(Passed this on 09th January, 2017)
Shri. S.P. Muley, President –
1. This is a complaint of unfair trade practice and deficiency in service against an insurance company in respect of settlement of insurance claim.
2. Facts in short are that the Opposite Parties No.1 to 3 are Head and local offices of ICICI Lombard General Insurance Company, O.P.4 is claim department of the company and the O.P. 5 is widow of the insured. The complainant No.1 is mother and No.2 is brother of late Tekchand Yadavrao Bisen ( hereinafter for short, the deceased). The deceased had purchased an insurance policy, ¨Critical Care Secured Mind¨ from the OPs 1to 3 to cover his personal accident and medical illness by paying one time premium. The policy was in force from 20/11/2007 to 19/11/2012. The deceased was working as a Civil Engineer with L&T Ltd at Surat. On 4/7/2011 he suffered heart attack and was therefore admitted to a hospital at Surat. There he was treated for heart ailment from 7/7/2011 to 12/7/2011. he was discharged with advice to follow up after 7 days. He was initially diagnosed with Left Bundle Branch Block (LBBB), Dilated Cardiomyopathy (DCM) and Congestive Cardiac Failure (CCF). However, on final diagnosis, he was diagnosed with suffering from 30% generalised hypokinesia and advised Automatic Implantable Cardioverter-Defibrillator (AICD) / Biventricular Pacemarker Therapy (CRT).
3. He was advised to undergo the above treatment due to his acute heart condition. On 21/7/2011 due to Myocardial Infarction (MI) or acute Myocardial Infarction (AMI), commonly known as heart attack, he expired. As per death certificate he died of Cardio Respiratory Cessation due to Coronary Heart Disease (C.H.D.) As such he died of heart attack caused by various complications developed due to the heartś malfunctioning. According to the complainants on first diagnosis of any of the diseases as mentioned in the policy, the deceased was entitled to entire sum assured Rs.6 lakh.
4. The complainant No.1 is legal heir of the deceased and No.2 is the nominee in the said policy. The O.P.5 has already received amount from L&T Company, the employer of the deceased, after the death of the deceased. She has been residing with her parents and is reluctant to co-operate and is not interested in claiming the insurance amount. Hence, she is joined as O.P. The complainants No. 1 and 2 promptly informed the OPs about death of the deceased and lidged claim with relevant documents. The O.P.4 on behalf of the OPs 1 to 3 by letter dated 10/5/2012 refused to settle the claim on baseless grounds. Alleging unfair trade practice and deficiency in service on the part of the OPs 1 to 3, it is prayed to direct the OPs 1 to 4 to pay a sum of Rs. 6 lakh with 12% interest along with compensation of Rs.2.50 lakh for mental and physical agony and Rs.50,000/- for cost.
5. The OPs 1 to 3 have resisted the claim by filing their written version and denied the status of the complainants to claim insurance amount. Not denying the insurance policy of the deceased, it is stated that indemnity under the policy was subject to terms and conditions of the policy. Admitting his death at Surat, it is stated that autopsy was conducted to ascertain exact cause of death, but the report has not been placed on record. All medical papers are not filed and nothing is mentioned in discharge summery about suffering from 30% generalised hypokinesia. There is no evidence of MI which is defined under the policy. Besides, the treating doctor replied in negative that the deceased had suffered with MI. Under the said policy only Stroke, Paralysis and Myocardial Infarction are covered. Since the death was not outcome of the said covered perils, the claim was rightly repudiated. It is denied that the complainants are entitled to a sum assured Rs. 6 lakh. It is denied that the deceased died due to MI. Denying deficiency in service or unfair trade practice, it is submitted to dismiss the complaint.
6. The O.P.4 despite service of notice, failed to remain present. Therefore the complaint proceeded ex-parte against it.
7. The O.P.5 by her written submission dated 2/9/2013 informed the forum that she has no objection to release the insurance claim in favour of the complainants. She did not participate thereafter in the proceeding.
8. We have heard Ld counsels for both the parties, perused documents and notes of arguments. Upon considering the same, we record our findings and reason as under.
FINDINGS AND REASONS
9. The dispute in this case is about the cause of death of the deceased. According to the OPs 1 to 3, the deceased died of some other cause, which is not covered under the policy. The complainants in their complaint have given detailed description of various conditions of heart ailment. We shall come to that a little later. First it would be convenient to peruse the terms and conditions of the policy.
10. It was a sort of medi- claim policy under which accident and some diseases were covered to indemnify an insured for expenses incurred on treatment. It offers financial support by making lump-sum benefit on first diagnosis of any of the nine listed major medical illness. We shall restrict ourselves to heart ailment and heart related disorders as the deceased was undoubtedly a patient of heart disease. The policy covers, inter alia, Coronary Artery Bypass Graft Surgery, Myocardial Infarction (Heart Attack), Heart Valve Replacement Surgery. An insured is entitled to medical expenses incurred for treatment on account of above said illness. However, following are excluded:
- Non ST-segment elevation myocardial infarction(NSTEM) with elevation of Troponin I or T,
- Other acute Coronary Syndromes,
- Any type of angina pectoris.
12. It is to be noted that the medical term Myocardial Infarction (MI) is commonly known as heart attack. The OPs in their said policy have explained what is Myocardial Infarction. It reads,
¨ the first occurance of an acute myocardial infarction leading to death of a portion of heart muscle (myocardium) as a result of inadequate blood supply to the relevant area.
The diagnosis for the same must be evidenced by all of the following:
- An episode of typical chest pain.
