CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

      UdyogSadan, C – 22 & 23, Institutional Area

              (Behind Qutub Hotel)

     New Delhi – 110016

       Case No.143/2018

KUNAL MEHRA

W-57A, GREATER KAILASH-I,

NEW DELHI- 110048                                                …..COMPLAINANT

Vs.

MAX BUPA HEALTH

INSURANCE COMPANY LIMITED

THROUGH ITS DIRECTORS

B-1/I-2, MOHAN COOPERATIVE INDUSTRIAL ESTATE,

MATHURA ROAD,

NEW DELHI 110044                                                  …..RESPONDENTS

Date of Institution-28.06.2018

Date of Order-25.08.2023

         O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on the part of OP in repudiating the medical claim of the Insured.

2. Brief facts as stated in the complaint are that the complainant purchased medical health insurance policy bearing no 30642160201700 for his family. The policy was operational from 08.03.2017 to 07.03.2018 after payment of a premium of Rs.33,752/-

3. On 08.11.2017, at 2:30 a.m., the complainant suffered from Status Epileptics at his residence. He was rushed to National Heart Institute where the doctors concluded that the he was not suffering from any heart ailments. At 5:20 a.m. The complainant was rushed to Max Super Speciality Hospital in emergency from and under supervision of National Heart Institute. It is stated that complainant was in a state of semi consciousness due to which he was drowsy, agitated and confused. He was immediately admitted and treatment was started. It is further submitted that doctors were informed about unverified symptoms like headaches, injuries, past medical condition etc. by family members and friends of the complainant.

4. The complainant was moved to ICU under supervision of Dr. J.D. Mukhejee, Dr. Mukesh Kumar and Dr. Khusbhu Goel of Max Hospital. It is submitted that after evaluating the test results of the complainant, the doctors concluded that the patient was suffering from Neurocysticercosis, a parasitic infection of human nervous system. The most common form of NCC involves infection of the brain parenchyma with the larval form of ‘Taeniasolium tapeworm’. The reports also displayed that the NCC was at the stage where cyst evolution had terminated and it had become non-viable and fully calcified nodule.

5. A preauthorization for cashless claim from the insurance company for hospital expenses was received vide email dated 08.11.2017 and a sum of Rs.63,000/- was approved by OP. On 10.11.2017, another preauthorization request was sent to OP who approved a sum of Rs.91,428/-.

6. On 11.11.2017, OP’s representative visited the Max Hospital questioning the complainant about the occurrence of seizure and the treatment following it. It is alleged that OP representatives falsely referred to the illness of the complainant as ‘Epilepsy’ and told the complainant that the doctors have informed the said representative that the complainant was suffering from Epilepsy since childhood.

7. On the same day i.e. 11.11.2017, OP vide an email denied the preauthorization request. The complainant was discharged on 13.11.2017. The complainant emphasises that he had never suffered from seizure and epileptic attack before this current episode. The attending doctors have clarified that there was no pre-existing history of epilepsy.  The complainant paid Rs.2,17,370/- towards the treatment of his illness. 

8. OP repudiated the claim of the complainant vide email dated 16.11.2017 and cancelled the policy. The complainant vide email dated 29.11.2017 replied to the aforementioned email. OP vide email dated 05.12.2017 stated that the policy was cancelled due to non-disclosure. Various correspondences were exchanged between the parties regarding denial of claim and cancellation of policy. The complainant further submits that he tried to renew his policy but it could not be renewed.

9. The complainant further submits that Dr. Mukesh Kumar of Max Hospital gave a letter dated 29.12.2017 confirming that Neurocysticercosis had no casual relation with epilepsy. The complainant has also filed medical literature.

10. The complainant prays for the claim amount of Rs.2,17,370/- towards full reimbursement of medical expenses, Rs. 10,83,780/- for mental agony caused by dishonest and unfair trade practice, deficiency of service, Rs.5,00,000/- for litigation expenses, withdrawal of cancellation letter and reinstatement of the cancelled policy.

