Punjab

Ludhiana

CC/19/564

Neeraj Singla - Complainant(s)

Versus

Iffco Tokio General Insurance Co.Ltd. - Opp.Party(s)

Shiv Sharma Adv.

07 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:  564 dated 10.12.2019.                                                       Date of decision: 07.06.2024. 

 

Neeraj Singla aged 50 years son of Shri Sohan Lal, c/o. M/s. Sohan Lal & Sons, Gill Road, Ludhiana.

                                                                                      ..…Complainant

                                                Versus

1. Iffco-Tokio General Insurance Company Limited having its registered office at Offco Sadan-C-1, District Center Saket, New Delhi-110017, through its Officer Incharge/Authorized Signatory.
2. Iffco-Tokio General Insurance Company Limited, IFFCO Tower II Plot No.3, Sector 29, Gurgaon      -122001 (Haryana), through its Officer Incharge/Authorized Signatory.                                                                                                                                              …..Opposite parties 

Complaint Under Section 12 and 14 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Shiv Sharma, Advocate.

For OPs                          :         Sh. Vyom Bansal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the case are that the complainant has been getting medical insurance from the OPs since 2016 by paying yearly premium and which were got renewed on 16.09.2019 till 15.09.2020. The complainant sent claim No.2019071000841 under policy No.52996413 for reimbursement but the OPs repudiated his claim invoking condition No.10.D of Health Insurance Guidebook of IHP.

                   The complainant stated that he was prescribed the usage of REBIF 22 MCG PFS Injection (Interferon Beta-1A 22 MCG) thrice a week and claim submitted regarding which was reimbursed by the OPs. Thereafter, the complainant was advised the usage of injection Tysabri by Dr. Sanjay Kumar Saxena, HOD Neurology, Max Health Care, Patparganj Branch, New Delhi, but the OPs wrongly held and repudiated the claim of injection Tysabri despite the fact that the complainant was fully covered under Health Protector Health Policy with them. The complainant further stated that he shocked to receive letter dated 05.09.2019 from the OPs whereby the OPs referred to some health insurance Guidebook which was never part of any policy nor the same was read over and explained to him. Neither the complainant admitted to same nor signed any guidebook nor any policy was issued by the OPs. The claim was repudiated by invoking clause 10.d mentioning that “No claim shall be given with regard to intravitreal injection/interferon injection/infliximab and like injection intra-articular injections.” According to the complainant, the injection Rebif is also an interferon injection regarding which claim was admitted by the OPs but has wrongly repudiated the claim vide letter dated 05.09.2019 which amounts to deficiency in service and unfair trade practice on their part. The complainant sent a legal notice dated 27.09.2019 to the OPs but no reply was received. Hence this complaint, whereby the complainant has prayed for issuing directions to the OPs to make payment of claim amount of Rs.1,66,758.74p along with compensation of Rs.2,00,000/- and litigation expenses of Rs.21,000/-

2.                Upon notice, the OPs appeared and filed joint written statement and assailed by complaint by taking preliminary objections on the grounds of maintainability; the complaint being misconceived and against the provisions of Consumer Protection Act etc.

                   In para wise reply, the OPs admitted the fact regarding issuance of Health Protector Policy No.52676047 in the name of the complainant as well as his wife Mrs. Anju Singla and two children Saurabh Singla and Sheena Singla w.e.f. 16.09.2016 to 15.09.2017 for a sum insured of Rs.6,00,000/-. OPs also admitted the renewal of policy from 2017-18, 2018-19, 2019-20. The OPs averred that the disputed claim is with regard to policy No.52996413 for the period from 16.09.2018 to 15.09.2019 having basis sum insured of Rs.7,00,000/-. The OPs received a cashless request from Max Super Specialty Hospital, Delhi of patient Mr. Neeraj Singla on 10.07.2019. On scrutiny of the documents, it was revealed that the patient was admitted in hospital with diagnosis of Multiple Sclerosis and during hospitalization immune-modular drugs (injection Natalizumab) was given. The cashless request was denied because Intravetreal injection like Natalizumab injection not covered in the policy and information regarding denial of cashless request was sent to hospital vide letter dated 11.07.2019. The Ops further averred that thereafter, the insured submitted claim documents for reimbursement of his medical expenses incurred on his treatment, on scrutiny of which, it was noted that the patient Neeraj Singla was admitted in Max Super Specialty Hospital, Delhi from 09.07.2019 to 11.07.2019 with diagnosis of “Multiple Sclerosis” for which treated with immune-modular drugs (natalizumab). The claim was not payable as the treatment/procedure given to the patient during hospitalization was not covered under the policy and same was repudiated as per condition No.10(d) of Health Insurance Guidebook at page No.41, which is reproduced as under:-

                   “General

10. Some common ailments/procedures not covered under the policy:

d). Intravitreal Injections/Interferon injections/Infliximab and like injections/Intra-articular injections.”

