Punjab

StateCommission

A/86/2018

Sushil Kumar - Complainant(s)

Versus

Iffco Tokio General Insurance - Opp.Party(s)

Mohit Sadana

04 Jun 2018

ORDER

                                                                             2^Nd ADDITIONAL BENCH

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

First Appeal No.86 of 2018

                                                          Date of Institution: 16.02.2018

                                                          Order Reserved on: 04.05.2018

                                                          Date of Decision:   04.06.2018

 

Sushil Kumar son of Tarsem Lal, resident of H.No.170, Ward No.3, Street No.1, Opposite BDO Office, Ajit Nagar, Sunam, Tehsil Sunam, District Sangrur.

                                                                                     Appellant/complainant

                                                Versus

1.      IFFCO Tokio General Insurance Company Limited, Branch Office; 2^nd Floor, Above Hot Chop Building, Kaula Park, Sangrur, throughits Branch Manager.

2.      IFFO Tokio General Insurance Company Limited, Registered Office; IFFCO Sadan, C-1, District Central Saket, New Delhi, through its Managing Director.

                                                                    Respondents/opposite parties      

First Appeal against order dated 15.12.2017 passed by the District Consumer Disputes Redressal Forum,  Sangrur.

Quorum:-

          ShriGurcharan Singh Saran, Presiding Judicial Member.

          Shri Rajinder Kumar Goyal, Member

Present:-

          For appellant                 :         Sh.Mohit Sadana, Advocate  

          For respondents                    :         Sh.,Rajneesh Malhotra, Advocate

           

RAJINDER KUMAR GOYAL MEMBER :-

ORDER

                    The appellant/complainant (hereinreferred to as complainant) has filed the present appeal against the order dated 15.12.2017 passed in Consumer Complaint No.362 of 2017 by District Consumer Disputes Redressal Forum, Sangrur (herein after referred as District Forum) vide which the complaint filed by the complainant was dismissed and parties were left to bear their own costs.

2.                Complaint was filed by the complainant under Consumer Protection Act, 1986 (in short, "the Act") against the respondents/Ops (hereinafter referred as Ops) on the averments that the complainant purchased a Family Health Protector Policy No.52560729 from the Ops for the period 15.12.2015 to 14.12.2016  which was subsequently renewed vide policy No.527147681 for the period 15.12.2016 to 14.12.2017 by paying premium amounting of Rs.10,491/- and Rs.10,537/- respectively for the sum assured amounting to Rs.2,00,000/-. The complainant suffered pain in his chest as such he was taken to Singla Nursing Home from where he was taken to Hero DMC Heart Institute and Hospital Ludhiana on 28.11.2016. After check-up the Doctors found his condition critical and required immediate bypass surgery of heart and the same was conducted on 02.12.2016. The complainant remained admitted in the hospital from 28.11.2016 to 10.12.2016 and during this hospitalization complainant spent about Rs.3,26,000/- on his treatment. After discharge from  the hospital the complainant submitted all the relevant documents/bills to the Ops for reimbursement, but the Ops repudiated the claim of the complainant vide letter dated 16.05.2017. Thus alleging deficiency in service on the part of Ops the complainant prayed to direct Ops as under:-

1. Release the claim amount of Rs.3,26,000/- along with interest at the rate of 18 per cent per annum from the date of admission in the hospital till realization.
2. To pay Rs.50,000/- on account of mental agony and harassment.

