BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.43 of 2019
Date of Instt. 12.02.2019
Date of Decision:24.08.2022
1. Inder Kumar Chauhan aged 80 years son of Shri Bhagat Ram, SR No.150375, R/o House No.292, Street No.6-A, Central Town, Jalandhar City-144001.
2. Sudershan Chauhan aged 76 years W/o Inder Kumar Chauhan, R/o House No.292, Street No.6-A, Central Town, Jalandhar.
..........Complainants
Versus
1. The New India Assurance Company Limited, Divisional Office No.2 (361000), 356, Guru Teg Bahadur Nagar, Jalandhar-144003 through the Senior Divisional Manager.
2. Life Insurance Corporation of India, Divisional Office, “Jeevan Parkash”, Model Town Road, Jalandhar-144001. Through its Senior Divisional Manager.
3. M. D. India Health Insurance TPA Private Limited, S. No.46/1, E-Space, Building A2, 3rd Floor, Vadgaonsheri, Pune- Nagar Road, Pune-411014.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Gagandeep Singh, Adv. Counsel for the Complainants.
Sh. Anuj Mehta, Adv. Counsel for OP No.1.
Sh. S. C. Sood, Adv. Counsel for OP No.2.
OP No.3 exparte.
Order
Dr. HarveenBhardwaj (President)
1. The instant complaint has been filed by the complainants, wherein it is alleged that the complainant No.1, retired from the service of OP No.2 as Assistant on 28.02.1998 from its Branch Office, Unit No.3, Jalandhar under the supervision and administrative control of OP No.2. The Central Office of OP No.2 devised a contributory scheme for reimbursement of Hospitalization/medical expenses to all classes of its in service employees/retired employees alongwith his dependants/additional dependants covered under LIC Group Mediclaim Insurance Policy for Sum Insured depending upon their basic salary/pension for normal and optional coverage of risk. The Scheme is regulated by Group Mediclaim (Hospitalization and Domiciliary Hospitalization Benefit) Policy covering against risk from any disease suffered from any illness or injury and surgical operation during the period of Insurance stated in Schedule or during continuance of the policy by renewal. The premium under Group Mediclaim Insurance Policy as prescribed is paid either in lump sum or in monthly installments deducted from salary/pension of the complainant No.1 as per option exercised by the insured at the beginning of financial year by OP No.2 and its Central Office pay consolidated premium collected with its own contribution directly to Head Office of insurer. OP No.1 has been nominated servicing office for the complainant, covered by LIC Group Medical Insurance Policy issued to Life Insurance Corporation of India and Opposite Party No.3 TPA (Third Party Administrators). The complainant No.1 and his wife Smt. Sudarshan Chauhan, complainant No.2 have been covered under Group Mediclaim Insurance Policy of LIC employees and its retiree ever since while in active service and after superannuation continuously without any gap or default. Smt. Sudarshan Chauhan complainant No.2 wife of the complainant No.1 is a patient of BLEPHROSPASHM C NID DH. ON BOTHTHORAPYHO ALLERGY TO BOTOX and he mediclaim reimbursement whenever Botox injection had fallen due and administered and Mediclaim submitted have been paid by Opposite Party No.1 without any rancor and demur for the last many years after his retirement from the date this disease was diagnosed save and except disowned in last year 2018. The complainant submitted prescribed CLAIM Form A and B and Medical Bill in the sum of Rs.26,500/- for her hospitalization for one day from 09.10.2018 to 10.10.2018 through OP No.2 which in turn forwarded to OP No. 3 as per inter se arrangement between OPs No1 & 2 for reimbursement. OP No.2 through its Manager (OS) after protracted follow up by the complainant delivered electronic print out copy of intimation received from OP No. 3 on 06.11.2018 by hand regarding repudiation of mediclaim which was repudiated on 06.01.2019 with reason as per claim documents received it is observed that the treatment given to the patient does not support need for Hospitalization hence claim is repudiated. The denial of the mediclaim has been made wrongly, arbitrarily, malafide and illegally and unauthorized by OP No.3. The OP No.3 has failed to mention any specific exclusion clause which disentitled the complainant from getting the mediclaim. The terms and conditions of Group mediclaim insurance policy have never been communicated to the complainant and as such, any exclusion clause not brought to the notice of the complainant or explained is not binding on the complainant in any way. The complainant had earlier filed consumer complaint no. 141 of 2014 before this Hon'ble Commission, which was decided on 23.04.2014 and accepted against OP No.1 and in favor of the complainant with respect to administering of BOTOX INJECTION. The claim there under was paid and subsequent Mediclaim in respect of administering of BOTOX INJECTION as and when administered had been paid by opposite parties. This factum is/was well within the knowledge of OPs No.1 & 2 who could have well acquainted OP No. 3 by OPs No.1 & 2, there would not have been any reason or occasion to disown the liability to pay Mediclaim of the complainant. It is apposite to mention from its panel doctor regarding the nature of disease and treatment