11. OP in its reply has admitted that complainant had applied for Health Companion Family Floater Insurance Policy for a period from 08.03.2017 to 07.03.2018. A cashless claim was received from Max hospital for the complainant who was admitted with episode of seizure (rigidity & tremors of B/I upper limbs, uprolling of eyeballs frothing from mouth) on 08.11.2018. Initially, the preauthorization was approved twice but during the scrutiny of medical documents it was noted that complainant was suffering from epilepsy at early childhood. Hence, the cashless claim was rejected vide letter dated 11.11.2017.

12. OP further submits that an investigation was conducted and thereafter, preauthorization was rejected. OP states that investigation report along with the Progress notes of critical care assessment of Max hospital reveals that the complainant was suffering from Epilepsy since childhood. Notice of cancellation of policy dated 16.11.2017 was issued to the complainant stating that due to non-disclosure of pre-existing illness/ medical condition, OP is unable to continue with the policy.

13.  OP states that claim was repudiated as complainant was suffering from epilepsy at early childhood. This condition was never disclosed in the Proposal Form nor at the time of pre-policy medical check-up. OP also submits that only preauthorization of cashless treatment was denied and the complainant has not filed a claim for reimbursement. OP further submits that the insurance company can carry out a proper investigation into the genuineness of the claim only if a claim is submitted.

14. The investigations conducted by OP are admitted as being matter of record while denying that the complainant answered all queries correctly. OP has also admitted doctor’s letter while stating that the letter is contrary to what is stated in the case sheet/daily sheet.

15. Complainant has filed his rejoinder denying the existence of any pre-existing disease. Complainant has stressed that the report mentioned “regular past medication; None”. Complainant has also clarified that once the policy is cancelled, he could not approach the OP for reimbursement. He has re-emphasized that he was suffering from Status Epileptics due to Neurocysticercosis.

16. Complainant has filed evidence by way of affidavit and has exhibited the following documents:

1. Copy of policy document is exhibited as Exhibit CW1/1.
2. Copy of receipt of payment is exhibited as Exhibit CW1/2.
3. Copy of emergency case sheet of National Heart Institute is exhibited as Exhibit CW1/3.
4. Copy of email and letter of authorization are exhibited as Exhibit CW1/4 and Exhibit CW1/5 respectively.
5. Copy of email and letter of authorization are exhibited as Exhibit CW1/6 and Exhibit CW1/7 respectively.
6. Copy of email and denial of authorization are exhibited as Exhibit CW1/8 and Exhibit CW1/9 respectively.
7. Copy of discharge summary is exhibited as Exhibit CW1/10.
8. Copy of the final medical bills along with payment receipts are exhibited as Exhibit CW1/11 (Colly).
9. Copy of the notice of cancellation of policy is exhibited as Exhibit CW1/12.
10. Copy of reply is exhibited as Exhibit CW1/13.
11. Copy of email is exhibited as Exhibit CW1/14.
12. Copy of reply is exhibited as Exhibit CW1/15.
13. Copy of letter issued by doctor of Max Hospital is exhibited as Exhibit CW1/16.
14. Copy of the information available on the website of WHO and ILAE are annexed as Exhibit CW1/17 and Exhibit CW1/18 respectively.
15. Copies of registered service requests emails are annexed as Exhibit CW1/19, Exhibit CW1/20, Exhibit CW1/21, Exhibit CW1/22, Exhibit CW1/23 and Exhibit CW1/24.
16. Copy of email is exhibited as Exhibit CW1/25.
17. Copy of the screenshots taken while renewing the policy is exhibited as Exhibit CW1/26.

17. OP has filed evidence by way of affidavit and has exhibited the following documents:

1. The letter of authorization is exhibited as Ex.OP-1/A.
2. Copy of the application/Proposal form is exhibited as Ex.OP-1/B.
3. Insurance certificate along with its terms and conditions are exhibited as Ex.OP-1/C(Colly).
4. Copy of pre-authorization form and medical documents are exhibited as Ex.OP-1/D & Ex.OP-1/E(colly).
5. Copy of letter for pre-authorization is exhibited as Ex.OP-1/F & Ex.1/G.
6. Copy of letter for denial of authorization is exhibited as Ex.OP-1/H.
7. Copy of the investigation report is exhibited as Ex.OP-1/I.
8. Copy of notice of cancellation is exhibited as Ex.OP-1/J.
9. Copies of the emails are exhibited as Ex.OP-1/K.

