Punjab

Ludhiana

CC/15/124

Raman Kumar - Complainant(s)

Versus

Apollo Munich Health Ins.Co.Ltd - Opp.Party(s)

Sanjeev Chopra Adv.

07 Feb 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No.124 of 27.02.2015

Date of Decision          :   07.02.2017

 

Raman Kumar, 92, Kot Baba Deep Singh Nagar, Jalandhar, Punjab, presently at 1401, Sukh Ram Nagar, Field Ganj, Ludhiana.

….. Complainant

Versus 

 

1.M/s Apollo Munich Health Insurance Company Limited, 2^nd and 3^rd Floor, ILABS Centre, Plot No.404-405, Udhyog Vihar, Phase-III, Gurgaon-122016, Haryana, through its Managing Director.

2.M/s Apollo Munich Health Insurance Co.Ltd., SCO, 2^nd Floor, 146, Feroze Gandhi Market, Ludhiana-141001, through its Branch Manager.

 

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

 

For Complainant                     :         Sh.Sanjay Chopra, Advocate      

For Ops                         :         Sh.Ajay Chawla, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Complainant purchased Online Health Insurance Policy No.10002766 from Ops for a sum of Rs.5 lac by paying the requisite amount. During the subsistence of the policy, complainant suffered heart problem on 26.12.2012, for which, he was treated in Dayanand Medical College & Hospital, Ludhiana (hereinafter in short referred to as ‘DMC, Ludhiana’).Treatment got was of“CAD-Unstable Angina”, which leads to heart attack. That illness is fully covered by the definition of critical illness as defined under the policy. On claim being duly lodged by the complainant, the same was repudiated on flimsy grounds vide decision dated 17.12.2014 conveyed to the complainant on 31.12.2014. That repudiation alleged to be illegal because decision based on conjunctures and surmises for denuding the complainant  his due. Repudiation of claim alleged to be an unfair trade practice adopted by Ops. This complaint filed after serving legal notice dated 17.1.2015 through counsel. Directions sought to Ops to pay Rs.5 lac, the insurance amount along with compensation for mental agony and sufferance of Rs.50,000/-, but litigation expenses of Rs.11,000/-.

2.                In joint written statement filed by Ops, it is pleaded interalia as if the complaint is not maintainable because the policy purchased from Jalandhar; no cause of action accrued to the complainant; complaint alleged to be filed for abusing the process of law; complainant has suppressed the material facts for misguiding this Forum and that claims are paid by the insurance company out of the common pool of funds belonging to all policy-holders of the company. Insurance company has to check the admissibility of a claim before honouring it. Complainant submitted proposal/application form for purchase of Easy Health Insurance Individual Standard Plan from Apollo Munich Health Insurance Company on 11.2.2012. That proposal was accepted on the standard rates based on the information provided by the insured. Admittedly, the policy in question was issued. However, benefits of the policy are subject to certain conditions and exclusions mentioned in the policy. This complaint alleged to be filed with ulterior motive for harassing and humiliating the Ops. Request for cashless claim on 27.12.2012 received from the insured regarding treatment got by him from DMC, Ludhiana. That treatment was regarding complaint of chest pain one day. Provisional diagnosis was of Unstable Angina with plan for angiography with an estimate of Rs.15,000/-. On post reviewing the documents, queries were raised on 27.12.2012 for providing of past treatment records of heart disease with duration certified by treating doctor, with present positive investigation report. On 27.12.2012, the complainant provided a written certificate of Dr.N.Aslam, in which, it was mentioned that the complainant was diagnosed as a case of Unstable Angina with chief complaints of chest pain since 1 day prior to admission. It was also mentioned in the certificate as under:-

“2 episodes precordial & exertional. No h/o risk factors ECG-QS III, avf, Trop T – ve. Quantitative SC. Echo- RWM Abnormalities.”

