BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 170 of 2014

Date of Institution: 26-03-2014

Date of Decision: 20-08-2015  

1. Surinder Mohan son of Sh.Ram Avadh.
2. Smt.Sharda wife of Sh.Surinder Mohan son of Sh.Ram Avadh, both residents of House No. 135-B, Opposite Shivala Bohar Wala, Jawahar Nagar, Amritsar. 

Complainants

Versus

The Oriental Insurance Company Limited, through its Divisional Manager/ Officer Incharge, Dwarka Dees Complex, Queens Road, Amritsar.  

Opposite Party

Complaint under section 12 & 13 of the Consumer Protection Act, 1986.

Present: For the Complainants: Sh.  Rajesh Bhatia, Advocate

              For the Opposite Party: Sh. Subodh Salwan, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by the complainants  under the provisions of the Consumer Protection Act alleging therein that in the month of April, 2013 the complainant No.1 purchased a Individual Mediclaim Policy from Opposite Party    bearing No.233300/48/ 2014/2010, Cover Note No.CHD-C864262. This policy was renewed policy of previous policy bearing No. 233300/48/2013/123, cover Note dated 13.4.2013. The policy in question was valid from 15.4.2013 to 14.4.2014. Under the said policy, both the complainants were duly covered upto the sum assured overall liability to the tune of Rs.One lac and the Domiciliary Hospitalization Limit was Rs.20,000/- per  person.  In the month of May, 2013 the complainant No.2 got her treatment from Nayyar Hospital, Amritsar and remained hospitalized from 17.5.2013 till 19.5.2013 and in the said treatment the complainants spent a sum of Rs.70,000/- and even after the said treatment, the complainants had been purchasing medicines & injections and spent a sum of Rs.1,22,192/- vide proper bills. The complainants submitted their claim with the Opposite Party within the stipulated time period and further provided each and every necessary paper to the Opposite Party, but the Opposite Party  repudiated the claim of the complainants vide letter dated 26.11.2013 on the ground that Injections were given on OPD basis and as per the policy term sand conditions procedures/ treatment usually done in OPD are not covered and payable under the policy even if converted to Day Care Surgery/ Procedure or as in-patient in Hospital for more than 24 hours and has recommended the claim as non payable.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to release the claim of Rs.1,92,192/- in favour of the complainants. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party appeared and filed written version in which it was submitted that the complainant No.2 had suffered from Hepatitis C Viral (HCV RNA) Genotype, Cirrhosis of Liver. The Opposite Party sought the medical opinion from its empanelled doctor Neelkanth Sharma with regard to the ailment of complainant No.2, who had given the observations in his opinion that “HCV is an RNA virus of the Flavivirus group transmitted in 60% of the cases due to drug abuse. Other modes of transmission are seen following accidental needle punctures in health care workers dialysis patients and rarely from mother to infant. Sexual transmission accounts for 10% of cases, chronic infection with HCV occurs in about 85% of infected individuals leading to fibrosis of the liver and Cirrhosis in about 20% of these patients. Risk for Hepatocellular carcinoma in a patient with chronic HCV is 1-5% after 20 years.”  While treating the patient Interferon injections were given after determining viral load. Injections are given on OPD basis and there is no need to admit the patient just to give a injection for the ailment in question and as per the terms and conditions. So, in the light of aforesaid terms and condition of the policy in question, the claim of the complainants has been rightly repudiated by the Opposite Party  vide its repudiation letter dated 26.11.2013. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainants tendered into evidence the affidavit of complainant No.1 Ex.C1 alongwith documents Ex.C2 to Ex.C62.
4. Opposite Party tendered into evidence affidavit of Sh.Sandeep Thapa, Divisional Manager, Ex.OP1 alongwith documents Ex.OP2 to Ex.OP10 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant No.1 got Individual Mediclaim Policy from Opposite Party bearing No.233300/48/ 2014/2010 (Ex.C31)  valid from 15.4.2013 to 14.4.2014. Under the said policy, both the complainants were duly covered upto the sum assured overall liability to the tune of Rs.One lac and the Domiciliary Hospitalization Limit was Rs.20,000/- for person.  In the month of May, 2013 the complainant No.2 became ill and was hospitalized in Nayyar Hospital, Amritsar from 17.5.2013 to 19.5.2013 and she paid a sum of Rs.70,000/- to the aforesaid hospital authorities and she also spent  a sum of Rs.1,22,192/- on medicines as per bills and receipts Ex.C3 to Ex.C20 and Ex.C35 to Ex.C45. In all the complainants spent Rs.1,92,192/- on the medical treatment of complainant No.2. The complainants lodged claim with the Opposite Party. However, the Opposite Party  repudiated the claim vide letter dated 26.11.2013 on the ground that    Injections given to the complainant No.2 could be given  on OPD basis, as such hospitalization of the complainant No.2 was not required. Therefore, as per the policy terms and conditions procedures/ treatment usually done in OPD are not covered and not payable under the policy in question.  Ld.counsel for the complainant submitted that the complainant No.2 was admitted in the hospital due to pain in upper abdomen and due to disease Hepatitis C Viral (HCV RNA) Genotype, Cirrhosis of Liver, septicemia as is evident from the discharge summary of Nayyar Hospital, Amritsar Ex.C51 that is why, Nayyar Hospital, Amritsar admitted the complainant No.2 for medical treatment in their hospital. Ld.counsel for the complainants submitted that the Opposite Party  was not justified in repudiating the claim of the complainants on this ground and all this amounts to deficiency of service on the part of the opposite party.
