BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 461 of 2022
Date of Institution : 21.07.2022
Date of Decision : 09.10.2024
Satpal son of Shri Ram Lal, resident of village Jodhpuria, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Aditya Birla Health Insurance Company Limited, Regd. Office: 10th Floor, R-Tech, Nirlon Compound, net to HUB Mall, Off Western Express Highway, Goregaon East, Mumbai- 400063 through its authorized signatory/ person.
2. Branch Manager Aditya Birla Health Insurance Co. Ltd. Office at Opposite Punjab National Bank, Dabwali Road, Sirsa.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
SMT.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………..MEMBER
Present: Sh. J.S. Sidhu and Sh. Pankaj Bansal, Advocates for the complainant.
Sh. Ashish Singla, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased health insurance policy namely Active Secure bearing policy No. 12-20-0091852-00 from ops for the period 19.01.2021 to 18.01.2022 for sum assured amount of Rs.8,00,000/- and made payment of premium amount of Rs.8979/- to the ops. On 14.06.2021, complainant suffered with critical chest pain and underwent checkup from Maharaja Aggarsain District Civil Hospital, Hisar where he was admitted on the same day and on check up he was diagnosed with Myocardial infarction (Wall MI) with critical condition and he was advised for further immediate treatment. That after treatment he was discharged from hospital on 15.06.2021 and after that complainant also got another opinion from Dr. Tareek Mohd. Tasleem (DM) Cardilogist and he was also diagnosed as patient of Myocardial infarction (Wall MI) at Astha Hospital, Sirsa as per ECG test, echo and lab reports. It is further averred that on 27.06.2021 complainant intimated the said fact to the ops vide claim/ intimation no. 612210003783 under the said policy and submitted all the relevant documents as required by ops for sanctioning of claim and requested the ops to sanction the claim and ops also assured him to sanction the claim within 30 days. That complainant also submitted second opinion from Dr. Ajit Lathar, Civil Hospital, Hisar in which he also confirmed the previous history of illness on 24.08.2021 as required by ops, however on 28.08.2021, complainant again received an email from ops whereby he was directed to submit the documents which were already submitted by him on 30.06.2021. It is further averred that ops have failed to pay the claim within 30 days against IRDA guidelines and policy and very purpose of purchasing the policy has gone futile and complainant is roaming the doors of ops but ops failed to redress his grievance due to which his future treatment is still pending and ops have adopted mal trade practice and have caused deficiency in service and harassment to the complainant. The complainant has got served a legal notice to the ops and also repeatedly requested the ops to admit the claim of complainant and to sanction the claim and to pay claim amount of Rs.8,00,000/- as per policy and compensation of Rs.5,00,000/- for unnecessary harassment and also to pay litigation expenses but the ops first of all went on avoiding the matter on one pretext or the other and now two days back they have flatly refused to do so. Hence, this complaint.
3. On notice, ops appeared and filed written version submitting therein that complainant has purchased a healthy insurance policy from ops on 19.01.2021. The term of the policy is from 19.01.2021 to 18.01.2022. The nature of the policy is critical illness policy i.e. it covers the loss caused to the insured by way of critical illness that are mentioned in II.A.1 (c) of the policy. It is further submitted that relevant clause of the policy is extracted herein below:-
“Conditions:
- For Plan 1 and Plan 2:
- Maximum liability during the lifetime of the Insured Person: 1000% of the Sum Insured
- Cover Termination: Once a claim for a listed condition under either plan is admissible in respect of any Insured Person, no further Renewals shall be allowed for that Insured Person under this Benefit.”