1. To pay Rs.11,000/- on account of litigation expenses.

3.                Upon notice OPs appeared and filed written reply taking legal objections that the complaint is wholly misconceived groundless and unsustainable in law. On merits, it was admitted that the complainant was issued a medi-claim insurance policy for Rs.2 lakhs for the period 15.12.2015 to 14.12.2016 which was renewed from 15.12.2016 to 14.12.2017 as per terms and conditions of the policy. A cashless treatment request was received by the Ops on 29.11.2016 from DMC Heart Institute  and Hospital Ludhiana upon which OPs sent a discrepancy letter on 29.11.2016 to provide requisite information in order to process the cashless claim and on scrutiny of the submitted information it was observed that liability of the cashless claim cannot be ascertained at this time and detailed valuation is required in this cashless claim. On receipt of reimbursement claim along with documents  and on scrutiny it was observed that some additional information is required which was sought vide letters dated 23.01.2017, 07.02.2017 and 22.02.2017 but the same was not submitted by the complainant. It was observed after perusal of the documents that it was case a hypertension, diabetes, mellitus type-II, coronary artery disease with  the acute coronary syndrome, double vessel disease, LVEF+22%, moderate MR, severe LV systolic dysfunction, mild plaue at CCA, LCCA & LCB and he underwent total arterial complete revascularization with bilateral IMA OPCABG X3. It was further averred that coronary artery disease, CAD has a direct co-relation with hypertension and there is two years waiting period from disease aggravating out of hypertension and diabetes in the policy, therefore, it was observed that the claim is not payable under Clause 5(b) of the insurance policy. The claim was rightly repudiated vide letter dated 16.05.2017. The other allegations leveled in the complaint were denied in toto.

4.                Before the District Forum the parties led their respective evidence.

5.                The learned counsel for the complainant has produced Ex.C-1 to Ex.C-27 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the Ops has produced Ex.Op-1 affidavit along with Annexure R1 to Annexure R-10 and closed evidence. 

6.                After going through the allegations as alleged in the complaint, written version filed by OPs evidence and documents brought on record the complaint filed by the complainants was dismissed as referred above.

7.                Aggrieved with the order passed by the learned District Forum the appellant/complainant has filed the present appeal.

8.                We have heard the learned counsel for the parties and have persued the record carefully.

9.                It was argued by the counsel for the appellant/complainant that the District Forum has failed to appreciate the advice of Dr. Anshuman Phull MBBS D.Card Consultant Cardiologist who has specifically suggested that acute coronary syndrome which was sudden and life threatening disease and it is not at all due to hypertension. ACS can happen any time and hypertension is not the cause of ACS. After admission in DMC Hospital the appellant informed the Insurance Company and  requested for cashless treatment as DMC heart institute was empanelled with the Ops company. On 30.11.2016, the insurance company refused the cashless request of the appellant/complainant with the remarks that at this time, liability of cashless claim cannot be ascertained and they may submit all the documents for reimbursement and will settle as per policy terms and conditions.  On 24.12.2016, the appellant filed his claim before the respondent company. On 01.01.2017 the claim of the appellant was also verified by the coordinator-cum-chief cardiologist of Hero DMC Heart Institute. On 16.05.2017 the respondent company repudiated the claim of the appellant by giving reference of policy exclusion 5(b) of terms and conditions whereas the claim of the complainant does not fall within exclusion clause 5(b) as stated above. The counsel finally prayed to allow the appeal and to set aside the order of the District Forum.

10.              The counsel for the Op argued that on perusal of the received documents it was noted that the patient claimant was admitted in DMC and Hospital Ludhiana from 28.11.2016 to 10.12.2016  as a case of Hypertension, Diabetes Mellitus Type-II, Coronay Artery Diesease (CAD) with acute Coronary Syndrome, double vessel disease, LVEF+22%, Moderate MR. Severe LV systolic Dysfunction, Mild Plaque at CCA, LCCA & LCB and he underwent total arterial complete revasculuarization with bilateral IMA OPCABG X3. The coronary artery disease has a direct correlation with hypertension and there is two years waiting period from disease aggravating out of hypertension and diabetes as per the policy terms.  The claim is not payable as per policy exclusion Clause 5b. Therefore, the claim of the complainant was repudiated rightly as per terms and conditions of the policy vide letter dated 16.05.2017.

