company/TPA within 7 days of discharge from the Hospital/Nurshing Home. In addition insured should also provide the company/TPA such additional information and assistance as the company/TPA may require in dealing with the claim. In reply the O.P. submitted that due to want of hospital registration certificate the claims were rejected. Earlier the O.Ps have allowed the claims No. 23876619, 23876625 and 23846627 undergone treatment under Dr. Biswas Ranajan Routray. Due to pandemic as TPA could not cover the place claims are allowed. The stand of the insurer is not acceptable as life is important for TPA personnel, likewise it is important for a patient. The same doctor has made the treatment. Non acceptance of the claim is not reasonable. Likewise claim No. 24598567 was rejected by the O.Ps which is not proper. The O.Ps received the 14^th session documents on 05.05.2022 but not given any reply nor any acknowledgement, which amounts to deficiency in service.

The treatment details of 16^th, 17^th and 18^th sessions have been acknowledged by the O.Ps but sought for hospital registration certificate. As per submission of the O.P No.1 the hospital does not fulfil the criteria as per the condition of the policy. From the very statement it clear that the O.Ps have investigated the matter but not submitted any documents to the effect. As the case covers the pandemic situation and there was huge and cry through out the world a patient’s treatment during the period is very difficult and Dr. Biswa Ranjan Routray has undertaken the treatment. The O.Ps have not considered the situation and treatment of Dr. Routray and rejected the claim which is not proper. Rejection of claim is non-application of mind of the O.Ps. in pandemic situation.

As per submission of the O.P. No.1 basing on the report of TPA claims are settled. In the present case the TPA has not submitted any report due to peak period of pandemic and claims rejected due to non-submission of registration certificate of the hospital. Taking into consideration the pandemic situations the O.Ps should have considered the claims of the Complainant liberally as the treatments are not denied.

Accordingly, it is ordered;

ORDER

The Complaint is allowed on contest against the O.P. No.1. The O.P. No.1 is directed to pay Rs. 1,48,777/- along with interest @7% P.A. w.e.f. date of claim within one month of this order. In case of non payment the amount will carry 12% interest P.A. till realisation. The O.P. No.1 is to pay litigation cost of Rs. 10,000/. No any cost and compensation.

Order pronounced in the open court on the day of 25^th Sept. 2023.

Supply free copies to the parties.