Order-13.

Date-18/01/2018.

        Shri Anupam Bhattacharyya, President.

The instant complaint has been filed by the Complainant under section 12 of the C.P. Act  to direct the OPs praying payment of insurance claims amount totaling to Rs.5,22,859.34 and for  compensation of Rs.5,00,000/-  for mental agony and harassment along with interest  at the rate of 18 percent p.a and Rs.1,00,000/- for litigation cost.

            The Complainant’s case, in brief, is that the Complainant insured with the OPs an Insurance Company paying premium of Rs.29, 467.97 in respect of “Easy Health Floater Premium” policy being No.150100/11053/1000025810-03 for the health in the name of the Complainant for the period from 31.03.2012 to 30.03.2013 for sum assured Rs.5,00,000/- for self  and his dependent wife and son.  The date of inception of the said policy was on 31.03.2009 The Complainant was admitted on 26.04.2012 in Apollo Gleneagles Hospital, Kolkata for treatment of “Ankylosing Spondylitis” where 1^st does of ‘Remicade’ injection was administered and discharged on 27.04.2012 and claim lodged with the Insurance Company on 05.07.2012 for  Rs.1,81,377/- and allowed the same and in the same way the claim for 2^nd, 3^rd dose for Rs.1, 37,689/- and Rs.97,740/- respectively were awarded by the Ld. Insurance Ombudsmen on 02.12.2014. The Complainant again claimed  Rs.1,89,156.28, Rs.1,49,689.41 and Rs. 1,84,013.65 respectively, totaling Rs.5,22,859.34 for administering 4^th, 5^th, 6^th dose Remicade Injections admitting in the same hospital as per advice of Doctor  which was illegally repudiated on the ground that if first dose of ‘Remicade injection’ is eventless, other doses can be administered on OPD basis.  Hence, the instant complaint case.

Written Version filed by the OP, in short is that Complainant approached for a Mediclaim Policy under ‘Easy Health Floater Premium’ being Policy No. 150100/11053/1000025810-03. The Complainant agreed, acknowledged and accepted the terms and conditions provided in the said policy. One of the terms under general exclusions of the said policy will not be covered for expenses incurred for conditions wherein treatment has been done on an OPD basis and 24 hours hospitalization was not necessary even where no anesthesia was required during the course of hospitalization. The Complainant had filed the claims dated 24.6.2015, 22.01.2016 and 16.09.2016 for reimbursement of expenses incurred for infusing the doses of Remicade  400 mg injection for treatment of Ankylosing Spondylities. In case of administration of the drug Remicade after first administration of this drug, if there is no side effects observed then the next administration can be done on an OPD basis and Complainant was well aware that 24 hours hospitalization is not required for administering Remicade Injection. The insured cannot claim anything more than what is covered by the Insurance Policy. The claim of the Complainant was validly and lawfully rejected in terms of the Exclusion Clause. The OP prays for dismissal of the instant complaint. Hence, the instant written version.

Considering the pleadings of both sides the following points have been raised for disposal of the case.

Points for Decision

1. Whether the case is maintainable in its present form and law?
2. Whether there is any cause of action to file the case?
3. Whether the case is barred by limitation?
4. Whether the complainant is entitled to get the relief as prayed for?
5. What other relief/reliefs the complainant is entitled to get?

Decision with Reasons

Points No.1 to 5  .  All the points are taken up together for the sake of convenience.

            The instant complaint case is  praying for payment of Rs.5,22,859.34 towards medical expenses for administering 4^th, 5^th and 6^th dose of Remicade Injection along with interest and compensation of Rs.5,00,000/- and litigation cost of Rs.1,00,000/-.

The Complainant’s main case is that on the basis of mediclaim policy the Complainant realized the amount of medical expenses towards administering 1^st, 2^nd and 3^rd doses of Remicade Injection admitting in the Apollo Gleneagles Hospital, Kolkata and on the same basis the Complainant claimed for realization of the medical expenses for 4^th, 5^th and 6^th doses being admitted in the same hospital for administering Remicade Injection. But the same was illegally repudiated on the ground that hospitalization for the purpose is not required if there is no adverse effect after first dose.

