Jharkhand

Bokaro

CC/16/68

Paranu Manjhi - Complainant(s)

Versus

The Branch Manager, The E- Meditek - Opp.Party(s)

Manwar Ansari

10 Feb 2022

ORDER

1       Complainant has filed this case with prayer to direct the O.P. to pay Rs. 2,50,714/- as purchase cost of Canmab-440 injection and to pay Rs. 50,000/- as compensation for harassment etc. and to pay Rs. 10,000/- as litigation cost.

2       The case of the complainant in short is that the complainant being ex-employee of Bokaro Steel Ltd. purchased mediclaim policy vide MIN No. 4741531 covering his wife Mayawati Devi and children in respect to medical expenditure. Further case is that his wife became ill who was diagnosed for breast cancer for which an injection was prescribed to be taken continuously from Oct. 2015 to March 2016 costing Rs. 50,000/- approx each. Further case is that said medicine was purchased by the complainant for Rs. 3,00,000/- about which claim was submitted but only Rs. 50,357/- for the month of Oct. 2015 was re-imbursed and rest of the amount was not paid by the insurance co.  In spite of sending of letters to O.Ps. no payment was made towards reimbursement of said amount though policy was covering regarding reimbursement of hospitality of diagnostic,  laboratory etc. charge/ expenditure of insured member when such member confined in any Hospital, Nursing home.  Further case is that in spite of sending of legal notice the outstanding dues of Rs. 2,50,714/- was not paid hence it caused huge loss, harassment etc. to the complainant hence he filed this case with above prayer.

3       Written version has been filed by O.P. No.2 United India Insurance Co. mentioning therein that case is not maintainable against this O.P. It is admitted fact that this O.P. had undergone a contract of mediclaim insurance policy with SAIL, Bokaro  valid from 01.04.2015 to 31.03.2016 in respect to its retired employees and their spouse. The contents of para 1, 2 and 3 have not been replied.  It is admitted fact that amongst the six phases of treatment only one i.e. for Oct. one was reimbursed by O.P. No.1 and rest of the claim was repudiated with valid reason.  Further reply is that no letters written by complainant were received by answering O.P. Further reply is that para 6 of the complaint petition is correct to some extent. Contents of Para 7,8,9,10,11,12 of the complaint petition have been denied.  Further it has been replied that the claim made by the complainant is highly inflated, exaggerated and over demanded hence it had been denied. Further reply is that there are several exclusions and limitations explained in the policy provided to the complainant and O.P. No.2 has given justified and correct reason to repudiate the claim who cannot get himself induced by any communications and meetings done by the complainant or any other on his behalf. As per terms and conditions intimation regarding hospitalization within 24 hours of hospitalization is compulsory but complainant failed to do so. Further reply is that as per clause 3.6 of the policy, Day care procedure means the course of medical treatment/surgical procedure in specialized day care centre which enables the insured to be discharged on the same day. Also, as per the indicative list of day care procedures detailed in the booklet of group mediclaim scheme-2015-16 for retired employees and their spouse provided to all members, admission of Cammab (Trastuzumab) is not mentioned anywhere. Further it is stated that the above clause clearly states that the day care procedures has to be in specialized day care centers and admission for injection Cammab (Trastuzumab) is not mentioned in anywhere in the SAIL booklet.  Hence it is replied that as per conditions mentioned in the policy the claim has been rejected and case is liable to be dismissed.

4       Written statement has also been filed by the O.P. No. 1 &3 mentioning therein that they are having no liability for reimbursement of the claim. Further it is mentioned that the injection Canmab(Trastuzumab) has not been included in SAIL day care procedures hence claim is not payable as per definitions 2.3.1 of the policy conditions :  When treatment/surgery such as Dialysis , Chemotherapy, Radiotherapy , Ophthalmic  Surgeries, Lithotripsy, Laproscopic, Microsurgery etc. is taken in the Hospital/Nursing Home and the insured is discharged on the same day, the treatment will be considered to be taken under hospitalization benefit section.  Hence, it is said that in view of the above insurance co. has denied the claim.

5       Following documents have been filed by the complainant :-

Photo copy of Medical Book ( Annexure -1) , Photo copy of claim farms ( Annexure -2,3,4,5,6 &7), Medical slips ( Annexure -8,9,10,11,12,13), Cash memo related to purchase of Canmab-440 mg vials on different dates ( Annexure -14,15,16,17,18 &19), Photo copy of applications ( Annexure -21 & 22)  and photo copy of legal notice dt. 16.05.2016 (( Annexure -20).