On post reviewing the submitted document, it was found that possibility of pre-existing disease regarding illness in question cannot be ruled out. So, cashless facility was not accepted. Complainant was advised to submit the possible reimbursement with all previous insurance and medical records, which was conveyed through query letter dated 27.12.2012. Complainant thereafter submitted claim form on 2.2.2013 for an amount of Rs.18,952/- along with medical documents. Ops after reviewing the medical documents had made a payment of Rs.14,663/- vide cheque bearing No.184330 dated 13.3.2013 drawn at HDFC Bank as per the terms and conditions of the policy for hospitalization period of 26.12.2012 to 28.12.2012. This was allowed against the stacked claim of Rs.18,952/-. That amount was encashed by the complainant on 22.3.2013. The complaint alleged to be filed for gaining undue benefit. Thereafter, complainant again claimed an amount of Rs.5 lac under critical illness of the given policy, but on reviewing of the documents, it was found that disease CAD-Unstable Angina does not qualify the definition of Critical Illness as stated by section 8 read with definition 4 of terms and conditions of the policy. As per sub clauses (ii) and (iii) of definition 4 of the terms and conditions of the policy, claim admissible for critical ailment on actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked by coronary artery bypass graft(CABG). Further as per these clauses, diagnosis must be supported by coronary angiography and realization of the surgery has to be confirmed by a specialist Medical Practitioner (Cardiologist/Cardiac Surgeon). Exclusionary clause provides that treatment with respect to Angiography and/or any other inter-arterial procedures or for any key-hole surgery or laser surgery is excluded. First heart attack of specified severity relates to the first occurrence of myocardial infarction, which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. So, history of typical clinical symptoms consistent with the diagnosis of acute Myocardial Infarction has to be traced. Even it is to be observed that there is no new characteristic electrocardiogram change etc. From evaluation of medical records and doctor certificate, it was made out that medical treatment got by the complainant is not a case of open chest CBAG because treatment is not of bypass (open chest) surgery. So, claim of the complainant was not falling under the definition 4(ii) of Section 8 of the terms and conditions of the policy. Medical condition of the complainant was not fulfilling the symptom of heart attack because there was no tightness, no nausea, no shortness of breath. Even there was no dyspnoea and nor cold sweat and nor fatigue/syncope and nor light-headiness. Medical documents particularly discharge summary provided by the complainant mentioned as under:-

a.Acute inferior myocardial infarction

  *ST elevation in the inferior leads II,III, and aVF

  *reciprocal ST depression in the anterior leads

b.Acute anterior myocardial infarction

  *ST elevation in the anterior leads V1 – 6, I and aVL

  *reciprocal ST depression in the inferior leads

c.Acute posterior myocardial infarction

  *(hyperacute) the mirror image of acute injury in leads V1 -3

  *(fully evolved) tall R wave, tall upright T wave in leads V1-3

  * Usually associated with inferior and/or lateral wall MI

3.                The medical literature provides that Electrocardiogram should show   acute inferior myocardial infarction, acute anterior myocardial infarction; acute posterior myocardial infarction etc. However, after going through ECG findings of the complainant, it was found that the same does not fulfill the symptom of heart attack because there was no ST elevation or no other changes. Cardiac enzyme studies measure the level of enzymes and proteins that are linked with injury of the heart muscle. These include the enzyme creatine kinase (CK) and the proteins Troponin I (TnI) and Troponin T (TnT). Cardiac enzyme studies must always be compared with symptoms, physical examination findings and electrocardiogram (EKG, ECG) results. From the documents received from DMC, Ludhiana including discharge summary, it was found that cardiac enzymes value were not raised, but they were in normal limits and hence, no cardiac muscle was found injured. As the disease suffered by the complainant does not fall in the list of critical illness and as such, repudiation of claim defended as justified. Moreover, it is claimed that the complainant has not presented the true facts because he failed to provide the terms and conditions of the present contract of insurance to support his contentions. Allegations of deficiency in service or of adoption of unfair trade practice denied along with other allegations of the complaint. It is claimed that the complaint is false, vexatious and frivolous filed for maligning the repudiation of Ops for dishonest intention. Even if the complainant has mentioned that he underwent treatment for CAD-Unstable Angina, despite that said treatment does not pertain to the critical illness. Rather, allegations of sufferance from heart attack by the complainant are contrary to the allegations in the subsequent paras of the complaint, where mention of getting of treatment of CAD-Unstable Angina are levelled. Contract of insurance is binding on the parties and as such, prayer made for dismissal of complaint.

