IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 26th day of October, 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
Sri. K.M. Anto, Member
C C No. 103/2021 (Filed on 07-07-2021)
Petitioners : (1) Roobesh Emmanuel
S/o. late Emmanuel George,
Aykkarakunnel House,
Hospital Road, Athirampuzha,
Pin – 686562 Kottayam.
(2) Rajesh Emmanuel,
S/o. late Emmanuel George,
Aykkarakunnel House,
Hospital Road, Athirampuzha,
Pin – 686562 Kottayam.
(3) Aniyamma Emmanuel,
W/o. late Sri. Emmanuel George Aykkarakunnel House,
Hospital Road, Athirampuzha,
Pin – 686562 Kottayam.
(Adv. P. Vinodji)
Vs.
Opposite parties : (1) The New India Assurance Co. ltd.
Registered & Head Office:
87 Mahatma Gandhi Road,
Fort, Mumbai – 400001
(2) New India Assurance Co. Ltd.
Kanjirappally Micro / Divisional
Office, 1st Floor, Palackel Arcade,
Kanjirappally – 686507
Rep. by its Branch / Divisional Officer
(For Op 1 and 2, Adv. P.G. Girijia)
(3) Medi Assist Insurance TPA Pvt.
Ltd. Medi Assist India Pvt. Ltd.
Tower D, Fourth Floor, IBC
Knowledge Park, 4/1,
Bennerghatta Road, Bangalore
Pin – 560029
(4) Medi Assist India TPA Pvt. Ltd.
Branch Office, 4th floor,
Chicago Plazza, Rajaji Road,
Off Mahatma Gandhi Road,
Kochi – 682035
O R D E R
Sri. Manulal V.S. President
The complaint is filed under section 35 of the Consumer Protection Act 2019.
Crux of the complaint is as follows;
Complainant are the legal heirs of the late Emmanuel George who along with the third complainant subscribed an insurance policy from second opposite party on 5-3-2004 having a coverage of Three lakhs rupees each for the insured persons. The policy used to be renewed each year regularly and was renewed for a period from 5-3-2019 to 4-3-2020. Emmanuel George was diagnosed with Metastatic Carcinoma Rectum and Type -II Diabetes Mellitus in the year 2016. The ailment is one that is entirely covered under the insurance policy the opposite parties on 19-4-2018 reimbursed an amount of Rs.13,681/-, Rs.13,2019/- on 2-5-2018 and Rs.13,753/- on 11-7-2019. In all communication regarding all these claim settlement it was stated that “this amount was settled for the treatment of late Sri. Emmanual George for “ Malignant neoplasm of rectum” . According to the complainants the ailment stood covered under the policy and all its agreed treatment expenses were reimbursed by the opposite parties at the prior instances for treatments for day’s admission and treatment, covering the expenditure as “Day Care Treatment “ defined and covered by the policy.
On 29-5-2019 said Emmanual George was advised to start immunotherapy with injection KEYTRUDA, which had been therapy essentially to be undertaken considering his condition. He undertook the therapy admitting him as inpatient at 12.35 P.M and discharged him at 2.41 P.M as the procedure was uneventful. An amount of Rs.2,00,348/- was incurred for the therapy and medicines. On 31-5-2019 a claim was lodged by said Emmanual George but the claim was rejected by the second opposite party stating the reason that day care treatment normally taken as an outpatient basis is not included in the scope of this definition. Thereafter on 11-7- 2019 Emmanuaal George also had to take another injection “KEYTRUDA100 mg/4ml which was purchased for an amount of Rs.1,76,736/- The claim for the reimbursement which was lodged on 12-7-2019 was rejected by the opposite party stating the same reason for rejecting the claim lodged on 31-5-2019. It is averred in the complaint that rejection of both the above said claim by the second opposite party is illegal and goes against the contract of insurance and amounts to deficiency in service. The opposite parties are bound to reimburse the amounts spend by late Emmanual George for his treatment and compensate him for deficiency in service. As legal heirs of the late Emanual George the complainant’s are entitled to claim and realise the contractual amounts under the insurance policy due to late Emmanual George. Hence this complaint is filed for an order to direct the opposite parties to pay an amount of Rs.4,69,447/- along with interest and a compensation of Rs.50,000/-.