6       On other hand no any document has been filed by the O.Ps.

7       On careful perusal of the pleadings of the parties it appears that the fact related to illness of the wife of the complainant is admitted fact. Fact related to purchase of medicine namely Canmab-440 mg is also not in dispute. It is also not in dispute that wife of complainant was administered Canmab-440 mg for the treatment of breast cancer. The price of said medicine is also not in dispute.

8       Only dispute is related to entitlement for reimbursement of the price of said injection regarding treatment given to the wife of the complainant as OPD patient. As per O.Ps. the complainant is not entitled for reimbursement of the cost of the injection purchased and administered as OPD patient in view of clause 3.6 day care procedure.

9       Thus only question for consideration by this Commission is that whether denial of reimbursement of part claim of the complainant by the O.P. is justified or not ?

10     At para 13 of the W.S. filed by O.P. No.2 it has been mentioned that “The statement made in para No.4 in the complaint petition by the complainant  is correct as among the 6 phases of treatment only one i.e. October one was reimbursed by the O.P. No.1 and rest of them was repudiated with valid reason.

11     On perusal of annexure 3 read with annexure 9 and 15 it appears that claim for purchase of said injection for the month of Oct. 2015 has been admitted and accepted by the O.Ps. On perusal of those annexure it appears that for injection given at Bokaro General Hospital (in short BGH) on 06.10.2015 reimbursement of the claim has been allowed. On careful perusal of other annexure it appears that there is no difference in other papers for which claim has been refused than the papers for which claim has been allowed by the O.Ps. In this way there will be Estoppel against the O.Ps. because for the same set of papers and treatment they cannot say contrary statement at same time

12     Another question has been raised in para 12 of the W.S. of O.P. No.2 that the fact that the required treatment was initiated on 07.09.2015 contradicts the statement mentioned in the complaint petition that the treatment was advised from Oct. 2015. Moreover, Docotor’s advise is not annexed. In this way the another challenge is that as per para 3 of the complaint petition wife of the complainant was directed to take injection continuously for Oct. 2015 to March 2016. It reveals from the record that as per annexure 2 read with annexure 8 and 14 said injection has also been administered in the month of Sept. 2015 to the wife of the complainant. Therefore, the claim for the reimbursement of the cost Rs. 50,000/- for the month of Sept. 2015 is beyond the facts of the complaint petition.

13     In light of above  discussion we are of the opinion that for the same set of papers/ facts like claim form, hospital slip, cash memo regarding purchase of injection and treatment, part of the claim has been accepted/ allowed by the O.Ps. and for the same set of papers rest of the claim has been rejected without any justified reason. As we have discussed above in view of the fact mentioned in para 3 of the complaint petition as well as para 12 of the W.S. of O.P. No.2 the claim for reimbursement of the cost of the injection for the month of September 2015 is beyond the facts mentioned in the complaint petition hence it is liable to be rejected by this Commission also. Since claim for reimbursement for the cost of the injection for the month of Oct. 2015 has already been allowed by the O.Ps. hence only the claim for reimbursement of the cost of the injection for the month of November 2015, December 2015, January 2016, and March 2016 as it is apparent from annexure 5 read with annexure 11 & 16, annexure 4 read with annexure 10 & 17, annexure 6 read with annexure 12 & 18, and annexure 7 read with annexure 13 & 19 respectively that said claim has not been accepted for reimbursement by the O.Ps. without any justified cause  for which complainant is entitled to get reimbursement.

14     In light of above discussion we are of the view that there is deficiency in service by the O.Ps. No. 1 and 2 in respect to mediclaim Insurance policy. Hence, claim of the complainant is liable to be partly allowed. Accordingly, prayer of the complainant is partly allowed and O.P. No.2 United India Insurance Co. Ltd. is directed to reimburse the claim for the month of November, Dec. 2015, Jan. and March 2016 for Rs. 2,00,714/-( Two lac seven hundred fourteen) only within two months from today   O.P. No.1 and 2 are further directed to pay Rs. 20, 000/- compensation for harassment caused to the complainant and also to pay Rs. 5000/- as litigation cost to the complainant.  Compliance of this order must be insured within two months from today failing which O.P. No.2 will pay interest on Rs. 2,00,714/- ( Two lac seven hundred fourteen) @ 10% from the filing of the case i.e. from 29.06.2016.