JUDGEMENT

          Complainant by filing this complaint has submitted that employer of the complainant i.e. Tablets (India) Ltd. as Group Medicals (Tailar made with Floater Policy) for the employees including the complainant through the op no.1 and op no.1 arranged policy from op no.3 for the period from 24.04.2010 to midnight of 23.04.2011 and also for the period 24.04.2011 to midnight to 23.04.2012 from the op no.2 and in both two policies complainant was under coverage of the said Mediclaim Policy.

          That the New India Assurance Co. Ltd. issued the policy being No.710802/34/10/87/00000216 and the National Insurance Co. Ltd. issued a policy being No. 500600/46/11/85/0000021.  Subsequently complainant was examined in the 1^st week of April, 2011 by Dr. S.N. Mukherjee as he was suffering from low back pain and stiffness.  That the said doctor after making investigation found that complainant was suffering from several Ankylosing Spondylosis and according to the advice of the said doctor complainant was hospitalized to take Infiximab (Remicade 100 mg) total 300mg and for that purpose as per advise of the doctor, he took admission on 20.04.2011 and was discharged on 21.04.2011 and accordingly he submitted the claim through op no.1 for reimbursement of the treatment amounting to Rs.1,03,488.70 paisa.  But the said claim being claim No.CHE-0511/CL-0003873 was denied and repudiated by letter dated 21.06.2011 issued by op no.1 stating inter alia that the said treatment was possible as an OPD basis and hospitalization was not required for the said purpose.

          Subsequently complainant again suffered problems and contacted with Dr. Sambhu Nath Mukherjee who on examination advised the patient to take admission in the hospital for taking injection Remicade – 300mg and the said advice was made on 09.05.2011.  Accordingly as per advice he was hospitalized on 10.05.2011 and after such treatment he was discharged on 11.05.2011.  Complainant made claim of Rs.1,03,464.18 paisa to the op no.1 out of the policy issued by National Insurance Co. Ltd. for reimbursement of medical expenses.

          Complainant being the insured made the claim for his genuine purpose and such refusal by the ops caused loss and sufferings to the complainant.  Complainant was not hospitalized for his own choice but as per his treating doctor he was hospitalized and treatment was given by the doctor and complainant followed the advice of the doctor.  But the decision taken by the ops was on mere surmise and conjecture and without any basis at all and as such refusal of the claim cannot stand and practically for the negligent and deficient manner of service and adopting unfair trade practice, complainant suffered much and for which complainant prayed for redressal and for release of Rs.1,03,488.70 paisa along with interest and other compensation.

          On the other hand New India Assurance Co. Ltd. op no.3 by filing written statement submitted that allegation of the complainant is completely false and practically for inoculating intravenous injection does not require for hospitalization of the patient and it may be done on OPD basis and it is very much apparent in order to invoke the coverage of the subject policy so as to get benefit of that injection he was hospitalized for a day and there was no investigation, diagnosis etc. but only for injection he was hospitalized that is not tenable in the eye of law and as per giving conscience of the said doctor that the process of injection takes roughly three hours to complete the process and for that cause hospitalization is not necessary for that treatment and from the entire fact, it is clear that to get reimbursement for the high value medicine required for reliving the pain, the insured got himself admitted to a hospital as allegedly prescribed by his treating doctor and which has been negativated by the relevant TPA and as such the question of genuinity of claim is on flimsy ground and so negligence and deficiency of service of the op does not arise at all.  Moreover it is a fact that complainant is suffering from pre-existing disease and so he is not entitled to get any benefit.

          On the other hand National Insurance Co. by filing written statement submitted that two separate policies were issued by two separate Insurance Companies op nos. 2 & 3.  So, cause of action arose under different place and different dates so it cannot be clubbed together under same cause of action and hence the present case is not maintainable in the eye of law.  Further it is contended by the op no.2 National Insurance Co. Ltd. that the insured claim after scrutiny of the claim documents as submitted it had been found that the claim is for Ankeylosing Spondylosis received Ramicade and such treatment is possible on OPD basis and medically period for treatment is only for two or three hours and as because treatment is possible on OPD basis Ramicade injection is not payable by the insurer and said opinion of the concern doctor’s the complainant’s claim is not tenable under the policy condition and hence instant complaint of the complainant should liable to be dismissed and on scrutiny of the claim documents as submitted it was found that there was no active treatment given and only injection was administered which is possible on OPD and no investigation was done, only injection was given.

