Ms. Nipur Chandna, Member

Complainant is the mediclaim policy holder of the OP vide policy no. 215601/48/2013/2184 w.e.f. 2.8.2012 to 1.9.2013.  It is alleged by the complainant that he was admitted on 5.8.2013 with the problem of “Ankylosing Spondylitis” at Indian spinal injuries centre hospital.  The complainant asked for cashless to the OPs but they denied the same. It is further alleged by the complainant that on 9.3.2013 complainant paid the bill amounting to Rs.1,85,203/- to the hospital and submitted all the claim documents with OP -2 vide claim form no. 122031300983.

     The claim of the complainant was rejected/repudiated by OP – 2 vide letter dated 13.3.2013.  It is further alleged by the complainant that he had sent a legal notice to the OPs to reconsider his claim. The OP neither replied to the notice nor settled the claim of the complainant.  Hence, the present complaint.

     OPs have contested the complaint and filed written statements. They have denied any deficiency in services on their part.  OPs have stated that the claim lodged by the complainant was rightly repudiated as this was a case of simple treatment which could have been taken as on OPD patient.  The complainant was hospitalized for three days and there was no justification for keeping the complainant hospitalized for the said period. They prayed for the dismissal of the complaint.

     Both the parties have filed their evidence by way of affidavits

     We have heard arguments advanced at bar and have perused the record.

     The counsel for OPs has contended that the OP – 2 had examined the matter of reimbursement of the claim of complainant and found that this was a case of simple treatment which could have been taken as on OPD patient.  The complainant was hospitalized for three days and the justification given by the doctor is not valid and as such OP – 1 has rightly repudiate the claim of the complainant.

     The counsel for the complainant on the other hand had drawn our attention on the certificate issued by Dr. Sanjeev Kapoor which reads as under:-

     This is to certify that Mr. Mohit Chadha 36/M is suffering from Ankylosing Spondylitis.  Patient needed to be administered injection Solumedrol (Methylprednisolone) and Remicade (Infliximab) 400 mg.   For this the patient was admitted in this hospital for two days. There is a risk of Anaphylaxsis in administering injection Remicade. Hence it was compulsory to administer injection Remicade under strict supervision & close monitoring by a senior doctor for at least 24 hrs.

     He had also taken us through the discharge summary which clearly spoke of the treatment given to the complainant. The relevant contents the discharge summary is reproduced as under:

 

“Patient was given injection Methyprednisolone + Injection Remicade 400 mg as slow IV infusion under strict supervision.  Post infusion was uneventful. Patient is now being discharged in a stable condition. 

 

      In view of the above discussion and the perusal of the documents placed on record, we are of the considered opinion that OP – 1 has repudiated the claim of the complainant on false and flimsy ground.  The treatment given to the complainant were given under the instruction and superintendence of the well experienced doctor in respect of which doctor’s certificate certifying the need of hospitalization of the complainant was also filed by the complainant with his claim documents with the OP .  This certificate was clearly ignored by the OPs at the time of processing the claim of the complainant.  We are therefore of the considered opinion that the repudiation of claim by OP is not justified.  Accordingly, we hold OP guilty of deficiency in services and direct it as under:-

1. To pay to the complainant a sum of Rs.1,85,203/- alongwith 10% interest from the date of repudiation of the claim till payment.

2. To pay to the complainant a sum of Rs.20,000/- for mental pain and suffering.

3. To pay to the complainant a sum of Rs.5000/- as a cost of litigation. 

      The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum.  If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.

Copy of the order be made available to the parties as per rule.                File be consigned to record room.

      Announced in open sitting of the Forum on.....................