“As per the T&C, Immunotherapy – Monocional Antibody to be given as injection – per policy period 10% of SI.”
It was imperative to point out that on same day i.e. 27.09.2021, Consumer/Complainant raised concern and query as below:-
“What is SI in this”
No justification of claim denial was given and was rejected out rightly under shoddy “10% of SI”.
Perusal to discharge summary received from opposite party No.4, it was prescribed to patient by physicians for Biologic Therapy (Rituximab) after screening for necessary medical tests. Confirming previous history of infusing on inj. Reditux RA (Rituximab) 1000 mg in 2019 and once she was stablized she was discharged by opposite party No.4. It was very much apparent from the above mentioned facts that all medical records with supporting documents were duly provided without any cause and error on part of his above mentioned client. Consumer/complainant further cooperated with opposite party and received pre-approval for the above mentioned tratment. Howeve,r it was really of great inconvenience to his client that opposite party did not ocmply to his office legal enforceable liability to approve medical claim for amount of Rs.1,00,591/-. However, the sme was denied citing reason which were never informed to consumer/complainant at the time of securing pre approval of the above mentioned hospitalization. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the complete claim amount of Rs.82,591/- alongwith post discharge medicine & tests amounting to Rs.7996/- with interest @ 24% p.a. from the date of filing of the complaint.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the complaint was not maintainable in view of the facts that insurance was a binding contract between the insured (complainant) and insurer . Court cannot add, delete or substitute anything in that contract. It was submitted that the complainant and his wife were insured with the answering opposite parties under Happy Family floater policy bearing No. 272400/48/2022/2960 w.e.f. 30.06.2021 to 29.06.2022 for sum insured of Rs.2,00,000/- under Silver Plan having Co-payment of 10% subject to its items and conditions in corporate therein. After receiving claim of Rs.1,00,591/- for medical expenses of injection Rituximab 1000 mg IV being diagnosed for Rhumatoid Arthritis of Smt. Krishna Devi same was got processed by the team of the doctors of opposite party No.3 and finally the claim was processed and permissible and admissible amount being as per clause G of the terms and conditions of the policy “Immunotherapy – Monoclonal antibody to be given as injection – per policy period 10% of sum insured was payable” hence the said claim was settled for Rs.18,000/- paid UTR No. 109272852233 dated 27.09.2021, the detail of deduction was of Rs.82,591/- (Rs.80,591/- immunotherapy – Monoclonal Antibody to be given as injection was payable upto 10% of sum insured per policy period, Clause No. 5 General Exclusion Compulsory Co-payment: Under the silver plan the insured had to bear 10% of admissible claim amount in each and every claim, so Rs. 2000/- were deducted for co-pay of 10% on each and every clam under silver plan) . In view of the aforesaid terms and conditions as well as details of documents stated above the complainant was not entitled for any further amount reason being the admissible amount had already been paid by the opposite party No.3 on behalf of answering opposite parties Nos.1 & 2, same was duly admitted by the complainant. The complainant was estopped by his own act, conduct, admission and commission from filing the present complaint. It was pertinent to mention that under the present policy the entitlement of complainant was “Immunotherapy - Monoclonal antibody to be give as injection - per policy period 10% of sum insured was payable” and being silver plan there was co-payment of 10% of the claim amount as mentioned in the terms and conditions of the insurance policy. Opposite parties Nos. 1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Shri Vikas C. Tiwari, counsel for the complainant has made a statement that he wanted to make opposite party No.3/TPA as proforma opposite party.” vide order dated 18.04.2022.
