Chandigarh

DF-II

CC/866/2016

Murti Devi - Complainant(s)

Versus

M/s The Oriental Insurance Company Limited - Opp.Party(s)

Deepak Aggarwal Adv.

15 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	866 of 2016
Date  of  Institution	:	06.10.2016
Date   of   Decision	:	15.11.2017

 

 

 

 

Murti Devi wife of Sh.Parmal Singh, resident of House NO.308, GH-7A, Sector 20, Panchkula (Haryana)     

             …..Complainant

Versus

1]  The Oriental Insurance Company Limited, through its Regional Manager, SCO No.48-49, Sector 17-A, Chandigarh.

2]  M/s Medi Asist India TPA Pvt. Ltd., through its Director, No.4/1, IBC Knowledge Park, Tower D, 4^th Floor, Bannerghatta Road, Bangalore 560029

                          ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

                                MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

 

Argued by: Sh.Deepak Aggarwal, Adv. for complainant.

 Sh.B.R.Madan, Adv. for OP No.1.

 OP No.2 exparte.

 

 

PER RAVINDER SINGH, MEMBER

 

 

          The facts in issue are that the complainant availed Group Mediclaim Policy with family floater from OP No.1 through OP No.2 under which she and her husband were insured for a sum assured amount of Rs.5.00 lacs.  It is averred that the said policy was effective from 13.5.2016 to 12.5.2016 and the same was renewed from time to time upto 12.5.2017 (Annexure C-1 to C-3). It is also averred that the complainant was admitted in Drishti Eye Hospital, Panchkula on 15.1.2016 for the complaint of Blurred vision and was diagnosed as B/L Uveitis with cme.  It is further averred that due to sensitive nature and high BP records, complainant was kept under observation for 24 hours w.e.f. 15.1.2016 to 16.1.2016 and treated with L/e Intravitreal Avastin Injection (Ann.C-4 colly.).  It is stated that Opposite Party No.2 was duly intimated during the hospitalization by the complainant regarding her treatment and requested for cashless facility.  Thereafter, a claim for reimbursement of the medical expenses incurred on the said treatment for a total sum of Rs.36,491/- was filed with the OPs, but the OPs repudiated the same on the ground that expenses on the hospitalization are admissible only if hospitalization is for a minimum period of 24 hours and that Injection Avastin is not listed in day care procedure (Ann.C-5 & C-6).  Thereafter, the complainant again approached the OPs, submitted fresh reimbursement claim form and clarified the position, but nothing positive was done by the OPs. A legal notice was also sent to the OPs, but to no avail. Hence, this complaint has been filed alleging the said repudiation of claim as deficiency in service and unfair trade practice on the part of OPs.  

 

2]       The Opposite Party NO.1 has filed reply and while admitting the factual matrix of the case, stated that after receiving the correct claim form, from the complainant, it was rightly repudiated vide letter dated 23.2.2016 & 22.10.2016 (Ann.R-1 & R-2).  It is stated that the complainant reportedly suffered from   Uveitis-related Cystoid Macular Edema, a disease of Eye, took treatment at Drishti Eye Hospital, Panchkula and the treatment involved Intravitreal Avastin Injection i.e. injection given directly into the eye and claim for reimbursement for Rs.36,491/- was filed.  It is also stated that for the treatment of ARMD and CNVM, drugs like Lucentis/Macugen/Avastin etc. is given as Intravitreal Injection and no hospitalization as in-patient is required for administration of this drug and the same is as OPD treatment and is not covered under the policy terms & conditions.  It is submitted that the treatment procedure of administration of injection Avastin underwent by the complainant neither falls under the list of approved day care procedures nor required 24 hours of inpatient hospitalization. It is also submitted that the claim of the complainant has rightly been repudiated and pleading no deficiency in service, the Opposite Party No.1 has prayed for dismissal of the complaint. 

 

         Opposite Party No.2 did not turn up despite service of notice sent through regd. post on 25.10.2016, hence it was proceeded exparte vide order dated 5.12.2016.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

5]       The complainant was insured under Oriental Bank Mediclaim Policy bearing NO.261301/48/2015/362 effective from 13.5.2014 to 12.5.2015 (Ann.C-2) and then under Policy No.261301/48/2016/389 effective from 13.5.2015 to 12.5.2016 (Ann.C-1) and also Policy No.231200/48/2017/1507 effective from 13.5.2016 to 12.5.2017 (Ann.C-3).  During the period under insurance, the complainant Murti Devi (insured) suffered from Blurred vision B/e and was diagnosed as B/L Uveitis with cme and was admitted in Drishti Eye Hospital, Panchkula on 15.1.2016 and after treatment with L/e intravitreal Avastin injection, was discharged on 16.1.2016.  As per certificate issued by Drishti Eye Hospital, Panchkula (Ann.C-4 Page/26), the complainant was, as apparent from the medical record issued by Drishti Eye Hospital, Panchkula, was remained admitted for 24 hours from 15.1.2016 to 16.1.2016.  The documents supplied by the complainant to the OPs in support of her claim for medical reimbursement has not been properly considered by OP Insurance Company and without application of mind, rejected the Mediclaim of the complainant stating:-

“On scrutiny of claim documents, it is found that patient was admitted for injavastin for macular edema of eye, this eye procedure is not listed in day care procedure. (clause 2.3). So this claim is denied under exclusion 2.3 Hence, we regret our inability to admit this liability under the present policy conditions and this claim is being repudiated and same is not payable.”

        

6]       The observations raised by the OPs in support of their plea for rejection of claim is totally biased, vague and legally not tenable. The complainant has been treated by admitting in the Hospital being found essential by the doctors concerned in the Hospital. The insurance company has no business or right to say that the said treatment required only attendance in OPD and not by way of admission of the Hospital.  The OPs, on the face of record, have indulged in unfair trade practice in this matter.  The claim of the complainant for reimbursement of Rs.36,491/- is legal, valid and permissible under the terms & conditions of the policy. 

7]       Keeping into consideration, the above facts & circumstances of the case, the OPs are found to be deficient in their services and also indulged into unfair trade practice, as such, the complaint is allowed with directions to Opposite Party No.1 to reimburse an amount of Rs.36,491/- to the complainant along with compensatory cost of Rs.10,000/- and litigation cost of Rs.5000/-, within a period of 30 days from the date of receipt of certified copy of this order.

         In case the OP No.1 failed to comply with the order within the stipulated period, then it shall also be liable to pay additional compensatory cost of Rs.10,000/- to the complainant apart from the above relief.

 

         Certified copy of this order be communicated to the parties, free of charge. After compliance, file be consigned to record room.

Announced

15^th November, 2017                                                    

                                                                                      Sd/-  

                                                                    (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER