Chandigarh

DF-II

CC/618/2017

Vishal Pahariya - Complainant(s)

Versus

Star Health and Allied Insurance Company Limited - Opp.Party(s)

Surjeet Bhadu Adv.

27 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	618 of 2017
Date  of  Institution	:	17.08.2017
Date   of   Decision	:	27.11.2017

 

 

 

 

Vishal Pahariya s/o Sh.Ramesh Jain, R/o H.No.3014, Sector 27-D, Chandigarh.       

             …..Complainant

Versus

1]  M/s Star Health and Allies Insurance Company Limited, through its Branch Incharge and having its Branch Office at SCO 130-131, 4^th Floor, Sector 34-A, Chandigarh 160022

2]  M/s Alliance Insurance Broker Pvt. Ltd. through its Managing Director and having its Office at 715, 7^th Floor, DLF Tower A, Jasola District Center, New Delhi 110025

3]  M/s Jain International Organization, through its Chairman/Presiding Officer and having its Office at Panchsheel Plaza, A Wing Basement, Near Dharam Palace, Hughes Road, Mumbai, Maharashtra 400007

                          ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

                                MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

 

Argued by: Sh.Surjeet Bhadu, Adv. for Complainant

 Sh.Gaurav Bhardwaj, Adv. OP No.1

 OPs NO.2 & 3 exparte.

 

 

PER RAVINDER SINGH, MEMBER

 

 

          The facts in issue are that the complainant, being a Member of Jain International Organization/OP No.3, purchased a Health Insurance Policy – “Shravak Arogyam” from OP No.1 through agent/OP NO.3 by making payment of Rs.29,950/- effective from 31.3.2017 to 30.3.2018 (Ann.C-1 & C-2).  It is averred that as per Clause 21 of the said policy, in case of insured persons suffering from pre-existing disease, the Insurance Company was liable to pay 50% of the cost of the treatment.

         It is stated that in June, 2017 the complainant availed of treatment for Inflammatory Bowel Disease (IBD) at N.M.Virani Wockhardt Hospital at Kalawad Road, Rajkot, Gujarat (Ann.C-4).  It is also stated that the complainant was also treated for Iron Deficiency Anemia, Enthesitis, Myopathy and Recurrent Pouchitis simultaneously, as all these further complications were a direct result of the main disease of IBD.  It is submitted that the said Hospital raised a bill of Rs.10,01,972/- and it was informed to the complainant that OP No.1 had rejected all requested for enhancement of cashless amount and the complainant would have to pay the entire bill with exception Rs.25,000/- exclusive of co-pay which was allowed as per Clause 23 of the policy (Ann.C-7).  It is also submitted that after paying the bill under protest, the complainant strongly raised his grievance with OPs No.1 & 3, but they wriggle out of their liability to pay 50% of the amount of the treatment i.e. Rs.5,00,986/- on frivolous and non-relevant grounds (Ann.C-8). Hence, this complaint has been filed alleging the above act of OPs as deficiency in service and unfair trade practice.

 

2]       The Opposite Party No.1 has filed reply and while admitting the factual matrix of the case, has stated that authorization was given for Rs.25,000/- because as per the policy 50% of the expenses are to be borne by the insured and 50% by the insurer in case of treatment relating to pre-existing disease (PED) and the term used is CO-PAY and clearly mentioned in the terms & conditions of the policy.  It is stated that on perusal of the document submitted, it is observed from the Admission and Physical Assessment Form that the complainant was admitted with complaints of generalized weakness and body ache, muscular weakness, anemia, pain both lower limb and blood diahorrea and diagnosed as known case of IBD 1998.  It is also stated that as per the certificate issued by the treating doctor dated 13.6.2017 the complainant had taken treatment for IBD, severe anemia and hyperproteinemia and was hospitalized for blood transfusion/albumin supplementation and biologics.  It is further stated that the complainant due to post surgery, recurrent ponehitis, has developed anemia and the treatment is mainly for the iron deficiency and anemia, hence Rs.25,000/- was allowed to him vide letter dated 14.6.017.  It is submitted that the claim was rightly rejected by OP No.1.  Pleading no deficiency in service and denying rest of the allegations, the OP No.1 has prayed for dismissal of the complaint.

 

         OPs NO.2 & 3 did not turn up despite service of notice sent through regd. post on 29.8.2017, hence it was proceeded exparte vide order dated 13.10.2017.

 

3]       The complainant has also filed rejoinder reiterating the contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have carefully examined the facts and pleadings along with entire evidence on record.

 

6]       The complainant has Group Health Insurance Policy – “Shravak Arogyam” No.P/900000/01/2017/000007 (Ann.C-2) valid from 31.3.2017 to 30.3.2018 for a sum insured of  Rs.10 lacs.  As per Medical Insurance Scheme details (Ann.C-1), the insured is covered for payment of 50% CO-PAY on all Pre-existing Disease Claims irrespective of age.

