DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.336/2018
Mrs. Nirupam Anand,
W/o Shri Harvinder Pal Singh
R/o 5 South Drive,
Chhatarpur Farms,
New Delhi
….Complainant
Versus
1. The Oriental Insurance Company Ltd.
Branch Office:
G-8, Hauz Khas Market,
New Delhi
2. Raksha TPA Pvt. Ltd.
Having its office at:
202, 1st Floor, Phase-III,Okhla,
Industrial Area-III
New Delhi-110020
Also At:
14/3, 1st Floor, Mathura Road,
Faridabad, Haryana 121003
Also at:
Escort Corporate Centre,
15/5 Mathura Road, Faridabad
Haryana - 121003
….Opposite Party
Date of Institution : 15.11.2018
Date of Order : 10.10.2024
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Present: Adv. Meenu Pandey for complainant.
None for OP.
ORDER
Member: Ms. Kiran Kaushal
1. Facts of the case as pleaded by the complainant are that complainant took a Mediclaim policy from Oriental Insurance Co. Ltd. hereinafter referred to as OP-1, Raksha TPA Pvt. Ltd. is referred to as OP-2.
2. It is stated that for the last 15 years the complainant was paying premium for the Mediclaim policy and OP-1 never brought to the notice of the complainant about the non-exclusion clause of treatment of any disease. It is stated that complainant in the year 2014 was diagnosed with Multiple Myeloma (cancer). Thereafter, complainant consulted the expert doctors and took several tests and other treatments at Ganga Ram Hospital. Complainant ensured that OP was intimated on each and every occasion. Complainant qua all the medical consultations and test raised a claim to the tune of Rs.4,00,299/-.
3. It is further stated that complainant got admitted BLK Super Speciality hospital on 17.11.2014 for bone marrow transplant and intimated OP-1 and OP-2 through an email dated 17.11.2014.
4. Complainant again got admitted on 23.11.2014 for surgery and was discharged on 17.12.2014 for which the hospital raised a bill to the tune of Rs.9,72,062/-. The said bill was also forwarded to OPs for cashless payments but no positive response was received from OPs. Complainant had no other option but to bear all the expenses for the treatment and care, spending Rs.9,72,062/- from his own pocket. It is stated that the complainant wrote several emails to OP regarding the claim which was denied alleging that the complainant’s disease is covered under Genetic Disorder.
5. Complainant clarified from a specialised doctor that the treatment received by her was not for any genetic disorder vide letter dated 12.12.2014. Thereafter, complainant again followed up with OP to pass the claim but to no avail. As the complainant did not receive any response from OP, legal notice was issued to OP. In the reply to legal notice OP admitted that complainant’s claim was lying under query for submission of certain documents and the same was never closed.
6. Alleging deficiency of service complainant prays for direction to OP to award Rs.13,72,361/-, the claim filed by the complainant with interest @24% per annum ; to pay Rs.50,000/- a damages for harassment and mental agony and Rs.25,000/- as litigation cost.
7. Written statement is filed on behalf of OP stating inter alia that the complainant has not come before the Commission with clean hands. It is stated that complainant has concealed the fact that the complainant was aware of the fact that treatment/surgery undertaken by the complainant is specifically excluded under the terms and conditions of the insurance policy. The relevant exclusion clause of the insurance policy is reproduced as under:-
“4. Exclusions:
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of
4.15 Genetic disorders and stem cell implantation/surgery.”
8. It is further stated that all the terms and conditions of the insurance policy were duly provided to the complainant along with the insurance policy. Hence the complainant was duly informed and was aware that the terms and conditions specifically incorporates the exclusion clause. It is thus stated that as the treatment/surgery was specifically excluded complainant was under the obligation to bear all the expenses incurred for the same. It is therefore prayed that complaint be dismissed with exemplary cost.
9. OP-2 filed its version stating inter alia that OP-2 is a licensed TPA under IRDA Act 2001 to act as a facilitator for processing of the claim. The insurance contract is between the insured and insurer. As per privity of the contract the insurance company or its TPA is obliged to process the claim as per the terms and conditions of the policy.
