State Consumer Disputes Redressal Commission
New India Assurance Company Ltd. vs Dr.Santokh Singh on 29 May, 2013
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR-37A, CHANDIGARH
FIRST APPEAL NO. 270 OF 2011
Date of Institution: 09.02.2011
Date of Decision: 29.05.2013
1. New India Assurance Company Ltd., Regional Office, SCO
No.36-37, Sector 17-A, Chandigarh through its Assistant
Manager (Legal).
.....Appellant
2. The New India Assurance Company Limited, 80, Court Road,
Amritsar through its Branch Manager.
.....Appellant/Opposite Party
VERSUS
Dr.Santokh Singh son of S.Warayam Singh, resident of 48, Hide
Market, Amritsar.
.....Respondent/Complainant
FIRST APPEAL NO. 321 OF 2011
Date of Institution: 17.02.2011
Date of Decision: .05.2013
Dr.Santokh Singh son of S.Warayam Singh, resident of 48, Hide
Market, Amritsar.
.....Appellant/Complainant
VERSUS
The New India Assurance Company Limited, 80, Court Road,
Amritsar through its Branch Manager.
.....Respondent/Opposite Party
First Appeals against the order
dated 20.12.2010 passed by the
District Consumer Disputes
Redressal Forum, Amritsar.
Quorum:
Hon'ble Mr. Justice Gurdev Singh, President
Sh. Baldev Singh Sekhon, Member
Present in First Appeal No.270 of 2011:
For the appellants : Sh.B.S.Taunque, Advocate
For the respondent : Sh.Updip Singh, Advocate
First Appeal No. 270 of 2011 Page 2 of 10
BALDEV SINGH SEKHON, MEMBER
The above referred appeals have been preferred against the order dated 20.12.2010, passed by the District Consumer Disputes Redressal Forum, Amritsar (in short "District Forum"), vide which the complaint filed by Dr.Santokh Singh, complainant, was allowed and opposite party was directed to pay Rs. 1,16,934/- to him. The opposite party was also directed to pay compensation of Rs.5,000/- alongwith litigation expenses of Rs.3,000/-.
2. In the appeal preferred by the opposite party, it has been prayed that this order be set aside whereas the complainant in his appeal has made a prayer for the enhancement of compensation.
3. Briefly stated, the facts are that the complainant suffered from Retinal Angiomatour Proliferans, a variety of CNVM in his right eye with visual distortion and visual deterioration, which was a very serious condition. He got himself checked from S.B.Dr.Sohan Singh Eye Hospital Pvt.Ltd., Amritsar where the doctor admitted him on 11.3.2009. During hospitalization, he had to undergo a lot of investigations under local anesthesia, in the operation theatre and Dr.Jatinder Singh, an expert surgeon, gave an injection of Lucentis (an anti-VEGF agent) on 13.3.2009 which is a sight saving drug in this case. According to the treating doctor, withholding of this drug could lead to serious visual loss and the procedure of injection of intraocular (Intra-veitreal) had to be done in the operation theatre and hospitalization was also essential. The second injection out of the purchased injection as a set/pack was injected again during hospitalization when he again got hospitalized on 6.6.2009 and First Appeal No. 270 of 2011 Page 3 of 10 discharged on 7.6.2009 for the same purpose. Since the complainant himself was a very senior doctor, the treating hospital did not charge any money for investigation as well as for hospitalization, doctor's fee and various medicines. However, since the injection Lucentis is a very expensive same was bought for him from the market and he made payment of Rs.1,16,934/-. Even though the claim was duly registered, vide claim No.90591013540 and was processed by Raksha TPA Pvt. Ltd. but opposite party arbitrarily without application of proper mind repudiated the claim, vide letter dated 30.4.2009, on the ground that Raksha TPA, through its reference No.90591013540 dated 28.4.2009, had made the claim non-tenable as per policy condition. It was also averred that policy terms and conditions were never supplied to him. The complainant represented to opposite party, vide letter dated 4.6.2009 to review their arbitrary decision but no response was received. He filed the complaint before the District Forum seeking directions to the opposite party to make payment of the claim amount of Rs.1,16,934/- with interest @ 18% per annum, Rs.50,000/- for harassment as well as mental agony and Rs.11,000/- as costs of the complaint.
4. Upon notice, the opposite party filed written reply in which it was pleaded that claim of the complainant was processed by Raksha TPA but it has not been impleaded though a necessary party. It was further pleaded that treatment of certain diseases, including Lucentis, was not covered by the scope of Health Insurance Policy because even though this injection was given in the operation theatre, was an OPD treatment. The complainant himself was a doctor and was fully aware First Appeal No. 270 of 2011 Page 4 of 10 of this fact but he has managed to arrange the report of the doctor and has shown himself admitted into the hospital and tried to cover the treatment as indoor treatment. It was also denied that the terms and conditions of the policy were not supplied to the complainant. Dismissal of the complaint was prayed.
