Delhi

North

CC/64/2021

VIJAY PRAKASH SHARMA & ANR. - Complainant(s)

Versus

THE ORIENTAL INSURANCE COMPANY LTD. - Opp.Party(s)

VED PRAKASH SHARMA

30 May 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

CONSUMER COMPLAINT NO.: 64/2021

In the matter of

Vijay Prakash Sharma

S/o Late Shri Baldev Singh                                              Complainant No. 1

 

Nishant Sharma

S/o Shri Vijay Prakash Sharma                                             

Both residents of

9-A/41, W.E.A. Karol Bagh

New Delhi- 110005                                                          Complainant No. 2

Versus

 

The Oriental Insurance Company Limited

Regd. Office: "Oriental House"

A-25/27, Asaf Ali Road

New Delhi- 110002                                                          Opposite Party No. 1

 

M/s Health Insurance TPA India Pvt Ltd.

2^Nd Floor, Majestic Omnia Building

A-110, Sector 4, Nopida- 201301 (U.P.)                            Opposite Party No. 2

 

ORDER

30.05.2023

(Divya Jyoti Jaipuriar)

By way of this complaint, the Complainant has sought directions for M/s Oriental Insurance Corporation Ltd. (OP-1) and it is a third party administrator namely M/s Health Insurance TPA India Pvt Ltd.(OP-2)  to settle the claim of the complainant and make the payment of Rs.4,29,518/- The Complainant has also asked for interest of the said amount as well as compensation on account of mental agony, harassment and undue hardship suffered by them. 

2. Briefly stated by the Complainant No.1&2 are the beneficiaries of mediclaim policy issued by OP-1.  The said mediclaim also was purchased by Complainant No.1 namely Sh. Vijay Prakash Sharma which covers him, as wife Ms. Dolly sharma, their daughter Ms. Mansi Sharma and his Son Mr. Nishant Sharma since 2006.  Subsequently, in the year 2016-17 the son Mr. Nishant Sharma became the primary insurer and Complainant No.1 became the dependent insurer in the mediclaim policy issued by OP-1 which was in continuation with the earlier insurance policies.  

3. It is the case of the Complainants in the month of March-April 2015, Complainant No.1 was diagnosed with Diabetic Macular Edema (DME) by the treating doctors of AIIMS and for the treatment of the said ailment, he has been admitted in AIIMS on several occasions when he received the treatment by Lucentis Intravitreal Injection and was discharged after one day. In the present complaint, the Complainant’s claim for his admission since 20.08.2018 till 08.02.2021 is in question. Complainant has been admitted at AIIMS on several occasions each for one day for receiving the injection and follow up. For every event of hospitalisation, the Complainant incurred expenses from Rs. 19,510/- per day to Rs. 45,415/- per day depending on the treatment so received.  Thereafter, the Complainant raised the claim with the OPs which were repudiated by OPs vide their repudiation letter on the grounds that treatment of Diabetic Macular Edema (DME) by way of Lucentis Intravitreal Injection and age related macular degeneration are not covered under Terms & Conditions under the policy.

4. In view of the fact that the Complainant had multiple occasion of admission in the hospital different insurer claim were failed. All these claim were repudiated on the same grounds vide repudiation letters 09.11.2018, 29.10.2018, 10.12.2018, 30.11.2018., 21.02.2019, 01.05.2019 23.04.2019, 30.04.2019, 27.06.2019 and 02.01.2020. During this period, Complainant incurred expenses of Rs. 4,29,518/-, which is duly supported by the invoices. For the brevity, the details of admission of the Complainant are put in this tabular format:

Date Of Admission	Date Of  Discharge	Expenses Incurred
20.08.2018	21.08.2018	45,415
10.09.2018	11.09.2018	18,439
29.10.2018	30.10.2018	45,415
17.12.2018	18.12.2018	45,415
18.02.2019	19.02.2019	19,664
06.03.2019	07.03.2019	19,664
22.04.2019	23.04.2019	19,510
01.07.2019	02.07.2019	19,510
08.07.2019	09.07.2019	19,664
14.10.2019	15.10.2019	19,510
02.12.2019	03.12.2019	19,664
02.03.2020	03.03.2020	19,664
04.05.2020	05.05.2020	19,664
11.05.2020	12.05.2020	19,664
31.08.2020	01.09.2020	19,664
19.10.2020	20.10.2020	19,664
01.02.2021	02.02.2021	19,664
08.02.2021	09.02.2021	19,664

 

5. At this stage, it is also to be noted here that when the Complainant stated to take the treatment for Diabetic Mecular Edema he was covered under the policy No.272101/48/2019/307.

