BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.290 of 2019
Date of Instt. 29.07.2019
Date of Decision: 15.02.2023
Shri Ashok Kumar son of Shri Ram Ji Dass, Resident of 54, Shiv Nagar, Sodal Road, Jalandhar.
..........Complainant
Versus
1. M/s Raksha Health Insurance TPA Pvt. Ltd., SCO 39, 1st Floor, Madhya Marg, Above Barbeque Nation, Sector 26, Chandigarh 160019 Through its Authorized Signatory.
2. Divisional Manager, United India Insurance Co. Ltd., Union Cooperative, INS, Building, 23, SI RPM Road, Fort, Mumbai 400028.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: None for the Complainant.
Sh. R. S. Arora, Adv. Counsel for the OPs No.1 and 2.
Order
Dr. Harveen Bhardwaj (President)
1. This complaint has been filed by the complainant, wherein alleged that the complainant purchased Policy No. 1202002818P114211757 Member ID UIC 5451581643SBIR SBI Pensioners GMC Policy B Non Domiciliary valid upto 15.01.2020 from United India Insurance Company Limited through Raksha Insurance TPA Pvt Ltd. Prior to this policy, the complainant was insured under the same scheme and category and this was in continuation of the earlier policy. The complainant is suffering from chronic Lymphocytic Leukemia (Blood Cancer) and presently, he is under process of Chemotherapy. The complainant is under treatment of Patel Super Specialty Hospital, Jalandhar having Patient ID No.PH/INT/ACT/EDP/PAT/16233. The complainant is getting the treatment since last year and the opposite parties have cleared the earlier three bills dated 20.10.2018, 19.11.2018 and 24.12.2018 submitted by the complainant regarding his treatment. Now, the OPs, through letter dated 15.3.2019 rejected subsequent three bills dated 19.1.2019, 15.2.2019 and 15.3.2019 on the ground that "Chronic Lymphocytic Leukemia. Biological therapy is not payable. This claim does not require 24 hours hospitalization. Therefore, the claim is not payable as per condition 2.15". On the earlier three occasions, when the OPs cleared the bills of the complainant, the complainant also remained hospitalized for 24 hours for the same therapy. Now under the same condition, the complainant has undergone the same treatment and remained hospitalized for 24 hours. As such, the rejection of the claim on the basis that the therapy undergone by the complainant does not require 24 hours hospitalization is illegal. Moreover, the Doctor under whom the complainant is undergoing the therapy has specifically issued letter dated 18.3.2019 whereby the Doctor has specifically gave opinion that as and when, the medicines which are infused in the body, patient develops hypersensitivity reaction to the biological agent and requires monitoring during and after infusion, as such, it requires 24 hours hospitalization. The act of the OPs in repudiating the insurance claim of the complainant is illegal, unlawful, negligent and deficient services which has further caused great mental tension, loss of money to the complainant and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to settle the insurance claim of the complainant as per policy. Further, OPs be directed to pay a compensation of Rs.1,00,000/- for causing mental tension and harassment to the complainant and also be directed to pay litigation expenses.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complainant has come by concealing material facts, therefore, the complaint is liable to be dismissed. On merits, the factum with regard to obtaining insurance policy by the complainant from the OPs is admitted and the facts regarding repudiation of the claim is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the OPs only as none has appeared on behalf of the complainant and have also gone through the case file as well as written arguments submitted by counsel for both the parties very minutely.
6. It is admitted and proved that the complainant purchased Policy No.1202002818P114211757 Member ID UIC 5451581643SBIR SBI Pensioners GMC Policy B Non Domiciliary from the OPs. The policy was valid upto 15.01.2020. It has been alleged by the complainant that he was suffering from Chronic Lymphocytic Leukemia i.e. Blood Cancer and he was under the process of chemotherapy. He was getting the treatment since 2018 and he sent the bills of treatment to the OP, which were cleared. These three bills were dated 20.10.2018, 19.11.2018 and 24.12.2018, but thereafter, the OPs wrongly rejected the bills dated 19.01.2019, 15.02.2019 and 15.03.2019 on the ground that ‘Chronic Lymphocytic Leukemia. Biological therapy is not payable’. The complainant has proved the policy Ex.C-1 and this fact of getting the insurance has been admitted by the OP also. Ex.C-2 is the repudiation letter which shows that the claim of the complainant was rejected on the ground that Chronic Lymphocytic Leukemia. Biological therapy is not payable and this claim does not require 24 hours hospitalization. Therefore, the claim is not payable as per condition 2.15. The condition 2.15 specifies the meaning of hospitalization, which has been mentioned in Ex.C-2 also.
7. The OPs have proved on record the conditions of the policy Ex.O-1. Perusal of this policy conditions show that there is a condition No.2.14 and no 2.15, wherein the hospitalization has been defined, which reads as under:-
‘Hospitalization means admission in a hospital/nursing home for a minimum period of 24 consecutive hours of inpatient care except for specified procedure/treatments, where such admission could be for a period of less than 24 consecutive hours.’
In this clause, it has specifically been mentioned that hospitalization means 24 hours minimum period of admission, but exception has also been mentioned in this clause, which says that except for specified procedure/treatments, where such admission could be for a period of less than 24 consecutive hours. The complainant has proved on record the bill of Patel Hospital, which has been admitted by the OPs and the same has been proved by the OPs as Ex.O-2 also. The complainant has also proved the three bills dated 19.01.2019, 16.02.2019 and 16.03.2019. These bills clearly show that the procedure was adopted for infusion. Certificate of the doctor has also been proved as Ex.C-3. Perusal of the certificate of the doctor clearly shows that he has certified that ‘the complainant is a diagnosed case of Chronic Lymphocytic Leukemia, currently on treatment with Rituximab, Fludarabine and Cyclophosphamide. The patient was admitted during Rituximab infusion, as patient develops hypersensitivity reaction to the biological agent and requires monitoring during and after infusion’. The certificate Ex.C-3 itself shows that there is specified treatment given to the complainant for Leukemia i.e. blood cancer and there is specified procedure for the treatment of Leukemia. In such cases of blood cancer, the 24 hours admission is not required as there is a specified procedure, the admission can be for a period of less than 24 consecutive hours as the doctor is to see the reaction of the medicine infused to the complainant. This treatment is chemotherapy specified for treating the chronic Lymphocytic Leukemia. Therefore, this treatment is very much covered under the meaning of hospitalization as per clause 2.14 of Ex.O-1 and it has specifically been mentioned in Ex.C-2 that except for specified procedure and treatment where such admission could be for a period of less than 24 consecutive hours. So, this treatment is covered under this clause i.e. exception. Therefore, the OPs are liable to pay the claim to the complainant and thus the complainant is entitled for the relief as claimed.
8. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay Rs.1,69,426/- as per bill of Patel Hospital produced on record as Mark-A, B & C. Further, OPs are directed to pay Rs.10,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
15.02.2023 Member Member President
