Punjab

Ludhiana

CC/15/287

Sarbjit Singh - Complainant(s)

Versus

oriental Ins.Co.Ltd - Opp.Party(s)

G.S.Sikka ADv.

09 Nov 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA

 

Consumer Complaint No.287 of 29.04.2015

Date of Decision        :   09.11.2016

 

Sarabjit Singh Jaggi son of Late S.Iqbal Singh r/o 131, Model Gram, Ludhiana, Punjab.

….. Complainant

Versus 

1.The Oriental Insurance Company Limited, Regd.& Head Office, A-25/27, Asaf Ali Road, New Delhi-110002. (Through its Managing Director).

2.The Oriental Insurance Company Limited, Vishwakarma Chowk, GT Road, Miller Ganj Road, Ludhiana, Punjab-141003. (Through its Branch Manager).

3.Medi Assist India Pvt. Ltd., B-20, Sector-2, Noida, UP-201301. (Through its Managing Director).

4.Global Heart and Super Specialty Hospital, Ferozepur Road, Near Octorai Post, Ludhiana, Punjab. (Through its Head/Incharge).

..…Opposite parties

 

(Complaint U/s 12 of the Consumer Protection Act, 1986)

 

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

MRS. VINOD BALA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                     :         Sh.G.S.Sikka, Advocate

For OP1 and OP2          :         Sh.B.S.Rampal, Advocate

For OP3                        :         Ex-parte.

For OP4                        :         Sh.Narotam Ghai, Advocate.

 

PER G.K DHIR, PRESIDENT

 

1.                          Complainant along with his wife Mrs.Sarabjit Kaur purchased a mediclaim policy from OP1 and OP2 in 2014 bearing policy No.233902/48//2014/932 with validity upto 10.6.2014. This policy was renewed vide policy No.233902/48/2014/897 with validity period from 11.6.2014 to 10.6.2015. Sum insured per person was for an amount of Rs.4 lac. This policy was purchased by the complainant being account holder of Punjab National Bank. In February 2014, the complainant got admitted in hospital for treatment of Prostate Cancer problem. This treatment was got from Khosla Hospital, Ludhiana and from Dr.Navdeep Singh of Super Specialty Hospital, Ludhiana. Claim with OP1 and OP2 was submitted and the same was settled by the OP1 to OP3 to the entire satisfaction of the complainant. OP1 to OP3 were fully aware of the medical condition of the complainant and treatment got by him in February 2014.

2.              Complainant got himself admitted in OP4 hospital number of times for Chemotherapy treatment as per advise of Dr.Navdeep Singh, but after PSA test. Chemotherapy treatment using injectable Zoledronic Acid was provided   at Op4 hospital on 5.7.2014, 9.8.2014, 15.9.2014 and 11.10.2014 respectively. Thereafter, Dr.Navdeep Singh shifted to Satguru Partap Singh Apollo Hospital, Ludhiana(hereinafter in short referred to as “Apollo Hospital,Ludhiana”)and the remaining Chemotherapy was got conducted at Apollo Hospital, Ludhiana. Complainant submitted the claim for Rs.46,700/- with OP3 for the period of treatment of 16.6.2014 to 12.12.2014. That claim was registered with No.10690089 by OP3. Thereafter, complainant received letter dated 28.01.2015 containing intimation as if the claim of the complainant is repudiated due to clerical error committed by OP4. Complainant approached OP4 for clarification about the treatment provided to him. Dr.Navdeep Singh issued certificate dated 7.2.2015 certifying that Chemotherapy done on complainant. Thereafter, complainant again requested Op1 and OP2 to consider his claim, but after submitting certificate issued by Dr.Navdeep Singh. However, OP1 and OP2 again rejected the claim of the complainant without assigning any reason. On approach to Dr.Navdeep Singh, he again issued certificate dated 23.3.2015 to the effect that inadvertently in the discharge certificates dated 5.7.2014, 9.8.2014, 15.9.2014 and 11.10.2014 word mentioned for disclosing  the supportive care treatment instead of Chemotherapy treatment. Further, he rectified the certificate issued by Apollo Hospital, Ludhiana. Complainant cannot be held liable for the mistake of the hospital. Due to act and conduct of OP1 to OP4, complainant suffered mental agony and as such, compensation of Rs.20,000/- for mental harassment sought along with reimbursement of Rs.46,700/- with interest @18% p.a. from the date of submission of the claim till actual payment. Legal notice through counsel got served on 7.4.2015, but no reply received from Ops. Rs.46,700/- were spent on treatment by the complainant and reimbursement of the same sought. Rs.25,000/- as litigation expenses even claimed.