 

7]       The complainant fell sick and admitted in Wockhardt Hospital Ltd., Kalawad Road, Rajkot (Gujrat) on 12.6.2017 and discharged on 14.6.2017 after treatment.  As per the Discharge Summary (Ann.C-4), the complainant was diagnosed IBD (Inflammatory Bowel Disease), Iron Deficiency Anemia, Enthesitis, Myopathy, Recurrent Pouchitis. The complainant developed myopathy and was unable to walk without support and also diagnosed Ulcerative Colitis and he was treated by Gastroenterologist at the cost of Rs.10,01,972/- (Ann.C-6).

 

8]       As per the terms & conditions envisaged under the insurance policy, the insurance company/OP No.1 is liable to pay 50% of the medical expenses incurred by the complainant, but he has been paid Rs.25,000/- only and rest of the bill amount has been denied to him. 

 

9]       Dr.Praful M.Kamani, M.D., D.M.B.(Gastro), Consultant Gastroenterologist vide Certificate dated 17.11.2017 (Ann.-9) has certified as under:-

“Mr.Vishal Pahariya was admitted under my care from 12^th June 2017 to 14^th June 2017 for IBD (Inflammatory Bowel Disease).  He had symptoms of Bloody Diarrhoea mucus and weakness, myopathy and anemia resulting from blood loss in stool.  He is on inj. Entyvio (vedotizumab) for Rg. Of IBD.”     

 

10]      It is worth to mention that Ulcerative colitis is a chronic disease, which causes inflammation and ulcers in the inner lining of the large intestine and is one of main forms of chronic inflammatory bowel disease. The inflammation can lead to abdominal discomfort, gastrointestinal bleeding, and diarrhea. Crohn’s disease is a chronic inflammatory condition that causes inflammation or swelling, and irritation of any part of the digestive tract – also called the gastrointestinal (GI) tract. Entyvio is an integrin receptor antagonist. Integrin receptors are proteins expressed on the surface of certain cells, which function as bridges for cell-cell interactions. Entyvio blocks the interaction of a specific integrin receptor (expressed on circulating inflammatory cells) with a specific protein (expressed on cells in the interior wall of blood vessels), and thereby blocks the migration of those circulating inflammatory cells across those blood vessels and into areas of inflammation in the gastrointestinal tract.

        

11]      The claim of the complainant has been rejected merely on ground that the complainant, due to post surgery, recurrent ponehitis, has developed anemia and the treatment is mainly for the iron deficiency and anemia, which is not covered as pre-existing disease as stipulated in the policy regarding payment of 50% of the medical expenses by the insurance company. The observations raised by the Opposite Party No.1 to substantiate its decision of repudiation of claim of the complainant are illogical, untenable and without merit.

 

12]      As is explicit from the details in the Discharge Summary (An.C-4), the complainant had:-

 

“K/C/O IBD-1998, ULCERATIVE COLITIS FLAIR UP IN 2004, PROCTOCOLECTOMY WITH IPPA IN 2004, POST SURGERY RECURRENT POUCHITIS & IRON DEFICIENCY ANAEMIA REQUIRING PARRENTAL IRON THERAPY, DEVELOPED EXTRAINTESTINAL MANIFESTATION IN 2014. IN FORM OF ENTHESITIS RECEIVED 14 DOSES OF ADALIMUMAB IN 2015 WITH NO IMPROVEMENT. RECEIVED 12 DOSES OF INFLIXIMAB 2015 TO 2017 WITH NO IMPROVEMENT AND WORSENING OF ENTHESITIS AND ANAEMIA SINCE LAST 6 MONTH. PATIENT HAS DEVELOPED MYOPATHY AND UNABLE TO WALK WITHOUT SUPPORT.

AT PRESENT COMPLAIN OF GENERALISED WEAKNESS AND BODYACHE

-MUSCULAR WEKNESS

-ANAEMIA

-OEDEMA BOTH LOWER LIMB

-BLOODY DIARRHOEA WITH MUCUS”

 

13]      The disease for which the complainant was treated in Wockhardt Hospital, Rajkot on 12.6.2017 to 14.6.2017 is ultimate outcome of his pre-existing ailment since 1998 and is not a fresh ailment for which he was admitted in the said Hospital.

 

14]      The Opposite Party NO.1 has not considered the claim of the complainant in right perspective and rejected the claim whimsically using colourable exercise of powers. The Opposite Party No.1 suffers from deficiency in service on its part.

 

15]      Keeping in view the above facts, as discussed in the preceding paragraphs, the complaint is allowed with directions to OP NO.1/M/s Star Health and Allied Insurance Company to pay Rs.4,75,986/- (Rs.5,00,986 minus Rs.25,000/-) to the complainant being the 50% amount of the medical expenses incurred/paid by the complainant, within a period of 30 days from the date of receipt of certified copy of this order.

         Taking into consideration the peculiar facts of the case, this Forum do not deem it proper to award any compensation or interest etc. to the complainant since several issues i.e. visit of complainant from Chandigarh to Rajkot (Gujrat) for treatment in Private Hospital wherein an unprecedented high bill of Rs.10,01,972/- raised for treatment of complainant during his admission in Hospital from 2.6.2017 to 14.6.2017 remain unsolved.  

 

16]      However, the complaint qua OPs NO.2 & 3 stands dismissed.

         Certified copy of this order be forwarded to the parties, free of charge. After compliance, file be consigned to record room.

Announced

27^th November, 2017                                                    

                                                                                      SD/- 

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER