Order-19.

Date-09/10/2015.

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that he purchased one individual Health Insurance Policy from the OP by paying total premium of Rs.16,570/- by obtaining domestic/hospitalization medical insurance cover for himself, his wife and his daughter and said policy covered the period from 18-10-2013 to 17-10-2014.

          During subsistence of the aforesaid mediclaim insurance policy complainant himself was detected to be inter alia, suffering from ankylosing spondylitis and during his medical treatment for such ailment he was advised by his treating doctor, Dr. Alokendu Ghosh to take injection ‘Remicade 100 mg’ with four vials of IV fluid under medical supervision of an internal medicine doctor after getting admitted to a nursing home of the choice of the complainant. 

          In fact, the intervenes administration of injection Remicade is to be performed only after elaborate pathological tests and under strict medical sup0ervision in a medical facility/hospital properly equipped for tackling any emergency and/or side effect.  Apart from the pathological test, the administration, intervenes transfusion of Remicade is done very slowly and it takes around 4-5 hours time when the patient is put under strict monitoring and necessary allied drugs are also administered.  Accordingly, the complainant patient was specifically advised to be hospitalized for administration of Remicade.

          It is pertinent to mention that a week before the administration of first doze of injection Remicade, the patient had to take three vaccinations to lessen the side effects of injection.  They are 1) influenza, 2) Pneumonia, 3) Hepatitis.  Truth is that complainant is a cardiac patient and he had undergone angiography on 24-02-2014 and was advised PTCA (Percutaneous Transluminal Coronary Angioplasty) and before transfusion of Remicade, the patient, considering his physical status, after considering his various pathological reports.  He was administered some other injection that is Paracitamol etc.  In the above circumstances, complainant was specifically advised to be hospitalized for administration of Remicade.  Complainant took admission in Columbia Asia Hospital on three occasions to undergo the full course of administration of Remicade of 4 virals of remicade 100 mg three times and he was hospitalized on 19-08-2014, discharged on 19-08-2014, then again admitted on 01-09-20143 and discharged on 02-09-2014 and finally admitted on 26-09-2014 and discharged on 27-09-2014 and all such admissions are within the period of insurance coverage that is 18-10-2013 to 17-10-2014 and on three occasions he spent total Rs.5,29,775/- that is on 23-08-2014 for Rs.1,83,614/-, on 11-09-2014 for Rs.1,76,126/- and on 09-10-2014 for Rs.1,70,035/- and it was claimed by the complainant after discharging for his medical treatment cost along with all papers.  Fact remains OP Insurance Company vide their letter dated 18-11-2014, inter alia, rejected the two insurance claim No.451502085 and 451502315 while the other claim being no. 451502705 remain unanswered and the contention of the insurance company regarding repudiation of the claim is that the injection Remicade can be given in an OPD set up and admission in a hospital is not required, the claim is not admissible under the policy terms and conditions.  But such a decision is completely preposterous in view of the fact it is absolutely prerogative after examining a patient as to whether he has to be admitted into a hospital or not for administration of the drug in reference.

           On receipt of such repudiation made by the OP complainant was shocked and suffered acute mental suffering, pain and agony and in fact, he already borrowed money for his treatment of his ailment and legitimately expected that his bona fide claim shall be honoured by the Insurance Company when he has already valid insurance, various correspondences were made but the matter was not entertained and the repudiation is completely illegal for which complainant has prayed for redressal. 

          On the other hand, OP by filing written statement has submitted that the entire complaint is not maintainable in view of the fact.  No doubt complainant took out an ‘Individual Health Insurance Policy’ valid for the period from 18-10-2013 to 17-10-2014 covering the risk of hospitalization expenses of himself and his other 3 family members of different sum insured values and specifically for himself with sum insured value of Rs.5 lakhs subject to its terms and conditions.  During subsistence of the said policy complainant was admitted at Columbia Asia Hospital at three times and also submitted claim and in all cases Remicade injection was apparent on the face of hospital bill but as per Clause 2.1 of the subject policy terms and conditions, the claim is not payable and the said clause inter alia states procedures/treatments usually done on outpatient basis are not payable under the policy even if converted as an inpatient in the hospital for more than 24 hours or carried out in Day Care Centre.  No doubt the cost of the injection is very high and said can be injected to the patient by observing 2 or 3 hours by infusion under doctors observation at any outdoor department of hospital and there is no necessity to admit the patient for administering any such fusion as per medical science and as because as per 2.1 of the subject policy expenses on hospital treatment of less than 25 hours is not admissible for which this procedure has been applied.  But the reasons for admission is not there and medical science have not support it and as because complainant was aware of the fact that so he is not entitled to get the cost of the Remicade injection for which he adopted such procedure and hospital authority was with the side of the complainant and it is not at all any part of surgery or any medical treatment.  At the same time the medical report supports that there was no question of admitting the complainant and keeping him for one day (more than 24 hours).  When nothing was effect after giving injection and in view of the above circumstances, the present complaint should be dismissed and there was no laches, deficiency on the part of the OPs.

