JUDGEMENT

          Complainant by filing complaint has submitted that he is a retired officer of Coal India Ltd. and op no.1 is licensed holder acting as a Third Party Administrator of the op no.2 and also authorized representative of the National Insurance Company Ltd. Kolkata Division-VI and insurance company directs to lodge claim on the TPA for settlement of the claim and so the all claims were always submitted to the op no.1.  But op no.2 issued a policy where the complainant used to pay a premium a per policy and any claim is also payable by the op no.2.

          Fact remains complainant has his mediclaim policy for long years under the op no.2 and its hospitalization and Domiciliary Hospital Benefit Policy being(individual Mediclaim) for himself and his wife SmtChhaya Roy long back in the year 2003-2004 and it is being continued and renewed year to year and renewed Insurance Company Mediclaim Policy will expire on 13.05.2013.  It is also submitted that the last renewed medical insurance policy was valid 14.05.2012 to 13.05.2013 and sum assured is Rs.50,000/- whereas bonus is Rs.17,000/- and Rs.19,500/- and in respect of complainant’s total sum assured cover is Rs.67,000/- and in respect of his wife Rs.69,500/-.

          It is further alleged that the wife of the complainant SmtChhaya Roy who is also covered by the above mentioned insurance policy last year suddenly fell  ill and due to her feeling tiredness and have a hey fever, stomach pain etc. so complainant consulted with Dr. AsokanandaKonar at Peerless Hospital & B.K. Roy Research Centre, Kolkatawho diagnosed the disease that she was suffering from “Hepatitis C Virus” and started treatment since 11.06.2011and she was admitted in the hospital number of times for her treatment as per advice of the doctor as it will be evident from the Case record of the Patient’s Health Cards which is filed by the complainant.

          Complainant has further submitted that his wife Chhaya Roy had his weight 50 Kgs. At the time of first detection of the disease and later on gradually reduced her weight as it will be evident from the treatment sheets and also evident that for giving injections, the patient has been admitted in the said hospital according to doctor’s advice of different dated and the complainant has not lodged any claim to the insurance company or to the TPA though the complainant incurred a huge expenses for last one year though the patient was admitted number of times to the said hospital and all such documents were furnished to the TPA for settlement but it is very unfortunate on the part of the op that in spite of having all relevant documents op did not settle the claim of the complainant in respect of treatment of wife of the complainant who is also covered by the said Mediclaim Policy and practically they rejected the claim on the ground the treatment was domiciliary treatment.  So, it was not admissible.

          On 12.05.2012 when the patient Chhaya Roy visited the Peerless Hospital, she was asked for admission for transfusion of blood and for urgent medication as she was reduced her weight constantly from health card treatment it may be found that during her treatment period, she was reducing her weight even after continuous treatment and the disease of Hepatitis C Virus is serious viruses which affects human liver and multiply its cell division into more infective more cells causing liver damage leading to death of the patient from this disease.

          On 12.05.2012 complainant purchased the injection medicines from Dhanwantary Medicare & Research Centre Pvt. Ltd., Kolkata vide Invoice/Cash Memo Nos. 794 and 795 both dated 12.05.2012 for Rs.26,400/- each total to Rs.52,800/- in the name of her wife Smt. Chhaya Roy and the medicine is costly medicine and the complainant purchased two days before the admission of the patient in the hospital according to the advice of the hospital on health card on 12.05.2012 and the expenses should have been considered by the op as pre-Hospitalisation expenses which are payable as per the policy condition no.3.1 and those two cash memos are also filed with the complaint.

          The complainant has further submitted that the patient was admitted on 14.05.2012 under Dr. AsokanandaKonar as her condition was serious and gradually reducing her wright and also for some other symptoms and doctor’s findings at the time of admission in the hospital were HCV (Hepatitis C Virus), CLD (Chronic Liver Disease) with Dilated SP Axis (Supra Spine Axis), Splenomegaly, Hypersplenism, ascites with anemia and the patient was treated in the hospital by injections and also by giving 2 units of PRBC (Blood Cell) transfusion and was discharged on 16.05.2012 with advice to take medicines and investigations.

