Delhi

East Delhi

CC/149/2015

YASH - Complainant(s)

Versus

MEDIA ASSIST INDIA TPA PVT.LTD - Opp.Party(s)

08 May 2017

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.       149/2015

                                                                                                   Date of Institution               13/03/2015

                                                                                                   Order reserved on               08/05/2017        

                                                                                                   Date of Order                       12/05/2017                                                                                     

 

In matter of

Mr Yash Pal, adult   

s/o Sh Karam Chand

R/o-9, IInd Floor, A-99/A, Rampuri,

Ghaziabad, UP 201011..………………….……………...…………….Complainant

                             

                                      Vs

 

1-M/s The Manager, Medi Assist India TPA

B-20, Sec. – 63, Noida UP

 

2-The The Manage, OIC

H-1A/18, Sec. 63, Noida, UP, 201301

 

3-The Med. Supdt,

Pushpanjali Medical Centre,

A-15, Pushpanjali Enclave,

Vikas Marg, Delhi 110092 …………………………………….….…………..Opponents

 

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, Sh Yash Pal, aged 77 years took PNB ORIENTAL ROYAL Mediclaim policy schedule through PNB, Brij Vihar, Ghaziabad having tenure from 13/08/2012 to 12/08/2013 for a sum assured (SA) Rs. 3 lacs for himself and for his wife Smt. Prakash Wanti, aged 72 years, vide policy no. 252400/48/2013/2169 and thereafter policy was renewed again from 19/08/2013 18/08/2014 as marked here Annexure A.

Complainant’s wife Smt Prakah Wanti was admitted at OP3/ Pushapanjali Medical Centre, Delhi on 27/07/2014 and was discharged on 04/08/2014 in the morning, but OP3 did not let her go till late evening due to non receiving of approval amount of hospital bill under cashless from TPA/OP1. Later it was informed that their cashless approval had been rejected so had to clear the hospital bill, thus after clearing the hospital bill of sum of Rs 44,013 /- complainant brought his wife home.

 

Thereafter complainant submitted his claim with OP1, but could not get any satisfactory reply from OP1 despite of repeated visits to OP. Complainant contacted OP2 for the reason of not clearing the claim. It was told that there was a gap of 7 days in the continuity of policy tenure, so his claim was withheld. After submitting a request letter to condone the delay in renewing, OP2 condoned the delay. Even after submitting all the relevant documents for processing the claim, OP1 did not pass the claim for long. Complainant sent a legal notice on dated 10/11/2014       for passing his claim. Thereafter complainant received rejection letter on dated 27/01/2015 stating that his claim was rejected on the terms and condition of policy under exclusion clause 4.2(xviii & xix). Aggrieved by the rejection of his claim, he filed this compliant claiming re imbursement of hospital/treatment bill with compensation for physical harassment and mental agony.  

 

After receiving notices, OP2 submitted written statement jointly for OP1 also denying all allegations of deficiency of OPs. It was submitted that complainant had not impeded OP2 as necessary party for claiming medical treatment expenditure for a sum of Rs 44013/-as he was insured under them, still OP2 had processed the claim, but was rejected under exclusion clause 4.2 of policy terms and conditions.

OP3 had also submitted their written reply and denied any deficiency in their line of treatment at OP3 hospital. It was submitted by OP3 that there was no deficiency or negligence in the line of treatment of complainant’s wife and had timely forwarded cashless claim papers to OP1. As there was considerable delay in getting information for sanction of claim amount from OP1, so patient/complainant’s wife remained in hospital for a day, but OP3 did not charge any amount from complainant. As soon as cashless rejection information from OP1 was received, complainant paid the hospital bill. Hence, there was no deficiency in their services and prayed for removal from the array of party.

 

OP2 submitted jointly evidences on affidavit through Sh Khem Chand, Sr. Divisional Manager at OP2, affirmed that policy was issued from OP office at Meerut and subsequently at the time of renewable, there was 7 days gap which was condoned as annexed OPW/R1. It was stated that rejection under clause 4.2 was based on the terms and conditions of exclusion clauses of the policy in reference to the findings of discharge summary issued by the hospital. It was clearly mentioned in the discharge summary that claimant had T2DM with severe Acute Gastroenteritis with dehydration and Cholelilithisis. The treatment pertains to DM, Cholelithiasis and severe dehydration.

The treatment for Diabetes and Cholelithiasis was excluded for two years in the policy and here complainant took treatment for DM and Cholilithisis in the second year policy as exhibited here in Annexure R2, 3 and 5. So, their repudiation was justified and prayed for dismissal of complaint.  

Complainant had also submitted his evidences on affidavit and affirmed that all the facts and evidences were true and correct and nothing had been submitted wrongly or hidden.

Arguments were heard from both the parties and order was reserved.

