Date of Filing 27.11.2023
Date of Disposal: 29.02.2024
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, MA. ML, Ph.D (Law), …….PRESIDENT
THIRU.P.VINODH KUMAR, B.Sc., BL., ……MEMBER-I
THIRU.P.MURUGAN, M.Com, ICWA(Inter), BL., ……MEMBER-II
CC.No.118/2023
THIS THURSDAY, THE 29th DAY OF FEBRUARY 2024
Mr.P.Jagadeeswaran,
No.33, First Floor, Elango Street,
Chelliamman Nagar, Athipet,
Ambattur, Chennai 600 058. ......Complainant.
//Vs//
1.The Branch Head,
National Insurance Company Limited,
Chennai Division – V, First Floor, AG 3/1,
Shanti Colony, Anna Nagar, Chennai 600 040.
2.The Officer in Charge – Claims,
MD India Health Insurance TPA Private Limited,
No.117, Ground Floor, Delta Wing,
Raheja Towers, Units -005.
Anna Salai, Chennai 600 002. ….opposite parties.
Counsel for the complainant : Party in Person.
Counsel for the opposite parties : M/s.T.V.Suresh, Advocate.
This complaint coming before us on various dates and finally on 07.02.2024 in the presence of complainant who appeared as Party in Person and M/s.T.V.Suresh, counsel for the opposite parties and upon perusing the documents and evidences of both sides this Commission delivered the following:
ORDER
PRONOUNCED BY Tmt.Dr.S.M. LATHA MAHESWARI, PRESIDENT
1. This complaint has been filed by the complainant U/S 35 of the Consumer Protection Act, 2019 alleging deficiency in service against the opposite parties in repudiating the medical insurance claim of the complainant along with a prayer to direct the opposite parties to pay the balance amount of Rs.2,04,995/- with interest provided under the policy and to pay a sum of Rs.20,49,950/- towards compensation and to pay a sum of Rs.15,000/- towards litigation expenses for every visit to the court.
Summary of facts culminating into complaint:-
2. Complainant an insured person under the policy was holding mediclaim policies since 19th December 2007, without any break for the last 16 years for him and his family members with the 1st opposite party on payment of premium. It was submitted that he had not made any claim in the last 15 policies and the first claim was in the 16th year policy which was valid till 18.12.2023. The complainant/insured underwent medical treatments and all the expenses were paid and reimbursements sought for and were pending with the insurance company. On 31.05.2023 the pathology medical report noted the illness as “Low grade ‘B’ non-hodgkin lymphoma of possible marginal zone type” and the doctor recommended treatment of Chemotherapy by way of injections in 4 cycles. The Hospital Authorities refused for cashless treatment, however the doctor advised for reimbursement of medical expenses with the insurance company for the treatment. Hospitalisation was planned on 05.06.2023, 12.06.2023, 19.06.2023 and 26.06.2023 in day care for administrating the chemotherapy by injection in 4 cycles. The total value of the bills submitted with the 2nd opposite party for reimbursement was for a sum of Rs.3,01,153/- but the 2nd opposite party had reimbursed only a sum of Rs.95,000/- and the balance of Rs.2,04,995/- was pending. Queries were raised by the 2nd opposite party in the form of ADR, from time to time which were replied to the 2nd opposite party. The 2nd opposite party issued a payment of Rs.52,524/- on 12.07.2023 and a sum of Rs.42,476/- on 17.07.2023 in respect of the bills for hospitalization of the complainant. However, the 2nd opposite party has refused to pay the balance claim quoting the reason as “As per the National Senior Citizen Mediclaim Policy Clause 1.2.11 the claim for modern treatment was limited to 25% of the sum insured”. Based on the pathology report dated 31.05.2023 the nature of illness declared by the doctors was Low grade B cell Non-Hodgkn’s Lymphoma which was not disputed or denied by the opposite parties. Treatment administrated to the patient was not oral chemotherapy but chemotherapy by injections in 4 cycles / hospitalization on 4 different dates. Prospectus issued by the opposite parties to the complainant while issuing the policy does not talk about the modern medical treatment clause. The insurance company was restricted to the clauses covered in the prospectus and it was not binding on part of the insured to accept any insertion of clauses by the insurance company on their own without making any specific notice to the insured which amounts to cheating and breach of trust when the contract of insurance was made on the principle of utmost good faith. Thus aggrieved by the act of the opposite parties the present complaint was filed to direct the opposite parties to pay the balance amount of Rs.2,04,995/- with interest provided under the policy and to pay a sum of Rs.20,49,950/- towards compensation and to pay a sum of Rs.15,000/- towards litigation expenses for every visit to the court.
