By Jehangir B Gai  There are certain ailments whose course of treatment involves a periodic series of procedures. If one claim is rejected, subsequent ones too will be rejected. In such circumstances, it would be harassment if the consumer must file a complaint each time he undergoes the procedure. Here is a case where the consumer forum, after holding the repudiation to be unjustified, directed not only payment of the claim, but also payment of subsequent ones. Case Study: Khurshed Pardiwala, was covered by a mediclaim policy from United India Insurance Co, obtained several years ago and renewed over the years. The coverage was Rs 1.75 lakh including the insured sum of Rs 1.25 lakh and Rs 50,000 as cumulative bonus.

Pardiwala (83), developed age-related macular degeneration of the left eye, which is treated by periodic administration of the injection Lucentis into the vitreous of the eye under anaesthesia in aseptic conditions. The patient must be carefully monitored, as it can result in adverse reaction. Hence, the procedure is conducted in the operation theatre.

He was given the first dose of Lucentis on November 23, 2012, the second on January 4, 2013, and third on February 8, 2013. He lodged three claims, all of which were rejected, saying that the claims were not payable as treatment could have been taken on OPD basis. Pardiwala then filed a complaint through the Consumers Welfare Association, demanding the settlement of his claims and a general direction that all claims pertaining to the same ailment requiring the same procedure be paid to avoid fresh litigation each time. The insurer contended that the complaint was frivolous.

The forum considered the medical certificate from Dr Burjor Banaji, the treating ophthalmic surgeon, which stated that administration of Lucentis is an intravascular procedure, requiring the use of sterile operation theatre and precautions required for eye surgery . It concluded that the procedure could not have been carried out on OPD basis.

The insurer then argued that claims are payable only when hospitalisation is for at least 24 hours. Since Pardiwala was discharged within a few hours on the same day , the claim was not payable. The forum rejected this too, noting that in case of certain treatments such as ophthalmic ones, the policy has an exception to the general requirement of 24 hour-hospitalization for claim payments. It observed that every time Lucentis was administered, Pardiwala had paid operation theatre charges, surgeon charges and room fees.So he had to be reimbursed.

Accordingly , by its order of December 8, 2015, the forum indicted the insurer for defi ciency in service and unfair trade practice. It ordered the insurer to settle the first claim by paying Rs 67,000 with interest at 9% from January 11, 2013, when the claim was repudiated, until payment. The second claim of Rs 62,000 too had to be paid with 9% interest from January 30, 2013. To ensure the total amount was within the overall limit of the sum insured, the third claim for Rs 57,000 was restricted to Rs 46,000, to be paid with 9% interest from March 1, 2013. The forum also awarded Rs 12,000 as compensation for mental harassment and Rs 5,000 towards litigation costs. It also directed the insurer to discontinue the unfair trade practice of refusing to settle similar future claims, limited to the policy coverage amount available.

Conclusion: This judgment will help curtail litigation, as one complaint takes care of all claims, including future ones.

(The author is a consumer activist and has won the Govt. of India’s National Youth Award for Consumer Protection. His e mail is jehang ir.gai.articles@hotmail.com)

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Source: TOI-MUM