          That the complainant purchased the medicines according to advice by the Hospital in the Discharge Summary dated 16.05.2012 vide cash memo no.8154 for Rs.34,020/-. Complainant also spent for Rs.1,110/- towards the expenses for Blood Tests according to the advice of the hospital in discharge certificate on 16.05.2012.

          After discharge from hospital and treatment of the patient by the said hospital, the complainant as an insured lodged claim on the op as TPA upon the advice of the insurance company and submitted claim form on 09.07.2012 along with all relevant documents in originals, including cash memo etc.  But the said op with a bad motive and intention denied the claim on flimsy ground saying the treatment was domiciliary treatment (pre and post hospitalization) and so not payable.  The letter of the op reveals so but op intentionally ignored the admission advices of the hospital records as referred and it is clearly stated that the patient had admitted in the hospital for her treatment and a few number of hospital admission and discharge certificates of previous dates are also filed to prove the ailment of his wife and the claimant also intimated to the insurance company about the admission on 14.05.2012.

          Only for admission as in-patient, an amount of Rs.5,000/- had to deposit to the hospital besides the treatment expenses incurred separately.  The complainant furnished reports in originals on 12.09.2012 as asked for by the op.  But practically

Complainant on 12.10.2012 received a letter dated 12.10.2012 of op enclosing a cheque for Rs.5,300/- in settlement of the claim against Rs.93,612/- towards payment of only hospital admission charges and the medicines and investigations done on the basis of the advice of the hospital discharge certificate has not been paid stating that the medicines are not related to the treatment.  The complainant was surprised to see the observation and failed to understand the reasons for rejection when everything was done at per advice of the doctor and she was admitted for such treatment and medicines and injections were not related to treatment of the disease.

          Being aggrieved by the said letter dated 12.10.2012 the complainant contacted with the attending Dr. AsokanandaKonar of Peerless Hospital when he issued a certificate stating that the whole nature of treatment required for life saving of the patient suffering from Hepatitis C Virus.  But even then the TPA did not agree to settle the claim.  That the said cheque for Rs.5,300/- was returned to the TPA on 13.12.2012 and needless to mention here that the insurance company advised the complainant to send the said letter along with cheque being No.065969 dated 12.12.2012 and case has been against TPA as op refused to grant anything.

          Again complainant wrote a letter on 17.01.2013 referring the Dr. Konar’s certificate requesting the op for settlement of the claim but the op lastly denied the claim vide their letter on 01.02.2013 stating another new plea that except the bill for only hospitalization, the entire treatment expenses was incurred for domiciliary treatment only under policy condition 4.27 but the op has not gone through the treatment sheet that the patient was admitted in the hospital for treatment and it must be said that the treatment was domiciliary, hence the claim is genuine and must be payable by the op.

          In the above circumstances complainant claimed a sum of Rs.93,612/- and details of the claim is as follows:-

Cash memo no. 794 dated 12.05.2012 Rs.26,400/-, cash memo No.795 dated 12.05.2012 of Rs.26,400/-, some are injections which were purchased prior to hospitalization and admissible as per 3.1 of policy condition, during hospitalization from 14.04.2012 to 16.05.2012 Rs.5,682/-, injection medicine bought on 16.05.2012 as per hospital discharge certificate dated 16.05.2012 of Rs.32,020/- and investigation done on 19.05.2012 and report submitted to TPA of Rs.1,110/- i.e. total of Rs.93,612/- and prayed for relief on the ground the op acted illegally and did not render proper service.

          Op no.1 TPA by filing written statement submitted that nodoubt Ganesh Chandra Roy the complainant submitted intimation and thereafter submitted complete treatment documents along with filled up claim form seeking reimbursement of expenses incurred for Rs.93,612/- (related to hospitalization of his wife – Mrs. Chhaya Roy at Peerless Hospital & B.K. Roy Research Centre, Kolkata).