who opined that BLEPHROSPAM is a condition in which there is acute closure of both eye lids & some patient have pain with irritation in eye balls. Injunction BOTOX is given in the Subcutaneous which is OPD procedure. Usually injunction is repeated after 6 months. Moreover, the complainant had also submitted opinion from Dr. Anurag Arora, who had been giving Botox Injunction and categorically opined that she is allergic partially to BOTHULIN TOXIN and so keeping abundant precaution she was admitted as an indoor patient and kept under observation for twenty four hours. The cause of action has accrued to the complainant on 09.10.2018 the date on which the wife of the complainant No.1 was hospitalized for administering of Botox Injection then on submission of claim and finally on rejection of the claim on 06.11.2018 and as such, the present complaint filed with the prayer that the complaint of the complainant may kindly be accepted and OPs be directed to pay the mediclaim expenses in the sum of Rs.26,500/- alongwith interest @ 12% per annum from the date of submission of the claim upto the date of payment. Further, OPs be directed to pay a compensation of Rs.20,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, but despite service OP No.3 failed to appear and ultimately OP No.3 was proceeded against exparte, whereas the OP No.1 appeared through its counsel and filed its written reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable against the OPs as there is no deficiency in service or negligence on the part of the answering OP. The complainant is not the consumer as provided under the provision of Consumer Protection Act and it is not a consumer dispute and does not fall within the ambit of the provision of the Consumer Protection Act as such, the complaint is liable to be dismissed summarily on this score alone. The present complaint is wholly misconceived, groundless and unsustainable in law and is liable to be dismissed as such. The complainant is stopped by his own act and conduct waiver and latches from filing the present complaint. It is further averred that the complainant has not come to the Commission with clean hands and suppressed the material facts from this Commission. In fact answering opposite party has repudiated the claim of the complainant due to the reason "as per claim documents received it is observed that the treatment given to the patient does not support the need for hospitalization hence claim is repudiated and further the Charges incurred at hospitals primarily for diagnosis, X-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury, for which confinement is required at a Hospital". On merits, the factum with regard to taking group mediclaim insurance policy of LIC by the complainant is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. OP No.2 filed its separate written reply and contested the complaint by admitting that the complainant No.1 retired from the services of OP No.2 and it is also admitted that the complainant No.2 is the wife of the complainant No.1. Taking of medi-claim insurance policy by the complainant was also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. Rejoinder not filed by the complainant.
5. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
6. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
7. It is admitted that the OP No.2 devised a contributory scheme for reimbursement of hospitalization and maternity expenses to all classes of its employees covered under LIC Group Mediclaim Insurance Policy. It is also admitted that the OP No.1 was nominated as a servicing office for the complainant covered by LIC Group Mediclaim Insurance Policy issued to LIC and OP No.3. The complainant has proved that the complainant and his wife Sudarhsan Chauhan were covered under the mediclaim insurance policy. This fact has been admitted by the OP No.2 also. The complainant has alleged that Smt. Sudarhsan Chauhan wife of complainant is the patient of Blephrospashm disease. It has been alleged by the complainant that the wife of the complainant used to be given Botox Injunction and the mediclaim submitted by the complainant from time to time after his retirement have been paid by the OP No.1. Her Botox Injunction was due and she was admitted in the Aastha Neuro Research & Rehabilitation Centre on 09.10.2018 and she was administered injection on the same day and was kept for observation for one day. The complainant has paid Rs.26,500/- for her hospitalization for one day alongwith other expenses and she was discharged on 10.10.2018. The mediclaim was submitted through OP No.2, which was forwarded to the OP No.3. Ex.C-3 to Ex.C-7 are the documents which show that she was admitted in Aastha Neuro Research & Rehabilitation Centre on 09.10.2018 and was administered injection. She was discharged on 10.10.2018 as per Ex.C-4 and the other charges have been proved by the complainant, vide Ex.C-5 to Ex.C-7. In the present complaint, the complainant has alleged that he has to bear the expenses of Rs.26,500/- for her hospitalization alongwith other charges. The claim was submitted, which has been repudiated on 06.01.2019 on the ground that ‘the treatment given to the patient does not support need for hospitalization hence claim is repudiated’.
