BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,

ERNAKULAM.

Date of filing : 16/11/2012

Date of Order : 30/06/2014

Present :-

Shri. A. Rajesh, President.

Shri. Sheen Jose, Member.

Smt. V.K. Beena Kumari, Member.

C.C. No. 707/2012

Between

And

Date of filing : 15/02/2013

C.C. No. 123/2013

Between

And

C O M M O M O R D E R

V.K. Beena Kumari, Member.

1. These complaints are filed against the very same opposite parties seeking direction against the 1^st opposite party insurance company to allow the medical insurance claimed by the very same complainant in respect of the very same treatment of the right eye of the complainant. Since the mediclaim is against the 1^st opposite party insurance company in both cases, these complaints are taken for joint trial and are disposed off by this common order.

2. The complainant who is working in Tanzania is a resident of Kochi and was holding mediclaim policies issued by the 1^st opposite party insurance company by which the complainant and his wife were insured towards medical expenses incurred in respect of any medical treatment of the complainant or his wife. The complainant was treated as an inpatient at Giridhar Eye Institute, Kochi for the disease of his right eye called Subfoveal Classic Choroidal Neovascular Membrane Right Eye, which may result in loss or deficiency in eye sight. The mediclaims of the complainant was repudiated by the 1^st opposite party insurance company on the ground that 24 hours inpatient treatment is necessary to allow the mediclaims. Hence these complaints are filed before this Forum seeking direction against the 1^st opposite party insurance company to allow the mediclaim in both cases with future interest @ 12% p.a. from the date of claim till realisation with costs of the proceedings.

2. The version of the opposite parties is as follows :-

In the joint version filed by the 1^st and 2^nd opposite parties namely the Oriental Insurance Company Ltd., Kochi and E-Mediteck (TPA) Services Ltd., Mamangalam, it is submitted that as per the individual mediclaim policies taken by the complainant, “Age Related Muscular Degeneration (ARMD) in the right eye of the complainant necessitating administration of Lucentis/Avastin/Macugen injections are not covered as the above said disease is to be treated as outpatient under OPD protocol.” The 1^st opposite party insurance company also contended that the complainant deliberately contrived to undergo the treatment as an inpatient for one day with a view to claim reimbursement of expenses from the opposite parties, that two similar mediclaims of the complainant were earlier allowed and payment effected due to an error and oversight by the 2^nd opposite party M/s. E-Mediteck. The 1^st opposite party prayed that dis- allowance of mediclaims by them may be adjudged correct and both the complaints may be dismissed with costs of the proceedings to the opposite parties.

3. In these cases, the complainant and his witness were examined as PWs 1 and 2 respectively. In C.C. No. 707/2012, the documentary evidence of the complainant were marked as Exts. A1 to A14. No oral evidence was adduced by the opposite parties. Ext. B1 was marked on their side. The evidences adduced by both parties are one and the same in these complaints. Heard the counsel for both parties.

4. The common issues to be decided in these cases are the following :-

1. Whether the complainant is entitled to get the mediclaim amounts claimed by him?

2. Whether the complainant is entitled to get costs of the proceedings from the opposite parties?

5. Point No. i. :- The complainant contracted with a disease called “Subfoveal Classic Choroidal Neovascular Membrane Right Eye” which may result in loss or deficiency in eye sight. It is a disease that affects the macular region of retina of the eye due to macular degeneration. The method of treatment adopted is intravitreal Anti VEGF injection with the right eye on every three months or as directed by the doctor. The complainant was admitted to Giridhar Eye Institute Kochi on 04-05-2011 and had undergone treatment and the result of the treatment was reviewed on 03-06-2011. It was found that there was significant reduction in macular detachment and reduction in the thickness of the central macular region. The complainant was admitted for treatment on 03-06-2011, 04-07-2011, 10-10-2011, 16-11-2011, 02-05-2012 and on 01-10-2012. The complainant was discharged on the very next day on all the above occasions after treatment. The details of admission (readmission and discharge from Giridhar Eye Institute, Kadavanthra, Ernakulam and the claim amount are as on detailed below :-

6. On all the above occasions of admission to the Giridhar Eye Institute, Lucentis and other injection were administered and the treatment of the complainant is still continuing. The above treatment was effected during the currency of the mediclaim policies. The mediclaim insurance applications of the complainant were repudiated on the ground that “Age Related Macular Degeneration (ARMD) necessitating administration of Lucentis/Avastin/ Macugen Injection are not covered, since the above said diseases are to be treated as outpatient under OPD protocol.” as stated in the joint version of the opposite party. But Ext. A8 repudiation letter says that “As per administrative circular of insurance company expenses related to the intravitreal injection (Lucentis) Right Eye is not payable.” It is to be noted that there is no whisper about the said circular in the terms and conditions of mediclaim policy therefore, the above ground is found not binding on the complainant and the repudiation of the claim is found incorrect and illegal. Further, the doctor who treated the complainant was examined as PW2, he categorically deposed that the treatment for “Age Related Macular Degeneration” is to be taken as inpatient as per the instruction of the National Accreditation Board for Hospitals (NABH) and the Giridhar Eye Hospital has accreditation to NABH. The requirement of hospitalisation for 24 hours is the minimum requirement for claiming hospitalisation charges only. The above requirement is not relevant to the cases at hand, since the admissions to the hospital and discharge from the hospital after administration of injection are only in connection with the prolonged and continuous treatment of the right eye of the complainant. Moreover, the opposite party could not adduce any evidence to show that the complainant deliberately contrived with the hospital authority to undergo treatment as “inpatient” for one day. From the facts of the cases, it is clear that Lucentis and other injection were administered for very long duration and the treatment is still continuing. In view of the above discussion and the facts of these cases, we find that the complainant is entitled to the policy amount as claimed in the claim applications submitted by the complainant with interest.

7. Point No. ii. :- Since the main grievance in both the complaints are allowed, we refrain from awarding any costs of the proceedings to the complainant.

8. In the result, the complaints are partly allowed and we direct that the 1^st opposite party insurance company shall pay the mediclaim of the complainant in both these complaints with interest @ 12% p.a. from the date of the complaints till realisation.

The order shall be complied with, within a period of thirty days from the date of receipt of a copy of this order.

Pronounced in the open Forum on this the 30^th day of June 2014.

Sd/- V.K. Beena Kumari, Member.

Sd/- A. Rajesh, President.

Sd/- Sheen Jose, Member.

Forwarded/By order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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