3.                In joint written statement filed by OP1 and OP2, it is pleaded interalia as if the complaint is not maintainable in the present form; complainant has not approached this Forum with clean hands; complainant is estopped by his act and conduct from filing this complaint; complaint is bad for non-joinder and mis-joinder of necessary parties; there is no deficiency in service on the part of Ops; complainant is not a consumer and complaint filed on false and frivolous basis. As per policy condition, if insured not satisfied with the denial reason, then he has right to appeal with the Regional Office of the insurance company or the Grievance Cell of the Head office of the insurance company and even he can approach the Insurance Ombudsman, an institution established by the Central Government. Insurance policy is a contract itself and the parties are bound by the terms and conditions of the policy and nothing can be added or subtracted out of it. Claim is not payable in view of exclusion clause 2.3 of the Mediclaim Insurance Policy. Complainant was duly informed about it. Mediclaim policy was issued to the complainant subject to the terms and conditions agreed by the complainant. Admittedly, the complainant was operated during the month of February 2014, but after discharge, he claimed reimbursement of medical expenses and claim in that respect was settled. Admittedly, the complainant received 4-5 cycles of Chemotherapy with injection Zoledronic Acid given as supportive therapy on different sessions. Zoledronic Acid injection is given subcutaneously and there is no need for hospitalization. This therapy is immunomodulator therapy which does not require the day care procedure and admission of 24 hours. So, claim of the complainant found falling within the purview of exclusion clause 2.3 of of the mediclaim insurance policy. Admittedly, after receipt of the claim, the same was sent for settlement to OP3, the Medi Assist India TPA Pvt. Ltd. Competent authority after considering the claim, duly denied the same and even sent intimation letter dated 9.2.2015 to the complainant. There was no mistake of the hospital at the time of admission. Each and every other allegation of the complaint denied by praying for dismissal of the complaint with exemplary costs.

4.                Op3 is ex-parte in this case.

5.                OP4 filed separate written statement by claiming that the complaint is not legally maintainable and there is no deficiency in service on the part of OP4 because dispute is between the insurer and insured. It is also claimed that the complaint is bad for non-joinder of necessary parties. Treatment got by the complainant i.e.Chemotherapy/supportive car on 5.7.2014, 9.8.2014, 15/9/2014 and 11.10.2014 is the same treatment which was also got by the complainant on 29.3.2014 and 26.4.2014. Claim on basis of that treatment put forth by the complainant with OP1 to OP3 was accepted. As per Day Care Discharge Card of hospital, the complainant was admitted and Chemotherapy/supportive care treatment was provided to him. Details of the Day Care Discharge Card and treatment are reproduced below:-

29.3.2014   -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

26.4.2014   -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

24.5.2014   -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

05.07.2014 -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

09.08.2014 -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

15.09.2014 -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

11.10.2014 -        Reason for admission-Chemotherapy/supportive care:

                             Pt.was admitted for ZA:4mg CT today.

There was no mistake on the part of OP4 because the treatment earlier   provided was on the same line and to the same effect as was                 specifically provided,for which,the claim put forth by the complainant was accepted. It is claimed that insurer is adopting illegal and arbitrary attitude on flimsy grounds. Terms Chemotherapy/supportive care is known as one and the same thing. It is claimed that the insurer has mischievously rejected the claim of the complainant in arbitrary manner. Complainant has not suffered mental agony on account of any reason attributed to Op4. No claim is payable by OP4. After receipt of legal notice from the complainant, detailed reply was submitted by OP4. As complaint against OP4 is not maintainable and as such, prayer made for dismissal of the complaint against OP4.

6.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C20 and Ex.C20A and thereafter, closed the evidence.

7.                On the other hand, counsel for the OP1 and OP2 tendered in evidence affidavit Ex.RA of Sh.Sanjiv Kumar, Sr.Branch Manager of OP1 and OP2; affidavit Ex.RB of Dr.Sunder Partha Sarathy of Medi Assist India TPA Pvt. Ltd., along with documents Ex.R1 to Ex.R7 and thereafter, closed the evidence.

8.                Counsel for OP4 tendered in evidence affidavit Ex.RW1/A of Dr.Brajesh K.Badhan, Chief Cardiologist of OP4 hospital along with documents Ex.R1 to Ex.R4 and thereafter, closed the evidence.

9.                          Written arguments and additional arguments submitted on behalf of complainant, but not by Ops. Oral arguments of all the counsel for the parties heard and records gone through minutely. 

10.               Undisputedly, the mediclaim insurance policy in question Ex.C1=Ex.R1 was purchased by the complainant and complainant after getting treatment for period of 16.6.2014 to 12.12.2014, submitted claim with Ops, which was registered and thereafter, processing the same, the same was rejected vide letter Ex.C13 on 28.1.2015. After getting certificate Ex.C13-a from treating Dr.Navdeep Singh, request for reconsideration was submitted by preferring appeal through letter Ex.C14, but the same was rejected vide letter Ex.C14=Ex.R2 of 9.2.2015 each.

