Delhi

StateCommission

A/891/2014

UNITED INDIA INSURANCE CO. LTD. - Complainant(s)

Versus

RAJ BERY & ANR. - Opp.Party(s)

08 Feb 2016

ORDER

IN THE STATE COMMISSION : DELHI

(Constituted under Section 9 of the Consumer Protection Act, 1986)

Date of Decision:08.02.2016

First Appeal- 891/2014

(Arising out of the order dated 14.07.2014 passed in Complainant Case No. 556/2012 by the District Consumer Disputes Redressal Forum (VI), M-Block, Vikas Bhawan, New Delhi)

United India Insurance Co. Ltd.,

Through Authorized Attorney,

DRO-II, Core-IV, First Floor,

Scope Minar Comlex,

Laxmi Nagar,

District Centre,

Delhi-110092.

                                                           ….Appellant

Versus

1. Raj Berry,

W/o Sh. C.B. Berry,

R/o I-1/46, Sector-16,

Rohini, Delhi.

 

2. M.T.N.L.,

Through its Asstt. Gen. Manager(M.R.),

Delhi-110050.

                                                                  ….Respondents

CORAM

Justice Veena Birbal, President

 

1.     Whether reporters of local newspaper be allowed to see the judgment?

2.      To be referred to the reporter or not?

 

Justice Veena Birbal, President

 

1. This is an appeal under Section 15 of the Consumer Protection Act, 1986 (in short, “the Act”) challenging judgement dated 14.7.14 passed by the Consumer Disputes Redressal Forum (VI), Vikas Bhawan, New Delhi (in short, “the District Forum”) in Complaint Case No. 556/2012.
2. Briefly the facts relevant for the disposal of present appeal are as under:

    Respondent herein was the complainant before the District Forum.  A consumer complaint under Section 12 of the Act was filed by her stating therein that she is employed as a Telephone Operator in Badli Telephone Exchange, Delhi.  On 10.3.11, she had availed Group Health Medical Insurance Policy for M.T.N.L. Working Employees-2011 with appellant/OP having Policy No.222800/48/10/41/00005791 which was effective from 10.3.11.  Respondent/complainant had alleged that she was suffering from Refractory Sero Positive Rheumatoid Arthritis and was admitted in All India Institute of Medical Sciences (in short “AIIMS”) on 9.9.11 and 23.9.11 for a medical treatment procedure termed as Rituximab Infusion.  The respondent/complainant had to purchase two injections worth Rs.64,000/- each for Rituximab Infusion as per the advice of the Doctors of AIIMS for curing her ailment.  She had incurred expenses of Rs.1,28,000/- towards the purchase of injections.  According to her, admission was given in AIIMS as indoor patient.  The bills for purchase of injections were submitted to appellant/OP through proper channel.  The appellant/OP repudiated her claim arbitrarily on the ground that the treatment could be given on out-patient basis and did not require any admission. She had filed a consumer complaint claiming Rs.1,29,220/- towards the medical reimbursement, Rs.30,000/- towards mental agony and Rs.20,000/- towards litigation expenses. 

3. Appellant/OP contested the claim by filing written statement before the Ld. District Forum.  It was alleged that the claim lodged by the respondent/complainant was not payable as the patient had taken injections for Rheumatoid Arthritis which is an O.P.D. procedure.  It was alleged that as per terms and conditions and scope of insurance cover granted to the respondent/complainant, the insurance claim was payable for the amount which was incurred as indoor patient and not as outdoor patient.  
4. Both the parties led evidence by way of affidavits before the Ld. District Forum.  The respondent/complainant had filed all the documents including hospital admission slips i.e. Admission slip of AIIMS dated 9.9.11; Face Sheet of AIIMS dated 9.9.11; Invoice No.R1-01237 dated 9.9.11 of Reditux injection for Rs.64,000/-; Admission Slip of AIIMS dated 23.9.11; Invoice No.R1-01343 dated 22.9.11 of Reditux Injection for Rs.64,000/-; discharge slip of AIIMS; legal notice dated 28.3.12; Certificate by Professor of AIIMS dated 3.1.12; postal receipts showing dispatch of legal notice to OPs and AD duly received by OPs i.e. exhibited as Ex.CW-1/1 to Ex.CW1/11. 
5. The Ld. District Forum after considering the pleadings and evidence on record held the appellant/OP guilty of deficiency in service and directed it to reimburse Rs.1,28,120/- along with interest @ 9% from the date of rejection of claim till payment.  Ld. District Forum also awarded Rs.30,000/- towards compensation for harassment and mental agony and Rs.10,000/-towards litigation expenses.
6. Aggrieved with the aforesaid order, present appeal is filed.
7. Ld. Counsel for the appellant has contended that the treatment taken by respondent/complainant was not requiring hospitalization as an indoor patient.  It is contended that as per condition 2.3 of the policy, expenses on hospitalization for minimum period of 24 hours are admissible.  It is contended that in the present case, respondent/complainant had only taken Rituximab Infusion which usually takes 4 to 6 hours and the treatment taken is an OPD procedure only, as such the impugned order is liable to be set aside.  It is contended that as per terms and conditions of the insurance policy, the claim of respondent/complainant was not payable, as such repudiation was legal and justified.
8. On the other hand, Ld. Counsel for the respondent/complainant has argued to the contrary and has submitted that the Ld. District Forum has passed the order after considering the material on record.  There is no illegality in the same.
9. We have heard the Counsel for the parties and perused the material on record. 
10. The repudiation letter of dated 19.12.11 of appellant/OP is reproduced as under:

