Order No. 9 dated 26/04/2017
The case of the complainant in brief is that the complainant is the holder of mediclaim policy under the o.p.1. The complainant on 30.04.2015 lost her vision and took opinion of Dr Arup Chakraborty who after examination advised for taking intra vitreal injection which required operation theatre. The complainant was operated at Amulya Jyoti Eye Foundation and the total operation charges along with costs of all medicines totaling a sum of Rs.28,914.23 was spent by the complainant. Again the complainant had suffered defect in the right eye and she was treated by said doctor and put injection on the right eye after recovery the complainant prayed for the payment of the said amount which was denied by the insurance company. The complainant thereafter filed this case claimed of Rs.57,014.23 towards the medical treatment and also prayed for compensation of Rs.25,000/- and litigation cost of Rs.5,000/-.
The o.p. insurance company filed a w/v denied all the material allegations of the complaint. It was stated that the patient was admitted for intra vitreal accentrix in right eye on 26.06.2015 total cost of Rs.28,100/-. Since the said treatment is opd treatment and do not require hospitalization and as per the terms and condition no.2.3 the said claim was repudiated by TPA. It was further stated that the claim made by the complainant was not in accordance with the terms and condition of the policy therefore there was no deficiency in service on the part of the o.p. insurance company. In view of the said fact the o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with the o.p.;
- Whether the complainant took admission in the hospital for the said treatment as per terms and conditions of the policy;
- Whether the complainant will be entitled to get the medical bill claimed from the o.p;
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant had trouble in a right eye and she was treated by Dr Arup Chakraborty and as per his advise intra vitreal injection was applied for the said injection and cost for the medicine the complainant had to bear the expenses of Rs.28,100/- and subsequently she was again treated by the said doctor. The complainant after incurring expenses for her treatment prayed for total claim of Rs.57,014.23 which was denied by the o.p. insurance company for which the complainant filed this case. The complainant argued that the insurance company repudiated the claim of the complainant without any justifiable cause and as such, the complainant will be entitled to get the relief as prayed for.
Ld. lawyer for the o.p. argued that the insured admitted to the said nursing home for treatment and submitted a bill for claim of Rs.57,014.23 and TPA doctors were in opinion that the patient admitted with Macular Oedema, Intravitreal Avastin Injection Done Under L.A. This treatment could be done on OPD basis. Hence, the claim falls under exclusion clause 2.3 of individual mediclaim policy. The parties of mediclaim or any contract are directly covered by the policy conditions and no exception or relaxation can be made on the ground of equity as such there was no deficiency in service in repudiating the claim by o.p.
In support of the said contention ld. lawyer for the o.p. relied on a decision reported in 1966(3) SCR 500 wherein it was observed by Hon’ble Supreme Court that in interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract however reasonable if the parties have not made it themselves.
In a judgment reported in 1997(1) CPR 22 NCDRC that the insurance company had taken decision on the claim after due application of mind, the said decision cannot be said to have taken otherwise than on good faith. On the basis of the facts and circumstances of the case ld. lawyer for the o.p. has prayed for dismissal of the case.
Considering the submissions of the respective parties it appears that the complainant and his wife was the holder of mediclaim at the relevant point of time and it has not been disputed by o.p. From the documents filed by complainant it appears that the wife of the complainant underwent treatment under Dr. Arup Chakraborty and she was applied injection of intra vitreal for her eye treatment and after the claim made by the complainant, the o.p. repudiated the claim with the observation that the said treatment could be done on OPD basis and the claim falls under exclusion clause no.2.3 of individual mediclaim policy. On perusal of the exclusion clause 2.3 mediclaim policy it appears that the procedure / treatment usually done in OPD are not payable under the policy even if converted to day care surgery / procedure or as inpatient in the hospital for more than 24 hours. In view of the said provision the o.p. denied the claim of the complainant.
In a judgment reported in 1997(1) CPR 22 NCDRC that the insurance company had taken decision on the claim after due application of mind, the said decision cannot be said to have taken otherwise than on good faith. On the basis of the facts and circumstances of the case ld. lawyer for the o.p. has prayed for dismissal of the case.
Considering the submissions of the respective parties it appears that the complainant and his wife was the holder of mediclaim at the relevant point of time and it has not been disputed by o.p. From the documents filed by complainant it appears that the wife of the complainant underwent treatment under Dr. Arup Chakraborty and she was applied injection for the treatment of maculer degeneration and retinal vascular occlusions and after the claim made by the complainant, the o.p. repudiated the claim with the observation that the said treatment could be done on OPD basis and the claim falls under exclusion clause no.2.3 of individual mediclaim policy. On perusal of the exclusion clause 2.3 mediclaim policy it appears that the procedure / treatment usually done in OPD are not payable under the policy even if converted to day care surgery / procedure or as inpatient in the hospital for more than 24 hours. In view of the said provision the o.p. denied the claim of the complainant. The complainant though filed a certificate from the doctor who stated that the said patient was under his care since 25.12.13 for treatment of retinal vascular occlusion and she was advised injection inravatrial right eye and systemic arrangement as Mrs. Barua, patient had the history of apisodin rise of BP. She was advised to later admission following the injection for physical check up. The said certificate issued by the said doctor does not speak that the patient had to be admitted as an indoor patient for applying the injection in her right eye and she took the admission after the applying the injection on her own accord. Considering the facts and circumstances of the case since the admission of the complainant’s wife was taken in the hospital on her own accord for lateral check up after the applying of injection and the said injection could have been applied to the said patient as an outdoor patient and he insurance company rightly held that the terms and conditions of the policy says in exclusion clause no.2.3 that the procedure / treatment usually done in OPD are not payable under the policy even if converted to day care surgery / procedure or as inpatient in the hospital for more than 24 hours.
Here in this case from the documents supplied by the o.p. and the different authorities wherefrom it is evident that an intra vitreal injection is the injection of a drag into the vitreous body and the injections are performed as an outpatient procedure either in the eye clinic or any operating theatre. They are performed as an outpatient procedure. In view of the facts and circumstances as stated above, we hold that since the complainant’s wife took the admission in the nursing home on her own accord and for the treatment of her illness it was not required for her to be an indoor patient in the said nursing home, therefore the o.p. rightly repudiated the claim of the complainant and as such, the complainant will not be entitled to get any relief. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.486/2015 is dismissed on contest without cost against the o.p.
Supply certified copy of this order to the parties free of cost.