18. Both the parties have filed written arguments.

19. The Commission has considered the pleadings and documents on record and arguments advanced by both the parties. It is admitted by both the parties that the complainant was a holder of Health Companion Family Floater Insurance Policy for a period from 08.03.2017 to 07.03.2018. It is further admitted that he was taken to National Heart Institute in Emergency on 08.11.2017 from where he was referred to Max Hospital on the same day.  He was admitted in Max Hospital on 08.11.2017 and discharged on 13.11.2017.

20. It is not disputed that OP Insurance authorized the cashless claim sent from the hospital vide email dated 08.11.2017 for Rs.63,000/- and authorized another cashless claim sent on 10.11.2017 for Rs.91,428/-. It is undisputed that OP’s representative visited Max Hospital and questioned the complainant on 11.11.2017. OP has also placed the investigation report on record. Thereafter, OP cancelled the policy on 16.11.2017. Various emails were exchanged between the parties regarding this cancellation. It is further admitted that the policy was not renewed.

21. The undisputed discharge summary shows that the complainant was diagnosed as follows : -
22.  

• STATUS EPILEPTICUS ?NEUROCYCTICERCOSIS
• RHABDOMYOLYSIS- IMPROVED

22. The cashless authorization was denied vide letter dated 11.11.2017. Relevant portion is as follows:-

Reasons for Denial:The details submitted alongwith the preauthorization suggest that patient has adverse medical condition due to which it is not possible to ascertain the liability at this juncture (due to gross non-disclosure of material facts-H/o epilepsy since childhood). Hence cashless cannot be extended to this case.

23. The policy was cancelled. Relevant portion of cancellation letter 16.11.2017 is as follows:-

This is with reference to your health insurance policy number 30642160201700 for which we have received Pre-auth/reimbursement Claim request Id 164390. We would like to inform you that during processing of your claim it has been noticed that there has been a non-disclosure of below mentioned pre-existing illness/ medical conditions at the time of applying for health insurance policy with us:-

In light of the facts and the information available with us, we regret to inform you that we are unable to continue with the policy coverage any further.

Also, as per clause 3 of Policy Terms & Conditions we are cancelling your policy. Relevant clause of the terms and conditions are re-iterated below for your reference.:

Clause 3: Cancellation by us:

Without prejudice to the above, We may terminate this policy during the Policy Period by sending 30 days prior written notice to your addressshown in the Schedule of Insurance Certificate without refund of Premium if:

1. You or any Insured Person or any person acting on behalf of either has acted in a dishonest or fraudulent manner under or in relation to this Policy: and/or
2. You or any Insured Person has not disclosed the material facts or misrepresented in relation to the Policy; and/or
3. You or any Insured Persons has not co-operated with Us.

Def 14:       Disclosure to Information Norm: The Policy shall be void and all premium paid herein shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material facts.

24. It is admitted by both the parties that an investigation was conducted by a representative of OP who visited the hospital and questioned the complainant in the hospital room. He submitted an investigation report. The relevant portion of report as follows:

Findings: (Manual)

I visited the hospital and found the patient is in Stroke Unit Bed number-08. As per hospital protocol they deny to investigate in Stroke Unit.

On 11.11.2017, again visited at hospital and found the patient in room number 3225, received copy of indoor case papers.

• Patient admitted with complaints of seizures FET since 8.11.2017 morning.
• As per emergency Card of NHI Hospital mentioned about Alcohol intake at night on 7.11.2017.
• History of epilepsy at early childhood.

H/O ALCOHOL, INTAKE IN NIGHT 07.11.2017

RECENT TREATMENT/REFERED FROM: NIIT

PAST/H/O [COMORBTDITIES] :

EPILEPSY AT EARLY CHILDHOOD

REGULAR PAST MEDICATION: NONE.

DATE of report assignment:        8.11.2017

DATE of report submission:        10.11.2017 & 11.11.2017

25. OP has enclosed the progress notes as supplied to them by Max Bupa Speciality Hospital. OP has relied on progress note dated 08.11.2017.

