District Consumer Disputes Redressal Commission, Hooghly
PETITIONER
VS.
OPPOSITE PARTY
Complaint Case No.CC/66/2022
(Date of Filing:-13.04.2022)
- Sri Avik Mondal, residing at
4/D Kumarpara Road, P.O. and P.S. Chinsurah,
Dist. Hooghly, Pin:- 712101.…………..Complainant
- The Branch Manager,
Star Health & Allied Insurance Co. Ltd.
153/F/3, N.S. Avenue, P.O. Serampore,
District:- Hooghly, Pin:- 712201……….Opposite Party
Before:-
Mr. Debasish Bandyopadhyay, President
Mr. Debasis Bhattacharya, Member
Mrs. Babita Choudhury, Member
PRESENT:
Dtd.12.08.2024
Final Order/Judgment
Debasis Bhattacharya:- PRESIDING MEMBER
The instant case filed under section 35 of the Consumer Protection Act 2019 arises out of the grievances of the complainant with regard to partial repudiation of claim filed against the policy number P/191142/01/2022/00371, dtd.03.05.2021 of the OP Insurance Company, held by him during the material period.
The brief facts of the case is that the policy under the title Family Health Optima Insurance Plan as mentioned above covered two persons i.e. the Complainant himself and his wife. The policy reportedly was a floater one with sum insured of Rs.5,00,000/- plus bonus amount of Rs.1,75,000/- and ‘recharge benefit’ of Rs.15,00,000/-. In addition to that the Complainant reportedly had ‘Top-up limit of Rs.25,00,000/-
The Complainant claims that he has been paying premiums in respect of the said policy on regular basis.
However, during the continuance of the policy, on 13.05.2021, the complainant insured had to be admitted in Apollo Gleneagles Hospital with high fever and headache/body ache.
On 14.05.2021, the particular medical diagnosis is claimed to have been made as ‘G. B. Syndrome.’
However during his stay in hospital he had difficulties in body movement, numbness over fingertips and difficulties with liver function. The final diagnosis was ‘Guillain Barre Syndrome and drug induced liver injury’.
After thorough treatment, the patient was discharged on 29.05.2021 and at the time of discharge the final bill amounted to Rs.6,41,183/-. But the OP insurance Company sanctioned to the tune of Rs.2,50,000/- only under claim no. CIR/2022/1911142/2610544 dtd.29.05.2021.
The Complainant somehow managed to pay the hospital bill in full and made an appeal to the ‘appellate authority’ of the OP insurance Company for reconsideration of the claim. A legal notice also was dispatched to the OP on 30.08.2021 in this regard and in the reply dtd.20.09.2021 the Complainant was asked to submit the claim as per terms and conditions of the policy along with some documents. The Complainant acted accordingly but the OP in their e-mail dtd.26.02.2022 informed that their medical panel on re-examination of the claim was of the opinion that the treatment undergone by the Complainant was ‘immunotherapy’, as monoclonal antibody was injected and the sub-limit for the same was Rs.2,50,000/-. Thus the OP Insurance Company claimed that the claim was properly settled as per policy condition.
On the other hand, the Complainant agitates over the issue that neither the medical certificate issued by the treating doctor was considered nor it was considered that the Complainant was treated with a particular injection which was a standard treatment for the disease. The treating doctor reportedly certified that ‘it was not biologic meditation/ not a monoclonal antibody’.
Considering the stance taken by the OP Insurance Company in the matter of the settlement of the claim as deficiency of service as well as illegal trade practice, the complainant filed the petition seeking direction upon the opposite parties to reimburse the medical expenses in full i.e. to pay the rest of the claim of Rs.3,91,183/-, to pay Rs.3,00,000/- as compensation for causing sufferings and mental agony and to pass any other order or orders as this Commission may deem fit and proper for the ends of justice.
Evidence on affidavit filed by the Complainant is to a considerable extent is the replica of the Complaint petition.
However, in the evidence on affidavit the Complainant in most of the cases, terms the statements incorporated in the written version by the OP Insurance Company as incorrect, false, improper, baseless, vague, ambiguous, intentionally misinterpreted etc.
However, the Complainant along with his evidence has submitted copies of policy document, premium receipt, customer information sheet related to the policy, medical documents including discharge summary, final bill, cashless authorization letter, medical certificate issued by the treating doctor, mail received from the grievance cell of the OP Insurance Company and the legal notice.
The opposite party contested the case by filing elaborate rebuttals in their written version, evidence on affidavit and brief notes of argument denying therein most of the allegations leveled against them.
In view of the above discussion and on examination of available records, it transpires that OP in the instant case was a service provider and hence the complainant is a consumer as far as the provisions laid down under Section 2(7)(ii) of the Consumer Protection Act 2019 are concerned.
The Complainant is a resident within the district of Hooghly and OP during the material period had their office within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/- Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
Now, the issues whether there was any deficiency of service on the part of the opposite parties and whether the Complainant is entitled to any relief, will be discussed in the concluding part of the order as the issues are mutually interrelated.
