Tamil Nadu

North Chennai

227/2012

Dr.J.Ramprasad, - Complainant(s)

Versus

Max Bupa Health Insurance Co., Ltd, rep. By Chief Operations Officer, - Opp.Party(s)

M/s.T.Natarajan

25 Apr 2017

ORDER

 

                                                            Complaint presented on:  27.09.2012

                                                                Order pronounced on:  25.04.2017

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

TUESDAY THE 25^th DAY OF APRIL 2017

 

C.C.NO.227/2012

 

 

Dr.J.Ramprasad,

S/o G.Jegadeesan,

59/124. Gokulam Flats,

Flat No.11, II Floor,

Saravana Perumal Street,

Purasawalkam, Chennai – 600 084.

                                                                                    ….. Complainant

 

..Vs..

1.Max Bupa Health Insurance Co.Ltd.,

Rep. by its Chief Operations Officer,

Having Corporate Office at,

D-1, 2^nd Floor, Salcon Ras Vilas,

District Centre, Saket,

New Delhi – 110 017.

 

2.Max Bupa Health Insurance Co. Ltd.,

Rep. by its Branch Manager,

Ampa Manor, 2^nd Floor,

107/2, Nelson Manickam Road,

Aminjikarai, Chennai – 600 029.

.....Opposite Parties

Date of complaint                                 : 01.10.2012

Counsel for Complainant                      : M/s.T.Natarajan,S.Natarajan,

                                                                    Dr.G.Jegadeesan

 

Counsel for   Opposite Parties                  : M.B.Gopalan, N.Vijayaraghavan,

                                                                 M.B.Raghavan

 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant to pay the sum insured amount of Rs.5,00,000/- under the policy with 18% interest from the date of claim and a sum of Rs.3,00,000/- towards compensation for mental agony with cost of the Complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The Complainant took a Health Insurance Policy with the 2^nd Opposite Party on 21.01.2011. The plan opted by the Complainant was ‘Heartbeat Gold’ and was insured for a sum of Rs.5,00,000/-. The Complainant was provided with the policy number 30020526201100: Customer ID:24624. The Complainant paid the premium of Rs.6,813/-. On 20.05.2011, he had breathing problem and he took a chest x-ray at Gemini Advanced MRI & CT Scan, Chennai which showed a lesion in his right chest. The doctors advised CT scan of chest and the report dated 31.05.2011 furnished by the Barnard Institute of Radiology  and Oncology, Rajiv Gandhi Government General Hospital., Madras Medical College, Chennai revealed ‘Pulmonary Arteriovenous Malformation’(AVM). The Complainant was referred to an Interventional Radiologist and one Dr.A.K.Gupta who treated the Complainant suggested, Angiographic Coil Embolization for treatment of Pulmonary Arteriovenous Malformation (AVM).

2.  The Complaint got admitted at Rajiv Gandhi Institute of Tuberculosis and Chest Diseases (RGIT & CD), Bangalore on 21.12.2011. On 22.12.2011, the Complainant was referred to National Institute of Mental Health and Neurological Sciences (NIMHANS), Bangalore for further treatment and after conducting various tests, on23.12.2011 the Complainant underwent Angiographic Coil Embolization of the Pulmonary AVM and the procedures were completed by Dr.A.K.Gupta at National Institute of Mental Health and Neurological Sciences (NIMHANS), Bangalore. Twenty six coils of various sizes were deployed in the pulmonary artery of the Complainant. After successfully completing the process, the Complainant was shifted once again to Rajiv Gandhi Institute of Tuberculosis and Chest Diseases. The Complainant had incurred totally Rs.6,26,844.48/- which is inclusive  of the costs towards viz., in-patient treatment, Medicine bills, Diagnostic Tests, cost of the coils and its deployment. The Complainant was discharged on 26.12.2011.

3. On 30.12.2011, he had sent a letter to the 1^st Opposite Party claiming the sum of Rs.6,26,844.48/- which he had incurred towards medical treatment. All the requisite particulars like 1) Claim Form, 2) ID proof/Age proof, with all documents. On 29.02.2012, there was an e-mail from the Opposite Parties stating that they are unable to admit the claim and thereby rejected/repudiated the claim on the ground that it falls under Permanent exclusion 4(e)(vi) Congenital Condition. The Complainant sent reply vide e-mail dated 17.03.2012 explaining them that it is not correct on the part of the Opposite Parties to reject the claim as ‘Congenital’ as the Complainant’s past medical history is good and devoid of any adverse remarks. Impact the Complainant was an athlete and hockey player at school level which would demand lot of physical energy and exertion and the Complainant never experienced any sort of health problem till he suffered from shortness of breathing during the month of May 2011 as stated supra. The Complainant sent a reply e-mail dated 17.03.2012 to the Opposite Parties that the repudiation made by the Opposite Party is not correct and also sent remainders on 07.04.2012 and 20.04.2012. Hence the Complainant filed this Complaint to pay the sum insured amount of Rs.5,00,000/- under the policy with 18% interest from the date of claim and a sum of Rs.3,00,000/- towards compensation for mental agony with cost of the Complaint.

