Consumer Complaint No. 247 of 2015
Date of filing: 23-12-2015 Date of disposal: 21-09-2016.
Present :
Sri Asoke Kr. Mandal, Hon’ble President,
Smt. Silpi Majumder, Hon’ble Member,
Sri Pankaj Kr. Sinha, Hon’ble Member,
Sri Gopinath Gupta, S/o. Lt. Jhumak Gupta, resident of 84,
Tagore Avenue Durgapur-4, Dist.-Burdwan, Pin-713214. Complainant.
VERSUS
- E-Meditek (TPA) Services Ltd., represented by its Director, having its Corporate Office at Plot No.577, Udyog Vihar, Phase-V, Gurgaon, Haryana, Pin-122016.
- E-Meditek (TPA) Services Ltd., represented by its Regional Manager, having its office at Suit No.6, 8th floor, Shanty Niketan Building, 8, Camac Street, Kolkata-700 017.
- National Insurance Company Ltd., represented by its Divisional Manager, having its office at Kundu Mansion (1st floor), 548, G.T. Road, Bhanghakuthi, Burdwan-713101.
4. Steel Authority of India, represented by its Director, having is registered office at Ispat
Bhavan, Lodi Road, New Delhi, Pin-110 003.
Opposite Parties.
Appeared for the complainant : Ld. Advocate Suvro Chakraborty.
Appeared for the Opposite Party No.1 & 2 : None.
Appeared for the Opposite Party No. 3 : Ld. Advocate Shyamal Kr. Ganguly.
Appeared for the Opposite Party No. 4 : Ld. Advocate Biswa Ranjan Bhattacharya.
JUDGEMENT
This is a case U/s .12 of the C.P. Act, 1986, for an award directing the O.Ps. to pay Rs.47,000/- as cost of injection, to pay Rs.30,000/- as compensation for mental pain, agony and harassment and to pay Rs.30,000/- as litigation cost, to the complainant.
The complainant’s case in short is that the complainant being a retired employee of SAIL (O.P. No.4) got mediclaim policies of the O.P. No.3 (National Insurance Company Ltd.) for himself and
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his spouse namely Shila Gupta, such policies were incepted firstly in the year 2002 and the O.P. No.3 on each and every year renewed the same after receiving the premium from the complainant. In that connection the O.P. No.4 issued two MIN Nos.2511433 and 2511434 in favour of the complainant and his wife respectively. For the year 2014 the policy of insurance issued in favour of the complainant, was made valid for the periods from 14.1.2014 to 31.12.2014 and for the year 2015, then said policy of insurance was made valid for the periods from 15.1.2015 to 31.3.2015 and 1.4.2015 to 31.3.2016, during the period of continuation of such policy the complainant begun to suffer problems in his eye side and he consulted with the doctor of Disha Eye Hospital, Durgapur. The treating doctor of said hospital opined that the problem in the eyes of the complainant arises due to bleeding in the eyes and he prescribed Intravit Lucentis injection. The complainant received said Intravit Lucentis injection on 17.12.2014 for the first time, paying Rs.23,500/- as cost of the same. Regarding said payment, the hospital authority gave intimation to the O.P. No.1 & 2, the complainant himself also gave intimation the matter issuing letter dated 2.1.2015 and submitted bill. Thereafter being adviced by the treating doctor, the complainant received Accentrix Injection on 7.1.2015 and on 4.2.2015 paying total cost of Rs.47,000/- (Rs. 23,500 + Rs. 23,500). The complainant as well as the hospital authority intimated the matter to the O.P. No.1 & 2 to get such amount. Subsequently, the O.P. No.1 & 2 vide their Mail dated 29.1.2015, 26.2.2015 and 4.3.2015 intimated the complainant that the O.P. No.3 Insurance Company repudiated the claim of the complainant stating that the Insurance Company shall not be able to make any payment of treatment of age related Macular Degeneration with injection Avastin/Lucentis/Macuzen as per provision of “6.0 Important Exclusion”. In the Exclusion Clause; the name of injection ‘Accentrix’ has not been mentioned, inspite of that with ill-intention and to deprive the complainant, the O.P. No.3 repudiated the claim of the complainant. The complainant made several requests to reconsider the matter but no fruitful result was achieved. The act of the O.P. No.3 clearly shows deficiency in service and unfair trade practice, on its part. Hence, this case with the prayer as mentioned above.
