For the complainant                      - Mr.Pradip Kumar Kar, Advocate

For the OP Nos. 1 & 2                   - Mr. Shyamal Sengupta, Advocate

For the OP 3                                     - Mr. Amitava Chowdhury, Advocate

FINAL ORDER/JUDGEMENT

SHRI ASHOKE KUMAR GANGULY, MEMBER

This is an application u/s.12 of the C.P. Act, 1986. The Complainant is the nominee of the Mediclaim Policy Nos. 106006501610005778 and 106006501710005421 of her husband Surendra Kumar Kanoria, since deceased, who died on 23.01.2018.The insured Sum assured was Rs. 6,00,000/-. As per submission, the Mediclaim Policy has been renewing since 2009. During the valid insurance period Surendra Kumar Kanoria was diagnosed with oral cancer in May 2016 and was recovered  by Oct.2016. Subsequently he was diagnosed with Lung Cancer in June 2017 and underwent treatment at Tata Medical Centre, Rajarhat, Kolkata. The disease diagnosed by the Hospital was Lung Squamons Cell Carcinoma NOS. After certain treatment the Hospital Authority advised the patient party to opt for either Immunotheraphy or Systematic Chemotherapy as the further course of treatment. The Complainant and her children opted for Immunotherapy. The doctors accordingly started the treatment on 25.11.2017 and advised them  to admit the patient for administration of injection Nivolumab to be given in ward on 29.11.2017 . Treatment session was supposed to be spreaded for six month with Nivolumab injection to be administered on every 14^th day. The patient underwent four Immunotherapy session from 28.11.2017 to 12.01.2018 and the next session was scheduled to be started on 24.01.2018. Subsequently, the patient’s condition got worsen and critical and he was again admitted to the Hospital on 21.01.2018 but unfortunately he passed away on 23.01.2018. For the said treatment of Immunotheraphy the expenses incurred was Rs.3,45,990/- which reimbursement was claimed by the complainant from the OP Insurance Company. But the OP 1 & 2 vide their letter dated 27.12.2017 and 02.03.2018 repudiated the claim on the ground that the treatment was conservative management (mainly for administration of injection Nivolumab immunotherapy). Since this procedure is not payable if it is done in stand alone basis of main hospitalization, payable if it is a part of hospitalization and more ever this procedure could be done through OPD basis and this management does not require the 24 hours hospitalization. Hence, the lodged claim is considered to be rejected as per clause No. 4.18. The complainant vide letter dated 19.02.2018 raised strong objection by stating that the hospitalization was according to the advice of the treating doctors and they cannot go beyond the advice of the doctor. Since immunotherapy is a new line of treatment the doctors decided to do the first session in IPD for better monitoring. The same procedure was done during chemotherapy in July 2017 and the expense bill of the said treatment was settled by Star Health and allied Health Insurance Company on 10.02.2018.The instant  policy was continued for more than 08 years and the repudiation of claim was beyond their expectation. The letter dated 19.02.2018 of the complainant was not responded by the OPs and hence the case.

The OPs 1 and 2  have contested the case by filing W/V contending inter alia that the instant complaint case is not maintainable both in law and in fact. It is false, vexatious and suppression of material facts and it is liable to be dismissed in limini.

The OP No.3 has also contested the case by filing their W/V  and denied allegation against them with the plea that whatever they have done they have done it as per guidelines of IRDA and terms and conditions of the policy. They have further stated that the complaint is not maintainable in the eye of law since the same has been filed with sheer malafide intention whereby suppressing material facts and making baseless statements.

Point for Determination

On the pleading of both the parties, the following points have necessarily come up for determination.

1. Whether the Complainant had a valid Insurance Policy.
2. Whether the OP have any deficiency in service or there is any indulgences of unfair trade practices on the part of OP.
3. Whether the Complainant is entitled for any relief as prayed for.

Decision with Reasons

Point Nos. 1 to 3:-

All the points are taken up together for the sake of convenience and brevity in discussion.

Both parties have tendered their Evidence on Affidavit. They have filed replies to the Questionnaire set forth by their adversaries. They have also submitted their BNAs.

We have travelled over all the documents placed on record.

Facts remain that the Complainant is the wife of the deceased policy holder Surendra Kumar Kanoria who during his lifetime had been owning the National Parivar Mediclaim Plus Policy with the National Insurance Company. The subject policy No. 1006006501610005778 was valid from the period from 26.12. 2016 to 25.12.2017 and policy No. 1006006501710005421 was valid for the period from 26.12.2017 to 25.12.2018. From the Patient Evaluation Summary of Tata Medical Center, New Town, Kolkata , Assessment date 25.11.2017,  it is observed that the policy holder Surendra Kumar Kanoria was suffering from Oral Cancer since Feb.2016 and   subsequently diagnosed Lung Cancer through relevant tests and examination. From the said report it is observed that the next course of treatment as advised by the said Hospital was either Immunotheraphy or Systematic Chemotheraphy. The Patient Party opted for Immunotheraphy. Accordingly Immunotheraphy started by taking admission on 28.11.2017 to the said Hospital. From the said Evaluation Summary the advice for admission was decided on 25.11.2017 with the remarks” Ward admission on 28.11.2017, Inj nivolumab to be given in ward on 29.11.2017. Contact admission desk. Review with reports prior to admission.” The said Evaluation Summary was signed by Dr. Suchandana Bhaumik, M.B.B.S.,MD Radiotherapy, Fellow, Regn. No. 65693, Department of Radiation Oncology. From the said document, it is established that the admission to the Hospital was as per the advice of the treating Doctor. Accordingly the first course of treatment appears to be completed by taking admission on 28.11.2017 and by receiving the injection on 29.11.2017. Similarly, the second one also appears completed by taking admission on 12.12.2017 and by receiving the said injection on 13.12.2017. On scrutinizing the entire documents, we do not find the admission papers for the third course of treatment as mentioned in the complaint petition. Moreover, from the submitted documents of second course of treatment it is observed that the patient party wished to receive the next cycle in DAY CARE and was advised to book DAY CARE on 27.12.2017. As such it is not possible for us to ascertain the third course of treatment. We also have scrutinized the documents placed on record and have not found any details of the cost of the treatment provided by the hospital for the first and second course of treatment as mentioned above. Even no document for hospitalization for the third course of treatment  and no document for its costs of treatment, were  furnished  by the complainant  as annexed in the complaint petition.

Under the above circumstances, the complainant has failed to substantiate her claim. In view of the above we are not inclined to allow her prayer.

 In the result the Complaint fails.                                                                      

Hence,

Ordered

That the complaint case be and the same is dismissed on contest against the OPs without any cost.