          The said claim had been registered against CCN HH111303836 and settled for Rs.5,300/- as per terms and conditions of the Mediclaim Policy and that matter was reported along with cheque on 09.01.2013to the complainant and against further clarification to the query of the complainant they also issued letter dated 01.02.2013 with reference No.HHSPL/092/01/13.  It is also stated that the treatment documents confirming necessity of hospitalization for management of severe anemia as advised by Dr. AsokanandaKonar as in patient w.e.f. 14.05.2012 to 16.05.2012 and discharge was allowed considering the discharge of the patient in a stable condition.

          Further from the treatment records that prior to hospitalization patient was on regular treatment on domiciliary basis for suffering from known HCV related CLD with Hyperplenism for which availing injection EPO and Interferon Therapy on weekly basis.  It is specifically mentioned that subject claim seeking reimbursement appears inclusive of hospitalization part of Rs.5,682/- as per Final Bill Statement of Peerless Hospital and Rs.87,930/- towards cost of medicines, injections for continuation of post hospitalization management related to HCV infection.

          By referring policy condition No. 4.27 op no.1 explained the necessity of disallowing the domiciliary treatment part which required for continuing management of the HCV related CLD during pre and post hospitalization period not warranting hospitalization treatment and thus falling outside scope of the subject hospitalization benefit policy and op has submitted that they have documentary evidences they justified it and reasonable quantum of settlement had been released in favour of the complainant.  So, op no.1 has no fault also on the part of it.

          But op no.2 Insurance Company by filing this written statement has submitted that there was no fault on the part of the op no.2 and TPA is the authority to determine the admissibility of the claim and they have also in their written statement submitted that the complainant had been suffering from continuous treatment of known of his domiciliary treatment for her Hepatitis C Virus related CLD with Hypertension for which complainant’s wife had been given weekly injection EPO and Interferon therapy on weekly basis and when she was admitted to hospital that was also given as legal process of treatment.  So, it was not the part of the present treatment and they have also submitted that as per policy 4.27 TPA for domiciliary treatment part which is required for continuing management of patient from HCV related during pre and post hospitalization period not warranting hospitalization treatment and thus falling outside scope of the subject hospitalization benefit policy.  Op no.2 in their written statement also submitted that the settlement claim of the complainant was duly decided by the TPA as per clause 4.27, so there was no fault on the part of the op no.2 and in all cases relying upon as per IRDA.  So, complainant will not get any relief for the reasons, so the above complaint should be dismissed.

Decision with reasons

          On over all study of the entire complaint, written version including the discharge certificate of the patient of Chhaya Roy issued by Peerless Hospital and B.K. Roy Research Centre, it is found that complainant was admitted to that hospital on 14.05.2012 and was discharged on 16.05.2012 and on investigation it was found that the patient Chhaya Roy had been suffering from known cause of Hepatitis C Virus related Chronic Liver Disease with Hypertension and that was her history of suffering from such disease.  But she was admitted to hospital on 14.05.2012 on the ground that she was further found suffering from anemia and in the said discharge report it is specifically stated that her hemoglobin level was 8.1% in spite of taking weekly injection EPO of 60,000 units by her and she was on constant interferon therapy and only to protect her from anemia she was given two units of PRBC transfusion and practically Dr. Konar gave two units of PRBC transfusion of blood.  But all other dosages as continued by the patient was also continued during the treatment.  Truth is that complainant had been suffering from HCV related CLD and also Supra Spinal Axis and fact remains complainant has admitted that fact in her complaint that his wife had been suffering from HCV and her treatment was started since 11.06.2011 and prior to this admission in the Peerless Hospital and B.K. Roy Research Centre on 14.05.2012 on various occasion for such disease she was admitted for treatment.

          So, it is clear that she had been treated for her past history of HCV related CLD Genotype one with Hypertension on interferon therapy, that means she was without admission also complainant was in domiciliary treatment constantly and per week or weekly she got injection of EPO of 60,000 units and she was on interferon therapy.  But when her hemoglobin rate was not increased she felt lethargy when doctor advised her to give two units of PRBC transfusion and for that purpose she was admitted and in the discharge certificate in the column history it is noted lethargy and treatment was for giving two units of PRBC infusion on the ground inspite of taking weekly injection EPO of 60,000 units and even after getting regular interferon therapy hemoglobin rate was not increased.  So, total treatment in the hospital was for transfusion of blood when she had her continuous history of HCV (Hepatitis C Virus) related CLD (Chronic Liver Disease) and Supra Spinal Axis.