The crux of the defence put forth by the opposite parties:-
3. Insurance company had reimbursed a sum of Rs.52,524/- on 14.07.2023 and Rs.42,476/- on 19.07.2023 towards the medical expenses for the treatment taken by the complainant as per the terms and condition of the National Senior Citizen mediclaim policy. It was denied that the complainant had taken treatment as inpatient. There was no admission in the hospital as an inpatient and the treatment taken was not listed under Day care treatment and hence cashless facility was not allowed. After going through the medical records and the terms and conditions of the National Senior citizen mediclaim policy payment of 25% of sum insured for modern treatment immunotherapy which amounts to Rs.95,000/- was reimbursed as per the terms and conditions and hence there is no deficiency in service as stated by the complainant. The 2nd opposite party which was dealing with third party Administrators under due process of Law has followed due process in dealing with the claim and the insured was duly kept updated. Rituxitmab drug injected to the complainant for the treatment comes under immunotherapy and hence as per the policy conditions claim payment of 25% was made. Thus they sought for the dismissal of the complaint.
4. On the side of complainant proof affidavit was filed and documents marked as Ex.A1 to Ex A24 were submitted. On the side of opposite parties proof affidavit was filed and documents marked as ExB1 & Ex.B2 was submitted.
Points for consideration:-
1) Whether the act of opposite parties in not reimbursing the entire medical expenditure for the treatment undergone by the complainant citing the terms and conditions of the National Senior Citizen Mediclaim Policy under clause 3.1.11 amounts to deficiency in service or not and if so whether the same has been substantiated by the complainant by admissible evidence?
2) To what relief the complainant is entitled?
Point No.1:-
5. Heard the Party in Person/complainant and the counsel appearing for the opposite parties.
6. The crux of the arguments advanced by the party in person/complainant is that he had availed medi claim policy for a long period with the opposite parties, however, had made claim only in the 16th year policy for illness “Low grade ‘B’ non-hodgkin lymphoma of possible marginal zone type” and he underwent treatment of chemotherapy by injections in 4 cycles. But he was denied medical reimbursement by the opposite parties citing the reason that the treatment undergone by the complainant would come under the category of immunotherapy and not chemotherapy. The injection Rituxitmab is said to be given for the complainant was only in pursuance of chemotherapy and hence would not come under immunotherapy as alleged by the opposite parties. It is argued by the complainant that as per Ex.A12 with regard to nature of illness the surgical pathology report reveals that “low grade ‘B’ non-hodgkin lymphoma of possible marginal zone type” for which he took treatment chemotherapy in 4 cycles scheduled on 05.06.2023, 12.06.2023, 19.06.2023 and 26.06.2023. It is further argued by him that Rituxitmab drug administration could not be brought under immunotherapy but only under chemotherapy as it was a drug used for cancer treatment. Further he referred to the prospectus issued by the opposite parties while availing the policy contending that the same does not talk about any modern treatment. Thus arguing elaborately he contended that the repudiation of the medi claim insurance citing clause 3.1.11 of the National Senior Citizen Mediclaim Policy is a clear deficiency in service and prayed for the complaint to be allowed as prayed for.
7. On the other hand the learned counsel appearing for the opposite parties argued vehemently supporting the repudiation of claim by placing reliance on the terms and conditions provided under the policy. It is his contention that as complainant was treated as an outpatient, as per clause 3.1.11 the maximum amount admissible for any one modern treatment shall be 25% of the sum insured and accordingly he was paid Rs.95,000/-. His argument solely was on the point that the treatment undergone by the complainant was only immunotherapy and not Chemotherapy based on the drug administered and his hospitalisation. Thus he sought for the complaint to be dismissed.
8. On appreciation of the entire pleadings and materials it could be found that the factum of the complainant taking treatment for Low grade ‘B’ non-hodgkin lymphoma of possible marginal zone type and the availment of medical insurance policy and the total expenses was not disputed by either of the parties. The only dispute is the quantum of reimbursement amount to be paid by the opposite parties towards the claim of the complainant. It is not in dispute that the complainant had availed the said policy for continuously for 16 long years and also admitted that except this present claim no claim was made in the earlier years by the complainant.
9. As per the medical records Ex.A12 the Department of Oncology had clearly stated that the patient/complainant had received Chemotherapy in four schedules as follows;
Patient received Chemotherapy in the following Schedule on 05.06.2023.
Inj.Avil lamp IV stat.
Inj.Hydrocortizone 100 mg IV push.
Tab.Paracetamol 1000mg P.O.stat.
½ an hour later.
Inj. Rituximab 600mg in 500ml NS IV over 4 hours.
After administration of medications, patient was discharged in stable health condition.
Follow up prescription given separately.
Patient received Chemotherapy in the following Schedule on 12.06.2023.
Inj.Avil lamp IV stat.
Inj.Hydrocortizone 100 mg IV push.
