MS. NIPUR CHANDNA, MEMBER
ORDER
12.08.2024
1. A complaint under Section 12 of Consumer Protection Act filed. In brief the facts are that complainant is the employee of TPDDL and is covered under the group mediclaim insurance policy taken by TPDDL from OP1. The complainant is regularly paying the premium against the policy in question and as such the complainant is covered with OP1 vide policy bearing no. 0408002818P101410617 for a sum insured of Rs. 4 Lakh w.e.f. 01.04.2018 to 31.03.2019.
2. It is alleged by the complainant that his wife Smt. Sheela Kathuriya have severe pain in heart in the month of July, 2018. On the advice of the treating doctor of OP2 the complainant’s wife undergone EECP treatment ( Effect Of Enhance External Counter Pulsation) and BCA (Bio Chemical Angio plasty) . It if further alleged by the complainant that his wife’s treatment continued with OP2 from 14.07.2018 to 27.07.2018 and as such the complainant incurred expenses to the tune of Rs. 1,34,844/-.
3. It is further alleged by the complainant that despite having the mediclaim policy, OP1 compelled the complainant to bear the entire medical expenses from his own pocket by rejecting the claim. It is further alleged by the complainant that he submit the certificate of treating doctor Sh. Bimal Chajjar dated 28.08.2018 for reconsidering the claim in question but OP rejected the claim in question vide letter dated 12.11.2018. Being aggrieved by the repudiation of the claim by OP complainant approached this Commission for redressal of his grievance.
4. Notice of the complaint was sent to OP-1 & 2. OP1 filed its written statement wherein it denied any deficiency in service on its part. It is further stated that OP has rightly and legally repudiated the claim in question as the complainant took the BCA treatment, which is OPD treatment and as such not covered under the policy in question. It is further stated that the present complaint is nothing but an abuse of process of law, hence, dismissed with cost.
Despite opportunity neither OP2 appeared nor filed its WS as such OP2 was ordered to be proceeded ex-parte by our ld. Predecessor bench vide its order dated 26.07.2011.
5. Rejoinder to the WS of OP1 filed thereby denying the averments made in the complaint. Complainant filed his evidence by way of affidavit wherein he has corroborated the contents of his complaint.
Despite opportunity neither OP1 appeared nor filed its evidence as such right to file evidence of OP1 stands closed vide order dated 23.01.2020.
6. Complainant has placed on record the copy of ID cards, copy of discharge summary, medical bills, copy of the certificate of treating doctor dated 28.08.2018, copy of repudiation letter dated 12.11.2018 in support of his contention.
7. Written arguments filed by complainant.
8. We have heard the arguments advance at the bar by Sh. D.K. Sinha counsel for complainant. Despite opportunity no one came forward to address the arguments on behalf of OP.We have perused the record.
9. The sole question for our consideration in the present case is whether OP1 was justified in repudiating the claim of the complainant.
10. Admittedly, in the present complaint case complainant’s wife undergone treatment for heart ailment. As per the discharge summary, complainant’s wife was admitted in OP2 hospital for special treatment from 14.07.2018 to 27.08.2018. She had taken EECP (Natural Bypass), 35 sittings and Bio Chemical Angioplasty (BCA ) 20 sittings. It is further stated in the discharge summary that the patient was hospitalized on 14.07.2018 only one day and thereafter she was hospitalized from 16.07.2018 to 27.08.2018 only for 4-5 hours of daily hospitalization. The OP Ins. Co. rejected the claim in question by citing the reason that the EECP and BCA treatment under taken by the patient is excluded under the policy. The OP Ins. Co. had failed to mention the relevant clause of the policy terms and condition in its repudiation letter which prohibits the Ins. Co. to entertain and disburse the claim in question.
11. We have carefully gone through the policy terms and conditions annexed with the WS by OP. The bare perusal of the clause 2.10 of the policy terms and conditions makes it clear that even though the patient was not admitted in the hospital for 24 hours the day care treatment is also reimbursable.
As per clause 2.10 (i) day care treatment referred to medical treatment which is undertaken under general or local anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement.
This clause clarify that any advance technological treatment is duly covered under the policy in question. Moreover, the treatment through EECP is approved by Food & Drug Administration and recognized by the GOI and the OP Ins. Co. has failed to place on record any authenticated evidence to show that EECP is not approved form of treatment for the ailment suffered by complainant’s wife. Last but not least the complainant’s wife has undergone the aforesaid treatment for her ailment only on the advise of the treatment doctor Sh. Bimal Chajjar and not on her own. The certificate of the treating doctor dated 28.08.2018 Mr. Bimal Chajjar itself justify the treatment in question is a day care treatment and as per clause 2.10 Day care treatment is covered under the policy in question.
12. In view of the discussion, we are of the considered opinion that EECP is technologically advance treatment where hospitalization is required for less than 24 hours and was duly covered under clause 2.10 (i) day care treatment of the policy terms and conditions, as such the repudiation of the claim in question by OP Ins. Co. is unjustified illegal and arbitrary resulting in the deficiency in service on the part of OP1.
13. We therefore, hold OP1 guilty of deficiency in service and direct it as under:
- Pay to the complainant a sum of Rs. 1,34,884/- @ 6% p.a from the date of filing of complaint i.e. 23.01.2019 till realization.
- Pay to the complainant a sum of Rs. 20,000/- for pain and mental agony suffered by her.
- Pay to the complainant a sum of Rs. 15,000/- on account of litigation cost.
- OP1 is directed to comply the order within 30 days from the date of receipt of this order failing which OP1 is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.
File be consigned to record room.
15. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry. Order be uploaded on.
Announced in open Commission on 12.08.2024.
(SANJAY KUMAR) (NIPUR CHANDNA) (RAJESH)
PRESIDENT MEMBER MEMBER
