Orissa

Cuttak

CC/352/2023

Sunanda Padhy - Complainant(s)

Versus

General Manager,Star Health & Allied Insurance Company Ltd - Opp.Party(s)

A K Sahoo & associates

29 May 2024

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION, CUTTACK.

C.C. No.352/2023

1.         Sunanda Padhy,

C/o: Sh. Prasanta Kumar Padhy,

Retd. Asst. Engineer,Kalinga Vihar Dura,

                   Berhampur,Dist: Ganjam,Odisha,

               Pin-761026.

 

2.         Anvesh Panda,

C/o: Sh. Prasanta Kumar Padhy,

Retd. Asst. Engineer,Kalinga Vihar Dura,

                   

                Berhampur,Dist: Ganjam,Odisha,

                 Pin-761026.

At present.

C/o: Tanaya Behera,

At;Jobra Nuasahi,

P.O:Collee Square,P.S:Malgodown,

                Pin-753003.                                                                        ...Complainnats

 

                      Vrs.

 

1.       General Manager,

Star Health and Allied Insurance Company Ltd.,

At: No.15,Sri Balaji Complex,

Ist Floor,Whites Lane,Royapettah,

                   Chennai-600014.

2.      Branch Manager,

Star Health and Allied Insurance Company Ltd.,

Branch Office:At Plot No.1677(P)/1678(P),

Holding No.608,2^nd Floor,Gajanan Complex,

Dolamundai,P.O:Buxi Bazar,

                  Cuttack-753001.                                                    ...Opp.Parties

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    26.10.2023

Date of Order:  29.05.2024

 

For the complainant:             Mr. A.K.Sahoo,Adv. & Associates.

For the O.Ps no.1 & 2:           Mr. U.K.Lenka,Adv. & Associates.

 

Sri Debasish Nayak,President

 

           Case of the complainants as made out from the complaint petition bereft unnecessary details in short is that the complainants had taken Health Insurance policy from the O.Ps on 7.2.2011 named and styled as “Family Health Optima Insurance Plan” wherein the insured value was of Rs.10,00,000/-.    The said policy covered both the complainants and it was being renewed year after year.  The premiums towards the renewed insurance policy were being duly paid.  Accordingly, the said policy was valid with effect from 7.2.2023 till the midnight of 6.2.2024 On 22.5.2023, both the complainants had some mental related complications for which they had gone to Kalinga Institute of Medical Sciences (KIMS), Pradyumna Bala Memorial Hospital for their diagnosis.  It was diagnosed there by Dr. Jigyansa Pattnaik that the complainant no.1 had recurrent depressive disorder as she showed signs of hopelessness, helplessness, guilt, decreased appetite and sleep.  It was also found that she is having severe episodes where she is suicidal.  Such condition was due to separation and the sudden demise of her husband in the month of May,2020.  She was admitted in the hospital with effect from 22.5.2023 and was treated there till 11.6.2023.

            Complainant no.2 is a teen-ager studying in 12^th standard and it was diagnosed that he was having severe depressive episodes with psychotic symptoms.  He was requiring Electro Convulsive Therapy (ECT) for his treatment and accordingly he was also admitted in the same hospital and was treated with effect from 22.5.2023 to 11.62023.  The O.P company were informed about the complainants being admitted to the hospital and on 22.5.23. The O.P no.1 vide claim number CIR/2024/191212/0234023 gave initial approval for Rs.10,000/- against the total estimated cost of Rs.51,000/- but later O.P no.1 through his email dated 3.6.23 to the KIMS Hospital had not only rejected the claim of the  complainants but also had withdrawn the approval of the initial amount of Rs.10,000/- and has  mentioned therein regarding the reason of rejection of the claim for complainant no.2 that expenses incurred at hospital for treatment of Alcoholism, drug, substance abuse and consequences is not admissible as per exclusion clause-12 of the policy.  The treating physician had made a clarification in this regard that complainant no.2 has a history of multiple substance abuse (Prescription Medication) only which was on and off. The reason for repudiating the claim which was intimated by the O.P no.1 on 21.7.2023 reflected that the patient could have been treated as an outpatient and hospitalisation was not warranted.  The complainants have urged through their complaint petition that after being diagnosed by the treating doctor they were advised to be admitted to the hospital keeping in view their poor mental conditions and severe depression.  Because of such repudiation, the complainants had to pay the final bills amounting to Rs.1,19,480/- towards their hospitalisation expenses.  As such, the complainants have come up with their case before this Commission seeking direction to the O.Ps in order to reimburse the medical expenses as incurred by both of them to the tune of Rs.19,248/- together with another sum of Rs.3,50,000/- towards their mental harassment and agony and further a sum of Rs.20,000/- towards their litigation expenses.  They have also prayed through their complaint petition for any other order as deemed fit and proper.

