Per :- Mr. Deshpande, President Place : BANDRA JUDGMENT The Opposite Party No.1 is an insurance company, whereas the Opposite Party No.2 is a hospital. The Complainant had taken a mediclaim insurance policy from the Opposite Party No.1 – Insurance Company; in the year 2004 for the sum assured of an amount in sum of Rs.5,00,000/- and it was renewed for the period 3/5/2005 to 2/5/2006. Under that insurance policy, the Complainant and his family members were covered. [2] The Complainant was hospitalized on 3/10/2005 with the Opposite Party No.2 – Hospital; for ‘Left Hemi paresis Diabetes Mellitus & Obesity’. The Complainant was discharged on 7/10/2005. The Complainant was allowed to avail cashless facility, by making payment of an amount in sum of Rs.50,000/- by the Opposite Party No.1 – Insurance Company. [3] The Complainant again required medical treatment on 9/1/2006 for chest discomfort and breathlessness. The Complainant was admitted at the Opposite Party No.2 – Hospital; on 9/1/2006 and he was discharged on 17/1/2006. However, this time, the Complainant was not authorized cashless facility for an amount in sum of Rs.1,50,000/- and the claim of the Complainant was repudiated on following ground:- “As per pre-authorization request, hypertension is since Oct-2005, whereas the indoor case-sheet states that hypertension is since 02-03 years.” [4] The Complainant then addressed a letter to the Opposite Party No.1 – Insurance Company; on 16/3/2006, stating that hypertension was since 02-03 months and the doctor on the duty at the Opposite Party No.2 – Hospital; had wrongly mentioned the same as ’02-03’ years. The Complainant produced certificate issued by Dr. J. P. Jadwani, a cardiologist by profession, with whom the Complainant was taking treatment, to the effect that the Complainant was not suffering from hypertension since 02-03 years. However, the Opposite Party No.1 – Insurance Company; did not change its stand. Ultimately, the Complainant filed present consumer complaint before this Forum on 28/7/2006, seeking direction as against the Opposite Party N.1 – Insurance Company; to pay an amount in sum of Rs.79,680/- together with interest thereon besides compensation in sum of Rs.1,00,000/-. [5] Pursuant to the notice of appearance issued by this Forum, the Opposite Party No.1 – Insurance Company; appeared and contested the complaint by filing its written version of defence and took stand that in the Discharge Card, issued by the Opposite Party No.2 – Hospital; with regard to this hospitalization during the period 9/1/2006 to 17/1/2006, it was specifically mentioned that the Complainant was suffering from hypertension since 02-03 years. According to the Opposite Party No.1 – Insurance Company; as per Exclusion Clause No.C-1, under the policy document, a claim for pre-existing disease was not payable. The insurance policy was purchased only one year prior to period of this policy and thus, since inception there was pre-existing disease. The Opposite Party No.1 – Insurance Company; also relied upon the fact that the Complainant was suffering from Ischemic Heart Disease as well as Diabetes Mellitus and thus, hypertension was naturally co-existing with these diseases. The Opposite Party No.1 – Insurance Company; also relied upon the entry in the Discharge Card and in that context, had alleged that Dr. Jadwani had tried to shield the Complainant. Thus, the Opposite Party No.1 – Insurance Company; justified its action of repudiating the claim of the Complainant. [6] The Opposite Party No.2 – Hospital; filed its separate written version of defence and took stand that the doctor on the duty had rightly recorded that the Complainant was suffering from hypertension since 02-03 years. [7] The Complainant filed his rejoinder to the written versions of defence, as filed by the Opposite Parties, and reiterated allegations in the complaint and again referred to the fact that in the Discharge Card of earlier hospitalization, which had taken place about three months back there was no mention of the Complainant being suffering from hypertension. The Complainant also relied upon certificate issued by Dr. J. P. Jadwani. [8] The Complainant filed his affidavit of evidence as well as copies of certificate issued by Dr. Jadwani. The Complainant has also produced on the record copy of the policy document as well as case-papers and discharge cards of both hospitalizations. The Opposite Party No.1 – Insurance Company; filed on the record an affidavit of evidence of its officer, by name – Mr. R. R. Desai. The Opposite Party No.2 – Hospital; has produced on the record an affidavit of Dr. H. C. Chulani. Parties to the complaint proceeding have also filed their respective written notes of arguments. [9] We have heard the Learned Advocate for the Complainant. [10] We have gone through the pleadings, affidavits and documents as well as written notes of arguments, as filed by the parties to the complaint proceeding. [11] We take the points that arise for our consideration and record our findings there-against as below:- Sr. No. | Points for consideration | Findings | 1. | Whether the Complainant has proved that the Opposite Party No.1 – Insurance Company; is guilty of deficiency in service on account of repudiating the claim of the Complainant with regard to claim of expenses for second hospitalization during the period 9/1/2006 to 17/1/2006 | YES | 2. | Whether the Complainant is entitled to recovery of compensation from the Opposite Party No.1 – Insurance Company? | YES. An amount in sum of Rs.1,00,000/- in lumpsum. | 3. | What order? | The complaint is partly allowed. |
