- HDFC Ergo General Insurance Co.Ltd.,
Rep.by its Branch Manager R/o.6-3-346/1,
2nd Floor, Opp: Jalagam Vengal Rao Park, Road No.1,
Banjara Hills, Above Scotia Bank,
Hyderabad, Telangana – 500 034.
- The Bank Manager,
HDFC Bank, A.S.Rao Nagar Branch,
, Hyderabad – 500 062. ……Opposite parties
Counsel for the complainants : Mr. V.Sarat Reddy
Counsel for the opposite Parties: Mr.N.Srinath Rao.
O R D E R
(By. Smt. CH. Lakshmi Prasanna,B.Sc. LLM (PGD ( ADR)., Member on behalf of
Bench)
- The complaint is filed under Sec.12 of The Consumer Protection Act against the Opposite parties for deficiency of service, seeking an appropriate direction to the Opposite Parties No.1 & 2 to pay health insurance claim of Rs.68,001/- along with interest @24% p.a from the date of claim till the date of realization, Rs.4,00,000/- towards compensation and Rs,50,000/- towards legal expenses incurred by the complainants.
2) The brief averments of the complaint are:-
Being an account holder of Opposite Party No.3, the complainants were referred to Opposite Parties 1 & 2 for health insurance and both the complainants obtained Health Suraksha Policy- Silver Plan from Opposite Parties No.1 & 2. For the present complaint Policy No.29552200801172902000/1pertaining to Complainant No.2 is relevant and was issued on 12/7/2016 on payment of an amount of Rs.12,325/- for an insured sum of Rs.3,00,000/-
On 9/6/2017, the complainant No.2 suddenly developed memory loss and was diagnosed with Transient Global Amnesia and admitted in Yashoda Hospital for treatment. When the medical card of the Complainant No.2 was referred to the O.P.No.1 & 2 for cashless treatment, the same was rejected on the grounds that the cashless facility cannot be extended for the following reasons, " As per the submitted documents, patient was admitted on 9/6/2017 with the diagnosis of Transient Global amnesia, ( which is a psychiatric ailment) and took treatment for the same. This claim is being repudiated under Sec.9.C.vi of policy terms and conditions which excludes from coverage 'psychiatric, mental disorders (including mental health treatments and sleep apnoea), parkinson and alzheimer's disease, general debility or exhaustion ( run-down condition)"
The complainant avers that as per the medical terminology, Transient Global amnesia is not a psychiatric ailment but a temporary episode of memory loss with vascular ( blood vessel) disease. And further the Discharge Summary clearly mentions that the patient-complainant No.1 is treated with antiplatelets, multivitamins, PPIs and supportive care and she did not have similar episodes thereafter and hence discharged in hemodynamically stable condition. Aggrieved by the rejection of the health insurance claim on unreasonable grounds, the complainants got issued a legal notice dt.25/7/2017 to the O.P.No.1 & 2 through International Consumer Protection Council but of no avail. Hence the present complaint seeking appropriate relief against the Opposite Parties No.1 & 2.
- The Opposite Parties No.1 & 2 have denied the allegations of deficiency of service on their part and contended that the medical insurance claim was rightly repudiated on the grounds of exclusion under Sec.9.C.vi of policy terms and conditions which excludes from coverage 'psychiatric, mental disorders (including mental health treatments and sleep apnoea), Parkinson and Alzheimer’s disease, general debility or exhaustion ( run-down condition)'. And hence, there is no cause of action and the complaint is liable to be dismissed.
4) In the enquiry, the complainants filed their evidence affidavit reiterating the averments in the complaint supporting his claim with Ex A1 to A6 including the policy certificate, discharge summary, legal notice, while Ex B1 & B2 are marked on behalf of the Opposite Parties 1 & 2, including the original policy terms & conditions, the medical reports of the policy holder in support of their written version and counter affidavit.
5) Based on the facts and material brought on record, and written arguments
submitted by both the parties, the following points have emerged or consideration:
- Whether there is deficiency of service on the part of the Opposite Parties
- Whether the complainant is entitled for the claim/compensation made in the complaint?
3) To what relief?
6) Point No.1:- The undisputed facts of the case are that the policy holder-Complainant No.2 underwent treatment for Transient Global amnesia, a temporary episode of memory loss with vascular ( blood vessel) disease and discharged in stable condition after medication of antiplatelets, multivitamins, PPIs and supportive care for about four days in Yashoda Hospital incurring a medical bill of Rs598,601.73ps. (Ex A 2). The medical insurance claim for cashless treatment of the complainant No.2 was repudiated by the O.P.Nos. 1 & 2 vide lr.dt.12/6/2017 (Ex A5) stating that the said condition is a psychiatric problem and is excluded under Sec.9 C vi of the terms and conditions of the policy. As per the Discharge summary (Ex A 6), it is clearly mentioned that the patient-complainant No.1 is treated with antiplatelets, multivitamins, PPIs and supportive care and she did not have similar episodes thereafter and hence discharged in hemodynamically stable condition. There is no mention of psychiatric problem in the medical records of the complainant. As per medical terminology, Transient Global amnesia is a temporary episode of memory loss, underlying causes attributable to history of migraines or overfilling of veins with blood due to some sort of blockage or other abnormality with the flow of blood (venous congestion). Thus the repudiation of the insurance claim of the Complainant No.2 by the Opposite Parties is based on incorrect perceptions of fact or incorrect assumptions totally devoid of any justification. It is an indisputable proposition that every policy holder who regularly pays the insurance money should have a legally enforceable instrument, not dependent on unreasonable/irrational discretion or charity of the Companies and cannot be construed in this outrageously unjust manner denying a legitimate claim. It is also relevant to mention here that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. In the present case, the denial of medical expenses reimbursement by the Opposite Parties 1&2 is utterly arbitrary as the medical condition of the patient-Complainant No.2 is not a psychiatric problem and does not fall under the list of diseases excluded from coverage under Sec.9 C Vi of the Health Suraksha Policy by any stretch of imagination. It appears merely an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior.
In view of the above discussion and findings, the point is answered in favour of the complainant.
7) Point No.2:- As mentioned in the coverage/benefits of the Policy terms and conditions, the complainant is entitled for in-patient treatment rendered during hospitalization as per the Medical Bill Ex A2 and the Opposite parties are liable to pay the amount of Rs.59,601.73/- to the complainant and an amount of Rs.1,00,000/-towards compensation and Rs.5000/- towards costs of litigation. Accordingly the point is answered in favour of the complainants.
8) Sequel to our above discussion, the complaint is allowed and the following directions are issued to the opposite parties:
i) to pay the sum of Rs.59,601.73ps to the complainants along with interest at the rate of 9% per annum from the date of submission of the claim till realization;
ii) to pay Rs.100,000/- towards compensation and
iii) to pay Rs.5,000/- as litigation expenses.
This order be complied with by the opposite parties, within 45 days from the date of receipt of the order, failing which the amounts at Sr.No.(i) & (ii) above shall carry interest @12% per annum from the date of this order till actual payment.
Dictated to steno transcribed and typed by her and pronounced by us on this the 27th day of January, 2020.
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1 - Insurance Policy
Ex.A2 – Inpatient Medical Bill
Ex.B3 – Repudiation letter
Ex.A4 – Discharge summary
Ex.A5 - Terms and c conditions of policies
Ex.A6 – Legal notice
Exhibits filed on behalf of the Opposite parties:
Ex.B1 - Policy along with terms and conditions
Ex.B2 – Treatment papers of complaint.
MEMBER MEMBER PRESIDENT