11.              It is vehemently contended by Sh.B.S.Rampal, Advocate representing OP1 and OP2 that earlier amount of Rs.1,27,124/- was paid on 17.2.2014; but Rs.1,26,624/- on 10.1.2015 and Rs.72,407/- on 10.5.2015 and as such, whatever amount due towards complainant, the same had already been paid to him. It is contended that the treatment in question got by the complainant for period of June 2014 to December 2014 was through supportive care and as such, in view of exclusion clause 2.3 of the insurance policy, complainant not entitled for the reimbursement because he was not admitted in the hospital for minimum period of 24 hours on any of the dates namely 5.7.2014, 9.8.2014, 15.9.2014 and 11.10.2014. However, it is vehemently contended by counsel for the complainant that word supportive care in the discharge certificate mentioned in place of Chemotherapy and that is why rectification certificate got from Dr.Navdeep Singh, who treated the complainant.

12.              Exclusion clause 2.3 of the mediclaim insurance policy in question Ex.R3 provides that expenses on hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. However, this time limit will not apply to following specific treatments taken in the Network Hospital/Nursing Home, where the insured is discharged on the same day because such treatment shall be considered to be taken under hospitalization benefit. List of those specific treatments given in exclusion clause 2.3 as under:-

i)Dialysis(haemo dialysis, peritoneal dialysis)

ii)Parental Chemotherapy(injectible)

iii)Radiotherapy

iv)Eye surgery

v)Lithotripsy(Kidney stone removal)

vi)Tonsillectomy

vii)Dilation and Curettage (D & C)

viii)Dental Surgery following an accident

ix)Hysterectomy

x)Coronary Angioplasty

xi)Coronary Angiography

xii)Surgery of Gall Bladder, Pancreas and bile duct

xiii)Surgery of Hernia

xiv)Surgery of Hyrocele

xv)Surgery of Prostrate

xvi)Gastrointestinal surgery

xvii)Genital surgery

xviii)Surgery of nose.

xix)Surgery of throat and ear

xx.Surgery of Appendix

xxi)Surgery of Urinary system

xxii)Treatment of fractures/dislocation excluding hair line fracture, contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization.

xxiii)Arthroscopic Knee surgery

xxiv)Laparoscopic therapeutic surgeries.

xxv.Any Surgery under General Anaesthesia

xxvi)Any such disease/procedure agreed by TPA/Company before treatment.

13.              Relevant portion of this exclusion clause 2.3 as such provides that in case, Parenteral chemotherapy (injectible) treatment got without admission for     24 hours in the hospital, then claim for insurance will be admissible.

14.            Question arises as to what is Parenteral chemotherapy(injectible). As per search on Google Internet, word parenteral is an adjective. It means the drug or a medicine administered by means other than through the digestive tract i.e. especially by an injection. So, parenteral medicine is designated as a drug to be injected. So, if a drug for treatment taken into the body in manner other than through the digestive canal, then the treatment will be of parenteral nature. That internet search on Google is made a part of this file.

15.              Further after search on Google Internet, it is found that Chemotherapy is a treatment of cancer with anticancer drugs. The main purpose of Chemotherapy is to kill the cancer cells. Chemotherapy is usually used to treat the patient with caner that has spread from a place in the body, where it started (metastasized). Chemotherapy destroys cancer cells anywhere in the body and even it kills cells that have broken off from the main tumor and travelled through the blood or lymph systems to other parts of the body. So, parenteral chemotherapy means the treatment through medicine injected in the body except through the digestive canal, but for killing cancer cells. So,  Chemotherapy is done by use of drugs/medicines required to kill the cancer cells only.

