CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Present
Sri. Santhosh Kesavanath P. President
Bindhu M. Thomas, Member
K.N Radhakrishnan, Member
CC No. 339/2009
Monday, the 28th day of February, 2011.
Petitioner : K. Joy Fenn
Thoppil House,
Vazhoor, Kottayam.
(By Adv. Suresh Babu Thomas &
Adv. Jacob Xavier)
Vs.
Opposite party : The New India Assurance Co.
Ltd., Divisional Office,
Polacherackal Chambers,
K.K. Road, Kottayam
reptd. by its Divisional Manager.
(By Adv. P.G Girija)
O R D E R
Smt. Bindhu M. Thomas, Member
The complainant’s case is as follows:
The complainant is the holder of a mediclaim policy of the opposite party with policy number 76150034081100000324 valid for a period from 31..3..2009 to 30..3..2010. The complainant submitted a claim for Rs. 33,240/- towards amount spent for the treatments of the complainant for carcinoma prostate. The opposite party denied claim stating that the bills submitted falls beyond the period as stipulated by clause 2-6 of the conditions. The complainant on receipt of the said communication gave reply along with a certificate from the doctor to substantiate his claim. According to the complainant he is suffering from an ailment coming within the conditions of the policy and he is entitled for the claim is proved beyond any doubt by the records of treatment. The complainant alleged that the claim was denied stating untenable contentions. The complainant further alleged that the acts of
-2-
the opposite party amounts to deficiency in service and unfair trade practice. Hence the complainant filed this complaint claiming the claim amount Rs. 39,902/-. and cost.
The opposite party entered appearance and filed version with the following main contentions.
i) The claim was repudiated based on terms and conditions in the policy. As per clause 2.6 of the policy “post hospitalization medical charges up to 60 days period immediately after the insured discharge from the hospital for that illness or injury is re-assumable. As per clause 1.0 the coverage of the policy is only for Hospitalization expenses as on inpatient. As per clause 3.4, ‘hospitalization’ means admission in any hospital/nursing home in India upto the written advice of medical practitioner’s for a minimum period of 24 consecutive hours.
ii) As per expert opinion obtained by the opposite party, administration of lucrin depot is believed to cause reduction in tumour growth in people with advanced prostate cancer. The above said hormonal treatment does not fall under specific chemotheraphy for prostate cancer but given as a prophylais to prevent further progress. The complainant’s claim being a SC administration of lucrin Depot not warranting hospital stay is not payable as per the mediclaim policy.
iii) There is no deficiency in service on the part of the opposite party.
Hence the opposite party prayed to dismiss the complainant with
compensatory cost to them.
-3-
Points for consideration are:
i) Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties?
ii) Relief and costs?
Evidence in this case consists of affidavits filed by both parties and
exhibits A1 to A4 and exhibits B1 to B3 .
Point No. 1
The fact that the complainant had taken a mediclaim policy in his name and the said policy commeced from 31..02..2009 is not in dispute. Ext. A1, is the mediclaim policy issued by the opposite party to the complainant. The complainant submitted the mediclaim in connection with his treatment and claimed Rs. 33,240/- by way of treatment expenses incurred for Carcinoma Prostate done at Lakeshore hospital. But the said claim was repudiated by the opposite party by A3, repudiation letter dtd: 7..10.2009. The grounds for repudiating the claim were (i) Lucrin depot is a hormonal treatment and does not fall under specific chemotheraphy for cancer prostate but given as a prophylaxis to prevent further progress. (ii) Chemotherapy is payable whether admission should be under inpatient or day care procedure of a few hours where hospital stay is a must for the procedure such as slow infusion IV drop cyber knife, laser procedures etc. Lucrin depot is given via an injection in to fatty lissue under the skin (sub cutaneous). The claim hence being a SC administration of Lucrin Depot cannot be paid under the mediclaim policy.
The counsel for the opposite party submitted that they had obtained an expert opinion which states that Lucrin depot is believed to cause reduction in
-4-
tumour growth in people with advanced prostate cancer and the said hormonal treatment does not fall under specific chemotherapy for prostate cancer. The said expert opinion is produced and marked as Ext. B2. In Ext. B2 it is stated that chemotherapy and hormone treatment are given to person suffering from Advanced Prostate Cancer. It is further stated in ext. B2, that the Lucrin depot is equivalent to chemotheraphy . Where as the counel for the complainant relied on clause 3.4 of the policy, which states that 24 hours hospitalisation is not made applicable for surgeries or procedures including parental chemotheraphy and radiotheraphy or any other surgeries/ procedure agreed by TPA/ Company which requires less than 24 hours hospitalisation due to subsequent advancement in medical technology.
On scanning Ext. A1 policy clause, it is seen that as per clause 3.4, the time limit of 24 hours will not be applicable for procedures like parental chemotherapy, radiotherapy etc. In our view Meta static carcinoma prostate is treated with antrogen block aid and for this purpose one of the most accepted treatment modality is Lucrin depot. Ext. B2 expert opinion clearly states that Lucrin depot is equivalent to chemotherapy. In our opinion, as per clause 3, 4 the time limit of 24 hours hospitalisation is not applicable to chemotherapy, it is also not applicable to Lucrin depot. We feel that the act of opposite party in repudiating the mediclaim on flimsy reason is a clear case of deficiency in service. Point No. 1 is found accordingly.
Point No. 2
In view of the findings in point No. 1, the complaint is allowed.
-5-
In the result, the complaint is ordered as follows.
The opposite party will pay the claim amount of Rs. 33,240/- to the complainant with interest @ 10% p.a from the date of repudiation till payment. As interest is allowed no compensation ordered. The opposite party will also pay Rs. 4,000/- as litigation cost to the complainant.
This order will be complied with within one month of receipt of the order.
Smt. Bindhu M. Thomas, Member Sd/-
Sri. Santhosh Kesavanath P., President Sd/-
Sri. K.N. Radhakrishnan, Member Sd/-
APPENDIX
Documents of the complainant
Ext. A1: The copy of the policy conditions
Ext. A2: Copy of the claim statement
Ext. A3: The copy of the repudiation letter
Ext. A4: Copy of the certificate from doctor.
Documents of the opposite party
Ext. B1: Copy of policy and clauses
Ext. B2: Original certificate of doctor Mr. Parakal
Ext. B3: Original letter Dtd: 8..7..2009.
By Order,
Senior Superintendent
Received on / Despatched on