The complainant was informed regarding repudiation of his claim vide letter dated 05.09.2019. According to the OPs, prior to selling the policy, their agent always educates the insured regarding coverage and its terms and conditions and also supply insurance policy with terms and conditions as well as Guidebook. They have not received any complaint from the complainant regarding non-receipt of the documents. The OPs further averred that the complainant is not entitled to get any relief from them as per terms and conditions of the policy as he is misleading the Forum by saying that the claim related to usage of REBIF 22 MCG PFS injection (Interferon Beta-1A 22 MCG) was reimbursed by the OPs. However, the complainant was admitted earlier in Max Super Specialty Hospital, Delhi from 28.11.2018 to 30.11.2018 with diagnosis of “FUC OF MULTIPLE SCLEROSIS WITH RELAPSE” for which patient was started on Inj Methylpred 500 mg for 3 days, patient was managed conservatively with iv fluids, tab baclofen statins and other supportive measures, patient is neurologically stable and was discharged. The OPs further stated that Inj REBIF 22 MCG PFS SUBCUTANEOUS 3 INJECTION was not given to the patient Neeraj Singla during the hospitalization period, it was prescribed by the treating doctor at the time of discharge not for treatment of Inj REBIF 22 MCG PFS SUBCUTANEOUS 3 INJECTION. The OPs reimbursed the earlier claim to insured as per terms and conditions of the policy and has not reimbursed the cost of Inj REBIF 22 MCG PFS SUBCUTANEOUS 3 INJECTION as claimed by the complainant. Further the claim of the complainant was not payable as the patient was specifically admitted in the hospital for treatment of Immuno-modulator drugs (Natalizumab) due to which the claim was not payable as per terms and conditions of the policy. As such, the claim of the complainant was rightly repudiated. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                The complainant filed rejoinder to the written statement reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement. However, the complainant stated that the OPs are adopting the policy of pick and choose by allowing the claim of REBIF 22 mcg PFS Subcutaneous Injections which is also Netalizumab Injection and by denying the claim of Intravetreal Injection. The complainant got treatment from a best hospital like Max Super Specialty Hospital from where the complainant was cured and regained his health. Further the OPs cannot teach or dictate any hospital as to which line of treatment and procedure they should follow. Even the OPs have not paid the pre-hospitalization claim illegally and arbitrarily which amounts to deficiency in service. Moreover, the injection Tysabri is an intravenously injected drug which is neither mentioned in clause 10.D as mentioned by the OPs nor can be rejected in this ground when once the  injection i.e. REBIF 22 MCG PFS injection i.e. an inter-feron injection was allowed by the OPs despite clause 10.D.  The complainant further stated that the OPs vide letter dated 27.12.2018 reimbursed the claim of REBIF 22 MCG PFS Injection in respect of reimbursement of bill dated 30.06.2018 for Rs.24,400/-. As such, now the OPs cannot repudiate the claim in question.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of legal notice dated 27.09.2019, Ex. C2 and Ex. C3 are the postal receipts, Ex. C4 is the copy of repudiation letter dated 05.09.2019, Mark-A and Mark-B are the copies of medical record of Max Healthcare, Mark-C is the copy of receipt of Rs.84,000/- of Brij Agencies (Pharma) and closed the evidence. 

                    During the course of proceedings, the complainant moved an application  for permission to lead additional evidence, which was allowed vide order dated 30.10.2023 by imposition of costs of Rs.1000/- to the complainant.

                   In additional evidence, the complainant produced document i.e. Ex. CX is the copy of claim payment letter dated 27.12.2018, Ex. CY is the copy of claim payment letter dated 27.12.2018 as well as medical record of Max Healthcare, Ex. CZ is the copy of inpatient bill dated 28.05.2018 as well as medical bills/receipts and closed the additional evidence.

5.                On the other hand, the counsel for the OPs tendered affidavit Ex. RA of Sh. Mridul Ranjan, General Manager of the OP office at Gurugram and tendered documents i.e. Ex. R1 is the copy of welcome letter dated 14.09.2018 and policy documents, Ex. R2 is the copy of Auth Denial Letter dated 11.07.2019, Ex. R3 is the copy of discharge summary dated 11.07.2019 of Max Healthcare, Ex. R4 is the copy of repudiation letter dated 05.09.2019, Ex. R5 is the copy of discharge summary dated 30.11.2018 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, rejoinder, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.

7.                The complainant, a holder of Health Protector Policy was having a coverage from 16.09.2018 to 15.09.2019 with a basic sum assured of Rs.7,00,000/- for himself his spouse and two children. Ex. R1 is the copy of policy schedule. It also reflects that the complainant had earlier also obtained policies having validity from 16.09.2016 to 15.09.2017 for a sum of Rs.6,00,000/-, which was renewed for the year 2017-2018, 2018-2019 and 2019-2020.