Upon notice first and second opposite parties appeared before the commission and filed joint version. Though the notice was served to the third and fourth opposite parties they neither appeared nor filed version. Hence third and fourth opposite parties are declared as ex-parte.
Version of the first and second opposite parties as follows:
Emmanuel George had availed a New India Medi- Claim Policy for a period from 5-3-2019 to 4-3-2020. The complainants have to prove Emmanuel George availed an insurance policy from 5-3-2004 and it was renewed. The averment that both late Emmanuel George and Aniyamma Emmanuel had no pre-existing disease is to be proved by the complainants. The opposite parties settled the earlier claim of the complainant as mentioned in the compliant. But it was for the inpatient treatment for the ailment Malignant Neoplasm rectum. The claim of the complainant for Rs.2,02,879/- was repudiated for the reason that as per clause 2-10 of the medi-claim policy day care treatment taken on outpatient basis is not included. The claim for Rs.1,76,736/- was also repudiated for the same reason. There is no deficiency in service on the part of the opposite parties as alleged. It is submitted in the version that Emmanuel George was covered for the sum insured of Rs.3,00,000/- only and not for Rs.6,00,000/-. The complainants are not entitled for any reliefs as prayed.
Fist complainant filed proof affidavit in lieu of chief examination and marked exhibit A1 to A17 from the side of the complainants. Asha R Thomas who is the divisional manger of the first opposite party filed proof affidavit in lieu
of chief examination and marked exhibit B1 .
On evaluation of complaint version and evidence on record we would like to consider the following points:
Whether there is any deficiency in service on the part of the opposite parties?
If so what are the reliefs and costs?
Point number 1 and 2 together.
There is no dispute on the fact that the Late Emmanuel George had availed a New india medi Claim Policy for a period from 5-3-2019 to 4-3-2020. On perusal of exhibit A1 which is the insurance policy bearing no. 76250434189500000059 we can see that said Emmanuel George and his wife Aniyamma Emmanuel are the insured persons and the sum insured was Rs.3,00,000 for each insured persons. In Exhibit A1 policy previous policy number was recorded as 76250434179500000034.Admittedly the earlier claims of the said Emmanual George on 19-4-2018, 2-5-2018 and on 11- 7-2019 were honoured by the opposite parties.
It is proved by exhibit A2 discharge summary dated 29-5-2019 that the said Emmanuel George was diagnosed to have Carcinoma Rectum in October 2016. It is further proved by the exhibit A2 that he was admitted in Rajagiri hospital on 29-5-2019 for initiating immunotherapy and injection KEYTRUDA 100mg administered him and the same day itself he got discharged from the hospital. Thereafter he had admitted in the Rajagiri hospital on 11-7-2019. Exhibit A 17 proves that he had administered chemotherapy on 11-7-2019 and discharged on the same day itself.
An amount of Rs.2,00,348/- was spent by said George Emmanuel on 29-5-2019 at Rajagiri hospital for chemotherapy vide exhibit A6. Exhibit A16 is the Tax invice dated 11-7-2019 issued by ADS Chemists, Druggist to Emmanuel George . On perusal of exhibit A17 we can see that the said Emmauel George has spent Rs.1,76,736 for Keytruda 100mg/4ml . ExhibitA17 is the inpatient bill issued from Rajagiri hospital to Emmanuel George on 11-7-2019 for an amount of Rs. 3,504/.
Admittedly both the claims lodged by Emmanuel George were rejected for the reason that as per clause 2-10 of the medi-claim policy day care treatment taken on outpatient basis is not included. Exhibit B1 is the policy and its terms
and condition .
Clause 2.10 of the B1 defines day care centre as any institution established for Day care Treatment of illness and / or injury or a medical setup within a Hospital and which has been registered with the local authorities , wherever applicable and is under supervision of a registered and qualified medical practitioner and must comply with all minimum criteria as under:
-has qualified nursing staff under its employment;
-has qualified medical practitioner/s in charge; Has a fully equipped operation theatre of its own surgery is carried out;
Maintains daily record of patients and will make these accessible to the insurance company’s personnel’ Clause 2.11 of the B1 is extracted hereunder:
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 twenty four hours.
