FINAL ORDER/JUDGEMENT
SHRI REYAZUDDIN KHAN,MEMBER
This is a complaint case filed u/s.35 of the C.P. Act, 2019.
The case of the complainant in brief is that the complainant was infected with Covid-19
On 07.01.2022.Upon perusal of blood tests and RTPCR reports and confirmation of Covid-19 positive,the complainant was advised to get an urgent admission in hospital for Monoclonal Antibody Therapy.Accordingly,the complainant got admitted in the hospital for Monoclonal Antibody therapy on 10.01.2022 and got discharged on the same date.The complainant lodged a claim bearing claim ID No.1122285041794 on 30.07.2022 by post.The OPs Insurance company replied by mail that Monoclonal Cocktail anti body day care treatment for Covid-19 illness advised by Dr.Rahul Jain was not justified. Hospitalization was for a period of 24 hours and as per terms and conditions the claim is not admissible and rejected accordingly.
The complainant mentioned several circular of IRDA where it was stated that policyholders shall not be denied the availability of health Insurance coverage for modern day care treatment including Monoclonal Antibody.
- The IRDA Circular memo No.IRDA/HLT/REG/CIR/177/09/2019 was introduced on 27.09.2019.Chapter V.
- Cicular bearing Ref.No.IRDA/HLT/REG/CIR/193/07/2020 was introduced on 22.07.2022.
The complainant further stated that the OPs frivolously repudiated the claim on the grounds of hospitalization for less then 24 hours.The procedure of treatment of the complainant covered in Chapt.V under heading ‘Modern Treatment Methods and Advancement in Technologies”Clause 1(E) as “Immunotherapy Monoclonal Antibody to be given as an injection under the supervision of a doctor,as it takes few hours only and no need for hospitalization for more then the prescribed time for administering the dosage. Insurer have been mandated to ensure that treatment procedures mentioned in chapter V of such circular shall not be excluded under Health Insurance policy contract.
Under such circumstances the Insurance company violated the IRDA circular dated 27.09.2019 and refused to approve the claim of Rs,90,600/-.The complainant on numerous occasions communicated the Insurance company through mail to act in terms of the agreement as agreed by them.The complainant further sent an Advocate’s letter on 17.04.2023 through mail to approve the complainant’s lawful coverage of Insurance ,but the OPs willfully and deliberately neglected the same.
The OPs Insurance company had committed unfair trade practice and deficiency in service for which the complainant prayed for the direction to OPs to approve the complainant’s claim of Rs,90,600/ along with @18% per annum along with compensation of Rs,10,00000 (Ten Lakh) only.
On perusal of records, it appears from order dated 30.01.2024 OPs failed to file their W.V in the statutory period and as such the case runs ex-parte against the OPs.
Points for Determination
1) Whether the OPs are deficient in rendering proper service to the Complainants?
2) Whether the OPs have indulged in unfair trade practice
3) Whether the complainants are entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 2 :-
The above mentioned points are taken up together for the sake of convenience and brevity in discussion.
We have travelled over the documents placed on record. The complainant has filed his Evidence supported by affidavit. The case has been proceeded ex-parte against OPs . The OPs have not filed the E-Chief. The fact of the case in brief is that the complainant had subscribed an insurance policy being No.23-18-0004577-05-00.In 2022 the complainant got affected by Covid-19.On advice of a Doctor the complainant took certain blood tests and RTPCR from Jeevan Rekha Diagnostic Centre for confirmation of Covid-19.Upon perusing the Covid-19 positive on 10.01.2022 Dr.Rahul Jain advised for urgent admission in hospital to the complainant for Monoclonal Antibody Therapy.Accordingly the complainant got herself admitted in Belle Vue Clinic ,Kolkata and after being the Monoclonal cocktail antibody treatment she was released on the same day.She had paid a sum of Rs,90600/ for the aforesaid treatment.
Firstly,on perusal of documents attached on record it is observed that the complainant was infected with Covid-19 on 07.01.2022 and after hectic efforts she manage to consult with Dr.Rahul Jain with several Blood test reports.The doctor advised her for urgent admission in hospital for Monoclonal Antibody Therapy on 10.01.2022. Insurance Regulatory and Development Authority (IRDAI) has also come up with certain mandatory guidelines for all insurance companies in order to provide the maximum benefit to the policyholders. While many general, health and life insurance companies are providing policies with variations, they still have varying claim parameters
As per IRDA guidelines under ref: IRDA/HLT/REG/CIR/177/09/2019 dated 27.09.2019 and in chapter V under the heading of “Guidelines on standardization of Exclusions in Health Insurance Contracts” in Point 1. “To insure that the policyholders are not denied availability of health insurance coverage to Modern Treatment Methods Insurers shall ensure that the following treatment procedures shall not be excluded in the health insurance policy contracts. These procedures shall be covered (wherever medically indicated) either as in patient or as part of domiciliary hospitalization or as day care treatment in a hospital “ which also included in (E) Immunotherapy-Monoclonal Antibody to be given as injection. In another circular bearing Ref No. IRDA/HLT/REG/CIR/193/07/2020 dated 22.07.2022 which also directed the insurers not to deny any claims pertaining to Monoclonal Antibody Treatment. The Insurance company neglected to follow the IRDA guidelines which is the paramount important for a insurance company. Why a normal human being opted for medical Health Insurance,it is only because it is the shield that enables a person to get the necessary medical treatment without worrying about the exorbitant costs.So the complainant took the Insurance policy by paying the premium on regular basis and at the same time the OPs deliberately refused to approve the claim amount of Rs,90600/ which resulted the deficiency in service and unfair trade practice.
Secondly,the OPs denied the claim as Hospitalization period is less than 24 hours.Here, since the Immunotherapy Monoclonal Antibody to be given as an injection and the same should be under the supervision of a doctor and it depends upon the concerned doctor whether the patient be kept for one day or more as per the prescription attached of Dr Rahul Jain where it mentioned “Urgent admission in Hospital for Monoclonal Antibody Therapy”. It was not in the hands and wish of the patient (complainant) to continue hospitalization for the illness.It was upon the doctor’s decision whether the patient to be kept for further medication or discharge at the rush hours in hospitals during Covid-19 period.
The complainant have cited several judgments :- In the High Court of Delhi
In the Matter of:-
1.W.P(C) 11799/2023,CM APPLs.46061/2023,59128/2023,59129/2023,8203/2024,11271/2024,11272/2024. Petitioner Through: Dr Amit George,Mr.Abraham Mathews and Adhishwar Suri..Advocates
Vs
New India Assurance Co.Ltd &Ors Respondent
Through: Mr.J.P.N Shahi,Advocate
Under the above facts and circumstances we are of the view that the complainant has established the case against the OPs. There is deficiency in service on the part of the OPs. As such, the complainant is entitled to get relief as prayed for. In the result, the Consumer Complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed on Ex-parte against the OPs with the following directions.
- The OPs are directed to pay jointly or severally to pay Rs.85,000/-(Rupees Eighty Five Thousand)only to the complainant against the medical expenses..
- The OPs is directed to pay jointly or severally a sum of Rs.10,000/- as compensation for causing harassment and also a sum of Rs.5,000/- as litigation cost to the complainant.
The above order is to be complied by the OPs within a period of 45 days from the date of this order. In default, the complainant will be at liberty to putthe order into execution.
Copy of the judgment be delivered to the parties free of cost as per the C.P. Act and Judgment be uploaded in the website of the Commission for perusal of the parties