6. We have issued the notice in this matter and Ld. Advocate on behalf of the OP-1 has appeared and participated in the proceedings. OP-1, in its reply and pleadings before this Commission has reiterated the stand of repudiation as stated in the repudiation letters so referred above. We have also heard the arguments of the Ld. Counsel appearing for the parties before reserving the order.

          7. We have perused the records and gone through the pleadings. The repudiation letters that have been issued by the OPs are identical in nature. The claims of the Complainant were repudiated on the same grounds that the Complainant was admitted that for Injection Avastin for treating Macular Oedema and the said treatment is not covered under Clause 2.3 of the Terms & Conditions. Hence, the OP has repudiated the claim maintaining that the claim is “not admissible”.

          8. Clauses 3.11 and 4.24 deal with the coverage of treatment for which the patient has been hospitalised for a period of less than 24 hours. In the case in hand, the Complainant No.1 was admitted for in the hospital for a period of just 24 hours or just above (few minutes) 24 hours. The OP-1, repudiated the claim possibly for the reason that the said treatment does not require hospitalisation. However, it is important to mention here that the treating doctor Dr. Atul Kumar has given the certificate to the effect that the patient was advised hospitalisation as movement of the patient could be restricted for success of the treatment.

          9. In view of the fact that the patient was hospitalised for at least 24 hours on all occasions on the expert advice and recommendation of the treating doctor, the repudiation of the claims by the OPs is unjustified and liable to be rejected.

          10. Another ground for repudiation by the OP-1 is that the treatment taken by the Complainant herein was for Diabetic Macular Edema, which according to the OP is Age Related Macular Degeneration and not covered under the policy terms and conditions. However, the OP-1 has not placed on record any medical journal to indicate that both these conditions- Diabetic Macular Edema and Age Related Macular Degeneration are same and identical. In fact, Diabetic Macular Edema and Age Related Macular Degeneration are two different medical conditions and cannot be considered as one.

11. During final arguments, Ld. Advocate for the Complainant has filed the claim settlement letter dated 30.03.2022 for a different claim, which is not a subject matter of this complaint. He argues that the OPs, vide the claim settlement letter dated 30.03.2022 have settled the subsequent claim of the Complainant for the same treatment and have not used any of the exclusion clauses which have been used to repudiate other claims which are subject matter of this complaint. He also argues that the claim settlement letter dated 30.03.2022 deals with the same policy, same terms and conditions and the same treatment of the same patient/ insured/ complainant. In view of the subsequent settlement of the claim by the OPs for the same ailment, it has been argued that the previous claims of the Complainant should also be directed to be settled.

12. We are also in agreement with the argument of the Ld. Advocate for the Complainant that the OPs cannot be permitted to take different stands in different claims when the all such claims are identical under the same policy governed by same terms and conditions. Hence, on subsequent settlement of identical claims by the OPs, we are inclined to direct the OPs to settle the claims that are subject matter of this complaint as well.

          13. At this stage, we would also like to refer the order of Hon’ble Delhi State Commission in the matter of Oriental Insurance Co. Ltd. Vs. Vijay Prakash Sharma (FA No.314/2017) in which Hon’ble Delhi State Commission deal with an identical situation. Hon’ble Delhi State Commission while dealing with the said case has held that the repudiation was unjustified and upheld the order passed by this Commission in CC No.218/2015. While dealing the case in hand, we would also like to rely on the judgment of Hon’ble Delhi State Commission in FA No. 314/2017 and accordingly direct as under:-

(a)     The repudiations of the claims of the Complainant by the OPs are rejected and set aside. OP-1 is directed to make the payment of the claims of the Complainant which is quantified at Rs. 4,29,518/- alongwith interest @6% p.a. from the date of institution of this complaint i.e. 24.03.2021 within a period of four weeks from the date of receipt of this order.

(b)     OP-1 is also directed to pay the sum of Rs.25,000/- towards the harassment, mental agony and litigation cost. The payments so directed must be made within a period of four weeks from the date of receipt of this order.

(c)     If the payments so directed above are not made within the stipulated time, the entire amount due at the end of the said four weeks period shall bear additional interest @12% PA till actual payment is made.

14. Office is directed to supply the copy of this order to the parties as per rules. Thereafter, file be consigned to the record room. Ordered accordingly.

 

 

___________________________

Divya Jyoti Jaipuriar, President

 

 

___________________________

Ashwani Kumar Mehta, Member

 

 

___________________________

Harpreet Kaur Charya, Member