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The District Consumer Disputes Redressal Commission of Chandigarh has directed LIC and an insurance company to pay Rs 4.22 lakh to a Panchkula resident, for not paying full medical claim of his daughter, who underwent stem cell transplantation procedure.
Pal Singh of Panchkula stated in his complaint that he and his family members were duly covered by Medical Claim Policy taken by the LIC of India from New India Assurance Company Limited for the year 2019-2020 having a coverage of Rs 30 lakh.
It was told that during the coverage period of the said policy, the daughter of the complainant namely Rajni Devi was detected with lung cancer.
She took treatment at different hospitals, medical institutes i.e. General Hospital, Sector 6, Panchkula, Fortis Hospital, Mohali, Denvax Cancer Cetre, Delhi etc. for the same and unfortunately died on January 18, 2020.
It is stated that the medical expenditure incurred by complainant on the cancer treatment of her insured daughter was settled by the insurance company only to the tune of Rs 57,772 and denied the balance amount of Rs 3,96,932 on the ground that she had undergone stem cell transplantation procedure, which is not payable under the policy.
The LIC of India in reply submitted that this particular treatment has not been covered under the policy in question and hence the claim for balance amount was repudiated which was valid and was as per policy terms and conditions.
The New India Assurance Company Limited in reply submitted the claim was filed for treatment taken for metastatic carcinoma of lungs during policy period and the complainant was informed that the remaining claim fell outside the scope & ambit of policy as Dendritic Cell Therapy being stem cell therapy was excluded in respect of cancer and there were sub-limit for different stem cells transplantation provided in the policy.
It is submitted that as per terms and conditions of the policy, the stem cell therapy was excluded from the reimbursement except in certain type of cancer which is bone marrow, blood cancer, myeloma etc.
MD India Health Insurance TPA Private Limited did not turn up despite service of notice sent through regd. post, hence it was proceeded exparte vide order November 17, 2021.
The Commission after hearing the matter held that any clause in the policy either exclusion or otherwise, cannot be read or introduced to the disadvantage of the policy holder and the insurance companies as in the present case cannot deny the claim on technical ground.
Finding that the LIC of India and the insurance companies have wrongly and illegally rejected the genuine claim of the complainant, the Commission directed them to pay balance claim amount to the complainant which is Rs 3,82,469 (Rs.4,40,241- Rs.57,772), the medical expenses incurred by him on the treatment of his insured daughter, along with interest at 10 percent per annum from the date of filing the present complaint which is December 15, 2020 till its realization, along with Rs 25,000 as compensation and Rs 15000 as cost of litigation.
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