4. WRITTEN VERSION OF THE  OPPOSITE PARTIES IN BRIEF:

The Complainant Health Insurance Policy No.30020526201100 from the Opposite Parties for the period 21/01/2011 to 20/01/2012 covering himself respect of Hospitalization expenses for a sum insured of Rs.5,00,000/-. The policy represents the contract between the parties and coverage is strictly subject to terms and conditions limits as set forth in the policy. The Complainant has conveniently suppressed the policy terms by merely filing the certificate. The policy specifically excludes from coverage, expenses for treatment arising out of any congenital condition vide clause 4(e)(vi). The Complainant lodged a claim on 30.12.2011 for treatment at Rajiv Gandhi Institute of Chest Diseases and NIMHANS, Bangalore during December 2011. The Medical Records of the Hospital and the Complainant’s own admission, it was found that the treatment was for Pulmonary Arteriovenous Malformation (PAVM) which are rare pulmonary vascular anomalies and invariably congenital. It has been established by medical study as reported in authoritative scientific journals (such as Post grad Medical Journal) that more than 80% of PAVMs are congenital. However, in few cases, it has been found possible to hepatic cirrhosis, metastatic carcinoma, mitral stenosis, infections (actinomycosis, schistosomiasis), and sustemic amyloidosis. The Opposite Party states that evaluation of claim was made by expert Doctor and during such claim scrutiny no evidence or cause noted which was suggestive of an ailment being acquired in as much as the medical records did not reveal any history or prior incident from which the PAVM could consider as having been acquired in the complainant’s case.  It is true that claim was intimated under letter of the Complainant dated 31.12.2011 but no information or document was furnished when the treatment was being planned, effectively keeping the Opposite Parties in the dark during those times. The allegations in para 7 purporting to question the conclusion of the Opposite Parties that the Malformation was congenital and disputing the conclusion are all self-serving and misleading. The Opposite Parties state that pulmonary arteriovenous malformations are caused by abnormal communications between pulmonary arteries and pulmonary veins, which are most commonly congenital in nature. The Complainant has given no explanation to suggest that it was acquired by a cause subsequent to insurance. The Opposite Parties specifically deny the allegation of Complainant being an athlete or Hockey player and Complainant is put to strict proof of the same. The Opposite Parties have not committed any deficiency in service in repudiating the claim made by the Complainant and prays to dismiss the Complaint with cost.

5. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

6. POINT NO :1 

          The admitted facts are that the Complainant took Ex.A2,  Health Insurance Policy with the 2^nd Opposite Party  and to avail the said insurance the Complainant paid a sum of Rs.6,813/- as premium amount  under Ex.A3 receipt and the Opposite Parties  issued Ex.A4 customer information sheet to the Complainant and the Complainant had breathing problem on 20.05.2011 and he took x-ray,  at Gemini Scans and Ex.A6 is the x-ray report and thereafter he went to the Rajiv Gandhi Government General Hospital  for further test and they issued Ex.A8 & Ex.A9 report  revealed that Pulmonary Arteriovenous Malformation (PAVM) and then he went to Bangalore and consulted at Rajiv Gandhi Institute of Tuberculosis and Chest Diseases on 21.12.2011 and thereafter he was referred to National Institute of Mental Health and Neurological Sciences at Bangalore and after the treatment they issued Ex.A10 certificate and he incurred expenses for the amounts mentioned in  Ex.A11 series receipts and thus  the Complainant was discharged from the hospital on 26.12.2011 incurring a total expenses of Rs.6,26,844.48/- and the Complainant  made a claim under Ex.A13 letter and Ex.A14 claim form to the Opposite Parties for the above said expenses and however the Opposite Parties rejected the claim that the policy specifically excludes from coverage, expenses for treatment arising out of any congenital condition vide clause 4(e) (vi) under Ex.A15.

          7. The contention of the Complainant that the PAVM disease is not a birth defect and the same was occurred to him only in the middle of his life and therefore he is entitled for the claim made by him and the repudiation made by the Opposite Parties is liable to be set aside.

          8. The Opposite Parties contended that the Complainant stated in his proof affidavit that the report showed a lesion in his right chest and further as per Ex.B2 signs and symptoms proves the Complainant suffered with congenital disease and therefore the repudiation made by the Opposite Parties is correct and prays to dismiss the Complaint.

          9. Congenital conditions mean a disease which exists right from the birth of the child. Admittedly the Complainant undergone various tests and treatment as inpatient in various hospital and the reports of the hospital discloses that the Complainant took treatment for  PAVM which is a pulmonary disease. According to the Opposite Parties the PAVM is congenital disease. However, the Opposite Parties themselves pleaded in the written version that “In few cases it has been found possible to acquire PAVM after birth due to chest drama, thoracic surgery etc.” Therefore, as per the above statement the Complainant could have occurred PAVM after birth.