REASONS FOR FINDINGS [12] There is no dispute in between the parties to the complaint proceeding as regards the fact that the Complainant had taken a mediclaim insurance policy from the Opposite Party No.1 – Insurance Company; and it was valid during the period 3/5/2005 to 2/5/2006. Copy of the policy certificate is produced on the record at Exhibit-A, which show that the Complainant was insured to the extent of an amount in sum of Rs.2,00,000/-, besides his family members. There is also no dispute between the parties as regards the fact that the Complainant was admitted at the Opposite Party No.2 – Hospital; during the period 3/10/2005 to 7/10/2005 for ‘Left Hemi paresis Diabetes Mellitus’. Case-papers regarding said hospitalization are at pages (23) to (35) of the compilation of the complaint. Copy of the Discharge Card dtd.7/10/2005 is at pages (35) & (36) of the compilation of the complaint. At page (34) of the compilation i.e. at the end of treatment-sheet, there is an observation to the effect – ‘Left Hemi paresis RIND’. Below that there is an entry, which reads – ‘Diabetes mellitus (newly detected)’. It is also not the case of the Opposite Party No.1 – Insurance Company; that the Complainant was suffering from diabetes mellitus since 02-03 years or rather, prior to inception of the mediclaim insurance policy. Be it noted that in any of the case-papers or Discharge Card, there is no mention of hypertension. On the contrary, copy of the history sheet, which is at page (20) of the compilation, there is following entry:- ‘Patient history. No diabetes mellitus. No PTB’ [13] Had the Complainant being suffering from hypertension then, certainly there would have been mention of history of hypertension in the history sheet. Thus, neither in the history sheet recorded at the time of admission during the first hospitalization or in the Discharge Card, there is mention of hypertension. On the contrary, at page (22) of the compilation, there is a copy of case-paper recorded on 3/10/2005 and below the caption of history, against there is an entry, which reads ‘NAD’, which in medical parlance means ‘No Abnormality Detected’. Against that entry there is an entry of Electrocardiogram and there is an endorsement – ‘WNL’, meaning thereby, within normal limits. At the time of admission on 3/10/2005, the Complainant’s blood-pressure recorded was ‘140/100’ viz. almost within normal limits. Be it noted that this hospitalization during the period 3/10/2005 to 7/10/2005 was only about three months prior to second hospitalization, claim in respect of which is in dispute. Admittedly, the Complainant was paid an amount in sum of Rs.50,000/- with regard to first hospitalization under cashless scheme. [14] Now, turning to the second hospitalization during the period 9/1/2006 to 17/1/2006, claim of which is in dispute, copies of the relevant papers are in the compilation of the complaint from pages (37) to (52). At page (37), there is a copy of Admission Card dtd.9/1/2006. Entries therein reveal that the Complainant, aged 53 years, was brought to the Opposite Party No.2 – Hospital; and the Complainant disclosed that there were two episodes of early morning breathlessness, since last 02-03 days. Patient had history of chest pain/palpitation/giddiness. Patient had gone to Dr. Jadwani’s clinic, where electrocardiogram was taken and then, the Complainant was shifted to the Opposite Party No.2 – Hospital; for further management. In this admission-sheet at page (37), there are following entries:- ‘Diabetes Mellitus since 03 months on regular treatment on Tablet Diazorm, Injection Mixtard (30:70), Hypertension since 02-03 years. On Tablet Envas 05 mg. and Tablet Amlopross.” [14] At page (38) of the compilation of the complaint, there is an entry, which reads to the effect that the Complainant was an old case of hypertension and diabetes mellitus and he suffered Cardio-vascular anomaly in the month of Oct-2005 and obesity. The entry further reads that the when the Complainant was admitted, his blood pressure was recorded as ‘160/108’. In the Discharge Card, a copy of which is at page (42) of the compilation, against the caption – ‘Diagnosis’, there is mention of Diabetes Mellitus, Hypertension & Ischemic Heart Disease. [15] Now, on the basis of entry in the admission sheet as well as discharge card regarding hypertension since 02-03 years, the Opposite Party No.1 – Insurance Company; repudiated the claim of the Complainant on the ground that it was a pre-existing disease. [16] The Complainant, along with the complaint itself, has produced on the record a notarized copy of certificate dtd.6/3/2006, issued by Dr. J. P. Jadwani, under whom the Complainant was taking treatment. Name of Dr. J. P. Jadwani appears in the admission card dtd.3/10/2005 as well as in the discharge card dtd.9/1/2006 in respect of second hospitalization. Dr. J. P. Jadwani, in his certificate at Exhibit-F ‘colly’, has observed that the Complainant was his patient from last two years and he was not having any history of hypertension. Dr. J .P. Jadwani, is referred to by the Complainant, in the complaint, as Cardiologist, Physician & Critical Care Consultant. This also appears on his letterhead on which he issued certificate. The Opposite Party No.1 – Insurance Company; in paragraph (08) of its written version of defence, has taken stand that since the Complainant was under the treatment of Dr. J. P. Jadwani, a Cardiologist, Dr. Jadwani must be giving treatment to the Complainant for Ischemic Heart Disease and/or Hypertension. This contention is based upon conjecture and there is no basis for this contention. There is no material on the record to prove that the Complainant was suffering from Ischemic Heart Disease before second hospitalization and barring entry in the admission note dtd.9/1/2006, there is no material on the record to show that the Complainant was ever suffering from hypertension. As pointed out above, history note dtd.3/10/2005 pertaining to first hospitalization shows that result of electrocardiogram test was within normal limits and no abnormality was detected. Thus, there is no basis to raise a contention to the effect that the Complainant was suffering from Ischemic Heart Disease. [17] The Opposite Party No.1 – Insurance Company; has relied upon the written version of defence as filed by the Opposite Party No.2 – Hospital; which shows that the Medical Officer had recorded entry in the admission note dtd.9/1/2006 to the effect that the Patient – the Complainant herein; had hypertension since 2-3 years. The Opposite Party No.2 – Hospital; mentioned that the history in the admission note was recorded as per narration given by the patient. However, Dr. Jadwani, in his certificate, has made a different statement and it is consistent with entries in the admission note and discharge card pertaining to the first hospitalization starting from 3/10/2005. [18] Moreover, even if, it is assumed that the entry of hypertension since 2-3 years, as recorded in the admission note dtd.9/1/2006 is correct, still then, it is required to be seen as to the complaint with which the Complainant was admitted at the Opposite Party No.2 – Hospital. Final diagnosis and line of treatment also assume importance. [19] Admission note dtd.9/1/2006 shows that the Complainant had history of two episodes of early morning breathlessness since last 02-03 days and he had no history of chest pain, palpitation and giddiness. Dr. Jadwani referred the Complainant to the Opposite Party No.2 – Hospital. In the admission note itself, it was mentioned that the patient had diabetes since three months and that entry is consistent with the discharge card pertaining to earlier hospitalization during the period 3/10/2005 to 7/10/2005. Coming to the second hospitalization, the Complainant was prescribed treatment for Ischemic Heart Disease and Diabetes Mellitus. Tablets and insulin mentioned in the treatment sheet shows that treatment Ischemic Heart Disease and Diabetes Mellitus was started. We have elaborated this because these documents show that that the Complainant was not admitted at the Opposite Party No.2 – Hospital; for hypertension. No doubt, in the discharge card, it was diagnosed that the Complainant had hypertension, but the Complainant was not admitted with a complaint of hypertension. [20] The Opposite Party No.1 – Insurance Company; repudiated the claim of the Complainant, principally on the ground that in the admission note, it was mentioned that the Complainant was suffering form hypertension since 02-03 years and that it was a pre-existing disease. Now, ‘Hypertension’ has been explained in the medical dictionary as follows:- “Hypertension : Abnormal elevation of systolic and/or diastolic arterial pressure. Systolic hypertension is generally related to emotional stress, sclerosis of the aorta and large arteries, or aortic insufficiency. Diastolic hypertension may be due to obscure causes renal disease or endocrine disorders. Level of blood pressure depends on physical activity stress, age and on certain diseases. It is labeled if in younger age group it rises above 140/90 mm Hg at rest. Essential