BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.294 of 2018
Date of Instt. 16.07.2018
Date of Decision:12.07.2022
Paramjeet Kaur aged 66 years W/O Iqbal Singh Oberoi, R/o 220, G. T. B. Nagar, Jalandhar-144003.
..........Complainant
Versus
1. United India, Insurance Company Ltd., Divisional Office, No.8, Banassurance, Union Co. Op. Insurance Building, 5th Floor, 23, Sir. P. M. Road, Fort, Mumbai. Through its Senior Divisional Manager.
2. M/s Medi Assist India (TPA) Pvt. Ltd., Tower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore-560029. Through its authorized signatory.
3. State Bank of India, Civil Lines, Jalandhar through its Assistant General Manager.
4. State Bank of India, Central Office, State Bank Bhawan Madame Canara Road, Mumbai-400021 Through its Chairman.
….….. Opposite Parties.
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Smt. Harleen Kaur, Adv. Counsel for the Complainant.
Sh. Darshan Singh, Adv. Counsel for OPs No.1 & 2.
Sh. A. K. Arora, Adv. Counsel for OPs No.3 & 4.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant retired as Senior Assistant from office of OP No.3. The complainant is covered under Group Mediclaim Health Insurance Scheme of OP No.1. The complainant ID and Membership number is 1583883. The mediclaim scheme obtained from OP No.1 is regulated by Group Master Insurance Policy to cover insurance risk for Domiciliary, hospitalization/Domiciliary treatment benefit with cap up to sum insured as stipulated and incorporated therein to the full extent without any limitation and deduction. Accordingly, the complainant being beneficiary has got the right of reimbursement for the whole of amount of medical expenses incurred by the complainant against peril covered under mediclaim scheme. The complainant covered under mediclaim scheme was admitted at Mohan Dei Oswal Hospital Ludhiana on 08.05.2017 with Carcinoma of breast. The complainant was treated with Inj. Biceltis 440 mg and discharged on 08.05.2017. After discharge from the hospital, the complainant preferred mediclaim for an amount of Rs.54,498/- for reimbursement for medical treatment and hospitalization as day care patient to OP No.1 which in turn forwarded to OP No.2-TPA for processing of claim of the complainant. The complainant submitted clinical and laboratory tests medicines expenses incurred by the complainant alongwith with Prescribed Claim Form-Part A and Part B alongwith the supportive bills with complete details of payment with receipts through OP No.1 for total amount of Rs.54,498/-. The complainant completed and complied with all requirements and formalities for prompt and quick settlement and reimbursement of mediclaim expenses within a mandatory period of 30 days from the receipt of claim. The OP No.1 at the behest of OP No.2 rejected mediclaim of the complainant on flimsy and strange reason as cryptically rejected mediclaim reimbursement vide dated 09.04.2018 wrongly and perversely without stating any exclusion clause of Group Medical Policy by virtue of which the mediclaim was not admissible under the said exclusion clause. The repudiation and denial of genuine and bonafide claim was made on lame excuses in mechanical and routine manner and treatment fall in realm of hormone replacement therapy not admissible under the policy. The OP No.1 and OP No.2 are guilty of rendering deficient service, negligent and adopted unfair trade practice and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay/reimburse mediclaim amount of Rs.54,498/- alongwith interest @ 12% per annum from the date of lodgment of claim upto date of actual payment to the complainant. Further, OPs be directed to pay a compensation of Rs.30,000/- and Rs.10,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs and accordingly, OPs No.1 and 2 appeared through its counsel and filed its joint written reply and contested the complaint by taking preliminary objections that a bare perusal of the complaint proves that the complainant has suppressed material facts from this Commission and moreover, this complaint is wholly baseless and unsustainable in the eyes of law. In present complaint complainant has not made the compliance of the letter for further information request for Pre-Auth No.#14042115 of the OP vide which the Hospital Authorities required to send the documents and also complainant has not made the compliance of letter of OP, in which the following documents are required:-
Send the chemo drugs other than becelits (transtuzumab) as these drugs are not admissible under policy, we request you to provide the document within 8 hours or before discharge, whatsoever is earlier. In case of non-receipt of information, careless benefit is denied.
The above information should be submitted by the treating doctor on the hospital doctor letter head.
The OP has made strenuously efforts to get required documents in present case but complainant neither cooperated nor made the compliance, even after sending letter as stated above. Under compelled circumstances OP had decided the claim. It is further averred that the present complaint is not maintainable under law. The dispute raised by the complainant in the present complaint is manifestly denied. The proceedings initiated by the complainant under the Act are nonest, null and void and without jurisdiction. The present complaint is wholly misconceived, groundless and unsustainable and untenable in law. The OP has received the claim form, filed by the complainant on 19.06.2017 which is the violation of the terms and conditions of the policy i.e. 5.4 and 5.5. All claim documents should be submitted within 7 days, after completion of such treatment. The complaint is false, frivolous and extremely exaggerated, the complainant is liable to be penalized under law. On merits, the factum with regard to taking health insurance policy by the complainant from OP No.1 is admitted. It is also admitted that the complainant was admitted in the hospital and discharged from hospital, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. OPs No.3 and 4 filed its separate joint written reply and contested the complaint by taking preliminary objections that there is absolutely no cause of action in favour of the complainant to file the present complaint against the answering OP and that being so the present complaint is liable to be dismissed against the answering OP with heavy costs. It is further averred that there is no alleged deficiency of service or unfair trade practice on the part of the answering OP and as such, the present complaint is not maintainable against the answering OP. The OPs No.3 & 4 have been unnecessarily made party to the present complaint without any cause of action. On merits, it is admitted that the complainant is retired employee of OP No.3 and the OP No.4 being the central office of OP No.3 has formulated health insurance mediclaim scheme of SBI Retried Employees Medical Benefit Scheme, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
5. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
6. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the complainant as well as counsel for the OPs No.1 and 2 very minutely.