          So apparently it is proved that as per policy condition no treatment was given and moreover the doctor of op no.1 came to a conclusion that such a treatment was not at all treatment as there was no diagnosis, not detection only for purpose of injection he was admitted and practically it was done only for purpose of getting the cost of the high price of injection.  So the present claim is not tenable and complainant’s entire allegation is false and fabricated.

                                                       Decision with reasons

          On proper scrutiny of the complaint and written version including the policies of National Insurance Co. Ltd. and New India Assurance Co. Ltd, it is found that as per policy insured is M/s Tablets India Ltd. of Egmore Chennai and complainant is the employee of M/s Tablets India Ltd. and as per Group Medicine Policy, complainant is an employee of M/s Tablets India Ltd as beneficiary of that policy.  But no part of transaction was held within West Bengal which is fact.  But truth is that registered office of the National Insurance Co. Ltd. is at 3, Middleton Street, Kolkata – 700071 where as the another policy of the New India Assurance Co. Ltd. is valid from 20.04.2010 to 23.04.2011 and insured is M/s Tablets India Ltd. and issuing office is at Egmore at Chennai.  But no registered office of the New India Assurance Co. Ltd. is at West Bengal.

          After hearing the Ld. Lawyers of both the parties and also considering the medical paper it is found that Dr. S.N. Mukherjee examined Santanu Roy and found that complainant had been suffering from low back pain for 9 to 10 months prior to both of his examination on 17.04.2012 and has been suffering from low back pain from the date of such examination and he was examined at the chamber of Dr. S.N. Mukherjee who only asked him to get Ramicade injection of 300mg. From the receipt of Dhanwantary Medicare Research Centre Pvt. Ltd. dated 19.04.2011 it is found that complainant purchased 3 foils of Remicade 100mg each and he paid Rs.99,429/- and no doubt the medicine is costly medicine and from the patient bill it is found that complainant was admitted at Apex Institute of Medical Sciences on 20.04.2011 and was discharged on 21.04.2011 at 6:00 PM and paid Rs.1,37,951/- but no treatment sheet of Apex Institute of Medical Sciences is filed and in fact complainant purchased the medicine prior to his admission to Apex Institute of Medical Sciences.  But no treatment sheet of Apex Institute of Medical Sciences is filed but one discharge summary is filed wherefrom it is found that the prescription which was given by Dr. S.N. Mukherjee on 17.04.2011 is replica and practically there was no diagnosis and or any treatment.

          But only for the purpose of giving that injection, complainant was admitted on 20.04.2011 and was discharged on 21.04.2011.  But it is proved that it was not the first history of low back pain of the complainant.  But it is clear that complainant has been suffering from stiffness for low back pain for long months prior to that and in fact after admission to Apex Institute of Medical Sciences no medicine was purchased but medicine was purchased on 19.04.2011 and in the hospital after admission no medicine was purchased.  Then it is clear only for the purpose of realization of price of the said injection this admission was made.

          Most interesting factor is that no diagnosis was done, but only patient discharge summary in one page was given.  In similar manner only for taking similar type of injection complainant was admitted on 10.05.2011 and was discharged on 11.05.2011 and similar injection was administered in the same hospital that means one injection was transfused on 20.04.2011 and another injection was transfused on 10.05.2011 just after one month.  But both the cases clinical summary and final diagnosis are absent.  But considering the entire fact it is clear that long prior of taking of those two injections, complainant had been suffering from Ankylosing Spondylosis and on other occasion also he received the same injection for which in all cases the name of same injection is preferred by the doctor and fact remains the price/value of the injection is very high.