“With reference to the above, we have gone through the claim file and reviewed the matter very well.  In the above case you have taken the treatment for Rheumatoid Arthritis, which very well can be taken in OPD i.e. the admission was not required for this purpose.  As such any treatment, which is not required admission in hospital is not covered by the policy terms and conditions.”

 

11.  The relevant clause of the Medi-claim Policy, on the basis of which claim is repudiated, is  reproduced as under:

“2.3       Expenses on Hospitalisation for minimum period of 24 hours are admissible.  However, this time limit is not applied to specific treatments such as –

 

	Haemo dialysis	femoral hernia
Coronary angiography		Parenteral Chemothrepay
Coronary angioplasty	Incision and drainage of abcess
Dental Surgery
Eye Surgery
dislocation excluding hairline fracture		Liver aspiration

 

or any other surgeries/procedures agreed by the TPA/MTNL which require less than 24 hrs hospitalization.

 

This condition will also not apply in case of stay in hospital of less than 24 hours provided –

 

1. The treatment is such that it necessitates hospitalization and the procedure involves specialised infrastructural facilities available in hospitals.
2. Due to technological advances hospitalisation is required for less than 24 hours only.

 

Note: Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours."

 

12. There are documents on record i.e. Admission Slip of AIIMS dated 9.9.11 showing admission of respondent/complainant in AIIMS on the said date.  There is also admission slip of AIIMS dated 23.9.11 which shows the admission of respondent/complainant in AIIMS on aforesaid date.  There are discharge slips on record showing her discharge from AIIMS on 10.9.11 and 24.9.11 respectively.  There is also certificate issued by Dr. Uma Kumar, Additional Professor of Medicine, AIIMS dated 3.1.12 which supports the case of respondent/complainant.  The same is reproduced as under:

“It is to certify that Mrs. Raj Bery w/o Chattur Bhuj Bery, 50 years old female patient registered in Medicine OPD (Registration No.43488/10) is suffering from Refractory Seropositive Rheumatoid Arthritis which is a chronic disease.  She was admitted in D2 ward on 9/9/2011 and 23/9/11 for Rituximab infusion since it cannot be given on outpatient basis.”

 

13. There is no challenge on aforesaid certificate.  No material is placed on record to show that the respondent/complainant is trying to convert OPD treatment to indoor patient, as is alleged.    The respondent/complainant is chronic patient of Refractory Seropositive Rheumatoid Arthritis as is evident from the aforesaid certificate of Dr. Uma Kumar. In the discharge slip dated 10.9.11, there is a certificate given by the Senior Resident, MOPD Unit-III, AIIMS, New Delhi wherein it is stated that the patient was observed for 24 hrs.  In these circumstances, it cannot be said that the OPD treatment is converted to indoor treatment, as is alleged.  Some injections have reactions on the patients.  The documents on record show that indoor treatment was given to respondent/complainant and she remained admitted for 24 hrs. on both the occasions in AIIMS.
14. Ld. Counsel for the appellant/OP has pointed out a cutting on date of discharge in the discharge slip dated 10.9.11 and has contended that aforesaid document is manipulated one. The cutting pointed out is meaningless as the date of discharge after cutting has been rewritten and is countersigned also.  Ld. Counsel for appellant/OP has also pointed out overwriting in the discharge slip dated 24.9.11 on date of admission i.e. 23.9.11 mentioned on it.  However, the overwriting pointed out is meaningless as there is a separate admission slip of 23.9.11 on record showing admission on said date.   Considering the overall material on record, cuttings/overwritings pointed out are meaningless. 
15. In view of above discussion, the contentions raised on behalf of appellant/OP have no force.  The impugned order is passed after considering material on record.  It has been rightly held by Ld. District Forum that repudiation is arbitrary and unjustified.  There is no illegality or perversity in the same which calls for interference of this Commission.  The impugned order is upheld.
16. Appeal stands dismissed.
17. A copy of this order as per the statutory requirement be forwarded to the parties free of charge and also to the concerned District Forum.  The record of District Forum be sent forthwith. Thereafter the file be consigned to Record Room.

 

(Justice Veena Birbal)

President