          Practically for that reason she was not admitted only her blood hemoglobin have not been increased even after such continuous treatment since 11.06.2011, that means all other medicines which were prescribed by this doctor was on the basis of the previous treatment sheet and during the stay at hospital that medicines were also given because it was the continuation of the previous domiciliary treatment and as per previous diagnosis chart.  So under any circumstances use of the two packs of injection as used during her stay at hospital was not a fresh part of treatment.  But it is continuation of the previous domiciliary treatment.

          So, as per provision of clause 4.27        of the terms and conditions of the policy no doubt TPA rightly rejected that part and fact remains only to get said amount of injection complainant admitted her because the cost of those injections are very high.  But only for giving injection hospitalization was not necessary.  But it was necessary on the ground that her hemoglobin rate was not increased even after taking injection on every week since June, 2011 and also for her continuous treatment on interferon therapy.  Further from the discharge certificate it is clear that the treatment had been given – received 2 packs of PRBC transfusion in between the period 14.05.2012 to 16.05.2012.

          Fact remains from other discharge certificate it is found that she was further admitted on 16.03.2012 and on 17.03.2012 treatment – received one unit of blood transfusion. Another treatment sheet discharge certificate dated 25.02.2012 reveals that she was admitted on 23.02.2012 and was discharged on 25.02.2012 treatment was given – received two units of blood transfusion.  So, it is clear that in all occasion when she was admitted to hospital treatment giving was only transfusion of blood but no other treatment because complainant’s wife is a chronic liver patient of Hepatitis C Virus infection along with Chronic Liver Disease and Supra Spinal Axis for which she had been constantly given medicines in domiciliary system since June, 2011.

          Taking into account of all the discharge certificates we are confirmed that no other treatment was given to the complainant’s wife Smt. Chhaya Roy by the Peerless Hospital & B.K. Roy Research Centre or by Dr. Konar but only treatment was transfusion of bold and transfusion of blood is required in view of the fact the treatment which was given by some expert doctors is domiciliary in nature and complainant is under medication since June, 2011 and same is being continued till now and when she is in hospital it is found that her date of taking Interferon therapy or injection of EPO of 60,000 units, so it was given.  But it is not part of the treatment but it is part of continuous domiciliary treatment that was continued by Dr. AsokanandaKonar. 

So, considering all the above fact and materials including the Clause 4.27 of the terms and conditions of the policy we find that TPA rightly rejected that part and that claim was in respect of Rs.52,800/-.  Similarly the claim of the complainant in respect of injection medicine bought on 16.05.2012 as per hospital discharge certificate dated 16.05.2012 total claim of the complainant of Rs.34,020/-.  We have minutely considered the prescriptions dated 16.05.2012  and in this regard we have gone through the clause 4.27 wherefrom it is found that treatment chart insured was on or before hospitalization and required to be on after discharge for the ailment/disease/injury different from one for which hospitalization was necessary and considering that clause it is clear that hospitalization was necessary only for blood transfusion and the other medicines had been taken by the complainant’s wife since June, 2011 for her pre-existing disease that are HCV related CLD with Hyperplenism for which she was on interferon therapy and for HCV she was given EPO of 60,000 units and that was also Espozen that 60000 was divided by 3 days @ 20,000 units only.  But that injection had been taken by the complainant’s wife since June, 2011.  So, under any circumstances that part of injection cannot be treated as part of this treatment because in all the discharge certificates it is specifically mentioned that the treatment was given only for blood transfusion.  No other treatment was done by the hospital authority or by the doctor that was evident from all the discharge certificates.

Moreover considering the details of reduction as made by the Heritage Health TPA it is found that Rs.34,020/- and against bill dated 16.05.2012 of Rs.26,400/- each having bill number dated 12.05.2012 are no way related to present treatment during hospitalization or after hospitalization. But all the injections were continuation for her previous ailment HCV and other existing disease because in the treatment sheet or the discharge certificate that medicines were not part of the treatment, only treatment was transfusion of blood for which she was admitted for various times.  

