Chandigarh

DF-I

CC/279/2018

Vishal Pahariya - Complainant(s)

Versus

M/s Star Health and Allied Insurance Co. Ltd. - Opp.Party(s)

Surjeet Bhadu

10 Jan 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/279/2018
Date of Institution	:	15/06/2018
Date of Decision	:	10/01/2019

 

Vishal Pahariya s/o Sh. Ramesh Jain, R/o H.No.3014, Sector 27-D, Chandigarh.    

… Complainant

V E R S U S

1]  M/s Star Health and Allied Insurance Company Limited, through its Branch Incharge and having its Branch Office at SCO 130-131, 4th Floor, Sector 34-A, Chandigarh 160022.

2]     M/s Alliance Insurance Broker Pvt. Ltd. through its Managing Director and having its Office at 715, 7th Floor, DLF Tower A, Jasola District Center, New Delhi 110025.

3]     M/s Jain International Organization, through its Chairman/Presiding Officer and having its Office at Panchsheel Plaza, A Wing Basement, Near Dharam Palace, Hughes Road, Mumbai, Maharashtra 400007.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                              

      

ARGUED BY	:	Sh. Surjeet Bhadu, Counsel for complainant
	:	Sh. Satpal Dhamija, Counsel for OP-1
	:	OPs 2 & 3 ex-parte.

Per Rattan Singh Thakur, President

1.         The long and short of the allegations are, the complainant purchased a health insurance policy namely “Shravak Arogyam” through Jain International Organization (JIO)/OP-3 of which he is a member.   The complainant paid a hefty premium of Rs.29,950/-to JIO.  OP-2 sold the policy and OP-1 is the insurance provider. Per terms and conditions of the policy, a maximum of 8 members of the family could be the beneficiary of the policy and were eligible to avail treatment upto the maximum insured amount of Rs.10.00 lakhs.  As per policy, in case the persons insured suffered from pre-existing diseases, OP-1 was liable to pay 50% of the cost of treatment availed of by the insured person whereas other 50% of the cost of treatment was to be borne out by insured persons themselves as co-payment. The complainant besides other treatment during the subsisting policy on 13.10.2017 was admitted at the Wockhardt Hospital, Gujarat and was discharged on 14.10.2017. The hospital raised the bill of Rs.6,71,054/-. Claim was submitted which was rejected by OP-1 on the ground, Plan of Management – Immunotherapy not payable. The case of the complainant is, complainant was diagnosed for Inflammatory Bowel Disease which had led to Anemia alongwith Enthesitis and Myopathy which was covered under the insurance claim.  Even prior to this treatment for same disease, claim was raised after treatment.  On being rejected by OP-1, learned District Forum-II, UT, Chandigarh had allowed it which judgment was accepted by OP-1 and the amount was reimbursed. Even subsequent to the present treatment, claim was raised under policy for the treatment of the same disease and was indemnified by OP-1. On rejection of claim, cause of action has arisen. Hence, on these averments the complainant has prayed for indemnification of Rs.3,26,139/- by OP-1 plus interest; compensation for mental and physical harassment and costs of litigation from OP-1 as well as OP-2 – mediator of selling the policy as well as OP-3 through whom it was done. 
2.         OP-1 contested the present consumer complaint, filed reply and, inter alia, raised preliminary objections of consumer complaint being not maintainable.  The crux of its reply is, the disease of which the treatment was taken falls in the exclusion clause as per policy and, therefore, the claim was rightly rejected.  Emphasis of OP-1 is, as per policy document, immunotherapy without indication is excluded from the applicability of insurance cover.  On these lines, the cause is sought to be defended.
3.         OPs 2 & 3 in spite of service did not contest the present consumer complaint and allowed themselves to be proceeded ex-parte vide order dated 20.8.2018.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsels for the contesting parties and gone through the record of the case. After appraisal of record, our findings are as under:-
6.         Per pleadings of the parties, the bone of contention inter se the parties revolves around the exclusion clause 3.19 of the policy which shows stem cell therapy, chondrocyte implantation, immunotherapy without proper indication are excluded from indemnification.  No other facts had been disputed. The justification for the coverage of exclusion clause is that injection Entyvio was administered which is immunotherapy, therefore, the treatment falls under the exclusion clause, referred to above.  As such, the claim was rightly rejected.
7.         We have scrutinized the averments made and the documents produced on record by the parties.  Perusal of Annexure C-6, copy of the order dated 27.11.2017 passed by learned District Forum-II in C.C. No.618 of 2017 shows, under the same policy and disease i.e. inflammatory bowel disease which has resulted into iron deficiency, anemia, Enthesitis, myopathy and recurrent Pouchitis. Claim was allowed by the Forum @ 50% pf the amount of the period 2.6.2017 to 14.6.2017. The said order was accepted by OP-2 and later on the payment was made. 
8.         Perusal of another record shows, even third claim raised after repudiation of the case in hand of February 2018 was for the treatment of irritable bowel disease and consequences of the same i.e. anemia etc. were also indemnified by OP-1.
9.         Per the first claim and third claim the main pre-existing disease was irritable bowel disease and its consequential diseases i.e. anemia and frequent stooling. The claim was accepted by OP-1 and payment was made on pre-authorisation to the hospital concerned or to the complainant. Now it does not lie in the mouth of OP-1 that this falls in the exclusion clause.
10.         Per record, Inj. Entyvio 300 mg. were administered during the period of admission at Wockhardt from 13^th to 14^th October, 2017. It seems OP-1 fell in error to say that Entyvio injections were for the disease of immunity system which falls in the exclusion clause while the record of the hospital where the treatment was obtained by complainant Annexure OP-1/2 shows that final diagnosis of the treatment was IBD/severe anemia/ ulcerative colitis/iron deficiency anemia/S/P Proctocolectomy/Recurrent pouchitis/Enthesitis/ Myopathy. This shows, the main treatment was confined to IBD which was a pre-existing disease and even then the OP-2 has sold the policy to the complainant. The price of one Entyvio injection 300 mg. has been quoted as Rs.3,25,000/- and for two injections it is Rs.6,50,000/- and these were administered for the disease of IBD which was a pre-existing one. 
11.         Not only this, even the first claim and third claim for the treatment of same disease were indemnified by OP-1 and even so much so in the next year April 2018, fresh policy of the same pre-existing disease was issued by OP-1 on payment.  There is no valid ground for repudiation of this claim by the insurer. 
12.         However, in one year three admissions were taken.  In the first claim Rs.10,01,9732/- were spent, 50% of which was indemnified by OP-1 and in the present claim the bill is of Rs.6,71,054/- and in the subsequent during the validity of insurance policy in February 2018, bill also runs in lakhs an exorbitant bill that of indoor treatment for 2 days in the hospital or say 3-4 days, but, it is the own empaneled hospital of OP-1 and they have not questioned the genuineness of the bill.  However, the bill seems to be exorbitant one for two days treatment and the pharmacy charges were quantified at Rs.6,50,484.33 and if the treatment is given once it is not the case that it is incurable disease or say requires repeated treatment. Bills in lakhs are being submitted, therefore, to our mind, it is not judicious to award compensation on the ground of mental and physical harassment as well as costs of litigation.
13.         In view of the above discussion, the present consumer complaint deserves to succeed and the same is accordingly partly allowed. The OPs are directed to immediately pay the claim amount i.e. Rs.3,26,139/- to the complainant i.e. 50% of total bill.
14.         This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amount mentioned above, with interest @ 12% per annum from the date of this order, till realization.
15.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
10/01/2019	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	President