4. It is further submitted that at the time of purchase, the entire policy document containing all the terms and conditions of the policy have been provided to the complainant. In June, 2021 the complainant filed a claim intimation form to the ops alleging that he was diagnosed with Myocardial infarction. The claim was not accompanied with all the documents necessary for evaluation of the claim and ops sent several emails to the complainant asking for documents such as discharge summary, all the test reports, medical records etc. It is further submitted that documents that were shared by complainant were sent to an independent doctor Mr. Bhupen Desai and upon scrutiny of the documents, the said expert has opined that the ECG (Electrocardiography) of the complainant was not suggestive of Myocardial infarction but suggestive of only ischemic heart disease (Myocardial ischemia). It is further submitted that even though the said medical condition sound similar, they are completely different in their nature and functionality. In case of ischemia, the blood flow to a tissue decreases which results in hypoxia or insufficient oxygen in that tissue, whereas in case of infarction, the blood flow gets completely cut off, resulting in necrosis, or cellular death. The complainant also submitted the echocardiography report and the expert doctor examined the said report and opined that even though the said report suggested of Myocardial infarction, it cannot be considered as accurate. This is because Echocardiography is dependent on the operator who conducts the test and in this particular case, the qualifications of the echo cardiologist were not provided and electrocardiogram and echocardiogram are two different tests. Electrocardiogram measures the pattern of electric pulses generated by the heart’s rhythm, whereas the echocardiogram uses sound waves to check the structure of heart. It is further submitted that in view of the contrasting difference in test results, the expert sought for 2nd Echocardiography to be repeated by a qualified and experienced Echo cardiographer with DM (Cardiology) Degree. It is submitted that expert opinion given by Dr. Bhpen N Desai by email dated 27.0-8.2021 is filed. The ops requested the complainant to repeat the echocardiography so that the exact nature of illness suffered can be ascertained. However, the complainant out rightly refused to get the tests done and insisted that money be paid under the claim. It is further submitted that complainant has also not submitted any discharge summary or a medical report summarizing the final diagnosis of the complainant to corroborate the medical condition alleged to be suffered. Thus, the complainant had submitted evidence only to show that the complainant was diagnosed with Myocardial Ischemia and not Myocardial Infarction. It is further submitted that with regard to reason for rejection it is submitted that Myocardial Ischemia is not covered under the list of critical illnesses mentioned in the policy schedule. This can be seen from Clause II Section II (c) at page no.23 of the policy. The table containing the list and definition of critical illnesses are found in the policy document. As per Clause II Section 11A.1- What is covered- only when the Insured Person suffers from a Critical Illness of nature as specified in the list specified in clauses at page no.23 of policy, the claim is payable. In other words, the policy becomes payable only when the Insured contracts any of the listed medical conditions. The disease for which the complainant had taken treatment i.e. Myocardial Ischemia is not a listed critical illness as per the policy and in view of this, the ops vide letter dated 20.10.2023 repudiated the claim/ policy. It is further submitted that it is well established by Hon’ble Supreme Court that the contracts of insurance are based on uberrima fidei i.e. utmost good faith and that every fact of materiality must be disclosed otherwise there is good ground for rescission in several cases. It is also submitted that it is denied that complainant is not suffering from any disease before purchasing any policy. It is specifically denied that complainant was diagnosed with myocardial infarction. The complainant was diagnosed with only myocardial ischemia and not myocardial infarction. The complainant has not filed the second opinion allegedly obtained from another doctor and hence it is denied that complainant got another opinion from a doctor who confirmed that he was suffering from myocardial infarction. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C22.
6. On the other hand, ops have tendered affidavit of Sh. Richard Herish as Ex. RW1/A and documents Ex.R1 to Ex.R6.
7. We have heard learned counsel for the parties and have gone through the case file. Written arguments on behalf of complainant as well as on behalf of ops have also been filed which have also been perused.
8. Learned counsel for complainant in oral as well as in the written arguments which has been filed after written arguments of ops in which while reiterating the contents of complaint he has submitted that ops in their reply have made false assertions. The complainant has provided the documents as instructed by ops through email and has given reply to all the emails sent by ops. He has submitted discharge summary Ex.C7 to Ex.C9 issued by District Civil Hospital, Hisar and other relevant documents to the ops. He has further submitted that complainant had suffered from myocardial infarction which is mentioned in the medical report of Maharaja Aggarsen Medical College and Hospital, Agroha District hisar and Dr. Tarik Mohammad, MBBS, MD, DM (Cardiologist) of Aastha Hospital, Sirsa. The ops have repudiated the claim of complainant merely on the ground that complainant had suffered from myocardial ischemia and not from myocardial infarction which was not covered under the aforesaid policy which is wrong and illegal. He has further argued that Dr. Vikram, MBBS, NISD (AIIMS), Metro Hospital, Hisar has clarified in his report dated 31.08.2024 that complainant suffers from CAD/ Inferior Wall Myocardial Infarction for which he was admitted in Civil Hospital, Hisar on 14.06.2021 to 15.06.2021 and that ECG shows inferior wall myocardial infarction. Patient also took treatment from Metro Hospital on 28.08.2024 on OPD basis and both myocardial infarction and ischemia resembles same that means reduced blood flow. He has further submitted that complainant was also having health policy covering critical illness from ICICI Prudential Life Insurance company and under this insurance policy, the claim of Rs.10,00,000/- (ten lacs) has been paid to the complainant for heart attack and as such prayed for acceptance of the present complaint.
9. On the other hand, learned counsel for ops in oral as well as written arguments while reiterating the contents of written version of ops has submitted that terms of the insurance policy are to be strictly construed. It has also been reiterated by the Hon’ble Supreme Court that the insured cannot claim anything more than what is covered by the insurance policy and these principles of law have been conclusively held in cases titled as National Insurance Company Versus The Chief Electoral Officer & Ors. (2023 INSC 104) and Vikram Greentech (I) Ltd. & Anr. Versus New India Assurance Co. Ltd. (AIR 2009 Supreme Court 2493) and has also relied upon above said judgments and prayed for dismissal of the complaint.