4.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C16 and thereafter, closed the evidence.

5.                On the other hand, counsel for OPs tendered in evidence affidavit Ex.RA of Ms.Deepti Rustagi, Vice President-Legal & compliance of OP1 along with documents Ex.A, Ex.OP1 to Ex.OP9 and then closed the evidence.

6.                Written arguments not submitted by any of the parties. Oral arguments alone addressed and those were heard. Records gone through minutely. 

7.                Certainly, the terms and conditions of contract of insurance are binding on the parties and to be construed strictly and nothing can be added or subtracted thereto as per law laid down in cases Ind Swift Limited vs. New India Assurance Co.Ltd. and others-IV(2012)CPJ-148(N.C.); Usha Sharma vs. New India Assurance Co.Ltd.-I(2012)CPJ-448(N.C.); United India Insurance Co.Ltd. vs. Harchand Rai Chandan Lal-IV(2004)CPJ-15(S.C.); Deokar Exports Pvt. Ltd. vs. New India Assurance Co.Ltd.-I(2009)CPJ-6(S.C.) and New India Assurance Co.Ltd vs. Panchsheel Jewellers-I(2013)CPJ-38(N.C.). So, the terms and conditions of the contract of insurance has to be taken into consideration for finding as to whether the claim of the complainant qua treatment for CAD-Unstable Angina is covered by the definition of critical illness or not?

8.                It is vehemently contended by counsel for complainant that CAD itself connotes to the heart attack, due to which, complainant got                                treatment for period from 26.12.2012 to 28.12.2012 from DMC, Ludhiana and as such, the complainant entitled to the insurance amount.However,counsel for Ops vehemently contends that CAD-Unstable Angina is not a condition of critical illness and as such, claim of the complainant rightly repudiated. Besides, it is claimed that payment for treatment qua period from 26.12.2012 to 28.12.2012 was allowed by paying Rs.14,663/- to the complainant through cheque which was received by him on 22.12.2013 and as such, this complaint has been filed for getting undue benefit.

9.                Ex.C1 and Ex.C2 is the copies of insurance cover notes, which provides that the insured was assured for sum of Rs.4,40,000/-. So, stacked claim of Rs.5 lac by the complainant is against the terms and conditions of the policy because no one can get amount in excess of the assured sum.

10.              Copy of discharge summary Ex.C3 of the complainant qua treatment period of 26.12.2012 to 28.12.2012 from DMC, Ludhiana shows that the complainant was diagnosed as a case of CAD-Unstable Angina. For that procedure of coronary angiography (single vessel disease) was adopted. Complainant complained of chest pain one day prior to his admission in DMC, Ludhiana, but he was not having history of dyspnoea, palpitation, cough, fever or syncope. Chest of the complainant was not having any problem and that is why B/L normal vesicular breathing mentioned in Ex.C3. Perusal of Ex.C4 reveals that the complainant was admitted with Angina. Troponin-T was found to be negative and the complainant was managed with LMWH, antiplatelets, beta-blockers, nitrates, statins, Ace-inhibitors and other supportive measures. Coronary angiography was done on 27.12.2012, which did show single vessel disease. Complainant was advised medical management and thereafter, he was discharged in stable condition. Indication of CAD-Angina and findings in Ex.C5 were to the effect that left main coronary artery was normal. Through Ex.C6, it was found that non-dominant and normal vessel and marginal were normal. Final diagnosis mentioned as CAD-Single Vessel disease and recommendation of medical management incorporated in Ex.C6. Follow up checkup after one week, in Ex.C7 reflects that in case the complainant developed sudden difficulty in breathing, chest pain or syncope, then he should report to the emergency immediately. Perusal of Ex.C8 and Ex.C9 shows that CAD-Regional wall motion abnormalities as mentioned were recorded. Ex.C10 is the Angiography report which too shows the single vessel disease. In view of myocardial thickness, thinning of inferior wall was noted through Stress Myocardial Perfusion Study report Ex.C11. Considerable amount of myocardium at jeopardy in inferior wall was found through final impression report Ex.C12. As per Ex.C14, illness benefit payable after survival of period of 28 days of critical illness in case of heart attack/myocardial infarction and as such, it is vehemently contended by counsel for complainant that complainant entitled for the insurance amount. In Ex.C14 itself it is mentioned that the first occurrence of myocardial infarction points to the death of portion of the heart muscle as a result of an acute interruption of blood supply to myocardium and as such, ailment suffered by the complainant was of heart attack. However, after going through Ex.C14 itself, it is made out that diagnosis regarding the first occurrence of myocardial infarction must be confirmed by the consultant cardiologist which must be based on history of typical chest pain and study of new electro cardio graphic changes. Angina is specifically excluded as per Ex.C15 itself. The medical record in detail pointed above shows that the complainant happened to have chest pain about one day prior to admission and as such, he was not having the typical chest pain. So, one of the diagnosis of first occurrence of myocardial infarction is missing in this case,if contents of Ex.C14 and Ex.C15 taken into consideration. As the disease of heart attack relates to death of portion of the heart muscle resulting in acute interruption of blood supply to a relevant area and as such, the diagnosis must be supported by three or more of the following five criteria, which are consistent with a new heart attack. Those criteria are as under:-