10. Further, the Complainant is  26 years old at the time of filing of the Complainant. No documents filed by the Opposite Parties that the Complainant suffered with congenital disease PAVM at the time of birth and continued thereafter.  From the available records it is seen that only at the age of 25 and after the Complainant suffered with PAVM. The Complainant also relied on Ex.A19 literature in respect of Pulmonary Arteriovenious Malformations (PAVM). In the said literature, it has been stated that “PAVMs may occur as acquired congenital or idiopathic lesions”. It is further stated that “most patients with HHT and PAVMs have no pulmonary symptoms. When they do occur, symptoms usually appear in the 3^rd or 4^th decade of life, though a monitary of cases are found in children.”  It is further stated under the heading of acquired PAVMs that “PAVMs May be acquired as a result of inflammatory conditions (usually infections) or trauma involving the lung. Tuberculosis, Actinomycosis, Schistosimiasis and chest trauma have been described as rare causes of PAVMs with right – to – left shunting. These arteriovenous malformations presumably arise as a result of chronic infection or ischemia.” Further “PAVMs may also be acquired in the setting of hepatic dysfunction.” The above literature clearly establishes that the disease PAVMs can also be acquired after birth. In the case in hand also the Opposite Parties have not produced sufficient materials that the Complainant had PAVMs  right     from his birth and therefore as contended by the Complainant  that he was not having  congenital disease right from his birth and he had acquired PAVMs only after his birth.

11. Since, it is decided above that the Complainant is not having congenital disease, the claim made by the Complainant was repudiated by the Opposite Parties  under Ex.A15 is deficiency in service on their part.

12. POINT NO:2

          Since the Opposite Parties committed deficiency in service in repudiating the claim of the Complainant, the Complainant is entitled for his claim from the Opposite Parties. The Complainant made a claim of Rs.6,26,844.48/- under Ex.A13 & Ex.A14. The Complainant policy is Ex.A2 and sum insured is only Rs.5,00,000/-  and the Complainant is entitled only for the amount insured the policy alone form the Opposite Parties. By rejecting the claim of the Complainant he had suffered with mental agony is accepted and for the same it would be appropriate a order a sum of Rs.50,000/- towards compensation for mental agony, besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally  are  ordered to pay a sum insured amount  of Rs.5,00,000/- (Rupees five  lakhs  only) towards the policy amount to the Complainant and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 25^th day of April 2017.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 21.01.2011                   Letter from 1^st Opposite Party

Ex.A2 dated NIL                     Insurance Certificate

Ex.A3 dated 21.01.2011                   Premium Receipt

Ex.A4 dated NIL                     Customer Information Sheet

Ex.A5 dated 20.05.2011                   Report of GKM Hospital P.Ltd.,

Ex.A6 dated 22.05.2011                   Chest x-ray report

Ex.A7 dated 31.05.2011                   Report from Radiologist

Ex.A8 dated 21.12.2011                   Referral Letter from SDS Tulerculosis & Rajiv

                                                   Gandhi Institute of Chest Diseases

 

Ex.A9 dated 22.12.2011                   Referral Letter from SDS Tulerculosis & Rajiv

                                                   Gandhi Institute of Chest Diseases

 

Ex.A10 dated 23.12.2011                 Embolisation of Pulmonary AVF Procedure and

                                                    post procedure

 

Ex.A11 dated 21.12.2011                 Details of bills/cash receipts/

   22.12.2011, 23.12.2011                 Invoice – 14 Nos

   24.12.2011, 26.12.2011

 

Ex.A12 dated 26.12.2011                 Discharge Card

 

Ex.A13 dated 30.12.2011                 Claim Letter

 

Ex.A14 dated 30.12.2011                 Claim form

 

Ex.A15 dated 29.02.2012                 E-mail from Opposite Parties rejecting the claim of

                                                    Complainant

 

Ex.A16 dated 17.03.2012                 Reminder e-mail from Complainant

 

Ex.A17 dated 07.04.2012                 Reminder e-mail from  Complainant and reply

                                                    from Opposite Parties

 

Ex.A18 dated 20.04.2012                 Reminder e-mail from Complainant

 

Ex.A19 dated NIL                             Extract from Lesson 10, Vol 13, Pulmonary

                                                    Arteriovenous Malformation

 

Ex.A20 dated 03.02.1996                 Merit Certificates &

03.02.2001,12.01.2002           Certificate of participation

2001 – 2002,2002-2003

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

Ex.B1 dated 21.01.2011                   Insurance policy with terms and conditions

 

Ex.B2 dated NIL                     Medical Articles

 

 

 

MEMBER – II                                                               PRESIDENT