         Together with their complaint petition, the complainants have filed a bunch of copies of documents in order to prove their case.

2.       Both the O.Ps have contested this case and have filed their joint written version.  According to the written version of both the O.Ps, the case of the complainants is not maintainable which is liable to be dismissed.  They have also urged that the petition of the complainants is barred by the principles of estoppel, waiver, acquisance, limitation, non-joinder and mis-joinder of necessary parties.  According to the written version of the O.Ps, the insurance policy as obtained by the complainants had certain terms and conditions and violation to any of the said clauses would repudiate the policy claim.  They admit that the complainants had availed Star Family Health Optima Insurance Plan  Policy covering both the complainants for an assured amount of Rs.10,00,000/- vide policy number P/191212/01/2022/012354 which was effective from 7.2.2023 to 6.2.2024.  It is the contention of both the O.Ps that complainant no.1 had raised pre-authorisation request to avail cashless facility but it was denied to her.  Subsequently, the complainants had submitted their claim form for reimbursement of their medical expenses as incurred by them.  While scrutinising the documents as submitted by the complainants, the O.Ps could notice in the discharge summary of the treating hospital that complainant no.1 had a history of suicidal ideation since 2019 which was aggravated for the last four months.  She had history of previous episodes of moderate depression following separation from her husband since 2014.  The complainant no.1 had also history of self-harm behaviour in the past.  The O.Ps have thus urged through their written version that they are not liable for payment towards the hospitalisation expenses as the same falls under the code of exclusion clause-22 of the policy.  The O.Ps could also notice from the O.P case sheet dated 17.3.2023 that the patient had history of high suicidal risk, suicidal ideas and suicidal intent which was also extended to her son.  The O.Ps thus had observed that the insured complainants were not requiring hospitalisation.  The O.Ps have also attracted the provisions of exclusion clause-36 of the Insurance Policy through which they are not liable in making payment under the policy where hospitalisation was not medically necessary for either of the complainants.  They had also observed that the O.P case sheet dated 22.5.23 reflected therein that the insured patient complainant had history of undergoing multiple substantial abuse (Ketamine, trauma doll and caffeine) and was admitted for depression and had suicidal risk.  They have also urged through their written version drawing the attention towards the exclusion clause-12 of the policy which states conditions of treatment for alcoholism, drug or substances abuse or any addictive condition and consequences thereof, the O.Ps  are thus not liable to reimburse the medical expenses as incurred by the complainants.  Accordingly, the O.Ps through their written version have urged to dismiss the complaint petition as filed by the complainants with cost.

          Together with their written version, the O.Ps have also filed copies of several documents including the “Star Health Insurance Plan” Policy papers in order to support their stand.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

  i.  Whether the case of the complainant is maintainable?

  ii. Whether there was any deficiency in service on the part of the        O.Ps  and if they have practised any unfair trade ?

iii. Whether the complainant is entitled to the reliefs as claimed by them?

 

Issue no.II.

          Out of the three issues, issue no. ii being the pertinent issue is taken up first for consideration here in this case.

           After perusing the complaint petition, written version, written notes of submissions as filed from both the sides as well as the copies of documents available in the case record, it is noticed from the discharge summary of the Kalinga Institute of Medical Sciences (KIMS), Pradyumna Bala Memorial Hospital that complainant no.1 had history of previous episode of moderate depression due to separation from her husband and subsequently due to the death of her husband.  She had history of similar illness in family which was detected with her mother and history of some psychotic illness in her sister.  She had self-harm behaviour in the past history.  The treating physician at the said hospital namely Dr. Jigyansa Pattnaik had noticed that the facial expression of the complainant no.1 was suggestive of anxious and depressive, her attitude towards interaction was non-cooperative with decreased psycho-motor activity.  She was not able to sleep properly with depressive cognition on her ideas of worthlessness, ideas of helplessness, ideas of hopelessness with suicidal ideation.  There was no perceptual abnormality.  She was advised admission for further management and detailed assessment.

