Sarita Jindal, complainant (here-in-after referred to as 'complainant') has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against Oriental Insurance Co. Ltd., & another (here-in-after referred to as 'opposite parties').
Briefly stated, the case of the complainant is that she is having one Bank account with Oriental Bank of Commerce, Gidderbaha. The opposite party No. 1 issued one Medi-claim insurance policy No.233200/48/2019/232 w.e.f. 01-05-2018 to 30-04-2019 under cashless scheme at Bathinda through OBC, Gidderbaha with opposite party No. 2 as TPA. This policy was issued under the scheme of Oriental Medi-claim Policy to their Account Holders. Cashless Card was also issued. Under the policy, Sarita Jindal and Mridul Jindal are duly insured for Rs. 5,00,000/- each. This insurance is continuous insurance since 2015. As per said insurance, any person of the policy holder can avail insurance upto Rs.5,00,000/- on the first basis or both can use the said amount upto Rs.5,00,000/-.
It is alleged that opposite parties never issued any complete policy to the complainant or her son. They have issued only Insurance certificate.
It is pleaded that complainant first time, admitted with the problem of pain and swelling of Knee joints and feet with difficulty in walking since 30 days. The son of the complainant got admitted her in Balaji Action Medical Institute, New Delhi on 20-06-2018 and she was discharged on 23-06-2018. The family of the complainant lodged cashless claim with the said hospital as it is network hospital for cashless treatment under the Insurance. The hospital sent information and registered claim with the opposite parties under their system by E-Mail. The opposite parties firstly approved the claim of Rs.75,000/- as initial amount when the complainant was in hospital. Thereafter with malafide intention, the opposite parties denied the cashless facility at the time of discharge. The complainant spent Rs.1,17,414/- for treatment and medicine charges. The original bills with original treatment file was submitted with opposite parties for reimbursement.
It is alleged that opposite parties firstly not provided cashless treatment from the aforesaid hospital and thereafter did not reimburse the expenses borne by complainant. The complainant again and again requested the opposite parties to release the claim of Rs. 1,17,414/- but finally on 13-8-2018, the opposite parties repudiated the claim through e-mail on the ground that patient was admitted as a case of Rheumatoid Arthritis with Active Disease and underwent treatment with injection Remicade. No active treatment was done during claimed hospitalization. The patient was admitted only for injection. According to policy terms ‘Expenses incurred for Investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission are not covered under the scope of policy'.
It is further pleaded that the amount of Rs. 1,17,414/- is still pending with the opposite parties. The Exclusion Clause neither supplied to the complainant at the time of Insurance nor at the time of rejecting the claim. The treating doctor Nagma Bansal also cleared that Remicade injection can be given only after hospitalization with proper vital monitoring. This treatment is not possible under OPD case. It is alleged that repudiation of claim is illegal.
On this backdrop of facts, the complainant claimed Rs. 1,17,414/- with interest; Rs. 50,000/- as compensation and Rs. 25,000/- as litigation expenses. Hence this complaint.
Upon notice, none appeared on behalf of opposite party No. 2. As such, it was proceeded against exparte vide order dated 4-10-2018.
The opposite party No. 1 appeared through counsel and contested the complaint by filing written reply. In written reply, the opposite party No. 1 raised legal objections that complainant obtained OBC-Oriental Medi-claim Policy-2017 with CSI Rs. 5,00,000/- through OBC, Gidderbaha. She was allotted policy No. 233200/48/2019/232 which is renewal of previous policy No.233200/48/2018/402. It is asserted that policy alongwith terms and conditions was duly supplied to the complainant.
Further legal objections are that claim of the complainant has rightly been repudiated vide letter dated 22-08-2018 as per general exclusion clause 4.13 and 4.14 of OBC-Oriental Medi-Claim Policy 2017. These clauses are reproduced as under :-
Clause (4) the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of :-
Clause 4.13 Expenses for investigation/treatment irrelevant to the disease in respect of which the insured person has been admitted or diagnosed.
Clause 4.14 Private nursing charges, Referral fee to family doctors, out station consultants/Surgeons fees, etc.
It is alleged that complainant was suffering from Rheumatoid Arthritis with active disease. Injection Remicade was given. The admission was only for injection Remicade Infusion. It is not payable as per policy terms and conditions. There is no active line of management. Admission was only evaluation. Claim is not payable as per terms and conditions of insurance policy.
It is also asserted that complaint is bad for non-joinder of necessary party. Oriental Bank of Commerce Gidderbaha has not been impleaded as party. That the complainant is stopped by her own act and conduct. She has not come before this Forum with clean hands. She has suppressed true and material facts. That the complainant has got no locus-standi or cause of action to file the complaint. Amount of compensation claimed is highly excessive and exorbitant one and lastly that the complaint is false, frivolous and vexatious to the knowledge of the complainant.
On merits, the opposite party No. 1 has controverted all the material averments and prayed for dismissal of complaint.
