| ORDER | BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR. Consumer Complaint No. 672 of 2014 Date of Institution: 22-12-2014 Date of Decision: 22-07-2015 Mrs.Kailash Soni wife of Late Sh.Om Parkash Soni resident of 38, Sawan Nagar, Amritsar, at present House No.53, Guru Nanak Avenue, Phase No-III, Majitha Road, Amritsar. Complainant Versus United India Insurance Company Limited, 1374/XVII, First Floor, Alfa Lane, Near Punjab & Sind Bank, Batala Road, Amritsar. Opposite Party Complaint under the Consumer Protection Act, 1986. Present: For the Complainant: In person. For the Opposite Party: Mrs.Neena Kapoor, Advocate. Quorum: Sh.Bhupinder Singh, President Ms.Kulwant Kaur Bajwa, Member Mr.Anoop Sharma, Member Order dictated by: Sh.Bhupinder Singh, President. - Present complaint has been filed by Smt.Kailash Soni under the provisions of the Consumer Protection Act alleging therein that she has been getting herself insured with the Opposite Party under their medical policy for the past approximate 10 years i.e. from the year 2003. The complainant has not reported any claim to the Opposite Party under the said policies and all the policies are claim free policies. Complainant alleges that in the year 2013, she suffered eye problem and she consulted Dr.Om Parkash Eye Institute Private Limited, The Mall, Amritsar and as per the advice of the doctor, she had to undergo diagnostic tests in the hospital. The complainant was diagnosed as a case of Occult CNVM in right eye, due to which, the complainant was advised for Inj.Avastin in right eye. Accordingly, the complainant was admitted in the hospital on 2.12.2013 and discharged on 3.12.2013 after completing their prior procedure for the treatment. Said hospital charged from the complainant, injection cost, surgeon fee, theatre charges, lab charges and room rent being admission and expenses incurred as a Indoor Patient towards the treatment of her right eye. After the treatment, the complainant submitted the claim of Rs.14,027/- alongwith all the medical documents to TPA i.e. Alankit Health Care TPA Limited, who is a medical claim settlement authority of Opposite Party. The documents were submitted as per the advice of the Opposite Party for the approval of the claim, but the Opposite Party refused to make the claim amount of the complainant vide their letter dated 23.1.2014 on the ground that the Injection Avastin being not payable. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay Rs.14,027/- being the amount of claim alongwith interest @ 15% per annum. Compensation and litigation expenses were also demanded.
- On notice, Opposite Party appeared and filed written version in which it was submitted that the medical expert reviewed the case and it has been perused that the insurance has been done, but it does not cover the expenses incurred by the complainant meaning thereby that policy in question is taken, but the treatment alleged to have taken are not covered. It has been specifically directed to all the TPAs for administering the claims of Injection Avastin Lucentis/ Macular in operation theatre in the case of ARMD (Age related Macular Degeneration). The treatment for ARMD is an OPD procedure only and not covered under mediclaim. The treatment shows no sign of positive existence of any ailment therefore, the admission in the hospital was not for any particular positive disease. In view of the terms and conditions of the policy, the claim of Injection Avastin is not payable under the policy in question, otherwise the matter was referred to Insurance Ombudsman, Chandigarh and the complaint was dismissed vide order dated 6.10.2014.While denying and controverting other allegations, dismissal of complaint was prayed.
- Complainant tendered into evidence her affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C27 and closed the evidence on behalf of the complainant.
- Opposite Party tendered into evidence the documents Ex.OP1 to Ex.OP4.
- We have carefully gone through the pleadings of the parties; arguments advanced by the complainant as well as ld.counsel for the Opposite Party and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for the Opposite Party.