Decision with Reasons

On comprehensive study of the complaint and the written version and also considering the argument as advanced by the Ld. Lawyers of both the parties and further relying upon the patient bill dated 19-08-2014 we fund that complainant was admitted on 18-08-2014 at 11:26 a.m. and discharged on 19-08-2014 at about 12:28 p.m. and bill amount was Rs.1,63,311-47. Another patient bill dated 02-09-2014 reveals that he was admitted on 01-09-2014 at 10:47:16 a.m. and discharged on 02-09-2014 at 01:04:00 and total bill amount was Rs.1,62,258-08 and another bill dated 27-09-2014 reveals that he was admitted on 26-09-2014 at 12:06:36 p.m. and discharged on 27-09-2014 at 12:45:00 p.m. and total amount paid was Rs.1,62,102-08.  In all cases complainant was administered with the injection Remicade and in all cases the cost of the injection is Rs.1,60,156/-.

          Vital question is raised in this case whether for transfusion of Remicade injection admission is necessary or not.  No doubt complainant was treated by Dr. Ranabir Chowdhury in the hospital Colombia Asia and from discharge summary it is found that only for transfusion of Remicade injection he was admitted and in the said discharge summary it is noted patient is admitted as per advice of Dr. Alokendu Ghosh.  So, we have gone through the prescription of Alokendu Ghosh who is specially noted in such a manner “Injection Remicade as advised under supervision of internal medicine doctor at any suitable nursing home of your choice” but noway doctor has started that for administration of the said Remicade injection he is directed to admit at first.  In this regard, from the bill summary it is clear that Remicade injection is of brand name Janssen.   Ld. Lawyer for the complainant submitted that as per doctors advice he has admitted and doctor took such decision for administering the said injection and as per doctors advice he was there and when doctor released and discharged he went away and it was not prerogative of the patient the complainant to be admitted but everything was done as per advice of the doctor of Colombia Asia and they thought that without his admission and stay for one day for observation that injection cannot be administered.  So, it is no doubt a hospitalization for more than 24 hours so, complainant is entitled to entire bill when the policies are valid.  Ld. Lawyer for the OP submitted it is the common practice of the private hospitals to administer injection to the person of a patient after admitting so that the concerned consumer may get the benefit of the insurance policy and it is the obliging character of the private nursing home.  In this regard it is to be mentioned that what is the actual procedure of administering Remicade as per literature of the Janseen so, we have collected the manufacturers article Janseen that is the Remicade wherefrom we have gathered that doctors cannot change the procedure in respect of administering the said Remicade injection because it is worldwide opinion about effect of Remicade injection and about its application.  First of all it is to be mentioned that this Remicade injection is manufactured by Schering Plough (Brinny Co.), Ireland and marketed by Johnson and Jhonson Ltd.

          Particularly Remicade is used for various type of pain and sufferings such as the crohn and pediatric crohn disease, ulcerative colitis, psoristic arthritis, psoriasis and also ankylosing spondylitis etc.

          Fact remains Remicade is the invention of a research work in the field of bio medical chemistry and after research the method of administration is also mentioned and the method of admission of remicade should be to administer intervenously over a 2 hours period and all patient administered remicade have to be observed 1-2 hours at post infusion stage to consider any acute infusion related reactions and prior to administering the said infusion patient may be treated antihistamine, hydrocortisone and or paracetamol and infusion rate may be slow in order to decrease the rate of infusion related reactions especially if infusion related reactions have occurred previously.