11.              Whether claim can be repudiate under Clause 5(b). For ready reference it is reproduced as below:-

          “Any expense on disease aggravated by Diabetes and/or Hypertension, incurred in the first two years of operation of the Insurance cover. However, if these diabetes and/or Hypertension is/are under pre-existing condition at the time of first proposal then these will be falling under Exclusion 2(a) above and will be covered after 48 months of continuous coverage’s with us”.

          Clause 2(a) is as under:-

          “Any conditions defined as per-existing condition in the policy on an individual basis, until 48 months of continuous coverage have elapsed, since inception of the first health insurance policy in respect of an insured person, whether group or individual, without any break in the insurance coverage”.

                   In the instant case, the complainant was admitted to DMC and Hospital from 28.11.2016 to 10.12.2016 as a case of CAD with ACS, hypertension type II DM, DVD, LVEF = 22% moderate MR severe LV Systolic dysfunction mild plaque at RCCA, LCCA and LCB, pre OP  IABP as per Ex.C-26. The treatment was taken in first year of the policy period from 15.12.2015 to 14.12.2016. As per report of consultant Doctor of the OP Dr.D.P. Lamba, M.B.B.S. (Annexure R-10) hypertension is a significant risk factor or coronary artery disease, and it has a direct correlation with hypertension. On the other hand, the treating Doctor of DMC Heart Institute & Hospital Ludhiana Dr. G.S. Wander Professor and Chief Cardiologist has certified (Ex-C-26) that the complainant was presented with the complaints of chest pain associated with dysponea on exertion since 10-15 days prior to admission. CABG was done on 02.12.2016. According to the hospital records there is no history of any above disease in the patient file. He was discharged on 10.12.2016 from the hospital in a stable condition.  Also as per Ex.C-19 Dr. Anshuman Phull MBBS D.Card., DEM (UK) has stated that ACS can happen any time and hypertension is not the cause for ACS. We are further fortified with  the judgment of Hob’ble National Commission in 2016(1) CPR 566 (NC) titled as LIC of India versus Kolla Santhi and Anr, wherein the Hon’ble National Commission observed that Blood pressure and diabetes are such diseases that are not sometimes known to patient, as they do not manifest any serious symptoms in patient-Actual cause of death has been cardio respiratory arrest which can also not be said to be pre-existing disease and can occur suddenly-Revision petition dismissed. Similarly, Hon’ble National Commission in the case titled as Satish Chander Madan versus M/s Bajaj Allianz General Insurance Company Ltd., 2016(1) CPR 753 (NC), observed that there is no evidence which would suggest that petitioner despite of having knowledge of his heart ailment concealed this fact in proposal form by giving a wrong information. Only fact established by reports is that petitioner prior to obtaining insurance policy was having history of hypertension-this does not lead to conclusion that petitioner was also having previous history of heart problem. Thus, repudiation of insurance claim by the respondent/opposite party is not justified.

12.              From the above, we are of the opinion that Ops have not lead any evidence to prove that heart disease/CAD  has any correlation with hypertension/diabetes and therefore, Exclusion Clause 5(b) is not applicable and the claim of the complainant was wrongly repudiated by the Insurance Company. The District Forum has not appreciated the reports of the Doctors Ex.C-19 or Ex.C-26 who are specialist in cardiology whereas the District Forum has wrongly considered the report of a Doctor Ex.R-10 who is only a MBBS practicing Doctor. The claim is payable which  was wrongly declined by the District Forum.  

 13.             Sequel to the above, we allow the appeal and the order of the District Forum is set aside. The complaint filed by the complainant is allowed and Ops are directed to pay Rs.2,00,000/- equal to the sum assured along with 9% interest from the date of repudiation of the claim till realization. Ops is further directed to pay Rs.10,000/- on account of the harassment and mental agony and Rs.5000/- as litigation expenses. This order may be complied within 45 days date of the issue of the order.

14.              Copy of order be sent to  the parties as per rules.  

 

                                                                     (Gurcharan Singh Saran)

                                                                   Presiding Judicial Member

 

                                                                  

June 04,  2018                                         (Rajinder Kumar Goyal)

PK/-                                                                        Member