10. It is stated that as per the policy and the claim filed in respect of the complainant who was hospitalized from 23.11.2014 to 17.12.2014 for treatment of Multiple Myeloma for stem cell transplant the claim was processed in accordance with the policy terms and conditions. As per clause 4.15 which excludes ‘genetic disorder and stem cell implantation/ surgery’ from the scope of policy cover hence OP-2 recommended to OP-1 that the claim to be non-tenable.
11. It is further stated that the complaint filed is not maintainable against OP-2 as the complainant has entered into a contract only with OP-1 and not with OP-2. In light of the same OP-2 is liable to be deleted as its neither a proper nor necessary party to the complaint.
12. Complainant has filed rejoinder to written statement of OP-1 stating therein that the exclusion reproduced by OP-1 exclude genetic disorders and stem cell plantation/surgery but the complainant was suffering from Multiple Myeloma which is a type of blood cancer of plasma cells it is neither a genetic disease nor is related to any previous disorder as per the specialised doctor’s opinion dated 12.12.2014 taken by the complainant. It is submitted that while signing the insurance policy representative of OP-1 had informed the complainant about the inclusions and did not explain anything about any exclusion.
13. In the rejoinder filed to the written statement of OP-2 complainant has submitted the repudiation letter was issued by OP-2 and it is on the recommendation of OP-2 that the complainant’s claim was repudiated.
14. Evidence and written arguments have been filed by complainant and on behalf of OP-1. Material placed on record is perused. Submissions made by Ld. Counsels are heard.
16. Admittedly, complainant who had taken the Mediclaim policy from OP-1 was diagnosed with Multiple Myeloma (cancer) and was admitted at Ganga Ram Hospital during the subsistence of the policy. Complainant’s claim was repudiated by OP as Multiple Myeloma for stem cell transplant was not payable as per clause 4.15. It is not complainant’s case that terms and conditions of the policy were not provided by OP. Terms and conditions appended at page 25 of the complaint clearly mentions the ‘Exclusions’ which inter alia include ‘Genetical disorders and stem cell implantation/surgery’ as Clause 4.15.
17. Complainant in support of her case has filed a letter from a doctor who is the Director, Bone Marrow Transplant Unit of BLK Super Speciality hospital which states as under:-
“Patient Mrs. Nirupam Kaur Anand, 62/ Female, MRD No.309850 admitted in BLK Hospital and is suffering from Multiple Myeloma. It is a type of blood cancer of plasma cells. This is neither a genetic disease nor is it related to any previous disorder and its etiology is not known.”
18. The said letter though has specifically stated that Multiple Myeloma is not a genetic disease but is silent on the second part of the exclusion clause ‘stem cell implantation/ surgery’. It is next observed that the Bone Marrow Transplant Discharge Summary of the complainant mentions “Patient received Autologous non-cryopreserved, peripherally harvested stem cells on 26.12.14.” The Discharge Diagnosis mentions, “Multiple Myeloma Post Autologous Stem Cell Transplant”. It is evident from the Discharge Summary that the complainant received the Stem Cell Transplant/Surgery.
19. The complainant in support of his complaint has referred to the judgment passed by Hon’ble High Court Delhi in Jay Parkash Tayal Vs. United India Insurance Company Ltd. bearing case No.RFA/610/2016. The ‘conclusion and reliefs’ in the said matter has been stayed by Hon’ble Supreme Court on 27.08.2018 vide SLP (Civil) Diary No. 29590/2018.
20. In view of the fact that stem cell implantation/surgery has been specifically excluded in the terms and conditions of the insurance policy which were provided to the complainant and OP has repudiated the claim of the complainant as per the terms and conditions of the policy. This commission is of the opinion that OP was within it’s rights to repudiate the claim. Hence the complaint is dismissed.
Parties be provided copy of the judgment as per rules. File be consigned to the record room. Order be uploaded on the website.
