CONSUMER CASE NO :- 11/2020
JUDGMENT AND ORDER
The case of complainant Mr. M. A. Choudhury, in brief , is that he is owner of a group insurance policy bearing no.-12070034190400000006- Eastern zone under which the complainant and his wife Smt. Merry Choudhury are insured and they have been paying premiums regularly. It is stated by the complainant that his wife was admitted to GNRC Hospital, Guwahati and she was discharged on 15/09/2019. In respect of her treatment an amount of Rs.67,096/- ( Rupees sixty seven thousand and ninety six) was incurred and accordingly claim was filed for the said amount alongwith necessary papers before the Opposite Party The New India Assurance Company Ltd.. The O.P. sent all the particulars to the TPA engaged by them and the TPA straightway rejected the claim on flimsy ground that the patient suffered from psychiatric disorder. It is stated that the actual disease of the patient was Hypothyroidism and this is mentioned in the discharge certificate. Subsequently the patient was operated at Sainath hospital, Chennai for her Parathyroid and it is mentioned in the discharge certificate. Phobia and anxiety was related to her disease of parathyroidism. According to the complainant, the patient is not a patient of psychiatric disorder and she is leading normal life. It has been alleged that the O.P. and their engaged TPA intentionally rejected the claim with ulterior motive causing disservice and harassment. The O.P. has also violated the provision of section 21 of Mental Health Care Act’2017 . Under the circumstances the complainant has prayed for passing award of claim of Rs.67,096/- , interest Rs.30,000/- , compensation of Rs.30,000/- for deficiency in service and further amount of Rs.30,000/- for mental suffering and Rs.10,000/- towards other cost.
Opposite Party New India Assurance Company Ltd. has submitted written statement stating, interalia, that the complaint is not maintainable, that this commission has got no jurisdiction to entertain the case, that the case is bad for non-joinder of necessary party, that the case is barred by law of limitation etc. etc. It has been stated by the O.P. that the liability of the Insurance Company is limited in accordance with the terms and conditions of the policy of insurance agreed upon. Further averment of the answering O.P. is that the claim documents of the complainant was properly scrutinized by the Third Party Administrator ( TPA ) of the Company strictly with reference to the terms and conditions appended in the contract. According to the O.P. , the TPA of the Company found that the treatment of disease claimed by the complainant falls in the psychiatric and psychosomatic disorders as mentioned in ‘Exclusion’ clause F(vi) of the terms and conditions of the policy and therefore the Insurance Company is not liable to make payment and thus rightly recommended rejection of the claims. The O.P. has denied the allegations of negligence, deficiency in service etc. levelled by the complainant. Under the facts and circumstances it has been prayed for dismissal of the case with costs.
In support of the case complainant Sri M.A. Choudhury submitted his evidence on affidavit as sole prosecution witness i.e., PW-1 and exhibited some documents. He was also cross-examined by the opposite party. On the other hand, from the side of Opposite Party evidence on affidavit of one Sri Bibhuti Bhusan Chanda, Asstt. Manager, New India Assurance Company Ltd. has been submitted as DW-1 and also some documents have been exhibited. Thereafter both sides have also submitted written argument in addition of oral argument put forward at length by the learned counsels of the respective parties. Perused the entire evidence on record. Let us now appreciate the evidence below
In his evidence as PW-1 the complainant has narrated the same facts as brought in the complaint petition. PW-1 has deposed in his evidence that he is having a group insurance policy bearing no.-12070034190400000006 - Eastern zone under which the life of his wife Smt. Merry Choudhury is also insured and he has been paying premiums regularly. It is stated by PW-1 that his wife was admitted to GNRC Hospital, Guwahati and she was discharged on 15/09/2019. In respect of her treatment an amount of Rs.67,096/- ( Rupees sixty seven thousand and ninety six) was incurred and accordingly claim was filed for the said amount alongwith necessary papers before the Opposite Party The New India Assurance Company Ltd. but the O.P. rejected the claim on flimsy ground of psychiatric disorder. It is stated that the actual disease of the patient was Hypothyroidism and the same is mentioned in the discharge certificate. Subsequently the patient was operated at Sainath hospital, Chennai for her Parathyroid and it is mentioned in the discharge certificate. Phobia and anxiety were also related to her disease of parathyroidism. According to PW-1, the O.P. failed to note the three diseases together and overlooked other two diseases mentioned in the discharge certificate. The patient is not a patient of psychiatric disorder and she is leading normal life. It has been alleged that the O.P. intentionally rejected the claim with ulterior motive violating the instruction dated 18/08/2018 issued by the Insurance Regulatory & Development Authority ( IRDA ) causing harassment and disservice . In support of his case PW-1 has exhibited the copy of Policy vide Ext.-1, the medical papers vide Exts. 2,3 & 4 . In addition PW-1 has submitted Annexure-1 photocopy of discharge certificate from Sainath Hospital and Annexure-2 the copy of Instruction dated 18/08/2018 of IRDA. On the other hand perusal of the evidence of DW-1 reveals that it is not in dispute in this case that the complainant being an employee of LICI holds a group insurance policy by virtue of contract between the LICI and the O.P. Insurance Company. Ext.-1/Ext.-A is the copy of said Mediclaim policy. According to DW-1 , in the instant case TPA after scrutiny found that the patient was hospitalized for phobic neurosis with anxiety state which is a psychiatric disorder and since the desease falls within the ambit of clause F(vi) of the contract document, hence TPA could not recommend the reimbursement.
