CWJC No. 20493 of 2011. Case: Usha Jhunjhunwala Vs The Oriental Insurance Company Limited & Ors.. High Court of Patna (India)

Case NumberCWJC No. 20493 of 2011
CounselFor Appellant: Mr. Gautam Kumar Kejriwal, Adv. and For Respondents: Mr. Sanjay Singh, Adv.
JudgesJ.N. Singh, J.
IssueInsurance Law
CitationAIR 2013 Pat 113, 2013 (2) PLJR 975
Judgement DateMay 14, 2013
CourtHigh Court of Patna (India)

Order:

J.N. Singh, J.

  1. Petitioner has filed this writ application for quashing the letter dated 8.8.2011 (Annexure-6 with the writ application) issued by respondent No. 3, the Divisional Manager of the Oriental Insurance Company Limited, by which her husband was informed that her claim was not found payable on the ground that "Injection Lucentis is not payable under the scope of the Policy." However, by the letter "one more opportunity" was given to substantiate her claim within 2 weeks from the date of receipt of the letter, before a final decision was taken, failing which her claim was to stand repudiated on the said ground, without further advices from them. She has also made a prayer in the writ application for quashing the letter dated 17.8.2011 (Annexure-8) issued on behalf of respondent No. 4, The Medicare T.P.A. Services (1) Pvt. Ltd., Kolkata, by which she was informed that her medical claim documents were processed, but, as per the opinion of its adjudication department and the doctors' panel, her claim was adjudicated as "No claim" in nature because of the reason that "Treatment/procedure related to inj Lucentis is not covered as per Insurance Co. guidelines. Hence the claim repudiated". It was also mentioned in the letter that "the respective Divisional officer has recommended repudiation vide letter dated 30.6.2011. Therefore the claim stands rejected". These two letters show that, as far back as on 30.6.2011, the respondent Divisional Manager had recommended to respondent No. 4 for repudiation of claim of petitioner, on which respondent no. 4 acted, resulting into issue of Annexure-8. Still respondent Divisional Manager issued letter dated 8.8.2011, Annexure-6, by which, though holding that her claim was not found payable, she was given "one more opportunity" to substantiate her claim. Petitioner, in response of the said letter of the respondent Divisional Manager Annexure-6, indeed, availed that opportunity and filed her application dated 1.9.2011 (Annexure-7). A reply dated 27.10.2011 of the respondent Divisional Manager of her said application, addressed to her husband, is Annexure-5 with the counter affidavit. The present writ application was presented in the Stamp Report Section of the High Court on 9.11.2011. Still the application is conspicuously silent about this reply, nor there is a pleading that petitioner had not received any final decision of the Insurance Company on her said application, Annexure-7. Since all previous communication and stand of the respondents stand merged in this final reply of the respondent Divisional Manager dated 27.10.2011, petitioner was required to challenge the same also before this Court, either through a prayer in the main writ application, or through an I.A. for liberty to do so, at least after filing of the counter affidavit in the case, which she has apparently not done.

  2. Be that as it may, coming to the merits of the case and issues involved, this Court finds that there is no dispute of the fact that, as appearing from the doctor's prescription dated 4.10.2010 (Annexure-1) also, petitioner was examined at Infiniti Eye Hospital at Mumbai. The diagnosis and advice to her was as under:--

    Mrs. Usha Jhunjhunwala was diagnosed as Wet ARMD with Mixed CNVM. She was advised FFA followed by Intravitreal Inj of Antivegf in each eye separately. Both Inj Lucentis and Avastin were discussed with her. She was traveling to Europe and wished to undergo the procedure after 10-12 days.

  3. The above diagnosis and advice contains medical terms and abbreviations. Hence, with the help of internet and medical books this Court could find their full form or explanations as under:--

    ARMD-Age Related Macular Degeneration

    CNVM-Choroidal Neo-Vascular Membrane

    FFA-Fundal Fluroscein Angiography

    Inj-Injection

    Intravitreal-Posterior chamber

    Antivegf-Anti-vascular endothelial growth factor. (Antivegf medications are a group of drugs used in the treatment of wet type AMD).

    (These drugs work by blocking the effects of a growth factor that blood vessels need in order to form and keep leaking and are most effective when used in the early stages of the condition. The anti-VEGF drugs stop the growth of new blood vessels, thereby reducing the risk of scarring and further sight loss)

  4. This is also not in dispute in the case, as also evident from Annexure-2 series and Annexure-3 series with the writ application, that petitioner received treatment in the left eye on 11.10.2010 and in the right eye on 13.10.2010, which was repeated on 11.11.2010 and 13.11.2010. As per discharge slips, the treatment was labeled as "operation", and was "intravitreal inj. Lucentis in Operation Theatre'. The discharge slips also show that on the first day petitioner was admitted and was discharged the next day only. Pleading of the petitioner is that she was admitted, hospitalized, and after operation remained under supervisions and post-operative care for a day. Issue is, in these circumstances, whether petitioner is legally entitled, or not, for reimbursement of her all expenses of treatment under the terms and conditions of the Mediclaim Insurance Policy she was having with the respondent Insurance Company.

  5. Though, with the writ application, petitioner has annexed a chart (appears to have been prepared by the Regional Training Centre of respondent Insurance Co.) containing comparison of "Mediclaim Insurance Old and New Policy w.e.f. 15.6.2006" as Annexure-9, but in the pleadings she has not referred to any particular clause, of either the old or the new policy, in support of her case of entitlement for her mediclaim. It also appears that neither in the initial application dated 1.12.2010 (Annexure-4), nor in the reminder dated 18.1.2011 (Annexure-5) sent by her husband, nor in her detail representation dated 1.9.2011 (Annexure-7), any specific clause of the policy was referred to or relied upon in support of her claim. Likewise, the respondent Divisional Manager also, in his impugned letter dated 8.8.2011 (Annexure-6), did not refer to any particular clause of the policy to deny the claim of the petitioner, except saying that "Injection Lucentis is not payable under the scope of the Policy". Respondent No. 4 also, in its impugned letter dated 17.8.2011 (Annexure-8) has not referred to any particular clause of the Policy, except saying that...

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