            Similarly, complainant no.2 while being examined by the treating physician Dr. Jigyansa Pattnaik of Kalinga Institute of Medical Sciences (KIMS), Pradyumna Bala Memorial Hospital on 22.5.2023, the treating physician had noticed low mood, loss of interest in daily activities, ideas of hopelessness and helplessness, ideas of worthlessness, fearfulness, active suicidal ideation, decreased sleep and decreased self-care since four years and has aggravated in the last 1 week, and shows minimal response to treatment with anti-depressants.  The complainant no.2 had history of being treated with anti-depressant like sertraline, mirtazapine, venlafaxine and has shown minimal response.  The complainant no.2 had history of multiple self-harm behaviour for eg, current wrist in anger and treated for OC symptoms like recurrent, intrusive thoughts and acts.  The patient has history of receiving ECT in view of treatment resistance.  His facial expression was suggestive of anxiousness and depression, his interaction was non-cooperative with decreased psycho-motor activity.  He was not being able to sleep and remember things, with depressive cognition i.e. ideas of worthlessness, ideas of helplessness, ideas of hopelessness with suicidal ideations.  As he was having severe depression, the patient was advised modified Electro Convulsive Therapy and was suggested for admission.

             Thus, both the complainants were hospitalised at Pradyumna Bala hospital at KIMS since because they were advised by their treating physician Jigyansa Pattnaik.  Thus, the contention of the O.P who had tried to attract the exclusion clause-36 of the terms and conditions of the policy; does not hold good here in this case since because when the treating physician Dr. Jigyansa Pattnaik who is a doctor and is competent to advise for hospitalisation and as per her instructions, the complainants were so hospitalised. The opinion of the O.Ps that the hospitalisation was not necessary for the complainants fails miserably because the O.Ps are not competent persons to decide as regards to the necessity of hospitalisation of the complainants of this case and thus this exclusion clause-36 has no role to play in the present case.

              The O.Ps through their written version at paragraphs no.9 & 10  have urged drawing attention towards the O.P case sheets dated 17.3.23 and 22.5.23 whose copies they have furnished,  wherein it is mentioned that either of the complainants had high suicidal risk.  In this context, they have urged pointing towards the provisions of exclusion clause-12 and 22 of the terms and conditions of the policy.  Perused the said terms and conditions as envisaged therein wherefrom it is noticed that exclusion clause-12 is not at all attracted against any of the two complainants of this case.  Now as regards to intentional self-injury, as per the exclusion clause-22 of the terms and conditions of the insurance policy, the intention of a person is to be taken into consideration when the said person is of sound state of mind where he does any act wilfully and voluntarily without any threat, coercion or undue influence and by that time the mind of that person was in a sound state.  But here in this case as it is made out from the available documents of medical treatment for both the complainants that both of them were under severe depression having suicidal ideation and were thus showing abnormal activities being non-cooperative to the interactions with the treating physician for which the treating physician Dr. Jigyansa Pattnaik has mentioned in both the cases that they had decreased pshyco-motor activity.  Thus, the question of intentional self-infliction in both cases of the complainants do not arise here in this case, as pointed out by the O.Ps.  Thus, considering the facts and circumstances of the case in hand, this Commission finds that the O.Ps with the intention to repudiate the genuine claim of the complainants had tried their level best but were ultimately found to be unsuccessful. This Commission thus arrives at an irresistible conclusion that infact by repudiating the insurance claim of the complainants who had obtained insurance policy from the O.Ps and the same was in force when they were hospitalised at the behest of the treating physician; the O.Ps had acted arabitrarily,unilaterally and whimsically which indicates improper application of mind by the O.Ps and thus there was infact deficiency in service on their part which also signifies the practice of unfair trade by the O.Ps.  This issue goes in favour of the complainants.

Issues no.i & iii.

             From the discussions as made above, the case of the complainants is definitely maintainable and the complainants are entitled to the reliefs as made by them.  Hence it is so ordered;

                                                                    ORDER

              The case is decreed on contest against the O.Ps who are jointly and severally liable here in this case.  The O.Ps are thus directed to reimburse the medical bill of both the complainants amounting to Rs.1,19,450/- by paying the same to the complainant no.1 within a month hence alongwith interest thereon @ 12% per annum from the date of her application till the total amount is quantified.  The O.Ps are further directed to pay a sum of Rs.2,00,000/- to both the complainants in total as compensation for their mental agony and harassment and  further to pay a sum of Rs.20,000/- in order to meet their litigation expenses.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

              Order pronounced in the open court on the 29^th day of May,2024 under the seal and signature of this Commission.

                                                                                       Sri Debasish Nayak

                                                                                       President

                     

 

                                                                          Sri Sibananda Mohanty

                                                                                             Member