Treatment normally taken an out -patient basis is not included in the scope of this definition.
Thus day care treatments refer to those medical treatments and procedures that need hospitalization, but not for more than 24-hours as to medical advancements and technology, the treatment processes are now a lot shorter.
On perusal of exhibit A2 and A17 we can see that Emmanuel George was admitted in Rajagiri hospital 0n 29-5- 2019 and on 11-7-2019 respectively for initiating immunotherapy and injection KEYTRUDA 100mg administered him and the same day itself he got discharged from the hospital.
On perusal of exhibit A3 we can see that the opposite party had approved the claim of Emmanuel George for Rs.17,779/- which was incurred for the treatment of Malignant Neoplasm rectum on 19-4-2018. On a mere perusal of exhibit A3 we can see that the treatment was given on day care basis on 19-4-2018 and the patient was discharged on the same day itself.
Further vide exhibit A4 the opposite party allowed the claim of the said Emmanuel George for Rs.19,698/- which was inured for chemotherapy on 2-5-2018. From exhibit A5, it is evident that the patient was admitted in the hospital on 2-5-2018 and discharged on the same day.
On a close scrutiny of available evidence it is evident that the first and second opposite parties had approved the claim of Emmanuel George for the treatment done earlier on day care basis. Therefore we are of the opinion that the first and second opposite parties had committed deficiency in service by repudiating the claims of the said Emmanuel George for the expenses incurred for the immunotherapy on 29-5-2019 and 17-9-2019. No doubt, the deficient act of the first and second opposite parties caused much mental agony and hardship to the Emmanuel George and his family members.
The first and second opposite parties have no case that the complainants are not the legal heirs of the Late Emmanuel George. As per section 2 (5)(vi) of the Consumer Protection Act 2019 in case of death of a consumer , the legal heirs of the such consumer can file a complaint before the consumer foras. Thus the complainant are eligible for the relief’s which are entitled by the late Emmanuel George.
In these circumstance we allow the complaint and pass the following order.
- We hereby direct the first and second opposite parties to pay Rs.4,67,447/- i.e. the amount spent by late Emmanuel in Rajagiri Hospital on 29-5-2019 and 17-9-2019 to the complainants .
- We hereby direct the first and second opposite party to pay Rs.25,000/- to the complainants as compensation for the deficiency in service on the part of the first and second opposite parties.
Order shall be complied within 30 days from the date of receipt of Order. If not complied as directed, the award amount will carry 9% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 26th day of October, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Copy of insurance policy in the name of Emmanuel Joseph
A2 – Copy of discharge dtd.29-05-19 from Rajagiri Hospital
A3 – Copy of cashless claim reference dtd.19-04-18 from Medi Assist to The Administrator, Rajagiri Hospital
A4 - Copy of cashless claim reference dtd.02-05-18 from Medi Assist to The Administrator, Rajagiri Hospital
A5 - Copy of cashless claim reference dtd.11-07-19 from Medi Assist to The Administrator, Rajagiri Hospital
A6 – Inpatient bill summary dtd.29-05-19 issued by Rajagiri Hospital
A7 - Inpatient bill summary dtd.29-05-19 issued by Rajagiri Hospital
A8 – Copy of deposit receipt dtd.29-05-19 issued by Rajagiri Hospital
A9 - Copy of deposit receipt dtd.29-05-19 issued by Rajagiri Hospital
A10- Settlement receipt dtd.30-05-19 issued by Rajagiri Hospital
A11- Settlement receipt dtd.30-05-19
A12- Inpatient bill dtd.29-05-19
A13- Copy of claim form
A13 (a) – postal receipts
A14 –Copy of letter issued by opposite party to Copy of claim form
A13 (a) – postal receipts
A14 –Copy of certificate dtd.19-06-2019
A15- Copy of letter issued by opposite party to Emmanuel George
A16- Invoice dtd.11-07-19 by ADS Chemist & Druggist
A17 –Inpatient bill dtd.11-07-19 issued by Rajagiri Hospital
Exhibits marked from the side of opposite party
B1 – Copy of insurance policy with terms and conditions
By Order
Sd/-
Assistant Registrar
