Delhi

East Delhi

CC/83/2017

MEENA RANI - Complainant(s)

Versus

HERITAGE HEALTH - Opp.Party(s)

09 Jul 2019

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.           83/2017

                                                                                                   Date of Institution                10/03/2017

                                                                                                   Order reserved on                09/07/2019       

                                                                                                   Date of Order                        11/07/2019                                                                                    

 

In matter of

Mrs Meera Rani Verma

w/o-Mr K.P. Verma-Advocate  

R/o- 269/B, New Layalpur Colony,

Delhi 110051...……………............................................…………….Complainant

                             

                                      Vs

 

1-M/s Manager, United India Insurance Co. Ltd. 

H.O.- IBA Cell, Vulcan Insurance Building

77Ground Floor, V N Road,

Charchgate Mumbai- 400020

 

2-Heritage Health Pvt Ltd- TPA

411, Lakshmideep Building, 4rth Floor,

Laxmi Nagar, Delhi 110092……………………..……………..….………..Opponent

 

Complainant  advocate                Mr. K. P. Verma

Opponent  advocate                     Mr. Pramod Kumar               

 

Quorum                                           Sh Sukhdev  Singh        President

                                                          Dr P N Tiwari                 Member

                                                          Mrs Harpreet Kaur       Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                         

Complainant, bank employee code 4369, after retirement from Banking Services, joined Indian Bank Association Group Mediclaim Policy with his wife aged 66 years vide health card ID no. HHS8 0700267377 having its TPA OP2/Heritage Health Pvt Ltd. It was stated that his wife had Severe both knee joint Osteoarthritis since long so took Acupunture therapy from 21/02/2016 to 09/07/2016 and had treatment cost of Rs 58,800/-(Ex CW1/2,2A,2B), so filed claim with OP2 (Ex CW1/3) which was provisionally rejected (Ex CW1/4) with reason as late submission.

Complainant lodged complaint with OP1 Grievance Redressal office at Chennai (Ex CW1/5) on 26/10/2012 and received registration no. NOG0000262016 on 17/11/2016 (Ex CW1/6) and thereafter lodged another complaint against TPA/OP2 office on 28/12/2016. Complainant also filed complaint for deficiency in services by OP2 before Insurance Ombudsman and received order to file complaint before a competent Forum with their order as final rejection letter from OP1 Grievance office dated 31/01/2017 (Ex CW1/7) stating reason as “Domiciliary Treatment for retired employees of State Bank Of Bikaner was not payable” so filed this complaint for reimbursement of Acupuncture Treatment taken for his wife and claimed Rs 58,800/-with harassment Rs 50,000/-.

In the written statement OP denied all allegations of deficiency in their services as alleged by complainant. It was admitted that complainant was a member of Indian Bank Association Group Mediclaim policy (Ex OPW1/1) which was formulated between the Bank Association and OP1 for benefit of their retired / retiring employees. It was a Tailormade Group mediclaim policy where certain clauses were re framed, but domiciliary treatment of any kind was not payable. Here in this case, complainant took Acupuncture treatment for his wife as Domiciliary treatment for about 4 and half month and submitted his claim. After proper scrutiny of treatment documents pertaining to B/L Knee Joint Osteoarthritis and lumpsum hand written bills from treating doctor, claim was finally rejected under Additional Conditions sub clause 2 which reads as –“No expense related to Domiciliary /OPD treatment was payable”, so after opinion from Grievance Cell of OP1 in reference to policy terms and conditions (Ex OPW1/1 colly) claim rejection was justified. Hence it was prayed that complaint may be dismissed.  

 

Complainant submitted rejoinder to written statement of OP and denied all replies of OP. He stated that facts of complaints were correct and true. He stated that he was having IBA Group Mediclaim Policy as he was retired employee of State Bank of Bikaner and took the said policy covering his wife also. It was also stated in his complaint para 5 that Acupuncture treatment was an experimental treatment which was taken as OPD based. It was also stated that ‘Domiciliary treatment was payable under the said group mediclaim policy. So OP had intentionally repudiated claim.

Complainant submitted evidences through her own affidavit where she affirmed on oath that all the facts were correct and true. She relied on group mediclaim policy copies (Ex CW1/1), all treatment bills of Acupuncture treatment (Ex CW1/2,2A &2B). Despite of submitting all required documents, OP did not consider her claim, so OP be directed to process claim as per policy terms and conditions. 

