w w w . L a w y e r S e r v i c e s . i n

Santanu Roy v/s TTK Healthcare TPA Pvt. Ltd. & Others

    First Appeal No. FA/769/2014
    Decided On, 22 May 2018
    At, West Bengal State Consumer Disputes Redressal Commission Kolkata
    By, MEMBER
    For the Appellant: Prasanta Banerjee, Advocate. For the Respondent: Swarajit Dey, S. N.Ganguly, Advocates.

Judgment Text
Utpal Kumar Bhattacharya, Member

Instant Appeal u/s 15 of the C.P. Act, 1986 has been filed by the Appellant/Complainant challenging the judgment and order dated 28.05.14 passed by the Ld. District Forum, Kolkata Unit –II in CC No. 104 of 2013 dismissing the complaint on contest against the Respondents /OPs.

The brief fact of the complaint was that the Tablet India Ltd., the Respondent/OP No. 4 had its employees , including the Appellant/Complainant , being the employee No. 1480, insured under G.I. Policies sponsored by the Respondent/OP No. 3 Insurance Company for the period with effect from 24.04.2010 to 23.04.2011 and by the Respondent /OP No. 2 Insurance Co. for the period w.e.f 24.04.2011 to 23.04.2012 .

The Appellant/Complainant felt acute low back pain within the validity period of the previous policy and diagnosed by the treating doctor to have been suffering from Ankylosing Spondelysis . He was advised urgent hospitalization by the said treating doctor prescribing to take infiximap (Remicade 100 mg) injection, total 300 mg . The Complainant, after being administered the said injection on 20.04.2011 was released on the following day , that is , 21.04.2011.

A claim for reimbursement of the cost for the above treatment to the tune of Rs. 1,03,488.70 was submitted by the Appellant/Complainant through Respondent /OP No.1. , the TPA. The TPA , however, repudiated the said claim on 21.06.2011.

Similar treatment was advised by the same doctor after a few days when the said Appellant/Complainant was again hospitalized on 10.05.2011 and was discharged on 11.05.2011. A claim submitted through Respondent /OP No.1, the TPA, to the tune of Rs. 1,03,464.18 was also not sanctioned .

The repudiation was made on the ground that the treatment might have been done on OPD basis without the patient being hospitalized .

The Appellant/Complainant, being aggrieved with the repudiation as above , had resorted to the Ld. District Forum filing the complaint case wherefrom the impugned judgment and order originated .

Heard Ld. Advocates appearing on behalf of the Appellant/Complainant , Respondent/OP No.2 and Respondent /OP No. 3 . All , in their very brief submissions , defended the interest of their respective clients in the same line as they had adopted before the Ld. District Forum .

The Appellant/Complainant’s submission was nothing new as he pointed out that there was valid policies at the time of hospitalizations and the patient was advised urgent hospitalization by the treating physician . The claim , as the Ld. Advocate contended , should not have been repudiated as the admissibility of the claim was never questioned by the Respondents/OPs on any feasible ground. The Respondents/OPs, as continued , repudiated the claim in an arbitrary decision without application of mind. The Ld. Advocate concluded with the prayer for allowing the Appeal setting aside the impugned judgment and order.

Ld. Advocate appearing on behalf of the Respondent /OP No.2 impressed upon the Bench to take into consideration one of the exclusion clauses under 4.22 in the guidelines of the policy . The said clause explains in favour of exclusion of coverage in case of stay in hospital for domestic reason where no active regular treatment is given by specialist. The Ld. Advocates for the Respondent /OP No. 2 cited the decision of the Hon’ble National Commission in revision petition No. 1570 /2011 [ National Insurance Corporation Ltd., Kolkata Division – VIII, -vs- Ms. Santosh Jewellers Jagannathpur] wherein the Hon’ble National Commission, while dismissing the aforesaid revision petition , observed against the State Commission’s ordered of sanctioning 50% of the sum assured as ex gratia since there was no such provision in the policy.

Ld. Advocate appearing on behalf of the Respondent/OP No.3 contended saying the injection 'Remicade' usually applied as a pain killer. It was not understood whether the subject pain was at all for the disease diagnosed. He also pointed out that administering an injection which needs only 3 hours including 1 hour specified for post injection observation, as envisaged in the medical literature of the subject disease, does not necessitate the indoor treatment which the Appellant/Complainant had undergone on the instant issue. As contended it was a purposeful hospitalization with an ulterior motive to create a justifying ground for filing the instant claim for reimbursement .