Tab.Paracetamol 1000mg P.O.stat.
½ an hour later.
Inj. Rituximab 600mg in 500ml NS IV over 4 hours.
After administration of medications, patient was discharged in stable health condition.
Follow up prescription given separately.
Patient received Chemotherapy in the following Schedule on 19.06.2023.
Inj.Avil lamp IV stat.
Inj.Hydrocortizone 100 mg IV push.
Tab.Paracetamol 1000mg P.O.stat.
½ an hour later.
Inj. Rituximab 600mg in 500ml NS IV over 4 hours.
After administration of medications, patient was discharged in stable health condition.
Follow up prescription given separately.
Patient received Chemotherapy in the following Schedule on 26.06.2023.
Inj.Avil lamp IV stat.
Inj.Hydrocortizone 100 mg IV push.
Tab.Paracetamol 1000mg P.O.stat.
½ an hour later.
Inj. Rituximab 600mg in 500ml NS IV over 4 hours.
After administration of medications, patient was discharged in stable health condition.
Follow up prescription given separately.
Therefore, as per the medical records it is clearly established that the complainant not only was administrated injection Rituximab but also was administrated some other medications in course of the Chemotherapy treatment. Thus, the opposite parties contending that administring Rituximab injection would only amounts to immunotherapy and not chemotherapy, could not be acceptable in the facts and circumstances.
10. Further the complainant availing treatment for 4 continuous schedules would clearly comes under Day care treatment as day care treatment is a procedure where a patient is discharged from the hospital within 24 hours of admission and for treatments which require very little hospitalization. In the present case the complainant was taking chemotherapy which very well comes under a day care procedure which is covered under the National Senior Citizens medi claim policy (for nearly 140 days). Only claim for minor injuries and common illness and regular check up etc., fall under the category of outpatient treatment and not under the day care procedure as per the literature found.
Also this commission came across the IRDA Guidelines on Standardization of Exclusion in Health Insurance Contracts. In the said guidelines we found the following clauses which are to be followed by the Health Insurance Sectors while dealing with the medi claim policies.
“Health Policies:-
Under Chapter II
Exclusions not allowed in Health Insurance Policies:
1) On examining the extant wordings in the health insurance policy contracts and the prevailing exclusions, it is directed that the following exclusions shall not be allowed in health insurance (Other than PA & Travel) Policies. No health Insurance Policy shall incorporate the following exclusions in the terms and conditions of the policy contract.
a. Diseases contracted after taking the health insurance policy, except for the condition excluded for which standard wordings are prescribed in Chapter III.
Therefore, when the complainant ailment “Low grade ‘B’ non-hodgkin lymphoma of possible marginal zone type” was contracted only after the policy is taken, the same could not be excluded by citing any exclusion clauses.
Further in Chapter V
Modern Treatment Methods and Advancement in Technologies:-
1)To ensure that the policy holders are not denied availability of health insurance coverage to Modern Treatment Methods Insurers shall ensure that the following treatment procedures shall not be excluded in the health insurance policy contracts. These Procedures shall be covered (wherever medically indicated) either as in-patient or as part of domiciliary hospitalization or as day care treatment in a hospital.
A. Uterine Artery Embolization and HIFU,
B. Balloon Sinuplasty.
c. Deep Brain stimulation.
D. Oral chemotherapy.
E. Immunotherapy – Monoclonal Antibody to be given as injection.
Thus, under chapter V, even as per the contention of opposite parties under Modern Treatment, immunotherapy could not be brought under the exclusion clause.
3. After completion of eight continuous years under the policy no look back to be applied. This period of eight years is called as moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of 8 continuous years would be applicable from the date of enhancement of sums insured only on the enhanced limits. After the expiry of moratorium period no health insurance shall be contestable except for proven fraud and permanent exclusions specified in the policy contract.
6. Insurance should not deny coverage for claims of Oral Chemo therapy, where Chemo therapy is allowed and Peritoneal Dialysis, where dialysis is allowed subject to product design”.
11. Further in the recent times it has been held by various forums and Commissions that for claiming medi claim insurance hospitalization for more than 24 hours is not a pre requisite. The District Consumer Disputes Redressal Commission, Ferozepur in Darshan Kumar Vs New India Assurance Company Limited, dated 18.08.2023 in a similar circumstances had considered the judgment rendered by the Punjab & Haryana High court in New India Assurance Company Limited Vs. Smt.Usha Yadav & Others reported in 2008 (30 RCR (Civil) Page 111 cited by the complainant holding as under;
“It seems that the insurance companies are only interested in earning the premiums and finds ways and means to decline claims. All condition which generally are hidden need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.”
