DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, GURGAON-122001.
Consumer Complaint No: 286 of 2015 Date of Institution: 03.06.2015 Date of Decision: 03.11.2015.
Pooja Yadav w/o Shri Rohit Yadav, R/o H.No.495, Sector-7, Gurgaon.
……Complainant.
Versus
- Apollo Munich Health Insurance Company, 2nd & 3rd Floor, iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon through its Manager.
- Apollo Munich Health Insurance Company, 1st Floor, SCF-19, Sector-14, Gurgaon through its Manager.
- Apollo Munich Health Insurance Company, 10th Floor, Tower-B, Building No.10 DLF Cyber City, DLF Phase II, Gurgaon through its Manager.
..Opposite parties
Complaint under Sections 12 & 14 of Consumer Protection Act,1986
BEFORE: SH.SUBHASH GOYAL, PRESIDENT.
SMT JYOTI SIWACH, MEMBER
SH.SURENDER SINGH BALYAN, MEMBER.
Present: Complainant Pooja Yadav in person.
Shri Harish Bhardwaj, Adv for the opposite parties.
ORDER SUBHASH GOYAL, PRESIDENT.
The case of the complainant, in brief, is that she has obtained Easy Health Floater Standard Policy since 13.01.2011 and the last policy bearing No.110103/11051/1000153053 which is effective from 13.01.2015 to 12.01.2016 with sum assured Rs.3 Lacs. During the subsistence of insurance policy she suffered a problem which was diagnosed as Wegener’s Granulomatosis and was admitted in Sir Ganga Ram Hospital on 11.03.2015 at 5:55 am and was discharged on 12.03.2015 at 6:22 pm vide discharge summary (Ann C-2) and a bill of Rs.93,821/- was raised (Ann C-4). As 2nd injection was to be administered after 15 days she was admitted on 26.03.2015 and after necessary treatment she was discharged on the same day vide discharge summary (Annexure C-5) and bill of Rs.9916/- was issued (Ann C-6). Though as per the policy the complainant was entitled to cashless facility but it was denied wrongly. She submitted the claim of Rs.1,03,737/- to the opposite parties but it was wrongly and illegally repudiated by the opposite parties vide letter dated 30.03.2015 (Ann C-7). Along with the reimbursement claim, the complainant had furnished certificate issued from Dr. Lalit Duggal, Chairman and Head of the Department of Rheumatology and Clinical Immunology of Sir Ganga Ram Hospital, Delhi certifying that the complainant had been admitted on 11.03.2015 and was administered 1 gm of Rituximab and planning for 2 doze after 15 days. This drug Rituximab belongs to the category of Chemotherapy drugs. As per Doctor’s opinion drug administered belongs to the category of Chemotherapy and the policy wordings reflect it at Sr.No.140 i.e. Cancer Chemotherapy of the appendix of Day Care Procedure. Previously she taken the same treatment at two occasions and her claim was reimbursed by the opposite parties but this time the opposite party has wrongly and illegally denied the claim of the complainant. Thus, the opposite parties are deficient in providing services to the complainant. The complainant prayed that the opposite parties be directed to reimburse the claim of the complainant to the tune of Rs.1,03,737/- with interest and to pay Rs. 1 Lac and Rs.22000/- towards litigation expenses. The complaint is supported with an affidavit and the documents placed on file.
2 OPs in their joint written reply have alleged that cashless request was received by the opposite parties from Ganga Ram Hospital, New Delhi for complainant who was diagnosed as Wegener’s Granulomatosis. After carefully reviewing the cashless request based on the relevant information/documents made available to the opposite party, the opposite party denied the cashless request due to the following reason:
“Cashless facility cannot be granted as the mentioned procedure is not covered in opposite party’s listed day care medical procedure list and at the same time subject procedure does not warrant 24 hrs hospitalization as well.”
