Haryana

StateCommission

A/803/2016

APOLLO MUNICH HEALTH INSURANCE CO. - Complainant(s)

Versus

SUCHI GUPTA - Opp.Party(s)

S.C.THATAI

30 Aug 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

                                               

First Appeal No.   :       803 of 2016

                                                Date of Institution :      07.09.2016

                                                Date of Decision          :        30.08.2017

 

1.      Apollo Munich Health Insurance Company Limited, Plot No.404-405, Udyog Vihar, Phase III, Gurgaon, New Address:- iLABS Centre, 2^nd & 3^rd Floor, Plot No.404-405, Udyog Vihar, Phase III, Gurgaon through Ms. Deepti Rustagi, Vice President-Legal & Compliance.

2.      Apollo Munich Health Insurance Company Limited, 105A, 106A, 107A, 108A, 136, 1^st Floor, Cears Plaza, Residency Road, Opposite Bangalore Club, Bengaluru, Karnataka-560025 through its Assistant Manager.

                              Appellants-Opposite Parties

Versus

 

Shuchi Gupta wife of Sh. Sachin Tayal, resident of DW-134, Sector 50, Nirvana Country, Gurgaon-122018.

Respondent-Complainant

 

 

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

                   Mr. Balbir Singh, Judicial Member.

                   Ms. Urvashi Agnihotri, Member.

 

                                        

Argued by: Sh. S.C. Thatai, Advocate for the appellants.

                   Mrs. Shuchi Gupta-complainant in person.

           

 

                                                   O R D E R

 

NAWAB SINGH J.(ORAL)

 

          Apollo Munich Health Insurance Company Limited and another-opposite parties (for short, ‘Insurance Company’) are in appeal against the order dated July 28^th, 2016 passed by District Consumer Disputes Redressal Forum, Gurgaon whereby complaint filed by Shuchi Gupta-complainant was allowed. The Insurance Company was directed to pay Rs.1,99,221/- alongwith interest at the rate of 9% per annum from the date of filing the complaint, that is, January 22^nd, 2016 till realization and Rs.20,000/- as compensation, to the complainant on account of medical expenses of her husband Sachin Tayal.

2.      The complainant was an employee of IBM India Private Limited. IBM India Private Limited purchased the insurance policy for its employee, spouse and children.  Sachin Tayal, husband of the complainant was a patient of Multiple Sclerosis (MS).  Multiple Sclerosis (MS) is a disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged.  This damage disrupts the ability of parts of the nervous system to communicate, resulting in a range of signs and symptoms, including physical mental and sometimes psychiatric problems.  The bill of expenses incurred on his treatment taken from Fortis Memorial Research Institute, Gurgaon for the period 2012 to 2014, which included the medicines and hospitalization, was paid by the Insurance Company.  He again got the treatment for the same problem in the year 2015 vide bills (Annexures A-10 & A-11) placed on record by the Insurance Company.  The expenses included the medicines and the hospitalization incurred on the treatment was Rs.1,99,221/-, which the District has awarded. 

3.      In appeal before this Commission, learned counsel for the Insurance Company has urged that the coverage of ailment/hospitalization was not covered as per Memorandum for Corporate Buffer and Forming part of the Policy No.120100/12001/2014/A001457-04.  Clause 7 is reproduced as under:-

“7.     Multiple sclerosis (MS)

                   An attack of MS requiring inpatient treatment would be covered under this definition. Admission for administration of interferon or monoclonal antibodies would not be covered.”

4.      It has been further urged by learned counsel for the Insurance Company that the Insurance Company was not liable for administration of interferon and monoclonal antibodies.

5.      The submission raised by learned counsel for the Insurance Company is not tenable for the reason that the prior to the bill in question, the Insurance Company had made the payment of the expenses incurred by the complainant on his treatment, which included medicines and hospitalization.  Interferons are endowed with multiple regulatory effects on the immune system; killer cell activity, macrophage activity, T and B Cell proliferation and differentiation.  It has been specifically stated in Exhibit C-4 by Dr. Shamsher Dwivedee, Director and HOD, Neurology Department, Fortis Memorial Research Institute, Gurgaon that for administration of injection Tysabri 300 MG, value of which was Rs.79,002/- (Annexure A-8) admission of patient was required.  Thus, it is held that the Insurance Company wrongly repudiated the claim of the complainant.

6.      For the reasons recorded supra, the impugned order passed by the District Forum does not require any interference.  Hence, the appeal is dismissed. 

7.      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 30.08.2017

(Urvashi Agnihotri) Member

(Balbir Singh) Judicial Member

(Nawab Singh) President

UK