Date of filing: 17.04.2013.
Date of disposal: 03.04.2014.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: Sri A. M. L. Narasimha Rao, B.Sc., B. L., President
Smt N. Tripura Sundari, B. Com., B. L., Member
Thursday, the 3rd day of April, 2014
C.C.No.59 of 2013
Between:
Smt P. Suseela, W/o P. Prabhakar Rao, Aged about 62 years, Resident of Flat No.7, Pramoda Apartments, Brindavan Colony, Labbipet, Vijayawada – 10, Krishna District.
….. Complainant
And
The Star Health and Allied Insurance Company Ltd., Rep: by its Authorized Signatory (Claims), Corporate Claims Department, 6th Floor, KRM Centre No.2, Harington Road, Chetpet, Chennai – 600031.
. … Opposite Party.
This complaint coming on before the Forum for final hearing on 20.03.2014, in the presence Consumer Guidance Society for complainant; Sri Nori Sridhar, advocate opposite party and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble President Sri A. M. L. Narasimha Rao,)
1. A beneficiary under health insurance policy filed this complaint under Section 13 Consumer Protection Act, 1986 for a direction to the opposite parties to pay Rs.85,994/- as benefit under the policy, to pay Rs.10,000/- as compensation and to pay costs.
2. The averments of the complaint in brief are as follows:
The complainant’s husband had subscribed to a health insurance policy for himself and the complainant making payment of Rs.8,592/- as annual premium with risk cover from 12.10.2011 to 11.10.2012. The complainant had developed rheumatoid arthritis and she had to undergo treatment in Manipal hospital, Tadepalli from 10.9.2012 to 11.9.2012 for infusion of chemotherapy – RITUXIMAB. She was admitted as inpatient as per the expert medical advice. The complainant incurred an expenditure of Rs.85,994/- for that treatment. She made a claim for the said amount. The opposite party had repudiated the claim on the ground that RITUXIMAB can be administered as out-patient treatment and so amount is not payable. The opposite party did not accept the claim even on further request to review the decision. So this complaint is filed.
3. The opposite party filed version denying the allegations made in the complaint and further stating as follows:
The opposite party admits the issue of policy and period of risk cover. The opposite party further states that the RITUXIMAB infusion can be done as ‘Day care procedure’ which is outside the scope of policy, that the complainant was an DMARDS (Disease Modifying Anti Rheumatic Drugs and Steroids) and she was suffering from Rheumatoid arthritis (RA) for number of years prior to inception of policy, it is a pre-existing disease and that the opposite party is not liable to pay the amount claimed.
4. The complainant filed her affidavit and additional affidavit as deposition of PW.1. The Zonal Manager of opposite party filed his affidavit dt.2.1.2014 as deposition of DW.1. Exs.A1 to A12 are marked on behalf of the complainant. Ex.B1 is marked on behalf of the opposite party.
5. Heard the arguments advanced by both the counsel. They filed written arguments also.
6. The points for determination are:
- Whether the opposite party is justified in repudiating the health insurance claim and if there is deficiency in service on the part of the opposite party?
- Whether the complainant is entitled to the reliefs prayed for?
Point No.1:
7. The parties are not in dispute as regards the policy taken and the period of risk cover. According to the complainant she had undergone treatment of chemotherapy i.e., infusion of RITUXIMAB from 10.9.2012 to 11.9.2012. Ex.A3 is inpatient bill and discharge summary issued by Manipal hospital for the treatment taken from 10.9.2012 to 11.9.2012. It appears from Ex.A3 that the patient was admitted at 11.52 am on 10.9.2012 and chemotherapy was done on 11.9.2012 and she was discharged on 11.9.2012. The diagnosis was rheumatoid arthritis and treatment given is 1st cycle of chemotherapy with injection REDITUX RA 1000 mg IVF. It is therefore clear that the treatment given is 1st cycle of chemotherapy.
8. The opposite party had repudiated the claim to the letter dated 25.10.2012 stating that the team of the insurance company re-examined the claim records and pointed out that RITUXIMAB diagnosis other than chemotherapy is not a FDA approved diagnosis and that the said injection is given as day care procedure and does not warrant hospitalization and therefore the treatment is not admissible as per the policy. So the claim was rejected on the ground that the injection administered was a day care procedure and does not warrant hospitalization and day care procedure is not covered by policy. The opposite party had not taken any other ground for rejection or repudiation. In the version filed by the opposite party they had taken the plea of pre-existing disease. Even in that regard the opposite party has not clarified if repudiation was on the ground of taking treatment for pre-existing disease not covered by any specific clause of the policy.