8.                Earlier during the subsistence of previous policy, the complainant remained admitted from 21.05.2018 at Max Super Specialty Hospital, Delhi and was discharged on 28.05.2018 (Inpatient Bill Ex. CZ). At that time, the complainant preferred the claim with regard to Injection REBIF which was approved and paid by the OPs through claim payment letter dated 27.12.2018 Ex. CX. During subsistence of the policy in question w.e.f. 16.09.2018 to 15.09.2019 Ex. R1, the complainant was admitted at Max Super Specialty Hospital, Delhi on 09.07.2019 with a diagnosis of Multiple Sclerosis. He remained under treatment at said hospital and was discharged on 11.07.2019 as per discharge summary Ex. R3. Following course of treatment was adopted by the hospital, which is reproduced as under:-

“Patient admitted in view of worsening of lower limb weakness with instbaility of gait. Patient was managed conservatively with iv fluids, tab baclofen, statins and other supportive measures, Injectable Immuno-modulator drugs (Netalizumab) were initiated. Patient responded well to treatment. Patient is neurologically stable and now is being discharged with following advice.”

 

At the time of discharge, the complainant was advised Injection Tysabri 300 mg I.V. Infusion every 4 weeks. During admission of the complainant, the hospital authorities applied for cashless authorization, which was denied by the OPs vide letter dated 11.07.2019 Ex. R2, the operative part of which reads as under:-

                   “We regret to inform that we are unable to provide authorization               for reason(s) as mentioned below:

                   Patient diagnosed as Multiple sclerosis and during hospitalization             immunomodulator drug (Injection Natalizumab) was given. As per            policy terms & condition, all previous authorization (s), if any,                       stand(s) cancelled.”

 

9.                While repudiating the claim, the OPs have relied upon condition No.10(d) under the Health Insurance Guidebook, which states as under:-

“General

10. Some common ailments/procedures not covered under the policy:

d). Intravitreal Injections/Interferon injections/Infliximab and like injections/Intra-articular injections.”

From the close scrutiny of the document, it is evident that the disease “Multiple Sclerosis” is covered under the policy but the procedure adopted by the hospital has been excluded from the scope of coverage. Prima facie this exclusion clause has nullifying effect on whole of the insurance agreement. This clause is in stark contradiction to object and purpose of the policy and does not call for consideration. Further, it is for the expert doctors to decide the course/procedure to be adopted so to cure a particular disease of a patient. The insurer at the time of issuing the policy cannot decide the same well in advance even when the said disease has not been contacted by the patient or by the insurer. The complainant has brought on record that earlier on 28.11.2018, the similar injections were administered to him as well and his claim was reimbursed under the previous policies. The existence of previous policies is admitted by the OPs, which has reflected in Ex. R1. The OPs were required to reconcile this fact why on earlier occasions, the claim on identical lines were allowed but the complainant did not produce the earlier policy schedule(s). It shows that such like injections were payable under the policy. If it is so, then it appears that during the continuous renewal of the policies, the change of conditions has taken place without express notice to the complainant. Such conduct of the OPs is impossible and also amounts to adoption of unfair trade practice. In this regard, reference can be placed on 2022 LiveLaw (SC) 937 in M/s. Texco Marketing Pvt. Ltd. Vs TATA AIG GIC Ltd. and others  whereby the Hon’ble Supreme Court of India has made the following observations:-

“Insurance Act, 1938 – An exclusion clause in a contract of insurance has to be interpreted differently. Not only the onus but also the burden lies with the insurer when reliance is made on such a clause. This is for the reason that insurance contracts are special contracts premised on the notion of good faith. It is not a loverage or a safeguard for the insurer, but is meant to be pressed into service on a contingency, being a contract of speculation. An insurance contract by its very nature mandates disclosure of all material facts by both parties.

Insurance Act 1938 – Duty of insurer is disclose exclusion clause  When an exclusion clause is introduced making the contract unenforceable on the date on which it is executed, much to the knowledge of the insurer, non-disclosure and a failure to furnish a copy of the said contract by following the procedure required by statue, would make the said clause redundant and non-existent.

Insurance Act, 193 – Any non-compliance of IRDA Regulations, obviously would lead to the irresistible conclusion that the offending clause, be it an exclusion clause, cannot be pressed into service by the insurer against the insured as he may not be in knowhow of the same.

Indian Contact Act, 1872 – Doctrine of Blue Pencil – The said doctrine strikes off the offending clause as void ab initio. An exclusion clause repugnant to the main contract ought to be effaced.

Consumer Protection Act, 2019 – Consumer Commission has power to issue directions for consequential relief if the terms of the contract are found to be unfair.”

 

Thus, the OPs were not justified in repudiating the claim of the complainant.

10.              As such, keeping in view the facts and circumstances of the case, it would be just and appropriate if the OPs are directed to settle and reimburse the claim of the complainant regarding his hospitalization at Max Super Specialty Hospital, Delhi from 09.07.2019 to 11.07.2019 as per terms and conditions of the policy along with composite costs of Rs.20,000/-.

11.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claim of the complainant regarding his hospitalization at Max Super Specialty Hospital, Delhi from 09.07.2019 to 11.07.2019 as per terms and conditions of the policy within 30 days from the date of receipt of copy of order failing which the OPs shall be liable to pay interest @8% per annum on the settled amount from the date of order till actual payment. The opposite parties shall also pay composite costs of Rs.20,000/- (Rupees Twenty Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

Announced in Open Commission.

Dated:07.06.2024.

Gobind Ram.