5. Both the parties led their evidence by way of affidavits and documents.
6. The learned District Forum, after going through the pleadings of the parties and evidence on record, allowed the complaint in aforesaid terms.
7. Aggrieved by those orders, both the parties have preferred these appeals.
8. Learned counsel for the opposite party submitted that the learned District Forum has wrongly observed that the complainant was admitted in Dr.Sohan Singh Hospital on 11.3.2009 and the injection was administered on 13.3.2009 but it has ignored the discharge summary of Dr.Sohan Singh Hospital. The learned District Forum has further erred by observing that the opposite party has failed to prove that opposite party had ever supplied the terms and conditions to the complainant at the time of issuance of the insurance policy. A perusal of the mediclaim policy clearly showed that it is a renewal of the already existing previous insurance policy from 2007 onwards. As such, the observation of the District Forum is not tenable. The District Forum has also ignored the circular of the opposite party company which clearly stated that the treatment taken for Lucentis injection is to be treated as an OPD treatment and thus First Appeal No. 270 of 2011 Page 5 of 10 not covered by the terms and conditions of the policy. It has also been wrongly held by the District Forum that it is no where mentioned in the policy that if the complainant is required eye treatment, he is not entitled for the treatment charges. Acceptance of the appeal and setting aside of the impugned order was prayed.
9. On the other hand, complainant in his appeal has prayed for enhancement of compensation awarded by the District Forum on the ground that once the District Forum has reached the conclusion that the complainant was harassed by the opposite party unnecessarily and the repudiation of the genuine claim was uncalled for, the complainant was entitled to interest on the claimed amount of Rs.1,16,934/- till the date of actual payment. Since the claim was repudiated on flimsy grounds and the complainant has been deprived of the claim amount, the compensation for harassment to the extent of Rs.5,000/- is too meager. It should have been exemplary.
10. We have thoroughly gone through the pleadings of the parties and have carefully perused the evidence on record and considered the submissions of the learned counsel for the parties.
11. The complainant has contended that he got the treatment for his eye from S.B.Dr.Sohan Singh Eye Hospital as an indoor patient and during the admission he was given injection of Lucentis (an anti- VEGF agent) for which he had to spend Rs.1,16,934/-. Since the amount was spent by him as an indoor patient, therefore, he was entitled to the claim. He also contended that the terms and conditions of the policy were never delivered to him alongwith cover note. On the other hand, the opposite party has contended that the First Appeal No. 270 of 2011 Page 6 of 10 administration of Lucentis injection is an outdoor treatment though it is given in the operation theatre. Therefore, the same is not covered as per the terms and conditions of the policy. Therefore, the claim of the complainant was repudiated as per recommendation made by TPA in its letter dated 28.4.2009 on the ground that treatment taken by complainant was an outdoor treatment. The opposite party has proved on record the copy of the mediclaim policy as Ex.R-7. Careful perusal of this document shows that it is primarily a Hospitalization Benefit Policy/Mediclaim Policy, 2007 and it has been mentioned in this policy itself that this policy is subject to Mediclaim Policy, 2007, clause attached herewith. The complainant has obtained a standard mediclaim policy, therefore, its terms and conditions are applicable. When a specific reference has been made regarding Mediclaim Policy, 2007 in the policy document itself, the complainant cannot say that its terms and conditions are not applicable or they were not handed over to him. The opposite party has further proved on record the terms and conditions of Mediclaim Policy, 2007 and Clause 1.0 of this policy states as under:-
"1.0 Coverage: NOW THIS POLICY WITNESSES that, subject to the terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the Company undertakes that if during the period stated in the Schedule any Insured Person shall contract any disease or suffer from any illness (hereinafter called DISEASE) or sustain any bodily injury through accident (hereinafter called INJURY) and if such disease or injury shall require any such Insured Person, upon the advice of a duly qualified First Appeal No. 270 of 2011 Page 7 of 10 Physician/Medical Specialist/Medical Surgeon (hereinafter called SURGEON) to incur Hospitalization Expenses (herein defined) for medical/surgical treatment at a Nursing Home/Hospital in India as herein defined (hereafter called HOSPITAL/NURSING HOME/DAY CARE CENTRE) as an in-patient, the Company will pay to the Hospital/Nursing Home Day Care Centre or reimburse the insured person, through the Company/Third Party Administrator, amount of such expenses as would fall under different heads mentioned below in respect thereof by or on behalf of such Insured Person but not exceeding in any one period of insurance the amount stated hereunder."