- The occurrence of typical new acute infarction changes (ST-T elevation) on the electrocardiograph and progressing to development of pathological Q waves
- Elevation of cardiac Troponin (T or I) to at least 3 times the upper limit of normal reference range or an elevation in CPK-MB to at least 200% of the upper limit of the normal reference range ¨
13. According to the OPs there was no evidence of Myocardial Infarction or in simple words heart attack, in the case of the deceased. MI, commonly known as heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to blockage of a coronary artery. The restriction of blood supply and ensuing oxygen shortage, if left untreated for a long period, can cause damage or death (infarction) of heart muscle tissue (myocardium). LBBB is a cardiac conduction abnormality seen on the ECG. Acute Myocardial Infarction is one of the causes of LBBB.
14. Now, let us turn to the cause of death of the deceased. For that purpose we have perused Discharge Summery of the deceased. It is mentioned, the provisional diagnosis was LBBB, DCM CCH H/O -CAG(N) 2007 and final diagnosis was CAG done- Normal Coronaries. Pacemaker therapy was advised. From the discharge summery it appears that the deceased had heart problem. In fact, death of the deceased did not occur during his hospitalisation, but he was brought dead to the hospital. Therefore his body was sent for post mortem. The PM report is not placed before us nor was it provided to the O.P.3 for verification. Nevertheless, as per the death certificate issued by the Surat Hospital, where the deceased was brought, has certified the cause as Cardiac Respiratory Cessation due to Coronary Heart Disease (C.H.D.). Since this is the only authenticated medical document on the cause of death, it will have to be given due weight in considering the case.
15. The complainants have filed on record ECG report of the deceased. It shows acute MI. The Ld counsel for the complainants has placed on record some medical literature to explain MI and ECG reading and what ST Segment represent in ECG. A comparative study of the ECG report with medical literature would reveal that ST segment elevation was conspicuous and it is the hallmark of ECG abnormality of acute Myocardial Infarction. We are alive to the fact that according to the doctor the deceased did not suffer MI during hospitalisation. The OPs relying on this statement of the doctor concluded that there was MI and hence repudiated the claim. In our opinion the statement of the doctor was not interpreted in correct perspective. What the doctor has said is that the deceased did not suffer MI during hospitalization. We put emphasis on the underlined words to say that the statement relates to the period of hospitalisation, where the deceased might not have suffered MI. He was discharged on 12/7/2011 and died on 21/7/2011. The fact that the deceased was hospitalised for heart ailment and was diagnosed with Left Bundle Branch Block (LBBB), Dialated Cardio Myopathy (DCM) and Congestive Cardiac Failure (CCF) cannot be overlooked. Thus his ailment related to cardiac complications. Since he died before he was taken to the hospital, exact cause of death could not be given and so Post Mortem was done. The death certificate shows Cardio Respiratory Cessation due to Coronary Heart Disease. Thus the cause of death was related to heart disease.
16. It is to be noted that Cardio Respiratory Cessation is the terminal event in all deaths. Myocardial Infarction is one of the causes and it can cause cardiorespiratory cessation. LBBB is the known sequel of MI. Likewise Dialated Cardio Myopathy (DCM) is also sequel of MI. The Left Bundle Branch is a nervous conducting tissue of the heart that regulates heart rate. This nervous tissue is damaged when the cardiac muscle embedding it dies or infarcts due to MI necessitating cardiac pacemaker. Past history of the deceased reveals he was a known case of Cardiomyopathy. During medical investigation his all cardiac chambers were found dilated and there was generalized left ventricular hypokinesia. Hypokenesia, in general, means the muscle tissue does not contract properly. Typical ventricle hypokinesis is a sign of coronary artery disease, heart failure, or a heart attack.
17. As we said earlier, the deceased might not have suffered MI during hospitalization, but that does not mean that he did not have heart problem. From the documents produced by the OPs it is evident that the deceased had coronary heart disease with dilated cardiomyopathy, which is a serious condition that weakens the heart muscle and causes it to stretch, or dilate. When heart muscle is weak, it cannot pump out blood sufficiently, so more blood stays in the heart after each heartbeats whereby heart muscle stretches even more and gets even weaker. This leads to heart failure. His ECG report shows ejection fraction was 20%. Ejection fraction measures how much blood is pumped from the patientś left ventricle during heart contractions , and a patient with an ejection fraction between 55 and 70% is in the normal range. An ejection fraction of less than 40% may indicate that a patient is suffering from heart failure. People with an ejection fraction of less than 35% are at higher risk of irregular heartbeats that can lead to cardiac arrest. From this medical study relating to heart disease and reports of the hospital, we can say that the deceased was suffering from heart ailment.
18. Upon due consideration of the history of the deceased placed before us and in the light of medical literature on various heart ailments and complications, we are of the opinion that the deceased had died of heart disease. Cardiorespiratory cessation is the ultimate event of death and it can be caused by MI. Patientś of CHD usually die of MI. The PM report is not available. The death certificate indicates heart disease and MI cannot be absolutely ruled out for cause of CHD. The deceased not suffering MI during hospitalisation does not rule out MI as cause of death. There was 8-9 days gap from discharge from the hospital and death. Thus looking to all these aspects and history of the deceased, it appears that the OPs, by adopting hypre technical approach, erroneously repudiated the claim. There is definitely deficiency in their service by erroneous repudiation. The complainants are thus entitled to get insurance amount from the OPs 1 to 3. hence, the complaint is allowed with following order.
ORDER
- The complaint is partly allowed.
- The OPs 1 to 3 are directed to pay, jointly and severally, a sum of Rs.6 lakh with 9 % p.a. interest from the date of the complaint to the complainants.
- The OPs 1 to 3 are further directed to pay, jointly and severally, compensation of Rs. 1 lakh and litigation cost Rs.5000/- to the complainants.
- The order shall be complied within 30 days from the receipt of certified copy of the order.
- Copy of the order shall be given to both the parties, free of cost.