Defense case
Initially in the written version the OP Insurance Company claimed that the instant complaint petition is not maintainable in law in its present form on the ground that the complaint petition is bad in law, devoid of cause of action, bad for mis-joinder and non-joinder of necessary parties, harassive, containing baseless allegation, full of concocted stories etc. However no non-maintainability petition was filed by the OP Insurance Company. Hence this issue does not deserve any discussion as prima-facie on perusal of the complaint petition and the enclosed attachments, it does not appear to be non-maintainable for the reasons as stated by the OP Insurance Company in their written version.
The OP Insurance Company went to the extent of alleging that the annexures attached to the complaint petition were not received by them. However in course of hearing the Complainant side was directed to supply the said annexures to the OP side. It appears that on receipt of the same they filed exhaustive written version and evidence on affidavit.
The OP insurance Company even advanced a ridiculous claim without assigning any specific reason that this Commission is devoid of any jurisdiction to try, entertain and adjudicate the instant case. The Commission does not find any reason to discuss over the issue as the claim is too hollow, funny, absurd, irrelevant and crappy to be discussed upon.
However the OP Insurance company focuses on their claim that the insured was treated with Immunotherapy drugs such as Globucel 5mg which is a drug used to strengthen the body’s natural immune system to lower the risk of infections in persons with weakened immune system. This treatment as claimed by the OP falls under the defined sub-limit of the policy.
The OP further points out that the terms and conditions of the policy were explained to the complainant at the time of proposing the policy and the same was served to the complainant along with the policy schedule and the complainant accepted the policy agreeing and being fully aware of such terms and conditions.
The OP insurance Company claims to have acted within the parameters of the policy conditions and puts stress on the issue that Insurance policy is a contract and terms and conditions thereof are strictly and equally binding upon both the insurer and the insured.
Finally in the written version the OP denies any sort of deficiency of service on their part.
There were exchanges of interrogatories and replies between the Complainant and the OP, the relevant, applicable and noteworthy parts of which will be mentioned in the concluding part of the order.
Decision with reasons
Even after making partial reimbursement of Rs.2,50,000/- the OP Insurance Company raised the issue in their interrogatories that the complaints with which the complainant was admitted in the hospital originated from some pre-existing diseases.
In reply the Complainant retorted that he did not have any symptoms of liver injury at the time of commencement of the policy. So question of disclosure in the proposal form did not arise.
Here the Commission is of the opinion that after making partial reimbursement, raising the issue related to pre-existing disease is simply a desperate attempt to avoid further reimbursement. Had it been a genuine reason for repudiation of the claim, the OP would have declined to grant a single penny reimbursement.
Secondly, human anatomy is thoroughly complex in nature and in many cases the origin of a particular disease may be dormant and may be in hibernation for a substantial period of time. No medical test can conclusively forecast the manifestation of a particular disease in near or distant future.
Thus, in the instant case so far as the physical complaints of the Complainant patient are concerned, possibility of suppression of pre-existing disease with some mala fide intention is ruled out.
So far as the terms and conditions of the policy are concerned, the limit per policy period for the treatment of immunotherapy/monoclonal antibody to be given as injection is Rs.2,50,000/- when the sum insured is Rs.5,00,000/-.
Now, the crux of the case lies on the issue whether the complainant patient underwent immunotherapy and whether the Complainant was deprived of appropriate reimbursement.
The OP insurance Company applied sub-limit of immunotherapy as it is claimed that the Insured was treated with Immunotherapy drugs.
In the interrogatories, the Complainant raised the question that from which medical record the OP formed the opinion that the ‘treatment undergone by the complainant is immunotherapy’. The OP responded by stating that ‘the discharge summary speaks for itself in deciding the claim as per policy terms and conditions’.
Materials on records are perused.
The Doctor, a highly qualified neurologist, who treated the Complainant patient opined that ‘Complainant was having Guillain Barre Syndrome for which he was treated with the injection immunoglobilin IVIG, which was a standard treatment for the disease’. The Doctor further certified that it was not biologic medication/not a monoclonal antibody.
Nowhere in the discharge summary it is mentioned that the Complainant underwent immunotherapy.
On the other hand, it is not clear that on what basis the OP insurance Company formed the opinion that the Complainant patient had to go through immunotherapy. The OP insurance company has not furnished the exhaustive composition of the medical panel and the respective qualifications of the said panel who made this decision.
Here the certificate issued by the treating neurologist plays the key factor. The statement in unequivocal terms that the patient had the standard treatment for the disease decides the fate of the case. The OP has miserably failed to offer any fitting retaliation composed by some medical expert having equivalent qualification and specialization.
In view of the above, the Commission is of the opinion that there was gross deficiency of service on the OP’s part and the Complainant deserves the reimbursement of medical expenses in its totality.
Hence, it is
ORDERED
that the complaint case no.66/2022 be and the same is allowed on contest but in part.
OP Insurance Company is hereby directed to reimburse the differential amount of medical expenses of Rs.3,91,183/- to the Complainant.
Besides, OP Insurance Company will also be liable to pay Rs.50,000/- towards compensation and further Rs.10,000/- towards litigation cost.
OP insurance Company is hereby directed to comply with this order within 45 days from the date of this order failing which they will be liable to pay Rs.20,000/- to the Consumer Legal Aid A/C.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgements/sent by ordinary post for information and necessary action.
The final order will be available in the respective website i.e. www.confonet.nic.in