 

Before coming to the conclusion of this case, we framed three clarifications as under –

1. What is Ac GE and direct nexus with T2DM or Cholilithiasis?
2. Whether repudiation of claim was justified by OP in reference to 4.2? 
3. How far justified to give mediclaim policy at 70+ age (without mandatory medical tests).

1- What is Ac GE and its causes with direct nexus with T2 DM?

Gastroenteritis literally means inflammation of the gastrointestinal tract. Viral gastroenteritis is also called "stomach flu." It is extremely common, especially in children, and is highly contagious. Bacterial gastroenteritis is also known as "food poisoning" and is caused by food that has been prepared or stored improperly.

 

Causes

Viruses such as the norovirus (formerly known as Norwalk virus) cause gastroenteritis.

Norovirus is the typical form of gastroenteritis in adults and older children.

Rotavirus mostly affects infants aged 3 to 15 months.

Viruses cause disease by infecting or irritating cells within the wall of the small intestine. This causes fluids, minerals, and salts to flush into the intestines, leaving the body as diarrhea.

Food poisoning results when a person eats food that has grown bacteria that can cause gastroenteritis.

 

Symptoms and Complications

Most people who become infected with these viruses won't have any symptoms, since almost half of these people are immune. Symptoms of food poisoning often include nausea, general weakness or exhaustion, headache, abdominal pain and cramps with abrupt vomiting, and diarrhea.

Making the Diagnosis

The symptoms are the telltale signs of viral gastroenteritis in adults and older children.

Treatment and Prevention –Urgent conservative management by IV fluids, antibiotics and (re hydration therapy) till the body electrolytes returns normal and vitals get stable. It usually takes 3-4 days management. Washing hands frequently provides the best defence against the norovirus. Most people do not wash their hands well enough.

 

2-Whether repudiation of claim was justified by OP in reference to 4.2?

First we would see the definition of 4.2 under this policy—Definition- (ref. Ex R1 & R5)-

“The expenses on treatment of following ailments/diseases / surgeries for the specified periods are not payable if contracted and /or manifested during the currency of the policy. If diseases are pre-existing at the time of proposal the exclusion no. 4.1 for pre existing condition SHALL be applicable in such cases.”

(Chart annexed with SN xviii & xix for Diabetes and Calculus diseases) and as per rejection letter as marked Annexure R5, OP had rejected treatment of DM and Cholilithiasis).

After going through terms and conditions of the policy and medical texts, there is no exclusion for the treatment of Ac GE in second year of policy. There are many causes of Ac GE with dehydration, but main cause is food poisoning and not DM or Cholilithiasis. Also there is no direct nexus of Ac GE and DM treatment though the duration of management last more than normal. As far as treatment of Cholilithiasis is concern, there are no special medicines or treatment for the diagnosis and treatment, but conservative line of management is adopted, first.

Taking reference of 4.2 exclusion clauses of terms and conditions and reference of discharge summary, complainant’s wife remained admitted for 08 days and had severe Ac GE and severe dehydration as a main cause of admission and treatment.

In severe Ac GE, loss of body electrolytes results due to oral infection through motion and vomiting which causes renal impairment and urine retention. But Cholilithiasis does not lead to Pre renal insufficiency. So, emergency conservative management of Ac GE is done.

As far as investigations for exclusion diagnosis of DM and Cholilithiasis are concern, cost may be deducted from the hospital bill. As OP has not filed indoor treatment details on record, so taking merit of the case, we are of the opinion that case has merit for allowing the complaint.

3-How far justified giving mediclaim policy at 70+ age—

Every mediclaim/life policy providing companies, it is mandatory to go far specified medical lab tests like CBC for blood related diseases, Eye Tests for Cataract and other age related ailments, ECG for heart problems, X ray chest for lungs problems like Koch’s, Sarcoidosis etc and Orthopedic reference for joint ailments for age related OA requiring joint replacement after or at the age of 55 years.  

Here in this case, OP has not submitted any such evidence pertaining to medical tests to insured/claimants and policy was issued without any hurdle which does not look transparent. Because, many age related ailments starts on or before 60 years. No evidence of policy proposal form, medical records of lab test and clearance from panel doctor was on record.   

By taking the applicability of status and evidence of this case, we pass the following order—

1. OP2 is directed to deduct 50% of hospital bill and balanced to be paid to the complaint within 30 days from the receiving of this order.
2. We also award compensation of sum of Rs 10,000/- for physical harassment and mental agony. This will include litigation cost also to be paid by the OP1.  
3. If order is not complied within stipulated time, complainant shall be entitled to recover entire awarded amount with 9% interest from the date of filing of this complaint till recovered.
4. There was no deficiency and negligence of OP3, so we do not put any liability on OP3.         
5. We also direct OP to be careful in issuing policy in such type cases by following IRDA guidelines in future.

Copy of this order be sent to the parties as per Act and file be consigned to Record Room.

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President