hypertension is that when no obvious cause is known for high BP. When high BP is due to kidney or other diseases usual complications of constant high BP may be retinopathy, Heart failure and kidney damage. [21] Thus, hypertension is effect and causes could be attributed to several factors, particularly retinopathy, Ischemic Heart Disease etc. Also, hypertension is related to blood pressure (BP). Blood pressure is the effect of certain conditions on account of disorders with the blood arteries. From this stand point also, the Opposite Party No.1 – Insurance Company; should not have considered entry in the admission note indicating hypertension since 2-3 years as a pre-existing disease. [22] The Opposite Party No.1 – Insurance Company; party could evoke exclusion clause in the policy for pre-existing diseases and not for proximate causes or consequences. [23] In addition to this, there is no material on the record to establish that the Complainant had knowledge of the hypertension at the inception of the policy. Had it been so, the Complainant would have mentioned the same in his admission note dtd.3/10/2005 in respect of first hospitalization. [24] As pointed out above, second hospitalization of the Complainant was for a complaint of breathlessness. On conducting certain tests, final diagnosis, as reflected in the Discharge Card, a copy of which is produced on the record at page (42) of the compilation of the complaint, was Diabetes Mellitus, Hypertension and Ischemic Heart Disease. Barring the entry in the Admission Note dtd.9/1/2006, there was no evidence as regards existence of Hypertension. Diabetes Mellitus was also detected only 02-03 months prior to second hospitalization. Ischemic Heart Disease was also not found at the time of first hospitalization with the same hospital. Thus, there is no nexus between the repudiation letter and the final diagnosis as recorded in the Discharge Card. Even otherwise, it does not appear that the Complainant was suffering from Hypertension since 02-03 years and he was undergoing medical treatment for the same. [25] In the background of above facts, we find that the Opposite Party No.1 – Insurance Company; was not justified in repudiating the claim of the Complainant. Thus, the Opposite Party No.1 – Insurance Company; is guilty of deficiency in service. [26] Coming to the question of grant of relief to the Complainant, in the complaint as filed, the Complainant has sought direction as against the Opposite Party No.1 – Insurance Company; to pay him an amount in sum of Rs.79,680/-. The Opposite Party No.1 – Insurance Company; has not disputed this figure and it is not the case of the Opposite Party No.1 – Insurance Company; that the Complainant had not spent this much amount for the treatment, and therefore, the Opposite Party No.1 – Insurance Company; shall have to pay this amount to the Complainant, as per the insurance policy. In addition to the above, the Complainant has sought direction as against the Opposite Party No.1 – Insurance Company; to him an amount in sum of Rs.1,00,000/- by way of compensation towards mental agony and legal expenses. In addition to that, the Complainant has sought an order from this Forum as regards payment of interest @ 9% p.a. on the principal sum. Having regard to the facts of the case, we find that a direction to the Opposite Party No.1 – Insurance Company; to pay to the Complainant, a lumpsum amount in sum of Rs.1,00,000/-, which shall include in it principal amount in sum of Rs.79,680/- towards reimbursement of medical expenses besides compensation, would be just & proper and it would meet the ends of justice. [27] Since we found that the Opposite Party No.2 – Hospital; is not guilty of deficiency in service, the complaint, so far it relates to the Opposite Party No.2 – Hospital; will have to be dismissed. With this, we proceed to pass the order as below:- ORDER The complaint is partly allowed. The Opposite Party No.1 – Insurance Company; shall pay to the Complainant, an amount in sum of Rs.1,00,000/-. The Opposite Party No.1 – Insurance Company; shall also pay to the Complainant, an amount in sum of Rs.10,000/- towards costs. The Opposite Party No.1 – Insurance Company; is hereby directed to comply with the foregoing order within a period of six weeks from the date of receipt of this order failing which, it shall also be liable to pay to the Complainant, interest @ 9% p.a., on the principal amount in sum of Rs.1,00,000/-, as from the date of expiry of stipulated period of six weeks till realization of entire amount by the Complainant. The complaint, as against the Opposite Party No.2 – Hospital; stands dismissed. Rest of the claims of the Complainant stands rejected. Parties shall be informed accordingly, by sending certified copies of this order.
| | [HONABLE MRS. Mrs.DEEPA BIDNURKAR] Member[HONABLE MR. Mr. J. L. Deshpande] PRESIDENT[HONABLE MR. MR.V.G.JOSHI] Member | |