The O.P. No.1 & 2 inspite of service of notices upon them, did not appear in this case to contest this case. Accordingly the case was heard exparte.
The O.P. No.3, National Insurance Company, contested this case by filing their written version, while denying the case of the complainant and stating inter-alia that the complainant has no cause of action to institute this case, this Forum has no jurisdiction to try this case and this case is barred by limitation. It has been further stated by this O.P. No.3 that the complainant was enjoying a mediclaim policy bearing No.351200/46/13/ 8500000174 being the Ex-employee of SAIL, having MIN No.2511433 for self and MIN No.2511434 for his spouse (Shila Gupta) with its validity upto 31.12.2014, during that period on 17.12.2014 the complainant was treated at Disha Eye Hospital Pvt. Ltd. with Intravitreal Lucentis injection under ‘Intravit Accentrix package’ for which a claim submitted by the complainant on 2.1.2015 for an amount of
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Rs.23,500/- along with cash memo, bill of Disha Eye Hospital and discharge certificate dated 17.12.2014, again on 7.1.2015 and 4.2.2015 the complainant was treated at Disha Eye Hospital Pvt. Ltd. For the problem in his eyes under ‘Intravit Accentris Package’ and a bill was submitted for Intraculation of injection on 7.1.2015 for Rs.23,500/-, again on 4.2.2015 the complainant was treated at Disha Eye Hospital Pvt. Ltd. as per ‘Intravit Accentrix Package’ for Rs.23,500/-, the complainant submitted the claim application on 4.3.2015 for Rs.23,500/- for obtaining Accentrix injection package, on receipt of the claim application, from the complainant this O.P. forwarded the same to O.P. No.1 for verification, the O.P. No. 1 being the third party agent reported that as per Exclusion Clause the Company shall not liable to make any payment in connection with the policy Ref. 351200/46/13/8500000174, in respect of any expenses incurred by any insured person for treatment of age related Macular Degeneration with injection Avastin/Lucentis/Macuzen and any other treatment for similar nature vide letter dated 29.1.2015. So the claim of the complainant was denied by this O.P. National Insurance Company Ltd. on the terms and conditions of the policy.
It has been also stated by this O.P. that the claim of the complainant was repudiated since the complainant being an elderly person and suffering from vision due to aging problem which does not cover under the policy condition and before undergoing the treatment the complainant never intimated the TPA, (O.P. No.1 & 2). It is, therefore, claimed by this O.P. that the case is liable to be dismissed against this O.P. No. 3.
The O.P. No.4 also contested this case by filing separate written version while stating inter-alia that the case is not maintainable against this O.P., M/s. Steel Authority of India Ltd., as an ex-employer it had an annual recurring scheme for ‘SAIL Mediclaim Scheme’ for facilitating a group mediclaim Insurance Policy for its ex-employees and their spouses which may opt for the same, so as to avail cashless hospitalization and other insurance benefits, the role of answering O.P. No.4 is only that of a facilitator to arrange such group mediclaim insurance policy for its ex-employees and their spouses for which it makes a substantial contribution (80-90%) of the total premium so that only the remaining portion of the premium is borne/shared by the individual members/policy holders, the O.P. No.4 is neither the insurer nor it received any consideration from the individual members of the scheme/ policy holders and it does not have any responsibility in the processing and settlement of claim made by the individual members who opt for the said scheme, the payments by the individual members of the scheme/ policy holders are made to the Insurer, the O.P. No.3, to accept or to reject the claim arising during the policy period by the O.P. No. 3, is based on processing and recommendations of the third party administrator here O.P. No.1 & 2, the O.P. No.4 is not accountable or answerable or liable to the complainant for any loss/damage incurred by the complainant on account of any alleged
deficiency in service on the part of the O.P. No.1, 2 & 3, the complainant is not the consumer of the O.P. No.4 and accordingly the case is not maintainable against this O.P. No.4.