Similar view has been taken in New India Assurance Co. Ltd. Versus Sunil
Kumar Saini decided on 16.07.2015 by the Hon’ble State Consumer Disputes Redressal Commission, Delhi.
12. Thus this commission found that the opposite parties citing clause 3.1.11 and paying only a part of the medi claim made by the complainant amounts to clear deficiency in service. When the policy is taken particularly for the benefit of senior citizens, citing one or other reasons to reject the claim is not proper on the part of opposite parties. The conduct of the complainant not making any claim for the previous year policy also has to be taken into consideration. Thus we answer the point accordingly in favour of the complainant and as against the opposite parties.
Point No.2:-
13. As we have held above that the complainant is entitled for the entire medi claim we direct the opposite parties to pay the balance amount of Rs.2,04,995/-. Further making the complainant to approach this Commission for the mental agony and hardship suffered by him we award a compensation of Rs.50,000/- to be paid by the opposite parties the complainant as well as we also award Rs.10,000/- towards litigation expenses to the complainant.
In the result, the complaint is partly allowed against the opposite parties 1 & 2 directing them jointly and severally
a) To pay a sum of Rs.2,04,995/- (Rupees two lakhs four thousand nine hundred and ninety five only) to the complainant within six weeks from the date of receipt of copy of this order;
b) To pay a sum of Rs.50,000/-(Rupees fifty thousand only) towards compensation for the mental agony and hardship caused to the complainant;
c) To pay a sum of Rs.10,000/- (Rupees ten thousand only) towards litigation expenses to the complainant;
d) Amount in clause (a) if not paid within six weeks from the date of receipt of copy of this order, interest at the rate of 6% will be levied on the said amount from the date of complaint till realization.
Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this 29th day of February 2024.
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MEMBER-II MEMBER-I PRESIDENT
List of document filed by the complainant:-
Ex.A1 | List of policies. | Xerox |
Ex.A2 | Copy of current policy valid upto 18.12.2023. | Xerox |
Ex.A3 | Copy of National Insurance Company Limited Mediclaim policy Prospectus. | Xerox |
Ex.A4 | Copy of National Insurance Company Limited Mediclaim policy document. | Xerox |
Ex.A5 | Status of medical bills presented for re-imbursement and dues as on date. | Xerox |
Ex.A6 | Email sent by the complainant to the 2nd opposite party customer service in regard to excess deduction of Rs.10,411/-. | Xerox |
Ex.A7 | Copy of Mail dated 20.07.2023 in regard to excess deduction in second bill and reason for repudiation in mail and claim payment settlement dated nil paid on 17.07.2023. | Xerox |
Ex.A8 | Copy of mail dated 13.07.2023 in regard to regularization of records. | Xerox |
Ex.A9 | Copy of SMS on 26.07.2023 with regard to claim of another person in complainant’s policy number. | Xerox |
Ex.A10 | Copy of show cause notice dated 05.10.2023. | Xerox |
Ex.A11 | Copy of second show cause notice dated 09.11.2023. | Xerox |
Ex.A12 | Key medical record – pathology report and hospital discharge summary. | Xerox |
Ex.A13 | Acknowledgement issued by the 2nd opposite party for receiving the bills and medical records. | Xerox |
Ex.A14 | Copy of mail from the 1st opposite party to the complainant. | Xerox |
Ex.A15 | Copy of claim intimation by mail dated 03.06.2023. | Xerox |
Ex.A16 | Copies of policies valid from 19.12.2007 to 18.12.2023. | Xerox |
Ex.A17 | Medical investigation report of TPA Doctor Balu Gunwantrao Tonpe. | Xerox |
Ex.A18 | Screen picture of medical bills status of the petitioner dated 26.01.2024. | Xerox |
Ex.A19 | Copy of letter dated 13.07.2023 from the complainant to the 2nd opposite party to correct the records of the complainant documents in respect of treatment dated 19.06 and 26.06. | Xerox |
Ex.A20 | Copy of letter dated 13.07.2023 from the complainant to the 2nd opposite party to correct the records of the complainant documents in respect of treatment dated 19.06 and 26.06. | Xerox |
Ex.A21 | Copy of mail dated 08.11.2023 from the 2nd opposite party in regard to repudiation of claim. | Xerox |
Ex.A22 | Copy of mail dated 5th & 6th Feb 2024 between the parties as implied acceptance for payment of compensation for mental agony. | Xerox |
Ex.A23 | Copy of 3rd show cause notice dated 15.12.2023. | Xerox |
Ex.A24 | Copies of mails and final confirmation on 25.02.2024. | Xerox |
List of documents filed by the opposite parties.
Ex.B1 | Policy document of the complainant. | Xerox |
Ex.B2 | Copy of National Insurance Company Limited Policy Document. | Xerox |
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MEMBER-II MEMBER-I PRESIDENT