9. There is absolutely no material available in the record to show that by the date of taking the policy the complainant was suffering from rheumatoid arthritis or the symptoms of RA. It is further to be noted that the policy was taken in the month of October, 2010 while the treatment was taken in the month of September, 2011 i.e., nearly after 11 months from the inspection of policy. There is no rule and the opposite party has not placed convincing medical literature to show that when the patient was suffering from RA an 1st cycle chemotherapy was administered the patient must have experienced symptoms of RA for more than 11 months or one year prior to the 1st cycle chemotherapy. For diagnosis of RA the minimum period required is six weeks. The learned counsel for the complainant filed medical literature according to which the RA is diagnosed if the answer is in the affirmative to all the following questions:
- Is musculoskeletal complaint is articular?
- If the complaint exists for six weeks and making it chronic?
- Is there prolonged morning stiffness – swelling, systemic symptoms and ESR or CRP elevated?
- Whether more than three joints are involved – involvement symmetric?
- Are PIP, MCP or MTP joints involved?
To get answers to these questions there is no need of waiting for one year or 11 months to commence chemotherapy. No doubt for some time prior to administration of 1st cycle of chemotherapy the patient may have symptoms but it cannot be readily said without some supporting literature that the patient must have had symptoms 11 months prior to commencing the 1st cycle of chemotherapy. Therefore we cannot readily accept the defence of pre-existing disease or condition raised by the opposite party. Ex.B1 has no value as the doctor who issued Ex.B1 did not see the complainant and did not examiner her.
10. The opposite party itself had stated in the version that expenses on hospitalization for minimum period of 24 hours are admissible however that limit will not apply to (1) dialysis ( 2) chemotherapy (3) Rheumatoid Arthritis etc., the opposite party again states that time limit will not apply for the present treatment taken by the complainant. Though it is stated in paragraph-9 of written version that copy of day care procedure is filed, no such document is filed by the opposite party. According to the aforesaid statement of the opposite party minimum period of 24 hours hospitalization is not required in case of chemotherapy. Infusion of RITUXIMAB is noted by Manipal hospital as chemotherapy procedure in Ex.A3. The opposite party does not deny anywhere that it is not part of chemotherapy. So even if administration of RITUXIMAB is considered as day care procedure the opposite party is bound to accept the claim.
11. It is not for the insurance company to decide whether a patient is required hospitalization or not or whether RITUXIMAB shall be given or not. It is for the treating doctor to take decision. Therefore keeping the complainant in the hospital for one day on the medical advice cannot be rejected by insurance company. Therefore we are of the considered opinion that the opposite party is not justified in rejecting the claim of the complainant. Consequently we hold that there is deficiency in service on the part of the opposite party.
Point No.2:
12. In view of the answer on point no.1 the complainant is entitled to the bill amount of Rs.85,994/- and also interest thereon from the date of rejection i.e., 25.10.2012 till payment or realization and costs assessed at Rs.2,000/-. We are not inclined to award further compensation.
13. In the result this complaint is allowed in part and the opposite party is directed to pay Rs.85,994/- with interest thereon at the rate of 9% p.a., from 25.10.2012 the date of rejection till realization and to pay costs of Rs.2,000/- to the complainant. The amounts awarded shall be paid within one month from the date of this order. The complaint for rest of the reliefs is dismissed.
Dictated to steno, N. Hazarathaiah, transcribed by him, corrected by me and pronounced by us in the open Forum, this the 3rd day of April, 2014.
PRESIDENT MEMBER
Appendix of evidence
Witnesses examined
For the complainant: For the opposite party:
Smt P. Suseela – PW.1 The Zonal Manager OP.
(by affidavit) DW – 1, (by affidavit).
Documents marked
On behalf of the complainant:
Ex.A1 Photocopy of policy.
Ex.A2 09.09.2012 Photocopy of pre-authorization request form.
Ex.A3 11.09.2012 Photocopy of inpatient bill.
Ex.A4 10.09.2012 Photocopy of authorization rejection letter.
Ex.A5 10.09.2012 Photocopy of certificate issued by Manipal hospital.
Ex.A6 Photocopy of claim form for medical insurance.
Ex.A7 25.09.2012 Photocopy of inpatient bill.
Ex.A8 25.09.2012 Photocopy of discharge summary.
Ex.A9 Photocopy of claim status.
Ex.A10 19.10.2012 Photocopy of letter issued by complainant to Op.
Ex.A11 25.10.2012 Photocopy of repudiation letter.
Ex.A12 18.11.2011 Original copy of blood report.
On behalf of the opposite party:
Ex.B1 03.10.2012 Photocopy of opinion letter issued by Dr. B. Pasupathy.
PRESIDENT
