Failed To Justify Denial Of Mediclaim To Schizophrenia Patient: Jammu & Kashmir & Ladakh High Court Directs National Insurance Corporation To Indemnify Treatment Costs
The case arose after National Insurance Corporation rejected a claim citing policy exclusions, a decision later overturned by the SCDRC.
The Jammu & Kashmir and Ladakh High Court dismissed a petition filed by National Insurance Corporation, challenging the decision of the State Consumer Disputes Redressal Commission (SCDRC), directing it to indemnify a schizophrenia patient’s medical expenses after the initial claim was denied.
A Division Bench of Justice Sanjeev Kumar and Justice Moksha Khajuria Kazmi held, “In terms of Clause 1.0 the claimant/respondent No.2 was fully eligible to claim insurance on account of his hospitalization due to major depressive disorder with strong suicidal ideation. As per the expert opinion, it was not proper to manage respondent No.2, at home. Learned State Commission has already held that petitioners could not substantiate alleged disqualification of an insured, suffering from disease of psychiatric, psychosomatic disorders to claim indemnification either being an indoor or outdoor patient.”
The Petitioners were represented by Advocate Suneel Malhotra, whereas Advocate Mohit Vaid appeared for the Respondents.
Brief Facts
The patient, Respondent No.2 herein, had filed a complaint against the Petitioners before the Divisional Consumer Forum (Consumer Forum), alleging that his mother had taken out a mediclaim insurance policy with the Petitioners during which period he had been diagnosed with schizophrenia and underwent treatment at various hospitals, incurring medical expenses.
The Petitioners submitted the claim to Respondent No.3, a third party administrator (TPA) with a panel of doctors, who rejected it, stating that psychiatric and psychosomatic disorders were excluded under the policy and that outpatient treatment was not covered. The Divisional Consumer Forum upheld the repudiation, and dismissed the complaint filed by the patient.
Aggrieved, the patient appealed before the SCDRC, which set aside the Consumer Forum’s decision, directing the Petitioners to indemnify the patient.
The Petitioners have therefore challenged the decision of the SDCRC before this Court.
Contentions of the Parties
The Petitioners contended that the SDCRC had exceeded its jurisdiction and that the impugned order was bad in law. It was further submitted by the Petitioners that the patient herein was suffering from such a disease which could have been treated as an outdoor patient and that psychiatric and psychosomatic disorders were specifically excluded under the policy. The petitioners also averred that he had been admitted to the facility due to a drug-related treatment, and not for psychiatry treatment.
The patient submitted that he suffered from the ailment and that the treatments he had undertaken at various hospitals had taken place during the currency of the policy, yet the Petitioners repudiated his claim without any reasonable grounds. The patient further submitted that an expert in the field had specifically rejected the opinion contained in the letter issued by the panel doctor of the TPA, wherein he specifically mentioned that any individual suffering from major depressive disorder with strong suicidal ideation had to be advised hospitalization and he could not be managed at home
Reasoning by the Court
The Bench adverted to the clauses under the policy and noted that in terms thereof, the patient was squarely covered and fully eligible to claim insurance on account of hospitalization due to major depressive disorder with strong suicidal ideation.
The Court observed, “Learned State Commission has already held that petitioners could not substantiate alleged disqualification of an insured, suffering from disease of psychiatric, psychosomatic disorders to claim indemnification either being an indoor or outdoor patient. Moreover, it has also been held by learned State Commission that the respondent No.2 has not based his claim on Clause 2.4 domiciliary hospitalization, as such, the same is not applicable to the claim of the respondent No.2.”
“Learned counsel for the petitioners has also failed to convince us with respect to applicability of Clause 4.8 of the Policy. He has stated that the medical treatment provided to respondent No.2 at “Santulan”, was because of his addiction to drugs, whereas it is clearly reflected in the impugned judgment/order that “Santulan” is a specialized centre for Management of Psychiatric and Alcohol/Drug problem, situated at Delhi. The respondent No.2 might have been admitted at “Santulan” for psychiatric treatment and not for any drug related treatment. Petitioners have failed to substantiate that respondent No.2 was admitted due to drug addiction, as such, his claim has to be excluded in terms of Clause 4.8 of the Policy.”, the Bench observed.
Consequently, the Court upheld the SDRC's decision, dismissing the petition while modifying the impugned judgment to relieve the Petitioners of Rs.30,000/- in damages.
Cause Title: National Insurance Co. Ltd. v. Jammu and Kashmir State Consumer
Disputes Redressal Commission (OWP No. 1448/2010)
