The instant case has been initiated under section 12 of the Consumer Protection Act, 1986 claiming an amount of Rs.01,76,287/- + Interest, Rs. 70,000/- towards compensation along with litigation cost of Rs.30,000/- against the Opposite Parties.
The matrix of the case, in brief, is that the complainant purchased/ renewed Individual Health Policy from Opposite Party No.1 on 12.06.2018 for getting financial coverage for the purpose of treatment of Complainant and a Policy vide no. 313592/48/2019/00058 was issued in favour of the Complainant by the Opposite Party No.1 for the period from 12.06.2018 to midnight of 11.06.2019 for total coverage of Rs.01,50,000/- only and the date of inception of the first policy was in the year 2013. In that policy the name of Opposite Party No.2 has been mentioned as TPA who will settle the claim as an agent of Opposite Party No.1 but Opposite Party No.1 took Rs.7,835/- from the Complainant for individual health coverage including personal accident cover. The Opposite Party No.1 never communicated the Complainant about the terms and conditions of the present policy and he only supplied the policy deed to the Complainant after purchasing said policy and communicated that he will cover Personal Accident Cover as well as Domiciliary Hospitalization cover. On 11.02.2019, the Complainant felt trouble with his vision so, he went to Priyamvada Birla Arbind Eye Hospital for treatment and it was diagnosed by them that he has to undergo a treatment through admission in their hospital and they inject accentrix injection under L.A in the left eye of the Complainant. The Complainant then preferred to obtain second opinion from Disha Eye Hospital Pvt. Ltd. and they also suggested the Complainant same mode of treatment in order to cure the problem. Disha Eye Hospital informed the Complainant that there are three phase of this particular treatment. In the first phase, first dose of Intravitreal Accentrix will be applied to Complainant after taking admission to their Hospital and after one month second dose will apply in similar manner and after one month of second dose, third dose will be applied and then after the total treatment package will be completed. This type of operation/surgery is called as Extremely guarded visual prognosis . As per suggestion of the Opposite Party No.1, the Complainant got admitted at Disha Eye Hospital Pvt. Ltd. on 09.03.2019 at 9.00 A.M. and the Complainant was brought to Operation Theater and local anesthesia was given and ultimately the Intravitreal Accentrix injection was administered in the left eye of the Complainant as in patient of said hospital and the Complainant was discharged from the Hospital at 12.00 Noon on the same day. The Complainant paid all the charges for the said operation to the said Hospital from his own pocket. Thereafter, observing all formalities, the Complainant submitted his claim to the Opposite Party No.1 through claim Form along with all relevant cash memos, bills etc. On 23.03.2019, the Opposite Party No.2 sent one Draft Rejection Letter in favour of the Complainant stating that the claim of the Complainant has been rejected due to two clauses of their policy terms and the Complainant is not entitled to get any claim for his eye treatment. According to the Opposite Party No.2, the treatment of the Complainant falls under day care treatment though it has been done in the operation theater after applying local anesthesia. This medical treatment of the Complainant requires hospitalization of more than 24 hours and as because the Complainant was discharged before 24 hours, his claim fortunately falls under exclusion clause of Opposite Parties.
The Complainant went under two further surgeries in similar manner in Disha Hospital Pvt. Ltd. The second surgery/operation was done on 13.04.2019 in the same institution and the third surgery/ Operation was done on 01.06.2019 in the same institution. Thereafter, all relevant cash memos, bills etc. of those two surgeries/operations of the Complainant are in the custody of the Complainant as the Opposite Party No.1 did not accept the claim Forms of two surgeries on the ground that the first surgery claim has already been repudiated by the Opposite Party No.2 due to the ground of hospitalization period. In spite of correspondence from the Complainant, surprisingly till date both the Opposite Parties are deliberately avoiding the Complainant without taking any necessary steps for making payment of said claim amount and they also avoiding the Complainant from accepting the other bills, cash memos of second and third operations and causing unnecessary delay, financial loss, mental pain and agony with oblique motive. Having no alternative, the Complainant files this case with a prayer as mentioned in the plaint.
Notice was issued upon the Opposite Parties No. 1 and 2 and both of them entered appearance and contested the case by filing single written version wherein the material averments made in the complaint are denied and it has been contended inter-alia that the instant case is not maintainable.