7. The complainant is a retired employee of OP No.3. OP No.4 devised health medical insurance mediclaim scheme captioned SBI Retired employees Medical benefit Scheme covering risk of insurance of its retired employee, spouse and disabled children of its member to reimburse expenses incurred for treatment. The complainant has proved on record the copy of the mediclaim health insurance policy since 2016 as Ex.C-1. The case of the complainant is that she was admitted in Mohan Devi Oswal Hospital, Ludhiana on 08.05.2017 with Carcinoma of breast and she was treated with Inj. Biceltis 440 mg and was discharged on 08.05.2017. The discharge summary has been proved as Ex.C-2. When the claim form was submitted, the same was rejected by the OP on 09.04.2018. Ex.C-14 is the rejection/repudiation letter. The ground for repudiation as mentioned in Ex.C-14 is that as per the discharge summary, medicine bill and other hospital documents claimant treated with inj.Biceltis 440 mg, it’s a hormonal drug and the admission has been sought mainly for hormone replacement therapy. Since hormone replacement therapy not admissible under the policy, the claim stands repudiated, but the reason given by the OP is against the record. The discharge summary Ex.C-2 clearly proves that the cycle of Chemotherapy given to the complainant was with the drugs and the same was targeted therapy and it has nowhere been mentioned that it was a hormonal replacement therapy. Similarly, the Protocol Form of Chemotherapy Ex.C-3 also shows that the medicine given for the Carcinoma breast was a targeted therapy. There is a certificate Ex.C-16/OP-4 of the Dr. Raman Arora, MS Senior Consultant and HOD, Medicine & Oncology, M. D. Oswal Memorial Hospital, Ludhiana. It has been certified that the Herceptin (Trastuzumab) is not a hormonal therapy, but it is targeted therapy. As per the Medical Literature Ex.C-17/OP-8 that Herceptin is a targeted therapy designed to lock the growth and spread of cancer by preventing the cancer cells from dividing or by destroying them directly. It may be used for breast cancer i.e. HER2 receptor positive. So, from the documents placed on record by both the parties, it is proved that the treatment given to the complainant for breast cancer was not hormone replacement therapy rather the same was targeted therapy. OPs have not produced on record the opinion of any Oncologist to show that the drug used inj.Biceltis 440 mg Herceptin (Trastuzumab) is a hormonal drug nor any medical literature show that it is a hormonal drug, therefore the ground on which the claim has been repudiated is against the documents. Even otherwise, it is the duty of the OPs to make the complainant aware about the exclusion clause. The complainant has alleged that the terms and conditions and exclusion clause was never supplied to the complainant. The OPs have not produced on record any document or anything to show that the terms and conditions and the exclusion clause was in the knowledge of complainant. It has been held in case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Rajwant Kaur and Other”, 2021 (3) CLT 540 (CHD) that the onus is on the appellant insurance company to prove that it provided the terms and conditions of the policy to the complainant and the same were in her knowledge-Appeal disposed off. It has been held in a case titled as “National Insurance Co. Ltd. & Ors Vs. M/s Saraya Industries Ltd”, 2020 (1) CLT 278 (NC), wherein it is held that it is the duty of the insurance company to supply all the terms and conditions of an insurance policy to the policy holder-there cannot be any presumption under law on the terms and conditions. It has been held in a case titled as “Manager, Shriram Transport Finance Co. Ltd. & Ors. Vs. M. A. Jose”, cited in 2020 (1) CLT 281 (NC), wherein it is held that it is settled proposition of law that a positive fact needs to be proved first-the contention of the OPs that they had supplied copies to the complainant is a positive assertion-Therefore the legal proposition of the law case the duty upon the OPs to discharge that burden. It has been held in a case titled as “Bhanwar Lal Vishnoi Vs. Oriental Insurance Co. Ltd.”, cited in 2017 (1) CLT 401, wherein it is held that the insurance co. has to prove that the exclusion clause under which the claim is sought to be repudiated was communicated to the complainant.
8. From perusal of above said facts and circumstances of the case and plethora of judgments, we are of the considered opinion that the complainant is entitled for the relief as claimed and as such, the repudiation letter is hereby set-aside and thus, the complaint of the complainant is partly allowed and OPs are directed to pay the mediclaim amount of Rs.54,498/- with interest @ 9% per annum from the date of lodging of the claim till realization. Further, OPs are directed to pay a compensation of Rs.10,000/- to the complainant for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
12.07.2022 Member Member President