26.  As per the progress report at 06:03 the complainant was admitted at 05:40 am in stroke ICU. The relevant portion of the progress report at 06:03 is as follows:-

CASE SEEN BY DR SANDEEP KUMAR AND DISCUSSED WITH DR MUKESH KUMAR

A 39 years old male was brought to ER by attendant in an outside ambulance with ryles tube and foleys ctahter in situ

With H/O episode of seizure (rigidity & tremors of B/L upper limbs, uprolling of eyeballs, frothing from mouth) which happened at approx. 2:30 am 08/11/2017

CNS- Drowsy, confused, agitated. (Post Ictal Phase)

Detailed Neurological Examination Not Possible

Plantar- Left Extensor.

Status epilepticus with post ictal state

Case discussed with Dr. Mukesh Kumar.

27. The progress report on the same day at 10:32 am by Dr. Naveen Jain is as follows:-

H/O ALCOHOL INTAKE IN NIGHT 07.11.2017

RECENT TREATMENT/REFERED FROM: NIIT

PAST/H/O [COMORBTDITIES] :

EPILEPSY AT EARLY CHILDHOOD

REGULAR PAST MEDICATION: NONE.

O/E:

DROWSY, SLEEPY, AFEBRILE

……………………….

NCC (LEFT FRONTAL REGION)

28. Progress report dated 09.11.2017 under Dr. Mukesh is as follows:
29.  

SEIZURE UNER EVALUATION ? NEUROCYSTICERCOSIS

Co- Morbidity:

29. Complainant has filed a doctor certificate by Dr. Mukesh Kumar, the treating doctor which is as follows:-

To whom it may concern

REF: KUNAL MEHRA.

Cam- Neurocysticercosis in left frontal cortex.

As per the critical condition this seizure & STATUS EPILEPTICUS is due to left frontal NCC which is a neural finding. This has no relation to any illness in childhood. There was no alleged H/o receiving anti epileptic medication in past.

30. OP has denied the claim on two grounds:-

1. The current treatment is for epilepsy.
2. The complainant had history of epilepsy since childhood.

31. The final diagnosis shows that patient was suffering from Status Epileptics? Neurocysticercosis. The progress report relied on by OP shows that complainant was in post ICTAL phase.

32. As per studies published by National Library of Medicine (https://www.ncbi.nlm.nih.gov/books/NBK430686/)

Status epileptics is defined as a seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. 

33. As per studies published by National Institute of Health:

• https://www.ncbi.nlm.nih.gov/books/NBK430686/#:~:text=Status%20epilepticus%20is%20defined%20as%20a%20seizure%20with%205%20minutes,activity%20without%20recovery%20between%20seizures)

Neurocysticercosis is a preventable parasitic infection caused by larval cysts (enclosed sacs containing the immature stage of a parasite) of the pork tapeworm (Taenia solium). The larval cysts can infect various parts of the body causing a condition known as cysticercosis. Larval cysts in the brain cause a form of cysticercosis called neurocysticercosis which can lead to seizures. Neurocysticercosis, which affects the brain and is the most severe form of the disease, can be fatal. Neurocysticercosis is considered a Neglected Parasitic Infection, one of a group of diseases that results in significant illness among those who are infected and is often poorly understood by health care providers.

How people get neurocysticercosis: A person gets neurocysticercosis by swallowing microscopic eggs passed in the feces of a person who has an intestinal pork tapeworm. For example, a person eats undercooked, infected pork and gets a tapeworm infection in the intestines. She passes tapeworm eggs in her feces. If she doesn’t wash her hands properly after using the bathroom, she may contaminate food or surfaces with feces containing these eggs. These eggs may be swallowed by another person if they eat contaminated food. Once inside the body, the eggs hatch and become larvae that find their way to the brain. These larvae cause neurocysticercosis.