          After thorough study of the entire research work about this composition it is clear that there is no question of admitting the patient for one day in any hospital or nursing home etc. and it is confirmed by the research scholar doctors that if remicade is administered invervenously over a two hours period and no side effect is found thereafter, within 1 or 2 hours then there is no scope to admit such a patient for any further observation.  So, method of administration of remicade is not for keeping the patient for more than four hours and there is no such opinion of the inventor of the said medicine.  When that is the fact then it is clear that for administration of remicade admission of a person is not at all required and as per inventor of the said medicine it can easily done in any nursing home at OPD or at hospital at OPD.  Now, we shall have to consider the report of the first Dr. Alokendu Ghosh dated 13-08-2014 and from its prescription that it is evident that there is no such instruction for admission at hospital but only doctor passed such note that injection remicade advised under supervision of internal medicine doctor of any suitable Nursing Home of complainant’s choice.  But nowhere Dr. Alokendu Ghosh advised for admission to any hospital or nursing home.  As per discharge summary it is found that complainant was particularly admitted for remicade infusion, not for any other treatment and in the said discharge certificate issued by Colombia Asia it is noted that the patient was admitted as per advice of Dr. Alokendu Ghosh under supervision of Dr. Ranabir Chowdhury for receiving 400 mg. of remicade infusion with proper precaution and period of hospital uneventful.  Considering the course in the hospital as noted by the doctor it is clear that infusion was given for two hours period and thereafter the entire situation was uneventful that means there was no symptoms of post infusion related any reaction when that is fact as per discharge certificate then it is clear that complainant just after admission after lapse of 4 hours or 5 hours ought to have been released when as per doctor’s opinion that after taking infusion there was no reaction and everything was uneventful but doctor has not noted for what reason patient was kept after another 18 hours and truth is that the inventor of the remicade already after research confirmed when there is no infusion related reaction then there is no question of keeping the patient for any further period and treatment is no doubt conservative form only in case of any uneventful situation of the patient and if infusion related reaction is found not detected in that case after 5 hours there is/was no chance for keeping the patient in hospital.  So, considering that fact and the argument as advanced by the OP we are confirmed that neither Dr. Alokendu Ghose advised for admission nor any eventful incident took place after taking the remicade infusion and considering that fact and the method of administering the said injection we are confirmed that the hospital authority and the doctor obliged the complainant for staying on the ground for getting the benefit of mediclaim policy when it is specifically mentioned that there must be a treatment in hospital for more than 24 hours and benefit in respect of the hospitalization can be given.  But it is a conservative treatment.  There is no question of admission in hospital or nursing home as indoor patient when this injection can be administered as per authenticated opinion and research work of the scientist who invented remicade injection.  So, apparently it is clear that he was admitted for administering remicade infusion, on the ground the cost of injection is very high and anyhow to get the refund of the entire amount the private nursing home like Colombia Asia, Amri, Fortis, Apollo Gleneagles are obliging the patient on the ground there is a term if any patient stays for 24 hours in that case he shall have to get the benefit of mediclaim policy and by adopting that procedure the private nursing home are selling foreign made injection infusion at a high rate.  Practically, cost of injection if it is purchased from a retailer the amount would be less than as noted in the bill but all the private nursing home and hospitals have adopted such unfair trade practice and they are obliging the patient by keeping the patient for 24 hours but no doubt there is no ground for keeping the patient in the hospital only for remicade infusion when patient was admitted for remicade infusion only not for any treatment purpose though Dr. Alokendu Ghosh did not advice the patient for admission.  He advised for taking the remicade infusion under one internal medicine doctor in any nursing home or hospital as per patient’s choice.  So, we are convinced to hold that stay of the complainant at nursing home for 24 hours was completely uncalled for and it was done with the connivance of the complainant’s and Colombia Asia doctor for the purpose of giving the relief to the complainant for getting benefit of the mediclaim policy as per clause.  But after thorough study of the policy condition we find that in all 3 cases the report is same, admission is for remicade infusion but as per the inventor’s research work and method there is no necessity for admission of any patient in any hospital or nursing home but in OPD it can be done and in all cases taking infusion in three occasions no eventful incidents took place and after taking the said infusion complainant did not suffer from any infusion related reactions then the stay of the complainant for 24 hours is not at all believable but we are convinced that the same was done with the connivance of the complainant and hospital authority, doctor to give a relief so the complainant cannot get back the entire cost including the high cost of the injection and if that injection would be given in OPD in that case complainant shall not have to get any disbursement for which this illegal method has been adopted by all the nursing home, private hospitals always.  In this regard Colombia Asia, Apollo Gleneagles are very familiar for practicing such sort of practice for continuing the admission of the patient for 24 hours though there is no necessity to stay for such patient.

          Moreover, after considering the Clause 2.1 last two lines we have gathered procedures/treatment usually done on outpatient basis are not payable under the policy even if converted as an inpatient in the hospital for more than 24 hours or carried out in Day Care Centres and relying upon the above clause and also the present facts and circumstances, we have gathered that as per said Clause complainant is not entitled to get any benefit. 