It has been contended by the Opposite Parties that the Complainant insured with them with Mediclaim Insurance Policy (Individual) vide Policy No.313592/48/2019/00058, Policy Period 12.06.2018 to 11.06.2019, Sum Insured Rs.1,50,000/- and the Opposite Party No.1 duly supplied to the insurer Policy Deed and Policy Documents i.e. terms and conditions of the said Mediclaim Policy. The Complainant is covered under Mediclaim i.e. Mediclaim Insurance Policy and as per terms and conditions of the above noted Mediclaim Policy, the Complainant is not entitled to get any amount for Intravitreal Injection. The Intravitreal Accentrix Injection is an OPD (outpatient department) treatment though this injection is given in the Operation Theater in view the nature of treatment falls outside the scope of our Mediclaim Insurance Policy. Hence, the treatment with administration of above drugs is excluded from the scope of policy and patient was admitted for less than 24 hours, the procedure is not listed in the list of day care treatment, procedures/ treatments usually done in outpatient department are excluded from the scope of policy. As per terms and conditions of the above noted policy as mentioned in clause 2.17 HOSPITALIZATION: means admission in a hospital for a minimum period of 24 in patient care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
The Opposite Parties have further stated that as per terms and conditions of the above noted policy as mentioned in clause 2.11 DAY CARE TREATMENT: refers to medical treatment, and / or surgical procedure which is: undertaken under General or Local Anesthesia in a hospital/ day care Centre in less than 24 hours because of technological advancement and which would have otherwise required a hospitalization of more than 24 hours. Procedures/ treatments usually done in a outpatient department are not payable under the policy even if converted to Day Care Surgery/ procedure or taken as an inpatient in a hospital for more than 24 hours. The Complainant has no active line of treatment and Intravitreal Injection is not listed in the list of day care treatment moreover he was admitted for less than 24 hours, hence, excluded from the scope of the policy. So, the claim of the Complainant is illegal and he is not entitled to get any claim amount from the Opposite Parties. Therefore, the instant case is liable to be rejected with cost.
In support of his case, the Complainant has filed photo copies of the following documents by Firisti -
1. Mediclaim Policy No. 313592/48/2019/00058 of Oriental Insurance Co. Ltd., Balurghat Branch for the period from 12.06.2018 to midnight of 11.08.2019 One page
2. Aadhar Card of Complainant One page
3. Total expenditure for three operations on and from 11.02.2019 to 01.06.2019 One page
4. Discharge certificate dt.09.03.2019 of Disha Hospital One page
5. Bills, vouchers treatment expenditures ten page
6. Discharge certificate dt.13.04.2019 Disha Hospital One page
7. Bill, vouchers of 13.04.2019 Seven pages
8. Discharge certificate dt. 01.06.2019 One page
9. Bill, vouchers related to dt. 01.06.2019 Seven pages
10. Rejection letter dt. 23.03.2019 Two pages
11. Draft Rejection letter of Opposite Party No.2 Two pages
12. Letter dt.21.05.2019 of Complainant (Original) One page
13. Certificate dt. 03.07.2019 of Dr. Arnab Das One page
14. Glass power of Complainant One page
On the other hand, no documents have been submitted by the Opposite Parties in support of their defense.
In view of the above mentioned discussions the following points cropped up for determination.
Points for determination
- Is the complainant a consumer to the Opposite Parties?
- Is there any negligence and deficiency in service on the part of the Opposite Parties?
- Is the Complainant entitled to get any relief/reliefs as prayed for?
REASONED DICISION
We have heard arguments by Ld. Advocates for the both sides at length. Perused the materials on record, written examination-in chief and written arguments filed by both the parties.
Let all these points be discussed one by one
Point NO. 1
It is not disputed by the Ld. Advocates for Opposite Parties during their course of argument that complainant is not a consumer to the Opposite Parties. Moreover, considering the facts and circumstances of the case with regard to the materials and evidence of the parties on record we do not find any materials to hold that the Complainant is not a consumer to the Opposite Parties. Hence, this Commission is of the view that the complainant is a consumer u/s 2 of Consumer Protection Act 1986 read with Consumer Protection Act, 2019.
Accordingly, this point is decided in favour of the Complainant.
Points No. 2 & 3
Both these issues are taken up together for the sake of convenience and brevity.
Admittedly, the Complainant is insured with the Opposite Parties with Mediclaim Policy (Individual), vide Policy no. 313592/48/2019/00058, Policy period from 12.06.2018 to 11.06. 2019 and sum assured was Rs.1,50,000/-. It is also an admitted fact that the Complainant on 09.03.2019 got admitted himself in Disha Hospital at 09.00 A.M and took Intravitreal Accentrix Injection and he was discharged on the same day at 12.00 Noon. But when the Complainant submitted his claim of Rs. 36,499/- before the Opposite Parties, the Opposite Parties repudiated the claim on the ground that as per terms and conditions of the said policy the Complainant is not entitled to get any amount for Intravitreal Injection . The Opposite Parties explained their terms and conditions in the manner that the Intravitreal Injection is an OPD (outpatient department) treatment and the nature of such treatment falls outside the scope of Mediclaim Insurance Policy. The Complainant admitted in the Disha Hospital, his treatment was done and discharged on the same day within 24 hours. Such procedure is not listed in the list of day care treatment because such treatment usually done in outpatient department so, such treatment is excluded from the scope of the policy. If the treatment of the Complainant took more than 24 hours, then the Opposite Parties would be liable to pay the claim of the Complainant.