Further fact is that the present patient had been suffering from the severe disease that was not disclosed anywhere not at the time of renewal and fact remains complainant’s claim is in respect of the present policy which was for the period from 10.05.2012 to 13.05.2013.  But fact remains that this patient had been suffering from severe disease of HCV related CLD with Hyperplenism for which she is on Interferon therapy on June, 2011 and it is being continued till to date and for her CLD and other Supra Spinal Axis and including for the HCV related CLD she was given continuous injections Espozen or injection of EPO of 60,000 units and EPO or Espozen on some categories of injection complainant had been taking EPO of 60,000 units but that was divided into 20,000 units only by the Dr. AsokanandaKonar by giving another injectionEspozen 20,000 units per week i.e. on Tuesday, Thursday & Saturday.  But it is not a treatment.  But it is a part of continuous treatment if complainant’s wife had not been admitted in the hospital in that case also his wife must have to take such injection as per previous advice of the doctors and truth is that complainant’s wife is under the treatment of Dr. AsokanandaKonarsince June, 2011 long prior to purchasing this Mediclaim Policy and she had been treated domiciliary for last 2 years prior to this admission. 

So, it is clear that TPA Authority considered all factors and rightly rejected the claim and in this regard it is to be mentioned that Hon’ble National Commission already decided that only in respect of the treatment the insured is entitled to get such relief and in this case in all the discharge certificates treatment given is blood transfusion and all other part of disease were not treated because for that purpose she had been treated continuously from June, 2011.

Another factor is that TPA already informed the complainant.  Further it is to be mentioned that Espozen or EPO are taken by any patient when a patient has been suffering from anemia and to maintain hemoglobin and white cell, EPO or Espozen are used and Viraferpegand injection or Riflavin Tablets are also related to maintain hemoglobin and white cell count and loss of hemoglobin in respect of this patient is a chronic history for which domiciliary she has been treated since June, 2011.  So, those medicines cannot be taken as part of treatment for admission.  Admission was caused because all those medicines were given after taking in which date and weekly complainant’s wife hemoglobin rate has not been increased for which only the treatment was given blood transfusion.  Other medicines are applied on continuous treatmentand it is not treatment of any other separate disease.

So, after considering all the above fact and also the explanation a given by the TPA in writing to the complainant we are confirmed to accept blood transfusion and related admission cost complainant is not entitled further benefit and the benefit which has been given as per true spirit of the policy terms and conditions.  In this case what we have gathered after applying our judicious mind that practically complainant has been spendinghuge money for his wife’s treatment.  But in any domiciliary he is not entitled to get any refund of the amount which has been spent for his wife’s treatment.  So, time to time by admitting his wife for blood transfusion he is trying to get benefit of the injection cost which is beingused for pre-existing continuous disease and for which he is submitting claim by admitting his wife for getting the benefit of the very costly injection which are constantly taken by the complainant’s wife and same are being noted by the doctor.

But truth is that doctor has completely noted that she has given treatment and that is blood transfusion and all other medicines continued as per her previous treatment sheet which was domiciliary in nature.  So, invariably any medicine which has been taken by a patient continuously are taken during any admission period shall not be treated as part of the treatment cost because if the patient would not be admitted in that case he/she must have to take it as domiciliary treatment.

So, considering all the above facts we are convinced that in any circumstances complainant is not entitled to get any further benefit against the claim.  No doubt we are expressing our painful sorrow for the ill-health of the wife of the complainant.  But we are the creatures of the legal system.  So, we are not able to give any further relief.  But anyhow we are not in a mood to give any further amount to the complainant by any means when there is clause by which both the parties are guided and in this regard we have also gone through a ruling reported in 2013 (4)CPR 165 NC wherefrom we have learnt that policy condition period shall be strictly governed by the policy condition and no exception or relaxation can be made on the ground of equity.

In the result, the complaint fails.

Hence, it is

ORDERED

That the complaint be and the same is dismissed on contest but without costagainst the op.