          Most peculiar factor is that in the bill the cost of the said injection is noted Rs.1,60,000/- and odd but no receipt is supplied by the Colombia Asia to show what is the actual market price of the remicade.  Truth is that no private hospital shall have to mention the actual market price of the remicade on the ground at a higher rate and practically above market price rate they are selling it and making profit dishonestly.  In this regard, we have searched out 100 mg vial infusion of remicade and it is found that in world market its valuation is 650 pound at present what we have collected from international market rate of remicade and for supplying the same to the different hospital at best along per vial cost would be rounded about Rs.65,000-70,000 but Colombia Asia would not be able to produce the said packet of the vial of 100 mg of remicade and in fact, 400 mg. remicade was infused then cost of the said vial is 650 pound for100 mg/vial and by converting it pound it is equivalent to Indian currency Rs.100/- so per vial 100 gm. price of the remicade is Rs.65,000/- when in the world market and international market the rate of remicade is 650 pound then how the Colombia Asia can charge Rs.1,60,000/-.  No doubt it is one kind of mal practice on the part of the Colombia Asia.  Whatever it may be Colombia Asiamust have to produce the market price as noted in the packet of the said 100 mg. vial of remicade and such sort of act on the part of Colombia Asia is also an unfair trade practice.  Anyhow, the bill as prepared by Colombia Asia is completely vexatious.  Selling of remicade at higher rate is also an illegal and unfair trade practice. 

          Further it is found that complainant was given an infusion of remicade 400 mg. but after taking information from the internet from company it is found that there is no such production of remicade more than 100 mg. and in fact, it is freezed, dried white pellate powder and with that remicade distilled water is mixed as per requirement then the weight of the infusion would found 400 mg. or 500 mg. that means 100 mg vial freezed died white pellate powder is mixed with distilled water to the extent of 300 mg. or 400 mg. or 500 mg. as per requirement and thereafter, the infusion is made and in this regard it is found from the prescription that 400 mg. infusion is given that means along with 100 mg. vial 300 mg. distilled water was mixed and then it became liquefied and when it was fixed for infusion but there is no production of remicade more than 100 mg. vial so considering that fact t is clear that 100 vial remicade (freezed dried white pellate powder) was mixed with 300 mg. distilled water and liquefied thereafter become infusion and it was infused but that has not been disclosed by the Hospital authority and that is the mal practice on the part of the Hospital Authority.  We have already discussed about cost of 100 mg. vial of remicade in the world market and it is no doubt Rs.65,000/- in the Indian market and all other markets also it is same and it is marketed by Johnson and Johnson in Indian Market and invariably Colombia Asia purchased it and charged Rs.1,60,000/- but the total price of remicade of 100 mg vial is Rs.65,000/- and along with that preservation cost may be added only with the cost so the cost of the remicade as administered in the person of the complainant would not exceed Rs.66,000/- but Colombia Asia charged Rs.1,60,000/- that is no doubt an illegal practice on the part of Colombia Asia, hospital and unfair trade practice is also practiced by the Colombia Asia Hospital that is also proved.  So, under any circumstances, the cost of remicade in the Indian Market cannot exceed Rs.66,000/- and as because Colombia Asia Hospital by practicing unfair practice charged Rs.1,60,000/- it is another factor for which there was no scope on the part of the OP to entertain such a claim.

          Moreover, considering the above facts and materials and also the Clause 2.1 (last 2 lines) and further the present facts and circumstances we are convinced to hold as per Clause 2.1 complainant is not entitled to get the benefit of the mediclaim because the entire process was not a treatment but only for taking infusion in the hospital and it is as per advice of Dr. Alokendu Ghosh.  So, the procedure of treatment usually taken in administering the remicade infusion maximum period is only 4-5 hours which can be done as outpatient but in this case only to give benefit to the complainant the hospital authority adopted an unfair trade practice and without any reasons converted the said 5 hours treatment as inpatient in hospital for more than 24 hours purposely.  In the result, we are convinced to hold that the defence as taken by the OP is quite justified, legal, valid and as per clause of the mediclaim policy both are connected and Forum cannot go beyond the clause and in view of the above facts and circumstances, this complaint bears no merit when deficiency, negligence or unfair trade practice on the part of the OP is not at all proved.

In the result, the complaint fails.

Hence,

Ordered

That the case be and the same is dismissed on contest but without any cost against the OPs.