8. The defence of the OP is that the administration of the Botox Injunction is an OPD procedure and there is no need for hospitalization for one day. Though, the terms and conditions of the policy have been filed on record by the OPs, but in the written statement, it has not been mentioned as to under which clause or terms and conditions of the policy, the claim of the complainant was repudiated. However, Ex.C-8 is the recommendation for repudiation of the claim by M. D. India Health Insurance Policy i.e. OP No.3. It has been recommended by the OP No.3 that ‘on perusal/scrutiny of above mentioned claim documents, the date of inception 01.April.2017 patient treated for Blepharospasm K/C/O-NIDDM from 09-Oct-2018 to 10-Oct-2018. It is evident that as per claim documents received it is observed that the treatment given to the patient does not support the need for hospitalization hence claim is repudiated. Hence, the claim is not admissible as per policy clause mentioned. Hence we regret our inability to admit this liability under the present policy conditions. We wish to point out that you still have right to appeal with insurer’. The denial/repudiation clause/s with description is/are that ‘charges incurred at hospitals primarily for diagnosis, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital’. And the repudiation clause has been reproduced by the TPA in Ex.C-8. This document shows that the claim of the complainant was repudiated only on the ground that the confinement of the complainant’s wife was not required at a hospital. But this observation and application of this clause is wrong and illegal in the present case. Perusal of the discharge certificate Ex.C-4 shows that Smt. Sudarshan Chauhan was admitted on 09.10.2018 and she was discharged on 10.10.2018. In the column of diagnoses, it has been specifically mentioned that she was suffering from BLEPHROSPASHM and NIDDM on botox therapy history of allergy to Botox. In the column of history, it has been mentioned that the patient was admitted with the history b/l twitching of face admitted for observation as patient is allergic to Botox. Since, she was having a history of allergy to injection Botox, which was to be administrated to the complainant’s wife, therefore it was necessary to keep her in the hospital for one day for observation as per the discharge card proved by both complainant and the OP. There is no document on the file proved by the OPs to show that her admission was not required for administrating her, the Botox injection specially when she was having the history of allergy with the Botox injection. Earlier also she was being given the Botox injection and was kept for observation in the hospital for 24 hours as per the judgment produced on record by the complainant as well as the OP dated 23.04.2014. This judgment shows that it has been specifically mentioned that she was earlier admitted in different hospitals for the injection and she is taking this Botox injection regularly. Once she was allergic to the Botox injection, therefore due to abandon precaution, so that she may not suffer any reaction to the said injection, her admission was necessary which is clear from the discharge card Ex.C-4. More so, the OPs are not medical experts nor any medical opinion has been filed on record by the OPs to the effect that though, the procedure for administering injection is an OPD procedure, but despite the fact that she was allergic, her admission was not required. Nothing has been proved by OPs.
9. In view of the above detailed discussion, the repudiation letter is wrong, illegal and is herby set-aside. The insurance policy is valid and existing during the period of admission of complainant in hospital. The complainant has filed on record the bills which are Ex.C-5, Ex.C-6 & Ex.C-7, in total Rs.26,500/- and the OP No.1 is directed to pay the said mediclaim expenses i.e. Rs.26,500/- alongwith interest @ 6% per annum from the date of submission of the claim, till its realization. Further, OP No.1 is directed to pay a compensation of Rs.10,000/- to the complainant for causing mental tension and harassment and Rs.5000/- as litigation expenses. The compliance of the order be made within 45 days from receipt of copy of this order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
24.08.2022 Member Member President
