Delhi

North East

CC/93/2021

Sh. Arun Kumar Aggarwal - Complainant(s)

Versus

Branch Manager, Oriental Insurance Co. Ltd. - Opp.Party(s)

28 Aug 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 93/21

 

 

 

In the matter of:

 

	Shri  Arun Kumar Aggarwal R/o 22, Rishabh Vihar, Delhi-110092	Complainant
	Versus
1.       2.         3.	Branch Manager, Oriental Insurance Co. Ltd, C-93, Subhash Road, Naveen Shahdara, Delhi-110032   PARK Medi Claim Insurance TPA 702, Vikrant Tower, Rajendra Place, New Delhi-110008   Max Super Specialty Hospital, Through its Director/M.S W-3, Sector 1, Vaishali, Ghaziabad, 201001, U.P.	Opposite Parties

 

 

DATE OF INSTITUTION:        JUDGMENT RESERVED ON:                           DATE OF ORDER:

30.07.21 03.08.23 28.08.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

ORDER

Anil Kumar Bamba, Member

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

 Case of the Complainant

1. The case of the Complainant as revealed from the record is the Complainant is holder of “Happy Family Floater -2015 Policy bearing policy no. 271702/48/2021/1078 and total sum insured is Rs. 8,00,000/-. In October 2020, Complainant’s wife found some abnormal pain in her chest and after 1-2 weeks she visited doctor and on investigation lump was found in her right breast and thereafter necessary surgery was conducted on 21 October. Complainant’s wife was discharged on 21.10.20 and Complainant also obtained certificate from doctor/hospital that such treatment/ chemo therapy is necessary for recovery to attain health. The total hospitalization claim partly settled by Opposite Party No. 1 for Rs. 7,34,756/- against total of Rs. 8,00,000/- as per policy and  after that the 6 cycle of chemo therapy was also partly settled. The Complainant contacted TPA and insurance company many times through email dated 14.04.21 and 05.05.21 for balance payment but they repudiated the claim on flimsy grounds in violation of policy condition. The Complainant stated that total expenses incurred on chemo therapy injection named Herclon 440mg is Rs. 78,332/- per session/dose/occasion. The Complainant stated that the above said policy is continuously renewed from 2009 and latest renewal of policy was done on 2020 after paying premium of Rs. 45,903/-. The Complainant stated that repudiation of cost of continuous treatment still undergoing for the disease “Breast Cancer” from the doctor and hospital advise from the starting date to till date. The repudiation/part settlement of claim is illegal as insured sum of 8 lac is available for the benefit of policy holder in the policy. The Complainant stated that it is mentioned at point 1 of policy terms and conditions it clearly mention that all the treatment cost of Disease/Accident/illness will be paid/reimburse, which is taken on treating doctor/surgeon advice up to the amount to policy sum assured. As there is no mentioned of rare disease/Diseases required long treatment on medical condition of patient and on treating doctor advice in policy terms and conditions. The Complainant stated that he had also email to the OICL for their intimation & seeking permission for the reimbursement of treatment cost as the treating Doctor had inform that the treatment of insured No.2 will last for longer period. No reply of insured email is ever received to insured. The Complainant stated that post hospitalization claim was duly deposited for approval of TPA which was denied/partly settled. The Complainant made numerous phone calls and visits to TPA office but of no use. The Complainant stated that TPA intimated Complainant about denial/part settlement also by email dated 14.04.21and 05.05.21. The Complainant stated that the terms and conditions of the policy was never supplied him along with policy bond so denial/repudiation on some point of such terms and conditions is held invalid when the terms and conditions to such effect is never supplied with the policy bond to insured, as it held in several judgment of Hon’ble Supreme Court. Hence, there is deficiency of service on behalf of Opposite Parties. Complainant has prayed to direct the OICL to reimburse the balance amount of Rs. 80,000/- cost of chemotherapy but limited to Rs. 65,500/- due to less amount available in policy bond for the year 2020-2021 and to reimburse all the cost, doctor fees and investigation cost occur on Doctor advice in future for same disease as pre and post hospitalization bill. He further prayed for Rs. 60,000/- on account of deficiency in service and Rs. 1,00,000/- for mental harassment. He also prayed for  Rs. 50,000/- for litigation expenses.   
2.  None has appeared on behalf of Opposite Party No.2 to contest the case therefore, Opposite Party No.2 was proceeded against Ex-parte vide order dated 01.04.22.