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DECISION WITH REASONS
To prove his case the complainant has relied upon his evidence on affidavit and the photocopies of several documents total 27 sheets which are connected with the policy in question, the treatment of the complainant and the repudiation made by the O.P. No.3.
On the other hand the contesting O.P. No.3 has only relied upon the Important Exclusion Clause (xii) as mentioned in E-meditek TPA Services Ltd. (Group Mediclaim Scheme 2014 for Retired Employees and their spouses).
We have carefully gone through the contents of the complaint petition and the written versions filed by the contesting O.P. No.3 & 4. It appears that both the contesting O.Ps. have admitted the case of the complainant that the complainant being a retired employee of SAIL (O.P. No.4) got mediclaim policies of the O.P. No.3 (National Insurance Company Ltd.) for himself and his spouse namely Shila Gupta, such policies were incepted firstly in the year 2002 and the O.P. No.3 on each and every year renewed the same after receiving the premium from the complainant, in that connection the O.P. No.4 issued two MIN Nos.2511433 and 2511434 in favour of the complainant and his wife respectively, for the year 2014 the policy of insurance issued in favour of the complainant, was made valid for the periods from 14.1.2014 to 31.12.2014 and for the year 2015, then said policy of insurance was made valid for the periods from 15.1.2015 to 31.3.2015 and 1.4.2015 to 31.3.2016, during the period of continuation of such policy the complainant begun to suffer problems in his eye side and he consulted with the doctor of Disha Eye Hospital, Durgapur, the treating doctor of said hospital opined that the problem in the eyes of the complainant arises due to bleeding in the eyes and he prescribed Intravit Lucentis injection, the complainant received said Intravit Lucentis injection on 17.12.2014 for the first time, paying Rs.23,500/- as cost of the same. Regarding said payment, the hospital authority gave intimation to the O.P. No.1 & 2, the complainant himself also gave intimation the matter issuing letter dated 2.1.2015 and submitted bill, thereafter being adviced by the treating doctor, the complainant received Accentrix Injection on 7.1.2015 and on 4.2.2015 paying total cost of Rs.47,000/- (Rs. 23,500 + Rs. 23,500), the complainant as well as the hospital authority intimated the matter to the O.P. No.1&2 for reimbursement, the O.P. No.1 & 2 vide their Mail dated 29.1.2015, 26.2.2015 and 4.3.2015 intimated the complainant that the O.P. No.3 Insurance Company, repudiated the claim of the complainant stating that the Insurance Company shall not be able to make any payment of treatment of age related Macular Degeneration with injection Avastin/Lucentis/Macuzen as per provision of “6.0 Important Exclusion”.
It appears that In the Exclusion Clause the name of injection ‘Accentrix’ has not been mentioned, inspite of that with ill-intention and to deprive the complainant, the O.P. No.3 repudiated the claim of the complainant.
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The containts of the complaint as mentioned, is supported by the photocopies of the documents (total 27 sheets) filed by the complainant. The complainant has stated in the complaint that the O.P. No.3 with malafide intention repudiated the claim of the complainant knowing the nonexistance of injection ‘Accentrix’ in the Exclusion Clause (XII).
