Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 70/05.07.2022
Pradeep Kumar Gupta r/o B-29, Gujranwala Town,
Chatrasaal Stadium Road, Part-1, New Delhi-110009 …Complainant
Versus
OP: New India Assurance Company Limited
(through its Senor Divisional Manager)
7E, Jhandewalan Extension, Delhi-110055 ...Opposite Party
Date of filing: 05.07.2022
Date of Order: 05.11.2024
Coram:
Shri Inder Jeet Singh, President
Ms Rashmi Bansal, Member -Female
FINAL ORDER
Inder Jeet Singh , President
It is scheduled today for order (item no.3)
1. (Case of complainant) –The complainant took health insurance policy having member ID H3236765, policy no. 31010034219500000801 w.e.f.15.09.2021 to 14.09.2022, for sum insured of Rs. 8 lakhs and cumulative bonus of Rs. 4 lakhs, thus total sum insured is of Rs. 12 lakhs for this period. The TPA is M/s MD India Private Ltd.
The complainant had undergone Radio Therapy and Chemotherapy at Apollo Hospital, Delhi, as complainant is patient of carcinoma buccal mucasa (ordinarily known as mouth cancer). The complainant had undergone for 32 sessions of Radio Therapy. The Chemotherapy consisted of 6 session of erbitrux medicine in dosages prescribed by the consulting doctor. The total cost of treatment was Rs. 10,92,905/- but TPA provided total approval of Rs. 9,18,413/- minus deductions. The bills of Rs. 1,41,793/- for last two chemotherapy sessions was completely rejected by TPA on frivolous grounds. A balance amount of Rs. 2,81,587/- is remaining out of sum insured. There is deficiency of services on the part of OP, that is why legal notice was also issued to OP but no result. That is why the present complaint against OP for cost of last two sessions of Rs. 1,41,793/-, compensation of Rs.1 lakh and cost of Rs. 10,000/-.
The complaint is accompanied with documents/copies of –policy for year 2021-22, medical treatment papers, denial of authorization letter, letters writtent to OP, legal notice and corrigendum with postal receipt.
2.1 (Case of OP)-This complaint is opposed by filing detailed written statement that neither there is cause of action nor any claim is made out. The OP has elaborated medical terms, non-medical terms, provisions of health insurance policy, deductibles besides other facts and circumstances of the case. Simply, the complainant was issued subject insurance policy. The medical insurance policy stipulates the limit of upto 10% of sum insured subject to maximum of Rs.1 lakh in case of treatment or procedure of oral chemotherapy and limit of upto 25% of sum insured, subject to a maximum of Rs.2 lakhs.
It is admitted fact that complainant was given first cycle of erbitrux 800 mg loading dose on 17.01.2022, the second dose of 500 mg was administered on 24.01.2022 and third and fourth cycle of erbitrux were given on 07.02.2022. The injured was also admitted on 14.02.202 and 21.02.2022 for standalone monoclonal antibody infusion. The erbitrux, falling under monoclonal immunotherapy, is covered under modern treatment, it is subject to limit of 25% of sum insured subject to maximum of Rs. 2 lakhs, by virtue of clause no. 3.19 of New India Medi-Claim Policy.
2.2. The medi-claim policy sets out terms and conditions on the basis of claim and benefit under the policy. It is established principle of law that insurer’s liability for all claims during the period of insurance will be up-to the sum insured, for which insured person is covered as mentioned in the schedule.
Since the insured had exhausted the limit cap of Rs. 2 lakh in illness treatment under the current policy, the cashless facility was denied through TPA by denial authorization letters dated 10.02.2022 and 19.10.2022. The complaint is liable to be dismissed.
2.3 The written statement is accompanied with documents/copies of –New India Medi-claim Policy, terms and conditions, cashless authorization letters medi-claim, denial of authorization letters and other documents.
3. After completion of the pleadings the case was put to evidence, which remained pending, thereafter the OP had filed an application that despite various opportunities the complainant was not appearing and leading evidence, let the matter be proceeded and to decide on merits. Therefore, by detailed reasoned order dated 22.11.2023 the complainant’s evidence was closed. The OP closed its evidence for want of leading evidence by the complainant.
4. (Final hearing)- At the stage of final hearing, again complainant had not appeared but Ms. Tanushree Sinha, Advocate for OP made the final submissions that the complainant failed to lead evidence and the complaint has not been proved.
5. (Findings) - The case of the parties as set-up including material on record are considered and assessed.
It is manifest that there is no evidence by the complainant and consequently for evidence by the complainant, the OP has not led the evidence. There is pleading/complaint along-with documents and its opposition by way of written statement with documents. There is admitted facts of insurance policy by the OP as well as that complainant had undergone the therapy. However, there is no admission on the part of OP in respect of any component of the remaining amount or of Rs. 1,41,793/-, alleged in the complaint.
To say, the complainant has not proved his claim as narrated in the complaint nor there is any admission, partly or wholly, by OP in its pleading with regard to the claimed amount. Therefore, the complaint is dismissed for want of proof of allegations. No order as to costs.
6. Announced on this 05th day of November, 2024 [कार्तिक 14, साका 1946]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliance; besides to upload on the website of this Commission.
[Rashmi Bansal]
Member (Female)
[Inder Jeet Singh]
President
[ijs134]
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