OP submitted their evidence on affidavit through Md. Gitanjali Chauhan, working as Administrative Officer at OP office and affirmed on oath that all procedures adopted by them were as per IRDA guidelines and tailor made Group Mediclaim policy was framed for IBA with terms and conditions effective from 01/11/2015 to 31/10/2016, where IBA was the proposer of this policy. It was stated that the said policy was for retirees of bank and both the parties were bound by terms conditions. OP relied on additional condition 2 of Part 1 which clearly states as “Domiciliary/OPD treatment was not payable”. Under part II of Policy, sub clause 2.3 under the head “Alternative Treatment” means other than treatment under Allopathy and includes Ayurveda, Unani, Siddha, Homeopathy and Naturopathy in the Indian context for hospitalization only and Domiciliary for treatment only under ailments mentioned under the clause 3.1 in a registered hospital by the State or Central authorities.

It was stated that under clause 3.1- Domiciliary treatment means “medical treatment for a period exceeding three days for such an illness/diseases/injury which in the normal course would require care and treatment at hospital, but is actually taken while confined at home under any of the following circumstances:-

1.  the condition of the patient is such that he/she is not in a condition to be  

                                  removed to a hospital or

 

                           b)-  the patient takes treatment at home on account of non availability of room

                                  in a hospital”.

 

It was also stated that under clause 3.4 -Alternate Therapy – “Reimbursement of Expenses due to hospitalization under the recognized system of medicines in Unani, Siddha, Homeopathy and     Naturopathy, if such treatment is taken in a clinic/hospital registered by the State or Central Govt.”

OP also stated that under clause 2.10- Day Care Treatment - Day care treatment refers to medical treatment and or surgical procedure are carried out under Local and General Anesthesia in a hospital / day care in less than a day because of technologies advancement, and this would have otherwise required a hospitalization of more than a day.

Treatment normally taken only on an OPD basis was not included in the scope of this definition.  Hence, the scrutiny done by OP2 was as per the policy terms and conditions pertaining to IBA Group Mediclam Tailor-made Policy for retiree of bank employees. So, this complaint may be dismissed.  

Both the parties submitted written arguments and taken on record. Complainant referred citation Shiva Kant Jha vs Union of India, II (2018) CPJ 19 SC which states that “Govt. Employee in service or retired were entitled to get benefit of medical facilities from the empanelled or non empanelled hospital.”

Arguments were heard from both the parties. After perusal of materials on record, order was reserved.

Before coming to the conclusion of this case, two questions to be explained as under –

*Whether treatment expenses pertaining to Acupuncture therapy payable by OP under     Domiciliary /OPD basis?  

*Whether any deficiency in services of OP proved under the policy conditions?

Question no. 1 -Whether treatment expenses pertaining to Acupuncture therapy payable by OP under Domiciliary /OPD basis?- As per the facts and evidences on record, treatment of Acupuncture was not covered under any system of Medicines as explained above.

After going through terms and conditions of the IBA Group Mediclaim Policy, additional condition 2 of part 1 which states that Domicilisry / OPD treatment was not payable. And even Alternative Treatment heads including Ayurvedic ,Unani, Siddha, Homeopathy and Naturopathy not payable until insured remains under a recognized hospital. More so, Domiciliary Treatment was covered only when insured remains as indoor or under the supervision of treating doctor and does not require continuous indoor. As Acupuncture treatment was not recognized by any State or Govt. till now, so could not be considered under Domiciliary Treatment or on OPD basis in reference to definition under clause 2.10 also. Hence claim does not falls under this clause and complainant was not entitled for claim.

Que. 2- Whether any deficiency in services of OP proved under the policy conditions?- Under policy terms and conditions of the said IBA tailor made Group Mediclaim policy, additional condition 2 sub clause (ii) clearly stated that Domiciliary / OPD basis treatment was not payable until treatment taken from recognized hospital. In this reference, OP was nowhere deficient in their services for repudiating claim for Acupuncture. Hence no liability could be fastened on OP.       

Hence, we come to the conclusion that this complaint deserves to be dismissed so dismissed without any order to cost.

First free copy of this order be sent to the parties under Regulation 18(6) of the Consumer Protection Regulations, 2005 (in short CPR) and file be consigned to Record Room under Regulation 20 (1) of the CPR.  

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                       

                                                  Shri  Sukhdev Singh  President