16.              As per search on Google Internet, Zoledronic Acid-Injection is injected for treating high blood calcium levels(hypercalcemia) that may occur with cancer. Zoledronic acid is also used with cancer chemotherapy to treat bone problems that may occur with multiple myeloma and other types of cancer(such as breast, lung) that have spread to the bones. Zoledronic acid belongs to a class of drugs known as bisphosphonates. Use of Zoledronic Acid lowers high blood calcium levels by reducing the amount of calcium released from the bones into the body. It works by slowing the breakdown of bones by cancer to prevent bone fractures. The dose of Zoledronic Acid may need be repeated depending on blood calcium levels in the body. For the treatment of multiple myeloma and bone problems caused by the spread of cancer, this medication is usually given every 3 to 4 weeks or as directed by doctor. It takes at least 7 days after a dose to get the full benefit of this drug. In this case before us, Zoledronic Acid injection was administered to the complainant by Dr.Navdeep Singh(the treating doctor) as revealed by discharge cards Ex.C8 and Ex.C9 of 5.7.2014; Ex.C10 dated 11.10.2014; Ex.C11 dated 15.11.2014 and 13.12.2014 each. Even certificates Ex.C13-a dated 7.2.2015 and Ex.C15 dated 23.3.2015 issued by Dr.Navdee Singh establishes that the complainant was given parenteral chemotherapy by using injectible Zoledronic Acid on 5.7.2014; 9.8.2014; 15.9.2014 and 11.10.2014. Though in these certificates, it is mentioned that in the discharge card, inadvertently, it is mentioned that supportive care provided, albeit the chemotherapy was done, but these later version contained in these certificate Ex.C13-a and Ex.C15 are not correct because parenteral chemotherapy stands on different footing than that of the administration of Zoledronic Acid Injectible. Purpose of using Zoledronic Acid Injectible is to treat the bone problems caused by the disease of cancer. When the drug of Zoledronic Acid Injectible administered through tract other than digestive, then such administration will be parenteral in nature. Administering of Zoledronic Acid injection certainly is supportive care treatment to the cancer treatment because for cancer treatment through chemotherapy, anticancer drugs are administered, whereas during the high blood calcium levels or the problem of bone caused by spread of cancer, Zoledronic Acid injectible administered. So, opinion submitted by Dr.Navdeep Singh through above referred certificates qua the treatment through administration of Zoledronic Acid and Ex.C13 and Ex.C15 only establishes that the said parenteral chemotherapy treatment was provided on the above referred dates of 5.7.2014, 9.8.2014, 15.9.2014 and 11.10.2014 for treating the problem of high blood calcium levels or the problem of bone caused by spread of cancer.

17.              As per internet search on Google, Chemotherapy may be given either orally or by injection or through a catheter or port or  topically. Oral chemotherapy is given by mouth in the form of pill, capsule, or liquid, but Intravenous(IV) chemotherapy is injected into a vein. Intramuscular(IM) Chemotherapy is injected through a muscle. Chemotherapy also may be given by a catheter or port permanently inserted into a central vein or body cavity. If that be the position, then injectible Zoledronic acid was a supportive care treatment to the cancer because said Zoledronic Acid administered for treating the problem of high blood calcium levels or for the bone problems on account of spread of cancer. So, use of word ‘supportive care’ in the discharge cards is not inadvertent. Rather, the same was on account of use of injectible Zoledronic acid meant for curing the side effect of cancer on bones. That Zoledronic Acid is not an anti cancer drug or medicine and as such, case of the complainant not covered by exception (ii) of part-A of clause 2.3 of Ex.C2 or Ex.C3=Ex.R3. Therefore, repudiation of claim is not improper. Merely because claim for same treatment on earlier dates of 29.3.2014 or 26.4.2014 was allowed, due to that alone,Ops not bound to perpetuate the mistake of misinterpretation of clauses of Ex.R3=Ex.C2 and Ex.C3. Entire record of internet search is made a part of this file.

18.              It is vehemently contended by counsel for complainant that OP4 in the submitted written reply specifically admitted that mischief committed by OP1 and OP2 in rejection of the claim, despite the fact that same treatment provided on dates of 5.7.2014, 9.8.2014, 15.9.2014 and 11.10.2014 as was provided on 29.3.2014 and 26.4.2014. It is further contended that if on account of providing of the treatment on same line on two intervals, claim for one interval of 26.4.2014 and 26.4.2014 accepted by the insurer, then the same liable to be accepted for second interval for treatment from 16.6.2014 to 12.12.2014. There is no admission on part of OP1 & 2 on that matter. Rather, this Forum   to found the truth by laying hand on such material as may be available because one party cannot be permitted to hold other to ransom. The kind of drug used though may be Chemotherapeutic Agent, but the same actually is not meant for killing cancer cells, but for curing the side effect of cancer on bones and as such, OP1 and OP2 rightly found that treatment through Zoledronic Acid Injection was supportive care treatment to the Chemotherapy treatment for treating cancer. For supportive care treatment of cancer, Ops not bound to reimburse as per the terms and conditions of the contract of insurance and this Forum cannot add or subtract anything to the terms of contract of insurance and as such, repudiation of claim being justified leans in favour of holding that there is no deficiency in service on the part of OP1 and OP2.

19.              Therefore, as a sequel of the above discussion, the complaint dismissed with no order as to costs. Copies of order be supplied to the parties free of costs as per rules.

20.                        File be indexed and consigned to record room.

 

                                      (Vinod Bala)                                (G.K.Dhir)

                               Member                                       President

Announced in Open Forum

Dated:09.11.2016

Gobind Sharma.