In support of her complaint, the complainant has tendered into evidence her affidavit dated 27-8-2018 (Ex. C-1), photocopy of policy (Ex. C-2), photocopy of Insurance Card (Ex. C-3), photocopy of discharge summary (Ex. C-4), photocopy of medical bills (Ex. C-5), photocopy of cashless approval letter (Ex. C-6), photocopy of cashless denial letter (Ex. C-7 & Ex. C-8), photocopy of e-mail (Ex. C-9), Certificate (Ex. C-10) and photocopy of no claim letter (Ex. C-11).
In order to rebut this evidence, the opposite party No. 1 has tendered into evidence affidavit dated 18-10-2018 of Roop Lal Baleem (Ex. OP-1/1), photocopy of proposal form (Ex. OP-1/2), photocopy of insurance policies (Ex. OP-1/3 & Ex. OP-1/4), photocopy of terms and conditions (Ex. OP-1/5), photocopy of repudiation letter (Ex. OP-1/6 &Ex. OP-1/7), photocopy of letter (Ex. OP-1/8), photocopy of policies (Ex. OP-1/9 to Ex. OP-1/12), photocopy of claim forms (Ex. OP-1/13 & Ex. OP-1/14), photocopy of ID Card (Ex. OP-1/15), photocopy of discharge summaries (Ex. OP-1/16 & Ex. OP-1/17), photocopy of CT Scan report (Ex. OP-1/18) and closed the evidence.
We have heard learned counsel for the parties and gone through the record.
The learned counsel for the parties have reiterated their version as pleaded in their respective pleadings.
We have carefully gone through the record and have considered the rival contentions.
The admitted facts are that the complainant availed insurance policy from opposite party No. 1 which was valid from 1-5-2018 to 30-4-2019. It was renewed policy. It was continuing since 2015. It is also not disputed that complainant took treatment w.e.f. 20-6-2018 to 23-6-2018.
As per complainant, she has spent Rs. 1,17,414/- for this treatment. Bills Ex. C-5 is produced on record to corroborate this fact. The opposite party has repudiated the claim vide letter dated 22-8-2018 (Ex. C-11). The claim has been repudiated under the following clauses :-
4.13 Expenses for investigation/treatment irrelevant to the disease in respect of which the insured person has been admitted or diagnosed.
4.14 Private nursing charges, Referral fee to family doctors, out station consultants/Surgeons fees, etc.
A perusal of repudiation letter reveals that opposite party No. 1 has concluded that expenses for investigation/treatment irrelevant to the disease. This conclusion is on the basis of letter of TPA i.e. opposite party No. 2. In this letter, TPA has observed and opined that admission only for injection Remicade infusion is not payable as per policy terms and conditions. There is no active line of management. Admission only for evaluation is not payable as per policy terms and conditions. TPA recommended that claim is 'Non-payable' as per clause 4.14.
The complainant has brought on record Discharge Summary (Ex. C-4). As per this document, diagnosis was :-
“Rheumatoid Arthritis with Active Disease (Das 28 CRP – 5.44) Injection Remicade (Infliximab) 200 Mg – First Dose Given.”
This document further reveals that it was also noticed that patient is a k/c/o Rheumatoid arthritis on treatment in the form of Injectable methotrexiate, eflunomide and steroids. Despite treatment for one year, patient had positive CRP and continuous pain. For last one month, she started complaining of pain and swelling of knee joints and feet with difficulty in walking. Now the patient has been admitted for further management. She also complaint of low grade fever.
Course during hospital stay reveals :-
Patient was admitted with above said complaint. She was started on steroids with physiotherapy CECT chest and upper abdomen was done and tuberculosis was ruled out. Viral markers were negative. ESR and CRP were raised. She was given intervenous solumedrol 40 mg. After ruling out latent tuberculosis, first does of injection Remicade (infliximab) 200 mg given alongwith with premedication in the form of injection hjydrocort and injection avail. Patient tolerated the procedure well and now being discharge with advice for second dose after 6 weeks.
The aforesaid document reveals that complainant was admitted with complaint of Rheumatoid Arthritis. She was given treatment for this disease. Therefore, the conclusion of the opposite parties that admission was only for injection is not acceptable. The admission was for treatment and not for only injection. As exclusion clause quoted by the opposite parties is not applicable to the case of the complainant. Therefore, repudiation of claim is not justified and it amounts to deficiency in service. As such, the complainant is entitled to claim amount of Rs. 1,17,414/-. She is also entitled to interest on this amount as compensation for harassment and mental agony caused to her on account of non-payment of claim.
In view of what has been discussed above, this complaint is partly accepted against opposite parties with cost of Rs. 10,000/-. The opposite parties are directed to pay to complainant claim amount of Rs. 1,17,414/- with interest @ 9% p.a. w.e.f. 22-8-2018 (date of repudiation) till realization.
The compliance of this order be made within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record.
Announced :
27-08-2019
(M.P.Singh Pahwa )
President
(Manisha )
Member
