O R D E R
SUBHASH GUPTA, MEMBER
The present complaint has been filed by the Complainant against the Opposite Parties, hereinafter referred as OP under section 12 of Consumer Protection Act, 1986 hereinafter to be referred as the ‘Act’. The facts as alleged in the complaint are that the complainant had taken a Medical Insurance Policy No.041703/48/12/97/000001341 from the OP affective from 19.11.2012 to 18.11.2013. It is alleged that the above said policy has been held by the complainant continuously for a number of years and there has not been any violation of the terms and conditions of the said Medical Insurance Policy by the complainant. It is alleged that the complainant is suffering from seropositive rheumatoid arthritis osteoporosis with diabetes mellitus. It is alleged that the complainant was admitted to the Indian Spinal Injuries Centre, Vasant Kunj, New Delhi on 19.8.2013 at 10.00 a.m. for her treatment and discharged on 20.8.2013 at 1.05 p.m. It is further alleged that the complainant spent about Rs.80,869/- on her treatment. It is further alleged that the treatment of the complainant was to be completed in two stages and the complainant was readmitted for further treatment on 16.9.2013 and she again spent a sum of Rs.82,129/-. It is alleged that the complainant had duly informed the Insurance Company of the course of the treatment prior to her admission in the hospital. It is further alleged that after discharge from the hospital the complainant submitted all the relevant documents to the OP seeking the reimbursement of the same but the claim has not been processed and sanctioned till date on the ground that (i) the age of the patient has been wrongly mentioned as 58 years instead of 56 years and (ii) hospitalization of the complainant was not required for the treatment. It is further alleged that the complainant had submitted all the proof regarding her age to the OP. It is further alleged that doctor of above hospital has certified that the complainant needed to be admitted for injection solumedrol as IV infusion for two days consecutively. It is further alleged that the complainant sent a legal notice to the OP but of no consequence. It is also alleged that the complainant has submitted all the original bills, prescription, certificates issued by the doctors to Vipul Med. Coprn. TPA Pvt. Ltd. but the claim has not been settled. On these facts complainant prays that O.P be directed to pay an amount of Rs.1,62,998/- alongwith interest @ 24% p.a. The complainant has also claimed a sum of Rs.5,00,000/- on account of mental harassment and agony including expenses incurred on correspondence, telephone calls and personal visits by the complainant and Rs.30,000/- towards litigation expenses.
2. O.P after issuance of notice appeared and filed the written statement. In its written statement O.P has not disputed that complainant had taken the policy referred to above. It has been however alleged that the complainant had concealed the facts with the OP and as well as TPA that the complainant, 56 years old and was suffering from seropositive rheumatoid arthritis osteoporosis with diabetes and was admitted in the hospital for administration of ristova injections methylprednisolone injection. It has been alleged that these type of injections is a day care process. It has been pleaded the as per the penal doctor report the patient was not required to be admitted in the hospital for such type of injection. It has been pleaded that claim of the complainant is not admissible technically as there was a specific breach of terms and conditions of the Mediclaim Insurance Policy. It has been further pleaded that it had been a fault of professional doctor who is treating the complainant. The doctors must know the roots of the treatment which they administer to their patient and the manner in which it is to be done so that the patient should have the positive results and shall be able to avail the benefits of the policy. It has been pleaded that it was duty of the hospital to have claimed the amount of the expenses incurred on the administration of medicines/injections through the cashless facility then the things would have been more clear whether the said procedure is available in the policy or not. It has been further pleaded that claim of the complainant has thoroughly been processed and after taking the opinion of the medical doctors of TPA the claim has been repudiated as the said treatment is a day care programme and said process is not covered under the terms and conditions of the policy. Dismissal of the complaint has been prayed for.
3. Complainant has filed her affidavit affirming the facts alleged in the complaint and has proved documents exhibited as Ex.CW-1/1 to CW-1/9. On the other hand Shri Rakesh Sachdeva, Sr. Divisional Officer has filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submissions of Ld. Counsels for the parties. The existence of the Insurance Policy of the complainant during the relevant period has not been disputed by the OP. The only issue in dispute in respect of repudiation of the claim is regarding whether the administration of the drugs/injection was to be given in day care in any hospital or overnight stay was necessary. The complainant has filed an affidavit as well as certificate issued by Dr. Sri Ram Garg, Sr. Consultant Rheumatologist, Joint Disease Centre, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi. Dr. Garg, who was the treating has on oath, stated that the patient was needed to the administered injection solumedrol(Methyiprednisolone) as IV infusion for 2 days consecutive days and injection Ristova 1 gm as infusion for one day. He has further deposed on oath that the injection was to be administered in the hospital. Dr. Garg further deposed and testified that it was mandatory to administer injection Ristova under strict supervision and close monitoring by Sr. Doctor for atleast 24 hours, patient needed to be given injection solumedrol beside injection ristova. The treating doctor, Dr. Garg has further deposed that the patient needed to be hospitalized and treatment could not be administered during the day care. An affidavit of the Dr. Garg is placed as Ex.CW2 and the certificate is placed as Ex.CW1/7.
5. In order to rebut the affidavit and medical evidence put forth by the complainant, the OP has filed an unsworn affidavit purported to have been signed by one Dr. Usha Raina, Consultant at Vipul Medical Corpn. This document cannot be treated as an affidavit in the eyes of law as the same has not been sworn before any competent authority and cannot be read in evidence.
6. The medical evidence filed by the complainant is of the treating doctor of the hospital which is also supported by his affidavit as well as certificate, therefore we have no reason to disbelieve the evidence of the doctor. We are in agreement and also of the considered view that the treatment taken by the complainant was in accordance with the medical advice suggested by the treating doctor.
7. The OP has also not filed on record proposal form filled in by the complainant at the time of inception of the mediclaim policy. Therefore, there is nothing on record to prove that the complainant concealed material facts or illness from the OP. Also the OP has failed to prove that the terms and conditions were ever supplied to the complainant at the time of inception of the policy or thereafter.
8. In view of above observations and the facts of the case, we are of the considered view that the repudiation by the OP was unjustified and illegal and has caused deficiency in service to the complainant. Accordingly, OP is directed to pay the complainant a sum of Rs.1,60,498/-(an amount of Rs.7500/- given as discount by the hospital in the bill dated 17.9.2013 has been deducted) alongwith interest @ 6% from the date institution of the complaint till its actual realization, we further award a sum of Rs.10,000/- towards harassment, mental agony and loss of time which will also include cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 18th day of April, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