In support of their contention, the Opposite Parties in Paragraph – 8 of their written argument have discussed an observation of Insurance Ombudsman held in Om Prakash Sharma Vs The Oriental Insurance Co. Ltd. that the insured person was admitted in the Hospital for administering the intravitreal injection only and discharged on the same day. This treatment is not covered as per policy terms and conditions under Day Care approved list and General Exclusion clause and not payable. Thus, the decision of repudiation made by the Insurance Company is correct and justified.
On the Other hand, the Complainant cited an observation of Ld. State Consumer Dispute Redressal Commission held in Sri Jai Karmakar Vs United India Insurance Co. Ltd., First Appeal No. A/661/2015, decided on 16 August, 2016 to the effect that the treatment of administering of lucentus injection was of surgical nature which may be done in less than 24 hours or may take more time. In clause 2.2 of the Policy schedule it has been clearly stated that the time limit of 24 hours is not applied in case of eye surgery among some other specified treatments. There is no specific bar under the policy terms that administering injection will not be permitted under hospitalization benefit.
In the instant case, the Complainant took advise of the doctor of Priyamvada Birla Arbind Eye Hospital for his eye treatment and the Complainant was advised that he has to undergo a treatment through admission in their hospital and they will inject accentrix injection under LA in the left eye of the Complainant. The Complainant also took the advice of the doctor of Disha Eye Hospital Pvt. Ltd. and they also suggested the Complainant the same mode of treatment in order to cure the problem. In such circumstances, the Complainant cannot go beyond the suggestions of the doctors. The expert opinion for admission to the Complainant for his treatment of left eye by administering accentrix injection, was necessary and could not be avoided by the Complainant. Further, the contention of the Complainant that the Opposite Parties did not disclose such terms and conditions at the time of taking policy to the Complainant, cannot be left beyond consideration.
The certificate of the Doctor Arnab Das dated 03.07.2019 clearly reflects that the Complainant had undergone treatment in left eye with Intravitreal Accentrix injection & this process is an indoor process & also in day care. The certificate of the said doctor has not been challenged by the Opposite Parties. So, the plea of the Opposite Parties that such type of treatment can be done as outdoor patient in the hospital has no legs to stand.
In clause 2.11 of the Policy Schedule DAY CARE TREATMENT- refers to medical treatment, and /or surgical procedure which is
I) undertaken under General or Local Anesthesia in a hospital /day care centre in less than 24 hours because of technological advancement, and
ii) which would have otherwise required a hospitalization of more than 24 hours.
In clause 2.17 of the Policy Schedule HOSPITALISATION: means admission in a hospital for a minimum period of 24 in-patient care consecutive hours except for specified procedures / treatments, where such admission could be for a period of less than 24 consecutive hours.
The Complainant got admitted himself in Disha Eye Hospital Pvt. Ltd. for treatment of his left eye for three times and the Intravitreal Accentrix Injection was administered and the total cost for the treatment incurred by the Complainant is Rs. 76,287
In the instant case, the Complainant was hospitalized and underwent treatment as advised by the attending doctor. In fact, there is no specific bar under the policy terms and conditions that administering intravitreal injection will be not be permitted under hospitalization benefit.
. In view of the above mentioned findings, this commission is of opinion that the Complainant is a consumer to the Opposite Parties and there is negligence and deficiency in service on the part of the Opposite Parties, so the Complainant is entitled to get relief as prayed for.
Both these issues are decided in favour of the Complainant.
Accordingly, the case succeeds.
Hence, it is
O R D E R E D
That the complaint case No. 87 of 2019 be and the same is allowed in part on contest with cost against the Opposite Parties.
The Opposite Parties are directed to pay a sum of Rs. 76,287/- (Seventy Thousand Two Hundred Eighty Seven) only as principal claim against Policy No. 313592/48/2019/00058 along with interest @ 8% p.a from the date of passing of this order till the realization.
The Opposite Parties are also directed to pay Rs. 5,000/- towards compensation and Rs. 5,000/- towards litigation cost to the complainant by issuing an account payee cheque in the name of complainant within 45 days from the date of passing of this order failing which the Complainant is at liberty to execute the order according to law.
Let a plain copy of this order be supplied to the parties forthwith free of cost.