10. We have considered the rival contentions of both the parties. From the policy schedule alongwith letter Ex.C13, it is evident that complainant purchased health insurance policy namely Activ Secure from ops for the period 19.01.2021 to 18.01.2022 for the critical illness cover for sum insured amount of Rs.8,00,000/- and complainant paid premium of Rs.8979/- to the ops on 03.01.2021 for the said policy as is evident from premium certificate. According to the complainant on 14.06.2021 i.e. during the period of said policy he suffered critical chest pain and was taken to Maharaja Agarsain District Civil Hospital, Hisar and was admitted there and was diagnosed with Myocardial Infarction (Wall MI) i.e. critical illness. After treatment he was discharged from said hospital on 15.06.2021 and after that he also got another opinion from Dr. Tareek Mohd. (DM) Cardiologist and there also he was diagnosed with disease of Myocardial Infarction (Wall MI) at Astha Hospital, Sirsa. According to the complainant the claim lodged by him under critical illness i.e. for sum insured amount of Rs. eight lacs has been wrongly and illegally repudiated by ops on the ground that complainant was diagnosed with Myocardial Ischemia and not with Myocardial Infarction and said disease of Myocardial Ischemia for which he had taken treatment is not listed as critical illness as per policy. In the treatment record of District Civil Hospital, Hisar Ex.C6, the diagnosis of the complainant is mentioned as Infarction wall MI and Dr. Vikram, MBBS, NISD (AIIMS) of Metro Hospital, Hisar has clarified in his report placed on file during the course of arguments that complainant is suffering from CAD/ Inferior Wall Myocardial Infarction for which he was admitted in Civil Hospital Hisar on 14.06.2021 to 15.06.2021 and that ECG shows inferior wall myocardial infarction. He has also submitted that patient also took treatment from Metro M Hospital on 28.08.2024 on OPD basis and that both myocardial infarction and Ischemia resembles same that means reduced blood flow. The complainant has also placed on file prescription slip dated 28.08.2024 of Metro M Hospital, Hisar in which while mentioning the factum of disease of Inferior Wall Myocardial Infarction the doctor advised him ECO and ECG and said reports of echocardiography and ECG dated 28.08.2024 conducted in Jindal Institute of Medical Sciences, Hisar have also been placed on file and on the basis of these reports, said Dr. Vikram gave his above said opinion. Even alleged expert namely Bhupen Desai in email Ex.R4 has mentioned that Echocardiography is suggestive of myocardial infarction but at the same time stated that qualification of echo cardiologist is not provided and therefore, ops have questioned about qualification of Echo Cardiologist which is not correct. Since it is proved on record from the treatment records of various hospital placed on file by complainant and from the above said report of Dr. Vikram that complainant is suffering from myocardial infarction and that even both myocardial infarction and ischemia resembles same i.e. reduced blood flow and myocardial infarction is listed in the list of critical illness, therefore, complainant is entitled to sum insured amount from ops. Moreover, as per their own letter dated 19.01.2021 of ops written to the complainant (Ex.C13) the said Active Secure Plan purchased by complainant from ops provides protection against unforeseen incidents that require immediate and assured financial assistance. Further more, the ops have not proved on record through any cogent and convincing evidence that list of critical illness and terms and conditions of the policy were ever supplied to the complainant alongwith policy schedule. Moreover, it is also proved on record that complainant was also having another health insurance policy from ICICI Prudential Life Insurance and said insurance company has already settled the claim of complainant and paid an amount of Rs.10,00,000/- to the complainant as per critical illness benefit rider as is evident from letter dated 06.11.2021 Ex.C14 whereas ops have wrongly and illegally repudiated the claim of complainant on above said technical reason which is unfair act on the part of ops and same amounts to deficiency in service and unfair trade practice on the part of ops. The complainant has duly proved on record that he is entitled to benefit of critical illness cover i.e. sum insured amount of Rs.8,00,000/- from ops and he is still taking treatment for said disease and the very purpose of purchasing the said health insurance policy i.e. Activ Secure Plan by complainant from ops has been defeated by ops due to their above said wrong and illegal act.
11. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay claim amount of Rs.8,00,000/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said claim amount of Rs.8,00,000/- from ops alongwith interest at the rate of @6% per annum from the date of this order till actual realization. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties free of costs as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 09.10.2024. District Consumer Disputes
Redressal Commission, Sirsa.