On the other hand the OPs case is that they have validly rejected in terms of the exclusion clause as the said administration of 4^th, 5^th and 6^th doses Remicade Injection can be done on an OPD basis, ‘24 hours hospitalization is not required where there was no question of anesthesia’.

            To prove the case both parties have adduced evidence on affidavit and filed questionnaire and replies vis-à-vis along with relevant documents in support of their respective case.

            In this case the OP Insurance Company has referred a decision of Hon’ble Supreme Court in Civil appeal No. 2080 of 2002 decided on 01.04.2009 in the case of Vikrama  Greentech (I) Limited and Anr Vs. New India Assurance Company Ltd. on the point that insurer cannot claim anything more than beyond the coverage of the Insurance Policy and  insured has to act strictly in accordance with that statutory limitations or terms of policy expressing set out therein.

There is nothing to dispute on this point.

Now the OP’s case is that they have repudiated on the basis of exclusion clause wherein this particular treatment in the case of administration of drug Remecide after administration of 1^st dose of this drug, if there is no side effects then the next administration can be done on an OPD basis.

But in this particular case the claim for medical expenses for administration of the 2^nd, 3^rd doses of Remicade Injection admitting in the hospital was allowed where there is nothing to show that there was side effects after 1st dose for that the same was allowed.

“From the documents filed by the Complainant, it is clear that OP Insurance Company repudiated the claim for 2^nd and 3^rd dose and the Ld. Insurance Ombudsman awarded the medical claim for administering 2^nd and 3^rd doses Remicade Injection.

It is true that this Insurance Ombudsman rejected the claim for the instant claim for 4^th, 5^th and 6^th doses.

But, we are of view for the same problem even if the exclusion clause is applied, then how 2^nd and 3^rd doses were allowed and for that the Complainant should not be deprived from the claim where he was admitted in the same hospital for 24 hours and the said injection were administered as per advice of doctor.

Considering the above discussions as a whole, we find that all the points are disposed of in favour of the Complainant in part and as such, the complainant is entitled to get Rs.5,25,859-34 towards medical expenses according to coverage and Litigation cost of Rs.5,000/-.

Hence,

Ordered

            That the instant case No. 225-2017 be and the same is allowed in part on contest against the OPs1 and 2 and dismissed against OP3.

            OPs 1 and 2 are jointly and severally liable to pay the awarded amount.

            OPs 1 and 2 are directed to pay an amount of Rs. Rs.5,22,859.34 according to coverage along with litigation cost of Rs.5,000/- only within 30 days from the date of this order, in default, the OPs 1 and 2 is to pay fine  at the rate of Rs.100/- per day delay and the amount so accumulated should be deposited to this Forum. Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision of the C.P. Act.

Order No. 14 / Dated 28/03/2018.

Record is put up on the strength of a petition filed on behalf of the Opposite Party- Apollo Munich Health Insurance Company Ltd. In the said petition it is stated that in compliance of order dated 18.01.2018 passed by this Forum in connection with CC/225/2017, the Opposite Party has already paid the decreetal dues to the Complainant vide Cheque No.250282 dated 12.03.2018 amounting Rs.1,84,014.00, No.250280 dated 12.03.2018 of Rs.1,89,256.00, No.250281 dated 12.03.2018 of Rs.1,49,689.00 and No.250283 dated 12.03.2018 of Rs.5,000.00 all drawn on HDFC Bank. Now the Opposite Party tenders a Cheque being no.496971 dated 23.03.2018 drawn on HDFC Bank amounting to Rs.6,100/- (Rupees Six Thousand One Hundred) Only in favour of  ‘President, DCDRF, Kolkata Unit-II’ as fine in compliance of the order aforesaid. Now the Ld. Advocate for the JDr. prays for acceptance of the said Cheque and for passing order to this effect.

                                Perused the petition filed for the Opposite Parties. Considering the facts afore, let the Cheque of Rs.6,100/- be accepted and office to deposit the same to the SCWF, WB. Issue receipt.