Haryana

StateCommission

A/1040/2015

BAJAJ ALLIANZ GENERAL INSURANCE - Complainant(s)

Versus

SATISH AGARWAL - Opp.Party(s)

P. M.GOYAL

26 May 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      1040 of 2015

Date of Institution:       07.12.2015

Date of Decision :         26.05.2016

 

1.     Bajaj Allianz General Insurance Company Limited, GE Plaza, Airport Road, Yerwada, Pune-411006 through Shri Navjeet Singh, Assistant Manager (Legal), Bajaj Allianz General Insurance Company Limited, SCO No.14, 4^th Floor, Urban Estate, Sector-5, Panchkula.

2.     Bajaj Allianz General Insurance Company Limited, 6^th Floor, 93 Ashoka Bhawan, Nehru Place, New Delhi-110019.

3.     Bajaj Allianz General Insurance Company Limited, SCO 102-103, Dwarka Complex, Sector-16, Faridabad.  

                                      Appellants/Opposite Parties

Versus

 

Satish Agarwal s/o Sh. R.P. Agarwal, Resident of House No.1469, Sector-14, Faridabad.

                                      Respondent/Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member                                                                                                                                         

Present:               Shri Gaurav Sharma, Advocate for appellants.

                             Shri Raj K. Narang, Advocate for respondent.

 

                                                   O R D E R

NAWAB SINGH J.(ORAL)

 

Bajaj Allianz General Insurance Company Limited (for short the ‘the Insurance Company’)-Opposite Parties, are in appeal against the order dated September 28^th, 2015 passed by District Consumer Disputes Redressal Forum, Faridabad (for short ‘the District Forum’), whereby it directed the Insurance Company to pay Rs.2.00 lacs alongwith interest at the rate of 9% per annum from the date of filing of the complaint, that is, July 1^st, 2013, till its realization; Rs.5500/- compensation on account of mental agony, harassment and Rs.2200/- litigation expenses to Satish Agarwal-complainant/respondent.

2.                Satish Agarwal-complainant/respondent (hereinafter referred to as ‘the insured’), purchased Health Guard Policy (Exhibit O-2) from the Insurance Company, in the year 2005 which was got renewed till October 21^st, 2013. The policy was valid from October 22^nd, 2011 to October 21^st, 2012 whereby the complainant was insured for Rs.2.00 lacs and his wife Veena Aggarwal for Rs.1.00 lac.  

3.                In the month of June, 2011, the complainant suffered fracture in Left Hip Joint and was treated in QRG Central Hospital, Faridabad and Sir Ganga Ram Hospital, New Delhi. His hip joint was replaced. The cause of the fracture later on was diagnosed as Multiple Myeloma (Blood Cancer).  He submitted bills for the treatment taken by him from QRG Central Hospital, Faridabad and Sir Ganga Ram Hospital, to the Insurance Company. The Insurance Company paid the amount.

4.                On account of Multiple Myeloma, the complainant underwent Autologous Bone Marrow Transplant in Dr. B.L. Kapur Memorial Hospital, New Delhi.  He incurred expenses of Rs.5.00 lacs on his treatment whereas the sum insured was Rs.2.00 lacs. He filed claim with the Insurance Company but it did not pay the amount on the ground that the disease for which the complainant was treated, was not covered under the policy. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed before the District Consumer Forum.

5.                Learned counsel for the appellant/Insurance Company has urged that Post-Autologous (ASCT) Stem Cell Transplant Therapy in Multiple Myeloma was not covered under the Insurance Policy. So, the complainant is not entitled to the amount of Rs.2.00 lacs, that is, the sum insured. In support, reliance has been placed upon Clause-C sub clause-11 of the policy (Exhibit O-2), which reads as under:-

                   “C.     What we will not pay

                             xxxx

11)    Convalescence, general debility, rest cure, congenital external diseases or defects or anomalies, genetic disorders, stem cell implantation or surgery, or growth hormone therapy.”

6.      Satish Agarwal was suffering from Multiple Myeloma (Blood Cancer) and was admitted in Dr. B.L. Kapur Memorial Hospital, New Delhi, for Hematology-Oncology & Autologous Bone Marrow Transplant on December 27^th, 2011 and was discharged on January 20^th, 2012 vide Medical Discharge Summary (Annexure-A).  

7.                The question arises as to whether the treatment of the complainant falls under Clause-C sub clause-11 reproduced above, or not?

8.                What is Stem Cell Transplant (Bone Marrow Transplant)? 9.             A stem cell transplant is a treatment for some types of cancer. For example, one might have it if he has leukemia, multiple myeloma, or some types of lymphoma. Doctors also treat some blood diseases with stem cell transplants. In the past, patients who needed a stem cell transplant received a “bone marrow transplant” because the stem cells were collected from the bone marrow. Today, stem cells are usually collected from the blood, instead of the bone marrow. For this reason, they are now more commonly called stem cell transplants.

10.              The treatment taken by the complainant, mentioned above, is not covered under Clause-C sub clause-11 of the Insurance Policy because in the said clause it has been stated that in case of convalescence, general debility, rest cure, congenital external diseases or defects or anomalies, genetic disorders, stem cell implantation or surgery or growth hormone therapy, the Insurance Company shall not pay the expenses incurred by the insured.

11.              In this view of the matter it is held that the complainant had not undergone stem cell implantation or surgery, rather he had undergone Autologous Transplant, which may be called High-dose chemotherapy with autologous stem cell rescue. In an Autologous Transplant, a patient gets his/her own stem cells after doctors treat the cancer. First, the doctor collects stem cells from the blood of the patient and freezes them and then powerful chemotherapy and rarely, radiation therapy is conducted and thereafter the frozen stem cells are put back in the blood of the patient through a tube placed in a vein (IV). No surgical procedure was involved. Thus, it was not a case of Stem Cells Implantation or surgery, so the Insurance Company is liable to pay the benefits of insurance to the complainant.

12.              For the reasons recorded supra, the appeal is devoid of merits. It is dismissed.

13.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 26.05.2016

Diwan Singh Chauhan Member

B.M. Bedi Judicial Member

Nawab Singh President

CL