12. As per this clause, only hospitalization expenses for medical/surgical treatment at a nursing home/hospital as an indoor patient are covered (list of which is given). Thus, the only point for adjudication before us is whether the treatment taken by the complainant was required to be taken as an indoor patient or same could have been given as an outdoor patient?
13. The complainant has proved on record the discharge slip of SB Dr.Sohan Singh Eye Hospital Pvt.Ltd. dated 7.6.2009 as Ex.C-12 in which diagnose of the patient has been mentioned as "RAP STAGE 2" and operation conducted has been mentioned as "INTRAVITREAL LUCENTIS II UNDER LA". It is evident that during the course of admission, the complainant was administered Lucentis II Injection. He has further placed on record the certificate from the doctor of the treating hospital as Ex.C-11, in which it has been certified that the patient was suffering from RAP (Retinal First Appeal No. 270 of 2011 Page 8 of 10 Angiomatous Proliferans) a variety of CNVM in his right eye with visual distortion and visual deterioration. He was given an Intravitreal injection of Lucentis (an anti-VEGF agent) on 13.3.2009, an essential sight saving drug in these cases. It is clear from the certificate as well as from the Discharge Slip that the patient was admitted only to administer injection of Lucentis. The complainant had only paid for the cost of the injection and no hospitalization and other related charges as an indoor patient had been paid, which clearly shows that the hospitalization was not at all required for the purpose of administering this injection. The complainant has contended that a number of tests were carried out during the hospitalization but no such report of tests carried out, if any, has been placed on record to substantiate the averments. Discharge slip (Ex.C-12) shows that no reference to any test or investigation, required to be done, has been made during the entire period for which the complainant was shown as hospitalized. Under the heading operation, "Right Eye: Intravitreal Lucentis II Under LA", has been mentioned. It clearly indicates that no investigation or tests were required to be carried out and only an Intravitreal injection Lucentis II was given under local anesthesia in the right eye of the complainant. The opposite party has proved on record its circular dated 9.2.2009 (Ex.R-6), in which it has been specified as under:-
"For treating "Age Related Macula Degeneration (ARMD)"
under mediclaim policy, 2007, the drugs like "Avastin" or "Lucentis" or "Macugen" and other related drug is given as Intravitreal injection. It is an OPD treatment though this First Appeal No. 270 of 2011 Page 9 of 10 injection is given in the operation theatre. In view of the nature of treatment, it falls outside the scope of our health policies. Hence the treatment of ARMD with administration of above referred drugs or any other drug is excluded from the scope of the cover."
14. The treatment given to the complainant as mentioned in the Discharge Slip (Ex.C-12) and explained in certificate (Ex.C-11) of the doctor is fully covered by the circular (Ex.R-6) an same can only be considered as an outdoor treatment, which is not covered under the provisions of the policy. The complainant, being a doctor, has tried to bring the administration of an injection of Lucentis into the ambit of an indoor patient treatment just to obtain undue financial gain. Ex.C- 11 does not indicate if any other treatment was given to the complainant during hospitalization. It only states that Intravitreal injection of Lucentis (an anti-VEGF agent) was given on 13.3.2009 whereas the complainant has been shown to be admitted, as per discharge slip, since 11.3.2009. There is absolutely no record to show for what purpose the complainant remained hospitalized for 3 days. No medical record or bed-head ticket has been produced to substantiate the fact that hospitalization for such a long period was actually required.
15. In view of the above discussion and findings, we are of considered view that for administering the injection of Lucentis no hospitalization, except the utilization of operation theatre for giving the injection, was required. Accordingly, the appeal of the opposite First Appeal No. 270 of 2011 Page 10 of 10 party is accepted and the impugned order is set aside. Consequentially, the complaint of the complainant is dismissed.
16. For the reasons stated above, the appeal filed by the complainant for enhancement of compensation stands dismissed. No order as to costs.
17. The opposite parties deposited an amount of Rs.25,000/- with this Commission at the time of filing the appeal. This amount alongwith interest which has accrued thereon, if any, be remitted by the registry for payment to the opposite parties, in equal shares, by way of a crossed cheque/demand draft, after expiry of 45 days under intimation to the learned District Forum.
18. The arguments in these appeals were heard on 14.5.2013 and the orders were reserved. Now, the orders be communicated to the parties.
19. The appeals could not be decided within the statutory period because of the heavy pendency of the court cases.
20. Copy of this order be placed in First Appeal No. 321 of 2011 (Santokh Singh V/s New India Assurance Company).
(JUSTICE GURDEV SINGH) PRESIDENT (BALDEV SINGH SEKHON) MEMBER May 29, 2013 VINAY