The Respondent/OP No. 3 also cited the decision of the Hon’ble Apex Court in Civil Appeal No. 2080 of 2002 [ Vikram Greentech (1) & Anr. –vs- New India Assurance Co. Ltd.] reported in 2013(2) CPR 315 (SC) wherein the Hon’ble Apex Court was pleased to observe that insured should not claim anything more than that was covered by the Insurance Policy.

With their respective citations , of course , the Respondents/OPs had tried to establish that violation of policy guidelines had very reasonably led to the subject repudiations on the instant issue.

Both the Respondents/OPs , with their above submissions prayed for the Appeal to be dismissed affirming the impugned judgment and order .

Perused the papers on record . It appeared on perusal of the letter dated 21.06.2011 of the Respondent /OP No.1 , the TPA, that the sole reason for repudiation of the claim was hospitalization with overnight stay of the patient when apparently , there was no necessity of any treatment other than OPD .

We have gone through the exclusion clause laid down at para 4.22 of the policy . Question is whether the hospitalization is intended to secure the claims for reimbursement under the policies in question .

The prescription dated 17.04.2011 of the treating doctor at running page – 29 indicates the name and symptom of the disease corroborating those laid down in the complaint . It has also recorded the duration of suffering from the disease as 9 to 10 months , that is , after the date of initiation of the first policy which is 24.04.2010 . This rules out the probability of the disease to be a preexisting one .

The prescription also has left indication that the patient needs urgent hospitalization . So, the hospitalization of the patient cannot be questioned as a motivated one , as alleged. The absence of any prescribed duration in the subject prescription which the Respondents/OPs have taken as a plea for repudiation of the claim , cannot be a feasible ground as the condition of the patient after the medication should be the determining criterion for releasing or discharging any patient .

The precaution for administering the injection 'Remicade' , as it is evident from the supplied medical literature , has been associated with acute infusion effects and a delayed hypersensitivity reaction and , therefore, all patient receiving the said medicine should be kept under observation for one hour post infusion for side effects.

It has also been clarified that the acute infusion reaction may develop immediately or within a few hours of infusion and in case of such reaction being developed, the infusion should be interrupted . Since this is an injection of Remicade 100 mg and the total volume to be injected is 300 mg, it is an obvious inference that the reaction has chance to develop at any point of time during the period of infusion warranting interruption . The literature itself is indicative as to the seriousness of keeping the patient under observation for hours .

The medical literature itself , most naturally is not specific as to the exact time by which the reaction is apprehended to occur . Therefore, the hospital authority or the treating physician would be or should be the best judges to decide the minimum period under which the patient should be kept under observation.

The Respondent /OP No.1 appeared to have become too hypertechnical while repudiating the claims on the ground which is not fundamental in nature.

In this context, we may refer to the decision of the Hon’ble National Commission in First Appeal No. 366 of 2014 [Royal Sundaram Alliance Insurance Co. Ltd and Anr. –vs- Melanie Das] reported in 2018 (1) CPR 720 (NC) against the order dated 02.04.2014 in complaint No. 17/2014 passed by the Ld. State Commission , Haryana where , while affirming the order of the State Commission towards payment of treatment cost with interest and compensation, the Hon’ble National Commission was critical about the Insurance Company’s activities as an effort to repudiate the claim on one or other ground.

We , in view of the above , are of considered views that the repudiations were not justified . Hence,


That the Appeal be and the same stands allowed with

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the direction upon the Respondent /OP Nos. 1 and 2 and Respondent /OP Nos. 1 and 3 to arrange for reimbursing the treatment cost in favour of the Appellant/Complainant to the tunes of Rs. 1,03,464.18 and Rs. 1,03,488.70 to be paid by the Respondent No. 2 and Respondent No. 3 respectively through their respective jobs yet undone. They are further directed to pay cost and compensation to the tunes of Rs. 3,000/- and 5,000/- each to the Appellant/Complainant. All the above amounts are to be paid to the Appellant/Complainant within 45 days from the date of the instant order , failing which , simple interest @ 9% p.a. shall accrue to Rs. 1,08,464.18 being the total of reimbursement amount and compensation to be paid by Respondent/OP No. 2 and Rs. 1,08,488.70 being the total of reimbursement amount and compensation to be paid by Respondent/OP No. 3 from the date of default till the above order is carried out in toto. The impugned judgment and order stands set aside.