Medi-Claim Policy – Cancer – Ceiling on expenses of injections
The petitioner had taken medi-claim policy initially for Rs.15 lakhs which was increased to Rs.22.5 lakhs and in 2015, the petitioner purchased policy of Rs.22 lakhs. Thus, total cover was Rs.44.5 lakhs.
In 2021, the petitioner was diagnosed with breast cancer. The petitioner is undergoing chemo therapy.
The claim was denied since it cannot exceed Rs.2 lakhs for giving Monoclonal Antibody injections under the terms of policy.
On consideration of the complaint of the petitioner, the Insurance Ombudsman vide Order dated 13.1.2023 directed the Insurer to settle the claims as precious life is being saved by such medical treatment as advised by the doctor.
The petitioner filed the writ petition since the said order was not complied with.
The Insurer contended that maximum amount of Rs.2 lakhs can be paid for immunotherapy – Monoclonal Antibody to be given as injection.
Clause 3.10.5 provided for limit upto 25% of sum insured subject to maximum of Rs.2 lakh for “Immunotherapy – Monoclonal Antibody to be given as injection”.
The important question was whether the sub-limit of Rs.2 lakhs for immunotherapy as mentioned in the Policy is applicable to “Chemo-immunotherapy”.
HELD that Chemo-immunotherapy is an emergent treatment option for cancer patients and is different from Immunotherapy. It is a combination of Chemotherapy and Immunotherapy. They are two different types of treatment. Clause 3.10.5 shows that ceiling of Rs.2 lakhs is applicable to Immunotherapy – Monoclonal Antibody given as injection. There is no ambiguity about the same.
Assuming that there is ambiguity, the doctrine of contra proferentem would be attracted in this case because there is an ambiguity in the policy as it prescribes limit for Immunotherapy – Monoclonal Antibody given as injection and not for Chemo-immunotherapy.
The petitioner, who is a cancer patient, has been harassed without any reason and has been deprived of the amount putting her to mental agony. This Court is inclined to impose cost of Rs.50,000/- on the Respondent No.1 Insurance Company.
Judgment dated 3.5.2024 in Writ Petition (Civil) No.11799 of 2023 of Garima Singh Vs. New India Assurance Co Ltd and others with connected matters.
