The Consumer Disputes Redressal Forum, Ahmedabad (Additional), has directed Oriental Insurance Company Ltd. to pay its valid health insurance policyholder Chirag Sanghavi Rs. 1.17 lakh, part of it with interest, for the expenses incurred by him on his medical treatment. The amount includes compensation of Rs. 10,000 for his mental agony and Rs. 2,000 towards the litigation cost. Consumer Education & Research Society (CERS), a co-litigant with Sanghavi, was also awarded Rs. 2,000 towards cost.
Sanghavi had been suffering from Crohn’s disease and, on 22-23 September 2005, had been treated at the local Dr. Jivraj Mehta Hospital. Only the previous month he had purchased a medical insurance policy from Oriental Insurance. But he did not make any claim since, as per the conditions, the company was not liable to pay any cost for treatment taken during the first six months of the policy.
On 5 August 2006 Sanghavi renewed the policy for another year. On 2-3 September 2006, he had to undergo treatment once again. This time, he was given Remicade – IV injection and was hospitalised for one day. On release, he claimed reimbursement of the total cost of Rs. 1,50,299. The insurance company settled only part of the claim, i.e. Rs. 44,826, saying the treatment did not require hospitalisation and so the entire cost was not payable.
Sanghavi made a representation to the company that in the opinion of the doctor who had treated him, hospitalisation was required as the dose of the injection might lead to certain side effects. But the company declined to agree. Sanghavi approached CERS, which filed a complaint in the consumer forum seeking reimbursement of the deducted amount along with interest, compensation for the mental agony faced by the complainant and the cost.
The insurer cited the opinion of a doctor from a third party agency (TPA) that since no side effects had been noticed when Sanghavi had been treated for the first time, hospitalisation was not required during the second time. CERS quoted the doctor who had actually treated the patient that no-reaction during the first course of treatment did not necessarily eliminate the risk involved when the procedure was repeated a second time and, therefore, hospitalisation was absolutely necessary in this particular case.
The forum observed that the opinion of the doctor treating the patient was more important than that of the doctor serving a TPA. The forum ordered the insurance company to pay Rs.1,05,473/- from 29 June 2007 @ 4% interest. It also directed the company to pay Sanghavi Rs. 10,000 for mental agony faced by him and Rs. 2,000 each to him and CERS towards the litigation cost.
