Delhi

East Delhi

CC/662/2015

MUKESH - Complainant(s)

Versus

U.I.C - Opp.Party(s)

06 Mar 2019

ORDER

                 DISTRICT CONSUMER DISPUTE REDRESSAL FORUM EAST Govt of NCT Delhi

                  CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

                                                                                                   Consumer complaint no.      662/2015

                                                                                                   Date of Institution              04/09/2015

                                                                                                   Date of Order                      06/03/2019                                                                                   

In matter of                                                                              Date of Order                      08/03/2019    

Mr. Mukesh Mittal  

s/o Sh Ishwar Dayal Mittal  

R/o Z 25 Naveen Shahdara, Delhi  110032………………..…………….Complainant                                                                   

                                                                      

                                                                          Vs

1-The Manager

United India Insurance Co.,

D8, CSA Marg, Laxmi Nagar,    

Vikas Marg, Delhi 110092

 

2-M/s United India Insurance Co.,

Regd Office 24, Whites Road, Chennai- 600014

 

3-The Manager

Medi Assist India Pvt Ltd.

B20, Sector 2, Nr Sec. 15 Metro Station

Noida, UP-201301………………………………..……..……….………………….Respondents

 

Complainant’s Advocate       RLA & Associates Advocates

Opponent’s Advocate            Mr Ashutosh Kumar

 

Quorum      Shri  Sukhdev  Singh    President

                     Dr P N Tiwari                Member

                     Mrs Harpreet Kaur      Member

                                                                                        

Order by Dr P N Tiwari, Member  

Brief Facts of the case                                                                                         

Complainant having mediclaim policy from OP1 from 05/10/2014 to 04/10/2015 vide policy no. 2215002814P104948238 as individual mediclaim policy for a sum assured Rs 5 lacs for himself and Rs 3,75,000/-for his wife and a sum of Rs 2.50,000/-for his child (Ex Anne. C-1). It was stated that wife of complainant was admitted in Indian Spinal Injuries Hospital in Delhi on 23/12/2014 and was discharged on 24/12/2014 as she had Ankylosing Spondilysis (AS) since long. Complainant after paying hospital bill of Rs 1,24,808/- submitted claim with OP3 on 30/12/2014 (Ex Anne. 2, 3 & 4). OP3 asked certain treatment documents for scrutiny of claim on 27/02/2015 which were submitted along with 10 years policy documents through email (Ex Anne. 6 &7). It was stated that his wife was also admitted from 13/04/2013 to 15/04/2013 for the same ailment in the same hospital. At that time the hospital bill was of Rs 25,809/-, but OP3 cleared for an amount Rs 19,404/-on 18/06/2013 and same amount was transferred via NEFT in the bank account (Ex Anne. 9) as on page no 49, but this time also she was admitted for the same ailment for one day, but claim was denied even after satisfying all queries (Ex Anne. 5&6). OP3 repudiated claim on 15/06/2015 (Ex Anne. 8) on ground of Exclusion clause 2.3.1 which states as admission was less than 24 hours and there was no necessity for admission in the hospital where all required treatment facilities were available in OPD. Legal notice was sent on 14/07/2015 through speed post. When no reply received, filed this complaint and claimed hospital bill of Rs 1,24,808/- with 12.5 % interest and Rs 3 lacs as mental agony and harassment with Rs 15,000/-as litigation charges.

After receiving notice, OP1 submitted joint written statement on behalf of OP2 and OP3. All the allegations were denied. As claim was repudiated under exclusion clause 2.3.1 which states admission was less than 24 hours as per terms and condition of the policy and there was no necessity of admitting insured/claimant in indoor for giving Injection Methylpredisolone and Inj Infimab 300 mg IV in a case of chronic Ankylosing Spondilysis (AS) where she was on regular OPD treatment. Treating hospital was well equipped with all advanced facilities in OPD, so repudiation was justified by OP3 in ref. to the terms and conditions of Policy. Hence, there was no deficiency in service by OP3, so this complaint may be dismissed.  

Complainant filed rejoinder to written statement and denied all replies submitted by OP. Complainant submitted that his claim was as per the policy conditions and his claim was under 4rth year of policy tenure. It was stated that his wife had back ach problem since long and OP had paid claim in 2013. He also submitted evidences though his own affidavit and reaffirmed on oath relying his evidence of policy documents (Ex Anne. C1) and claim submitted to OP (Ex Anne. 2&3) in ref to treatment bill (Ex Anne. 4). He relied on claim passed in 2013 (Ex Ann. 9), so claim was genuine under the policy condition and was filed in time, hence, claim be passed.