 

*History of typical chest pain.

*New Electrocardiogram (ECG) changes proving infarction.

*Diagnostic elevation of cardiac enzyme CK-MB.

*Diagnostic elevation of Troponin (T or I)

*Left ventricular ejection fraction less than 50% measured 3 months or more after the event.

11.              Record of history of typical chest pain not produced. Even the record of New Electrocardiogram (ECG) changes providing infraction has not been produced. Medical record does not show elevation of cardiac Troponin or cardiac enzymes. Produced record at the most shows the sufferance of single vessel disease by the complainant due to thinning of inferior wall (as disclosed by contents of Ex.C11, Stress Myocardial Perfusion Study). Final impression report Ex.C12 shows the considerable amount of myocarium at jeopardy in inferior wall, but the same does not show in adequate blood supply due to death of a portion of heart muscle. Even in Ex.C13 mention regarding infarct with Peri Inrarct Ischaemia is made. So, from all the above referred documentary evidence of medical records, it is made out that single vessel disease was suffered by the complainant , due to which, coronary angiography was done, but he was having no history of dyspnoea and palpitation,meaning thereby as if the complainant was not suffering from breathing problem.

12.              Serious coronary artery disease is one which causes the narrowing of the lumen of at least one coronary artery by a minimum of 75% and of two others by a minimum of 60%, as proven by coronary arteriography, regardless of whether or not any form of coronary artery surgery has been performed. That narrowing to the extent of 75% or 60% is not found in this case because 40% of narrowing alone found in Ex.C6. Angina is specifically excluded as per Ex.C15 and as such, repudiation of claim is quite proper, even if it may be unstable angina as reported through Ex.C3.

13.              Repudiation of claim is done after calling for requisite information from DMC, Ludhiana as revealed by contents of Ex.OP3. Rather, through letter dated 27.12.2012 on the letter pad of DMC, Ludhiana, it is mentioned that there is no L/o heart disease and as such, it is obvious that treatment was not for heart disease and that is why coronary angiography alone was done. Rejection of claim for cashless facility was done through letter dated 27.12.2012 by giving right to complainant to file claim for reimbursement by presenting all the medical records. Through this letter dated 27.12.2012, the complainant was disclosed that as and when the reimbursement claim will be submitted, then the same will be considered on merits. Even in Ex.OP4, mention made regarding CAD-Unstable Angina diagnosis only.