Case of the Opposite Party No.1

3. The Opposite Parties contested the case and filed their written statement. It is admitted that Complainant obtained the “Happy Family Floater -2015 Policy vide  its policy No. 271702/48/2021/1078 for a sum insured of Rs. 8,00,000/- only for the period of one year w.e.f 17.08.20 to 16.08.21 and accordingly policy schedule along with its terms, conditions and exclusions were issued to the insured. However, the wife of the Complainant was diagnosed and treated by the Opposite Party No.3 and she was treated with TCH based chemotherapy once in 21 days for 6 cycles RT maintaince Tradstuzumab + Hormone therapy. Whereas, as per policy wordings the cashless claim of the patient/ Complainant falls under the exclusion clause “3.11 Day Care Treatment of Happy Family Floater -2015 Policy, refers to medical treatment, and/ or surgical procedure which is a.) undertaken under general or local Anesthesia in a Hospital/day care centre in less than 24 hours because of technological advancement, and b) which would have otherwise required a hospitalization of more than 24 hours. Treatment normally taken on an out patient basis is not included in the scope of this definition. Hence, the cashless claim for chemo therapy was rightly denied by the TPA, as the patient was hospitalized less than 24 hours and injection Herclon 440 MG is also not listed in day care procedure list of appendix 1 of the policy vide email dated 05.05.21.
4. It is emphatically denied that the Opposite Party was ever deficient, inaction and negligence at any stage and any clause of action was ever arisen in favour of the Complainant and against the Opposite Party. It is further denied that the Complainant is entitled for any claim amount as claimed in the instant complaint.

Case of the Opposite Party No.3

5. The Opposite Party No. 3 contested the case and filed their written statement  and submitted that no allegation has been levelled against us, Opposite Party No.3 is only made a performa party, but if Complainant wants to pursue his case against Opposite Party No.3, the Max Super Speciality Hospital should be made as proper party. Otherwise, the Complainant may drop his case against Opposite Party No.3. Further the Opposite Party No.3 has prayed to dismiss the complaint.

 

 

Rejoinders to the Written Statements of Opposite Party No.1 and 3

6. The Complainant filed separate rejoinders to the written statements of Opposite Parties wherein the Complainant has denied the pleas raised by the Opposite Parties and has reiterated the assertion made in the complaint.

Evidence of the Complainant

7. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party No.1 and 3

8. In order to prove its case Opposite Party No.1 has filed affidavit of Shri Rajeev Chopra, Sr. Divisional Manager and Opposite Party No.3 has filed affidavit of Ms. Nidhi M Dev, Medical Representative of Opposite Party No.3 wherein the averments made in the written statements of Opposite Parties have been supported.

Arguments & Conclusion

9. We have heard the Ld. Counsels for the Complainant and for the Opposite Party No.1 and 3. We have also perused the file and the written arguments filed by the Complainant and Opposite Party No.1.
10. The case of the Complainant is that he has purchased “Happy Family Floater -2015 Policy for the sum of Rs. 8,00,000/-. During the validity of the policy Complainant’s wife admitted to the hospital for the treatment and after necessary surgery she was discharged on 21.10.20. Complainant also stated that he has obtained certificate from doctor/hospital that such treatment/ chemo therapy is necessary for recovery to attain health. It is further stated by the Complainant in terms of the policy provision he filed his claim for reimbursement of Rs. 8,00,000/- with Opposite Party No.1  and Opposite Party No. 1 settled the claim for Rs. 7,34,756/-. As per the Complainant, Opposite Party No.1 refused to settle the claim of chemo therapy which amounts to     Rs. 78,332/- on the ground that it is in the violation of the policy condition. As per the Complainant repudiation/ part settlement of claim is illegal as insured sum of 8 lac is available for the benefit of policy holder in the policy.  It is further submitted by the Complainant that it is mentioned in point 1 of policy terms and conditions that all the treatment cost of Disease/Accident/illness will be paid/reimburse, which is taken on treating doctor/surgeon advice up to the amount to policy sum assured. Hence this shows deficiency on the part of Opposite Parties. Complainant has prayed to direct the Opposite Party No. 1 to repay the Complainants amount of Rs. 80,000/- cost of chemo therapy but limited to Rs. 65,500/- as balance amount available in the policy bond along with mental harassment and litigation expenses.  
11. Opposite Party No.1 admitted that Complainant is having valid policy for the sum of Rs. 8 lac only for the period of one year valid from 17.08.20 to 16.08.21  as per terms and conditions and exclusion of the policy “3.11 Day Care Treatment of Happy Family Floater -2015 Policy, refers to medical treatment, and/ or surgical procedure which is a.) undertaken under general or local Anesthesia in a Hospital/day care centre in less than 24 hours because of technological advancement, and b) which would have otherwise required a hospitalization of more than 24 hours. So Treatment normally taken on an out patient basis is not included in the scope of this definition. Hence, the claim for chemo therapy was rightly denied by them as the patient was hospitalized less than 24 hours.
12. As per the policy bond clause 1.2 coverage, SI No. A,sub clause xiv Note: 2) Relaxation to 24 hours minimum duration for hospitalisation is allowed in a day care procedure/ surgeries( appendix 1) where such treatment is taken by an insured person in a hospital/ day care centre. Serial No. 116 of appendix 1 is regarding cancer chemo therapy is covered under the said note.
13. Therefore, in view of the above discussion the complaint is allowed. Opposite Party No.1 is directed to pay Rs 65,500/- to the Complainant with interest @ 6 % p.a. from the date of filing the complaint till recovery. Opposite Party No.1  is further directed to pay Rs 25,000/-  on account of mental harassment and Rs. 10,000/- as litigation expenses to the Complainant along with interest @ 6 % p.a. from the date of this order till recovery.

 

14. Order announced on 28.08.23.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

( Anil Kumar Bamba)             Member

(Surinder Kumar Sharma) President