Hence the cashless facility was not extended and the denial letter was sent on 12.03.2015. Later on the same claim was submitted by the complainant with claim form and other medical documents. It was noted from the discharge summary that the patient was admitted at the said hospital where there was no requirement for admission in the hospital. So, based on the documents it was noted that the procedure do not require 24 hours hospitalization and it do not come under day care procedure list. Claims of the complainant on merits repudiated and the same was communicated to the complainant through letter dated 30.03.2015. Thus, there was no deficiency in service on the part of the opposite party.
3 We have heard the parties and perused the record available on file carefully.
4 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the parties, it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that her claim for reimbursement was wrongly declined by the opposite parties vide letter dated 30.03.2015. The complainant contended that previously she was diagnosed for the same disease and was treated from the same hospital and the claim was approved by the opposite parties but this time they have wrongly repudiated the claim.
5 However, the contention of the opposite parties is that as per discharge summary the patient was admitted in the said hospital though there was no requirement for admission in the hospital as per the documents and thus, the procedure does not require 24 hrs hospitalization and it does not come under day care procedure list. Hence, the claim of the complainant was rightly repudiated by the opposite parties vide letter dated 30.03.2015. Learned counsel for the opposite parties has also contended that the medicine i.e. rituximab which was prescribed by the concerned doctor for the patient was not meant for treatment for which she was suffering.
6 Therefore, after going through the facts and circumstances of the case and the evidence placed on file it is evident that the complainant has taken health policy from the opposite parties and during the subsistence of the policy she had taken treatment from Sir Ganga Ram Hospital, New Delhi and remained admitted there from 11.03.2015 at 5:55 am and was discharged on 12.03.2015 at 6:22 pm vide discharge summary (Ann C-2). 2nd injection was to be administered after 15 days, she was admitted on 26.03.2015 and thus, she has spent a sum of Rs.1,03,737/- on her treatment.
7 The complainant has produced copy of certificate issued by Dr. Lalit Duggal, Chairperson & Head, Department of Rheumatology and Clinical Immunology, Sir Ganga Ram Hospital, New Delhi which reads as under :
“Mrs. Pooja Yadav, 38 years female, case of Wegener’s granulomatosis with BVAS-I(relapse) has been admitted at Sir Ganga Ram Hospital on 11.03.2015 is being administered 1 gm of Rituximab and planned for 2nd dose after 15 days. This drug Rituximab belongs to the category of Chemotherapy drugs.”
Thus, the argument of the learned counsel for the opposite parties that the medicine which was prescribed by the concerned doctor for the treatment was not meant for the treatment for which the complainant was suffering is not sustainable in the eye of law because the above said doctor has certified that drug Rituximub belongs to the category of Chemotherapy drugs and the same is included in Day Care Procedure at Sr. No.140 under head “Cancer Chemotherapy” of the terms and conditions of the insurance policy and thus, the contention of the opposite parties that mentioned procedure is not covered in their listed day care medical procedure list is also not sustainable.
However, it is the doctor/hospital who has to decide the duration of the period of the admission of a patient considering the nature of disease and ailment and thus, the contention of the opposite parties that in the instant case 24 hours admission in the hospital was not required is not sustainable.
It is also pertinent to mention here that insurance company has given the claim to the complainant under the medi-claim policy for the same treatment which was taken from the same hospital. Thus, we hold that the repudiation of the claim of the complainant in the present case tantamounts to deficiency in service on the part of the opposite parties. Therefore, we direct the opposite parties to reimburse the claim of the complainant to the tune of Rs.1,03,737/- with interest @ 9 % p.a. from the date of filing of the present complaint i.e. 03.06.2015 till realization. The complainant is also entitled to Rs.15,000/- as compensation for the harassment and mental agony caused to her by the opposite parties and Rs.3100/- as litigation expenses. The opposite parties shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the records after due compliance.
Announced (Subhash Goyal)
03.11.2015 President,
District Consumer Disputes
Redressal Forum, Gurgaon
(Jyoti Siwach) (Surender Singh Balyan)
Member Member