7. Whereas the case of the Opposite Party is that the complainant No.2 had suffered from Hepatitis C Viral (HCV RNA) Genotype, Cirrhosis of Liver. The Opposite Party  sought the medical opinion from its empanelled doctor Neelkanth Sharma regarding the ailment of complainant No.2 insured Smt.Sharda, who had given the observations in his opinion that “HCV is an RNA virus of the Flavivirus group transmitted in 60% of the cases due to drug abuse. Other modes of transmission are seen following accidental needle punctures in health care workers dialysis patients and rarely from mother to infant. Sexual transmission accounts for 10% of cases, chronic infection with HCV occurs in about 85% of infected individuals leading to fibrosis of the liver and Cirrhosis in about 20% of these patients. Risk for Hepatocellular carcinoma in a patient with chronic HCV is 1-5% after 20 years.”  While treating the patient Interferon injections were given after determining viral load. Injections are given on OPD basis and there is no need to admit the patient just to give a injection for the ailment in question and as per the terms and conditions No.6 of the policy “procedures/ treatment usually done in Out Patient Department  are not payable under the policy even if converted to Day Care Surgery/ Procedure or as in patient in the Hospital for more than 24 hours” and has recommended the claim as non payable.       So, in the light of aforesaid terms and condition of the policy in question, the claim of the complainants has been rightly repudiated by the Opposite Party  vide its repudiation letter dated 26.11.2013. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that the complainants were duly insured with Opposite Party  vide  Individual Mediclaim Policy bearing No.233300/48/2014/2010 (Ex.C31)  valid from 15.4.2013 to 14.4.2014 with sum assured  Rs.1 lac, with  Domiciliary Hospitalization Limit Rs.20,000/-.  Complainant No.2 became ill and she was admitted in  Nayyar Hospital, Amritsar where she remained hospitalized from 17.5.2013 to 19.5.2013 and she was diagnosed as a case of Hepatitis C Viral (HCV RNA) Genotype, and she had history of pain in upper abdomen,   Cirrhosis of Liver, septicemia as is evident from the discharge summary of Nayyar Hospital, Amritsar Ex.C51 for which the hospitalization of the complainant No.2 was necessary. She was not only suffering from HCV i.e. Hepatitis C Viral but she was also suffering from other dieases i.e. pain in upper abdomen, Cirrhosis of Liver, spleen, septicemia, etc. The complainants have spent a sum of Rs.1,92,192/- on the medical treatment i.e. payment to the aforesaid hospital and medicines as is evident from the bills and receipts Ex.C3 to Ex.C20 and Ex.C35 to Ex.C45.  the Opposite Party  sought opinion of their doctor, Dr.Neelkanth Sharma who has given his opinion Ex.C27 and proved the same through his affidavit Ex.OP2 for which he has stated that medical record of the patient shows that the complainant No.2 had suffered from Hepatitus C Viral (HCV RNA) Genotype, Cirrhosis of Liver. Patient in such treatment is given Interferon injections after determining viral load and the injections are given on OPD basis and there is no need to admit the patient just to give  injection for the ailment in question. This witness Dr.Neelkanth was cross examined by the complainants and in his cross examination, this witness admitted that he is not a Gastroenterologist. His opinion regarding HCV +ve is not final as the complainant No.2 was suffering from other diseases also and as such, the authorities of Nayyar Hospital, Amritsar have found it necessary that admission of complainant No.2 in the hospital, is necessary for the treatment.
9. Resultantly, we hold that the Opposite Party  was not justified in repudiating the claim of the complainants only on the ground that Dr.Neelkanth has opined that treatment of the patient could be done on OPD basis and hospitalization was not necessary.
10. As regards the amount of the claim, no doubt, the complainants have spent a sum of Rs.1,92,192/- on the treatment of complainant No.2, but the policy Ex.C31 covers  complainant No.2 only to the extent of Rs.1 lac. As such, we hold that the complainants are entitled to the reimbursement of Rs.1 lac only  on account of medical treatment/ hospitalization of complainant No.2 in Nayyar Hospital, Amritsar.
11. Consequently, we partly allow the complaint with costs and the Opposite Party  is directed to reimburse the complainants to the tune of Rs.1 lac, (One Lac)  within one month from the date of receipt of copy of this order, failing which the Opposite Party  shall be liable to pay interest @ 9% per annum on this amount of Rs.1 lac, from the date of filing the complaint till the payment is made to the complainants. Opposite Party  is also directed the pay litigation expenses to the complainants to the tune of Rs.2,000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 20-08-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member