In his cross-examination PW-1 has admitted the fact that there is a exclusion clause F(vi) in the contract at page-20. For best reasons known to PW-1 he has not submitted the page no.-20 of Ext.-1 document. However the same document exhibited by DW-1 as Ext.-A contains the page no.-20 which describes ‘ EXCLUSIONS’ clause in serial no.-F. This exclusions clause describes the nature of deseases in respect of which the Insurance Company shall not be liable to make any payment. Column no. (vi) of Exclusions clause (F) contains specifically that treatment relating to all psychiatric and psychosomatic disorders are excluded.This fact is, however, not in dispute in this case. According to the O.P. , as the patient was treated in respect of her desease of psychiatric disorder and since the said desease falls within the ambit of exclusions clause so claim can not be allowed. The complainant in one hand has claimed that the patient was not hospitalized for desease of psychiatric disorder and on the other he has caimed that in view of the Mental Health Care Act’2017 he is entitled to get claim & compensation even if the desease of the patient (his wife) falls under Exclusion Clause F(vi). It is a fact that perusal of medical papers of GNRC exhibited by the complainant shows that the patient was suffering mainly from psychiatric disorder and she was treated accordingly. According to the complainant side in view of the provision of Mental Health Care Act’2017 the O.P. Insurance company is liable to pay the mediclaim to the patient even if it is found that the patient was hospitalized and diagnosed as patient of psychiatric disorder. In this connection PW-1 i.e., the complainant has submitted Annexure –2 copy of letter dated 16/08/2018 issued by the Insurance Regulatory and Development Authority of India to all Insurers directing to comply with the provisions of Mental Health Care Act’2017.
Section 21(4) of the Mental Healthcare Act,2017 directs every Insurer to make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness. As such as per provision of the Mental Health Care Act’2017 after enactment of this Act a patient for his/her treatment relating to psychiatric disorder will also be entitled to get Mediclaim. During the course of argument the learned counsel appearing for the O.P. Insurance Company has submitted that according to the circular dated 27/09/2019 issued by the IRDAI in respect of Guidelines on Standardization of Exclusions in Health Insurance Contracts which is applicable since 01/10/2019 the complainant is not entitled to get any relief in this claim. But the learned counsel for the complainant has raised strong objection against the said submission. On the other hand, perusal of the Mental Health Care Act’2017 does not disclose that the effect of this Act in respect of insurance will depend on the decision of any other authority at subsequent date. That being the position, we are of the considered opinion that as the treatment of the wife of the complainant took place after enactment of the aforementioned Act so even though the medical papers of the patient show that the treatment was taken for psychiatric disorder the Exclusions clause of the Policy can not disentitle the patient from getting the. mediclaim. The materials on record go to show that the complainant is entitled to get relief in the case. As such by not allowing the claim of the complainant the O.P. Insurance Company has caused disservice towards the complainant. There also does not appear any defect in the case.
In view of the above it is ordered that the O.P. Insurance Company shall pay to the complainant an award of Rs.67,096/- ( Rs. Sixty seven thousand and ninety six ) only towards claim amount. In addition the O.P. Insurance Company shall pay to the complainant an amount of Rs. 3,000/- ( Rupees three thousand) as compensation for mental agony & pain. The Complainant is also entitled from the O.P. Insurance Company an amount of Rs.10,000/- ( Rupees ten thousand) only towards cost of litigation. The entire amount shall be payable within a period of 90 ( ninety) days failing which interest @ 9 % per annum would accrue on the amount from the date of this judgment till realization.
With the above relief awarded the case stands allowed on contest against O.P. Insurance Company. The judgment is pronounced with our seal and signature on this 18th day of February’2023.