14.              As per Ex.OP5, all people suffering from heart attacks does not have the same symptoms or the same severity of symptoms. Some heart attacks strike suddenly, but many people have warning signs and symptoms hours, days or weeks in advance. The earliest warning may be recurrent chest pain(angina) that’s triggered by exertion and relieved by rest. Angina is caused by a temporary decrease in blood flow to the heart as per Ex.OP5. However, a heart attack differs from a condition in which heart stops suddenly. A heart attack can cause cardiac arrest, but it’s not the only cause. In this case before us, chest pain was felt by the complainant one day prior to admission in DMC, Ludhiana and as such, it is not a case of recurrent chest pain. Being so, submissions advanced by complainant or his counsel has no force that complainant suffered from heart attack, for which, he got treatment.

15.     Causes of Angina are given in Ex.OP8 to the effect that angina is the pain felt when one or more of coronary arteries becomes damaged, blocked or narrowed and isn’t able to bring enough oxygen-rich blood to the heart. This pain may occur during physical activity, exercise, stress, periods of extreme cold or hot temperatures, after heavy meals or while drinking alcohol or smoking. So, Angina puts one to the risk of having a heart attack, but that Angina itself is not a heart attack.

16.              As per Ex.OP9, Unstable Angina and CAD does not cover under the definition of critical illness by an heart attack as per policy terms and conditions and that is why the claim was repudiated through this document Ex.OP9 itself.  Critical illness defined in definition No.4 as the actual undergoing of open chest surgery for the correction of one or more coronary arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG). The diagnosis must be supported by coronary angiography and realization of the surgery has to be confirmed by a specialist Medical Practitioner (Cardiologist/Cardiac Surgeon). Angioplasty and/or any other intra-arterial procedures excluded. Present is not a case, in which, the complainant has undergo for CABG. So, case of the complainant not covered by critical illness defined in Section 8 of definition No.4(ii) of the terms and conditions of the policy. The first occurrence of Myocardial infarction resulting in death of a portion of the heart muscle and consequent in adequate blood supply to the relevant area also falls in the definition of critical illness as per Section 8 of definition No.4(iii) of the terms and conditions of the policy. However, exclusionary clauses provides that non ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T is excluded. Even other acute coronary syndromes are excluded. Any type of angina is also         excluded. In this case, Coronary Angiography alone was done and surgery was not performed and as such, certainly case of the complainant is not covered by the critical illness defined in section 8 of definition 4 of the terms and conditions of the policy. Moreover, medical management alone was done and it is a case of myocardial infarction and as such, certainly it is not a case of critical illness defined in Section 8 of definition 4 of the terms and conditions of policy. So, repudiation of claim is duly justified. Even in case titled as Bajaj Allianz Life Insurance Company Limited and another vs. Bhupinder Kumar-2015(2)CPJ-8(State Consumer Disputes Redressal Commission, Punjab), it has been that if record produced at the most shows that the complainant underwent PTCA with stenting to CAD, then the same does not fall under the definition of critical illness and as such, repudiation of claim as per the terms and conditions of the policy is justified. In the reported case also, it was found that CAD was not requiring surgery, but complainant concerned underwent for angioplasty followed by the fixing of stent. Same is the position in the case before us because surgical operation was not got conducted and nor the complainant shown to have got the stent affixed. So, simple diagnosis of CAD-Unstable Angina will not make the case       of the complainant fit for acceptance of the claim. Even in case of SBI Life Insurance Co.Ltd. vs. Ashwani Kumar Junejaj-2013(3)CPR-582(N.C.), it has been held that angioplasty or any other intra-arterial procedure will not bring the case of the complainant concerned in category of critical illness, particularly when exclusionary clauses provides that for such procedure, the claim is not covered by the terms and conditions of the policy. Same is the position in the case before us as discussed in detail above and as such, complainant unable to prove that Ops provided deficient service, due to repudiation of the claim.

17.              Therefore, as a sequel of the above discussion, complaint dismissed without any order as to costs. Copies of order be supplied to the parties free of costs as per rules.

18.                        File be indexed and consigned to record room.

 

                      (Param Jit Singh Bewli)                        (G.K.Dhir)

                                  Member                                        President

Announced in Open Forum

Dated:07.02.2017

Gurpreet Sharma.