          Now the question is whether the injection can be given conservatively at OPD or at home.  From the letter of Dr. S.N. Mukherjee written to TTK Health Care Services Pvt. Ltd it is clear that doctor in his last para of the letter admitted that complainant is a very middle class family and could not afford such expensive treatment.  So, he requested to TTK Health Care Services Pvt. Ltd. to help him to get proper financial assistance and no doubt as doctor he showed his morality and from that letter it is clear that the doctor adopted the procedure for admission only to give the relief of middle class family but from the Journal Remicade it is found that in case of Ankylosing Spondylosis Remicade treatment is to be administered under the supervision of experienced doctor for diagnosis and treatment of Ankylosing Spondylosis and further it is specifically mentioned in that Journal that infusion time is only two hours and all patient administered Remicade injection are to be observed for at least one hour post infusion for side effects, medication in or other ways and they must be available or the treatment of this effect as precautions.  But in case of Ankylosing Spondylosis 5mg/kg given as an intravenous infusion over a 2 hour period followed by additional 5mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 6-8 weeks after the first infusion, then every 8 weeks thereafter. 

          So, it is clear that Remicade infusion is part of continuous process of taking such injection and from the present documents it is clear that complainant prior to that took such medicine and previously the price of the present Remicade was very standard but subsequently it was increased and complainant is unable to purchase it.  Further it is clear that complainant has been suffering from pre-existing disease of Ankylosing Spondylosis for which he had been treated but subsequently when complainant realized that it would not be possible to afford such money for purchasing such sort of Remicade injection, so he somehow requested the doctor and doctor gave him such chance to admit so that he may get the cost of injection and the last line of the letter of doctor to TTK Health Care simply speaks that letter was submitted by the complainant’s doctor S.N. Mukherjee in respect of treatment from 20.04.2011 to 21.04.2011 and for the sake of the argument if it is accepted that doctor on humanitarian ground admitted the complainant on 20.04.2011 and was discharged on 21.04.2011 to give him relief to get the benefit of the reimbursement in respect of the Remicade injection infusion, then invariably in next occasion on 10.05.2011 the said doctor adopted the same procedure and fact remains prior to that this complainant was examined by the same doctor and the doctor also advised him to take same type of injection.  At that time the price of the injection was very low.  So, complainant did not take any chance for his admission for reimbursement.

          Truth is that complainant in respect of the first dose i.e. for the period 20.04.2011 to 21.04.2011 without any diagnosis doctor came to final diagnosis Ankylosing Spondylosis.  But this diagnosis was already diagnosed prior to his admission that means complainant had been suffering from Ankylosing Spondylosis long prior to his admission and for last 10 months prior to first admission to the hospital and no doubt he had been getting such doses by same doctor because as per medical journal in case of Ankylosing Spondylosis of infusion for every two hour period followed by additional 5mg/kg infusion dose at 2 and 6 weeks after first infusion, then every 6-8 weeks after the first infusion, then every 8 weeks thereafter for this Remicade in fixing is taken into account.

          So it can safely be said that this two injections were last part of total treatment and doctor has admitted, in his letter to TTK Health Care that as because the complainant is middle class family member and such cost of injection is expensive.  So his matter may kindly be properly considered it indicates that doctor knowing fully well that such sort of injection can be given at OPD but only to get the benefit of the mediclaim policy he was admitted for one day because if any patient is not admitted for 24 hours, he shall not have to get benefit of the medicine including the admission.

          So, his admission was given 24 hours but there was no reason to keep the patient for 24 hours for giving Remicade but it requires only 2 hours, one hour for infusion and another one or two hour for observation required but not 24 hours and itinerary does not support that one day admission is required in any case.  Moreover considering the discharge summary issued by the hospital it is found that the complainant was admitted on two different days and no treatment was given except giving Remicade for two occasions as infusion.

          So, considering that fact it is clear that the present injection as given to the complainant by the doctor was the part of continuous process because complainant has been suffering from some diseases for more than 10 months prior to first admission on 20.04.2011.  So, it was nothing but continuous process of the previous treatment and as per previous diagnosis he was admitted only for taking that injection not for any other purpose and during hospitalization there was no fresh diagnosis or any fresh part of treatment.  But it is continuation of the previous domiciliary treatment.  So as per provision of clause 4.27 of the terms and conditions of the policy, no doubt TTK rightly rejected that part and fact remains only to get the said amount of injection complainant admitted because the cost of the injection is very high and only for getting reimbursement with the help of the doctor, he was hospitalized and considering the two discharge summary in all occasions he was admitted at the hospital only for getting injection, but for no other treatment cost.  Complainant is a patient of chronic Ankylosing Spondylosis and for which Remicade is the only injection which is required to be given to any such patient earliest on one occasion and thereafter one month thereafter every 6 to 8 weeks and fact remains he was under constant treatment prior to this admission and this treatment can be given in domiciliary system and taking into account of both the discharge certificate we are confirmed that no fresh treatment was given to the complainant by the present hospital or the doctor but only for the purpose of transfusion of Remicade he was hospitalized and after reading the literature regarding dosages and administration it is found that it can easily be transfused in OPD or in domiciliary manner and only two to three hours are sufficient for that purpose and further it is found that in respect of Ankylosing Spondylosis Remicade is the only medicine and it is not part of treatment for each and every admission as made by the complainant.