- From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant has been getting medical insurance policy from the Opposite Party for the last about 10 years i.e. from the year 2003 onwards and during the subsistence of the insurance policy in the year 2013, the complainant suffered eye problem and she was admitted in Dr.Om Parkash Eye Institute Private Limited, The Mall, Amritsar on 2.12.2013 and discharged on 3.12.2013. During hospitalization, the patient/ complainant was given Injection Avastin in her right eye. The complainant paid a sum of Rs. 14,027/- to the aforesaid hospital authorities. The claim was lodged with the Opposite Party, but the Opposite Party vide letter dated 13.6.2014 repudiated the claim of the complainant on the ground that Injection Avastin is not payable. Complainant submitted that all this amounts to deficiency of service on the part of the opposite party.
- Whereas the case of the Opposite Party is that the expenses incurred by the complainant on his medical treatment are not covered under the policy. In view of the terms and conditions of the policy in question, the claim of Injection Avastin is not payable and is not covered under the policy because as per clause 4.19 of the terms and conditions of the policy Ex.OP4, the treatment for Age related Macular Degeneration (ARMD) or for Enhanced External Counter Pulsation (EECP) etc. are not payable. The matter was also referred to Insurance Ombudsman, Chandigarh and the claim of the complainant as also not accepted by Insurance Ombudsman, Chandigarh and the plea of the Opposite Party was admitted. Ld.counsel for the Opposite Party also submitted that the claim of Injection Avastin Lucentis/ Macular in operation theatre in the case of ARMD (Age related Macular Degeneration) is an OPD procedure only and not covered under medi claim policy. So, the Opposite Party has rightly repudiated the claim of the complainant.
- From the entire above discussion, we have come to the conclusion that the complainant has been continuously getting the medical insurance policy from the Opposite Party for the last about 10 years i.e. from the year 2003 continuously and during the subsistence of the insurance policy for the year 2013-2014, the complainant suffered eye problem and was admitted in Dr.Om Parkash Eye Institute Private Limited, The Mall, Amritsar on 2.1.2013 and discharged on 3.12.2013 as per medical record of Dr.Om Parkash Eye Institute Private Limited, The Mall, Amritsar Ex.C4 to Ex.C17 and the complainant was given Injection Avastin in her right eye during hospitalization in the aforesaid hospital and the complainant paid Rs.14,027/- to the aforesaid hospital as per bill Ex.C4 to Ex.C17. The claim was lodged by the Opposite Party, but the Opposite Party repudiated the claim of the complainant vide letter dated 13.6.2014 Ex.C2 on the recommendation of TPA that the Injection Avastin is given for treatment for Age related Macular Degeneration (ARMD) and it can be done in the OPD for which the hospitalization is not required. So, these expenses are not covered under the policy in question. The complainant has produced on record the certificate dated 14.7.2015 from Dr.Om Parkash Eye Institute Private Limited, The Mall, Amritsar in which Dr.Rajan Bhatia of the said institute has certified that the complainant was diagnosed as a case of Occult CNVM (Choroid neo vascular membrane) in right eye and the patient was admitted in the said hospital and was advised for Inj.Avastin in right eye. Said hospital has further certified that Injection Avastin was given to the patient for the treatment of above referred disease i.e. Occult CNVM (Choroid neo vascular membrane). The complainant was admitted in the hospital as she was suffering from disease Occult CNVM (Choroid neo vascular membrane) in right eye and it was not Age related disease and this Injection Avastin was given to the complainant for the treatment of the aforesaid disease and its hospitalization is necessary and this disease is not Age related disease. So, the case of the complainant is not covered under clause 4.19 of the terms and conditions of the policy Ex.OP4. We are, therefore, of the opinion that the Opposite Party has wrongly repudiated the claim of the complainant vide letter dated 13.6.2014 Ex.C2.
- Resultantly, we allow the complaint with cost and the Opposite Party is directed to pay the amount of Rs.14,027/- spent by the complainant on her medical treatment, within one month from the date of receipt of copy of this order, failing which the Opposite Party shall be liable to pay interest @ 9% per annum on this amount, from the date of filing the complaint till the payment is made to the complainant. Opposite Party is also directed to pay to the complainant the costs of litigation to the tune of Rs.2,000/-. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Dated: 22-07-2015. (Bhupinder Singh) President hrg (Anoop Sharma) (Kulwant Kaur Bajwa) Member Member | |