OP1 submitted their evidences on affidavit through their Senior Division Manager Mr Y R Kanaujia working with OP1. He affirmed their repudiation justified under the Exclusion clause 2.3.1 where Co. would not be liable to pay the hospital expenses if claimant/insured got admitted and discharged within 24 hours (Ex OPW1/A). It was timely intimated to complainant about claim rejection (Ex OPW1/B).

Both the parties submitted their written arguments and taken on record. OP1 in written argument, stressed clauses 3.9 and 3.10 of policy terms which states that “admission under OPD procedure/Day care Treatment be medical or surgical procedures done under Local or General Anesthesia, claims were not be payable by the Insurer”/OP1. OP1 had also referred citations pertaining to above clauses in –

i-Suraj Mal Ram Niwas Oil Mills Pvt Ltd vs UIICL & others (2010)10SCC 567 and

ii- Vikram Green Tech India Ltd & others vs NIAC Ltd. (2009)5 SCC 599.  

Where it was laid down that ‘Insurance contract was based on obligations of terms of contract’  and risk of duration would be determined the extend of liability of the Insurance.   

Arguments were heard from both the parties. After perusal of evidences on record, order was reserved. After seeing all the facts of the case, it was observed that complainant’s wife was a case of Ankylosing Spondilysis (AS) and was taking OPD treatment even before getting admitted on 23/12/2014 for Inj. Infimab 300 mg with Inj Methyl Prednisolone IV slow infusion. The said Inj Infimab was given on 23/12/2014 with all tests were done on the same date and Invoice of Inj Infimab. On 24/12/2014, USG and Cardiac evaluation (both reports were normal) were done which do not require indoor admission. So, this means insured/claimant remain admitted on 23/12/2014. No active line of treatment was done on 24/12/2014 except giving Inj Methyl Prednisolone (long acting steroid) which do not require indoor admission beyond 24hours. The said ailment AS is a very chronic ailment of lower backbone vertebrae and in passage of time, disc gets severely compressed (due to demineralization) leading to moderate to severe pain during routine work. It was evident that claimant/Insured was admitted in the same hospital in 2013 for the same ailment for three days, but this time she was admitted from 23/12/2014 to 24/12/2014 for one day, so OP1 repudiated claim under exclusion clause 2.3.1. We have also seen discharge summary (Ex Ann.14) which showed one Inj Infimab (Ex Ann.15A) invoice for Rs 25,305/. This injection has a fixed schedule of administration between 0 week to 6^th week and thereafter depending upon radiological opinion and blood parameters, but such facts were not mentioned. As far as claim amount is concerned, we have seen that Pharmacy bill of Rs 99,175/ which also has not been clarified as how many Inj Infimab 300 mg were administered in one day or purchased. Because this injection being very costly (over Rs 25,000/-per vial) and has a long acting anti inflammatory effects, so proper prescription has to be on record which was not available against the hospital bill of Rs 99,175/-.

Inj. Infliximab (Infimab) being a first line of Immunosuppressive drug of treatment in severe active AS. A dose of 5 mg/kg body weight with intervals for IV infusion between 0, 2 & 6 weeks depending on the disease activity. Treating hospital has not clearly written doses schedule of Inj Infimab besides unwarranted investigations were done as Colour Doppler ECOCARDIOGRAPHY, USG Upper Abdomen and Mantoux Test (for TB) in the treatment of AS (Ann. 15 & 16). Bills raised by complainant for Dr Kakkar’s Clinic dated 17/12/2014, 19/12/2014 and 21/12/2014 pertains to allergic ailment (Anne. 17A,B&C). OP1 had passed claim in 2013 for same diagnosis/AS for three days admission which was certainly more than 24 hours and claim was justified, but certainly this claim falls within 24 hours of hospital admission and Inj Infimab 300 was given on 24/12/2014, so repudiation is justified by OP3. There is no evidence of 10 years policies on record as stated by complainant. That being so, this complaint has no merit and the same deserves dismissal so dismissed without any order to cost or direction to OP1 & 3(TPA) and OP2.     

The first free order copy be sent to the parties as per the Consumer Protection Regulations and file be consigned to the record room accordingly.

 

(Dr) P N Tiwari – Member                                                                      Mrs Harpreet Kaur- Member                                              

                                    

                                                Shri  Sukhdev Singh - President