          But such treatment is a part of continuous domiciliary treatment and that had been continued prior to admission of the complainant which is evident from the prescription dated 17.04.2011.  Truth is that on 19.04.2011 complainant purchased the said medicine but not after admission and so admission of complainant was on the mercy of the doctor under whom he had been treated earlier.

          Considering all the above fact and materials including the clause 4.8 of the terms and conditions of the policy and also the reason for rejecting the claim of the complainant we have gathered that the claim of the complainant was rightly rejected and from the doctor’s own letter it is clear that anyhow 24 hours admission in the hospital is not at all required for causing infusion of Remicade.  So, it is clear that hospitalization was necessity only for reimbursement of the price of the said medicine Remicade injection.  But the present disease is pre-existing disease and complainant had been suffering from long 10 to 12 months and had been taking the said injection and no doubt complainant has suppressed the fact and at the same time doctor has also not stated that for any reason it was not possible to give such injection in OPD.

          Another factor is that in both the occasions no fresh diagnosis for every treatment was done by the hospital authority or by the doctor that is evident from all the discharge certificates.  Further it is undisputed fact that as it is evident from the other prescription that the present complainant has been suffering from Ankylosing Spondylosis but that matter was not disclosed initially at the time of purchasing the present policy.  Fact remains complainant did not report the fact to his employer also.  At the same time complainant has failed to produce any document to show what was his leave period from his duty to the employer during last 10 months and if it would be produce in that case it would be found that he had been suffering from several diseases and he took several leave for taking medicine in his house or some other places.

          But anyhow it is a part of continuous treatment and considering all the facts it is clear that TTK authority considered what is the factor and rightly rejected the claim and fact remains Hon’ble National Commission already decided that only in respect of treatment the insured is entitled to get such relief but in all discharge certificate no treatment was given only injection was given and it is part of domiciliary treatment and fact is that TTK authority already informed the complainant.  So after considering the above facts and also the explanation given by the TTK in writing to the complainant we are convinced to hold that the present related admission of the complainant was made by the doctor only to give a chance to the complainant to get reimbursement of the price of the injection but no for treatment and diagnosis.

          So, applying our judicious mind we have gathered that practically complainant has been spending huge money for taking such medicine Remicade for getting relief from pain but complainant ought to have got it in domiciliary form time to time but by admitting again and again for taking this injection complainant is trying to get benefit of the injection which is being used for his pre-existing disease for which complainant is not entitled to but truth is that the cost of the injection is very high.  But complainant has taken it previously and subsequently such sort of injection only gives relief for such sort of diseases and same can only be taken in domiciliary form.  But truth is that doctor has completely noted in its treatment sheet that no other treatment and medicine diagnosis were not done except for infusion of Remicade. 

          So, it is clear that it is domiciliary in nature.  So invariably the complainant is not entitled to get any benefit in the present case.  No doubt we have gathered that complainant has been suffering from Ankylosing Spondylosis for long period and for which he has been spending huge money and fact remains we are guided by the terms of the policy so we are not able to give any exgratia relief.  But anyhow both the parties are guided as per terms and conditions of the policy and also in this regard the ruling reported in 2012 (4) CPR 165 NC is applicable and as per observation of the said ruling we are also guided and no doubt both the parties of this case shall be strictly governed by the policy condition and no exception and relaxation can be made on the ground of equity.

          In the above findings, the complaint fails.

          Hence, it is

                                                               ORDERED

          That the complaint be and the same is dismissed on contest against op but without any cost.