4. Opposite party No.4 put in appearance through counsel and filed written statement wherein Opposite party No.4 refuted claim of the complainant and submitted that complainant while filing the present complaint had sought recovery/refund of alleged amount of Rs.82,591/- alongwith alleged post discharge medicine & tests amounting to Rs.7996/- on the ground that it was entitled for same as per the alleged insurance policy. Opposite party No.4 had n neither issued the alleged insurance policy nor wa sin receipt of any alleged premium, nor any claim amount from any of the parties. Opposite party No.4 had only provided treatment to complainant, against which complaint had made the payment to the opposite party No.4 hospital, without any protest and demur. It was submitted that the opposite party No.4 was only the treating hospital, who treated the complainant’s wife for her ailments and had raised the bills according to the prevailing tariff for the treatment. It was submitted that keeping in view the clinical condition of the patient it was decided to start her on Biologic Theraphy i.e. Inj. Rituximab. She tolerated the infusion well and her vitals remained stable during and after infusion and she was discharged from the hospital in a stable condition. The denial of the claim of the complainant was between the TPA (opposite party No.3, who was appointed by the opposite party No.1 insurance company) and the complainant. Opposite party No..4 (hospital) had no role to play in the rejection of the complainant’s claim. The terms and conditions of the insurance policy were between the complainant and the opposite parties Nos.1 & 2. Opposite party No.4 (hospital) was not privy to the same. It was submitted that opposite parties Nos.1 & 2 had rejected the claim raised by the complainant at the advice of the TPA, appointed by opposite party No.1The answering opposite party No.4 had nothing to do with the repudiation of the said claim. Opposite party No.4 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties– The Oriental Insurance Company Ltd. & Ors. with the prayer to: a) pay the complete claim amount of Rs.82,591/- alongwith post discharge medicine & tests amounting to Rs.7996/- with interest @ 24% p.a. from the date of filing of the complaint. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CE1/A – affidavit of Hakim Rai Chauhan, Ex.C-1 – insurance policy valid from 30.06.2021 to 29.06.2022, Ex.C-2 – Pre Authorization Approval Letter dated 01.09.2021, Ex.C-2(colly) – Pre –Authorization Denial Letter dated 0209.2021, Ex.C-3/A – email, Ex.C-4 – email dated 27.09.2021, Ex.C-5 – legal notice.
On the other hand counsel for the opposite parties Nos.1 & 2 strongly agitated and opposed. As per the evidence of the opposite parties Nos.1 & 2 Ex.RW1/A – Ramesh Kumar, Sr. Div. Manager of the Oriental Insurance Co. Ltd. Ex.C-1 – Happy Family floater-2015 Policy Schedule, Ex.CR-2 – terms and conditions, Ex.R-3 – Reimbursement Main Claim No.211400221836.
As per the evidence led by opposite party No.4,Ex.RW4/A – affidavit of Mr. Hem Chandra Gupta presently working as Assistant General Manager (:ega;) at Indraprstha Medica Corporation Ltd., having its registered office at Delhi –Mathura road, Sarita Vihar, New Delhi..
8. It is evident from Happy family floater – 2015 Policy Schedule, & Pre-Authorization Approval Letter vide Ex.C1 & C2, the complainant has himself and his wife namely Krishna Devi Chauhan insured with opposite parties Nos.1 & 2 vide policy No 272400/48/2022/2930 & TPA No. YA0000000371 for policy from 30.06.2021 to 29.06.2022.. Insured Krishna Devi Chauhan was suffering from Rhumatoid Arthritis and in order to diagnose the same visited opposite party No.4 hospital and was advised for hospitalization. Pre-approval authorization vide claim No. 211400198097 dated 01.09.2021 was approved by opposite party No.3 for amount of Rs.16200/- with below comments:-
“Final settlement will be done strictly as per agreed hospital tariff irrespective of authorization issued. 10% copay deduction”.
Claim No. 211400198097 dated 01.09.2021 pre-authorization had been rejected by opposite party No.3 vide letter dated 02.09.2021 on the ground that “….Admission is not justified only for injection. Liability cannot be ascertained at this juncture. Hence, pre-authorization facility can’t be extended in this case.”
9. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties Nos.1 to 3 are directed to process the claim of the complainant as per the terms and conditions of the policy within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties Nos.1 to 3 are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 17.02.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