In para-2(d) of its W.V. the O.P. No.3 has stated that the third party administrator (O.P. No.1 & 2) informed it that the injection ‘Accentrix’ administered to the complainant on 7.1.2015 and 4.2.2015 is also covered by the Exclusion Clause (Sub-clause-XII) as the said injection ‘Accentrix’ has the same composition ‘Renibizumab’ as that of ‘Lucentis’ injection and is used for the treatment of patients with age related Macular Degeneration and as such this O.P. repudiated the claim of the complainant. We carefully have perused the Important Exclusion Clause XII which says that the Insurance Company shall not be liable to make any payment in respect of any expenses whatsoever incurred by the insured person in connection with treatment for age related Macular Degeneration with injection Avastin/Lucentis/Macuzen. So there is no bar to get the reimbursement of the expences incurred by the insured person in connection with his treatment for age related Macular Degeneration with injection ‘Accentrix’. The materials on record show that the complainant’s treatment for age related Macular Degeneration, was made with injection ‘Lucentis’ on 17.12.2014. So, the complainant is not entitled to get the reimbursement of the expences incurred by him in connection with his treatment for age related Macular Degeneration with injection ‘Lucentis’ on 17.12.2014. But the materials on record and from the admission of the parties, it is clear that the complainant was treated for age related Macular Degeneration with injection ‘Accentrix’ on 7.1.2015 and 4.2.2015 incurring cost of Rs.23,500/-+ Rs. 23,000/- total Rs.47,000/-. No explanation from the side of the O.P. No.3, has been given as to why the name of injection ‘Accentrix’ has not been mentioned in Exclusion Clause-XII, where the injection ‘Lucentis’ has been mentioned therein. As in Sub-clause-XII of Important Exclusion, the injection ‘Accentrix’ has not been mentioned, we are of the opinion that the complainant is entitled to get reimbursement of the expences incurred by him on 7.1.2015 and 4.2.2015 in connection with his treatment for age related Macular Degeneration with injection ‘Accentrix’. From the evidence on record it also appears that the complainant in time made claim to get such treatment cost of Rs.47,000/- incurred by him on 7.1.2015 and 4.2.2015.
In para-17 of its written version, the O.P. No.3 has stated that the claim of the complainant was repudiated on the ground that complainant is not entitled to get reimbursement of the expences incurred by him on 7.1.2015 and 4.2.2015 as the treatment was made for age related Macular Degeneration with injection Avastin/Lucentis/ Macuzen and any other treatment of the similar nature”. The Important Exclusion Clause-XII, is completely silent in respect of words “and any other treatment of similar nature”. So, the O.P. No.3 is not entitled to get benefit of said words “and any other treatment of similar nature”. From the evidence on record it is clear
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that by adding such words, the O.P. No. 3 has illegally denied/repudiated the claim of the complainant. In view of the above discussions we are of the opinion that the complainant is not entitled to get the cost of treatment made on 17.12.2014 but he is entitled to get the cost of Rs.47,000/- for his treatment made on 7.1.2015 and 4.2.2015.
As applying unfair trade practice and with ill-intention the O.P. No.3 repudiated the claim of the complainant and as for the act of the O.P. No.3, the complainant has suffered from mental pain, agony and harassment, the complainant is entitled to get an amount as compensation. An amount of Rs.10,000/- as compensation will meet the ends of justice.
For the fault of the O.P. No.3, the complainant has been forced to come before this Forum for an award. So, the complainant is also entitled to get Rs.2000/- as litigation cost.
In view of our above discussions the complaint succeeds.
Fees paid is correct. Hence, it is
Ordered
that the complaint case be and the same is allowed on contest against the O.P. No.3 and the case is dismissed on contest against the O.P. No.4 and ex-parte against the rest, the complainant do get an award directing the O.P. No.3 to pay total Rs.47,000/- as cost of treatment made on 7.1.2015 and 4.2.2015, along with interest @8% on such amount, from the date of filing of this case, to pay Rs.10,000/- as compensation for mental pain, agony and harassment and to pay Rs.2000/- as litigation cost to the complainant within 45 days, failing which the entire awarded amount shall carry interest @ 12% p.a. upto the date of final realization of the same and the complainant will be at liberty to put this order in execution against the O.P. No.3 in accordance with law.
Let copies of this final order be supplied to the parties free of cost.
Dictated and corrected by me. (Asoke Kr. Mandal)
President
D.C.D.R.F., Burdwan
(Asoke Kr. Mandal)
President (Silpi Majumder) (Sri Pankaj Kr. Sinha)
D.C.D.R.F., Burdwan Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