34. As per studies published by Epilepsy Foundation (https://epilepsyfoundation.org.au/understandingepilepsy/seizures/seizurephases/#:~:text=The%20middle%20(ictal)%20stage%20of,Loss%20of%20awareness )

MIDDLE (ICTAL) PHASE

The middle (ictal) stage of a seizure is called the ictal phase. It’s the time from the first symptom to the end of the seizure activity. It is during this time that intense electrical activity is occurring in the brain. Some common signs of this phase include:

• Loss of awareness
• Memory lapse
• Felling confused
• Difficulty hearing
• Odd smells, sounds or tastes
• Difficulty speaking or saying strange words
• Twitching
• Loss of muscle control
• Repeated movements (such as lip smacking or chewing)
• Body convulsions
• Racing heart
• Trouble breathing

ENDING (POST-ICTAL) PHASE

The final post-ictal stage occurs after the active (ictal) part of the seizure. This is the recovery stage and during this phase any physical after effects of the seizure are felt. The type of seizure and the part of the brain involved will determine how long it takes for a person to return to their usual self. 

Some common signs of this phase include:

• Confusion
• Lack of consciousness
• Tiredness (fatigue)
• Exhaustion
• Headache
• Loss of bladder or bowel control
• Fear and anxiety
• Frustration
• Shame or embarrassment
• Thirst
• Nausea
• Sore muscles
• Weakness in parts of the body
• Injury (head, cuts, broken bones)

Once the seizure is over, some people may remember having one, remember parts of it, or not remember at all.   

35. As per studies published by www.healthline.com (https://www.healthline.com/health/epilepsy/epilepsy-vs-seizure#bottom-line):

What is epilepsy?

36.What’s a seizure?

Your brain works by sending electrical signals through nerve cells. If these signals are altered or interrupted, it can cause a seizure.

Seizures are the primary symptom of epilepsy, but they can also be caused by a number of other events.

37. What’s the difference between epilepsy and seizures?

Seizures are individual occurrences of abnormal electrical activity in the brain. There are many causes of seizures, including singular events like a medication reaction. Epilepsy, on the other hand, is a chronic neurologic disorder that causes repeated seizure activity.

It’s important to treat the underlying cause of individual seizures and to know when to differentiate between a standalone seizure and epilepsy.

38. It is clear from the aforementioned medical literature that a status epileptic is a seizure with 5 minutes or more of seizure activity. Seizure is interruption of electrical signal by brain. Epilepsy is a condition where recurrent seizures are experienced. However, one seizure alone does not mean that the patient had epilepsy.

39. Perusal of progress report filed by OP does not mention any subsequent seizure after admission. In fact, the progress report relied on by OP shows that conservative management was done. From the same progress report, it is seen that the complainant was admitted at 05:40 am. The progress report continues at 06.03 am it is noted that the case was seen and discussed with Dr. Mukesh kumar. The report continues to show that the complainant at that time was in a drowsy, confused and agitated state. The impression was that the complainant was suffering from Status Epileptics with post ICTAL State. The progress report on the same day at 10:32 am shows that the complainant on examination was drowsy, sleepy and afebrile. At the same time the history was taken and recorded as epilepsy at early childhood. The progress report at 06.03 am and 10.32 am mentions post ICTAL which is categorized by disorienting symptoms such as confusion, drowsiness, hyper-tension, headache, nausea etc. These symptoms have also been mentioned in the progress report at both the time.

40. The treating doctors have even putting a question mark after Status Epileptics and have given a probable diagnosis of NCC. This condition is caused due to condition of contamination of faeces by larvae cyst of tapeworm. The treating doctor certificate clearly states that Status Epileptics was due to Left Frontal NCC and complainant has never received any anti-epileptic medication in the past. The complainant was not suffering from epilepsy when he was admitted in Max Hospital.

41. Hon’ble National Commission in Star Health & Allied Insurance Co. ... vs Vineet Khanna & 5 Ors. on 17 September, 2021 has observed:

In the repudiation letter dated 04.11.2019, it has been mentioned that letter of Dr. Manjeet Nath Das dated 17.09.2019, was supplied by the complainant along with the papers submitted for reimbursement of medical claim. This fact has been denied in the complaint. Then in written reply it has been stated that when Columbia Asia Hospital made request for approval of cashless treatment, then queries were made then the hospital had supplied this letter. In this letter it has been written that "As history given by the patient relatives, patient was on mild medication for last 20 years and since last two years, after his mother passed away, his mental condition deteriorated and he was started on high and multiple dose of Anti Psychotic Medication".

Indian Medical Council (Professional Conduct Etiquette and Ethics) Regulation, 2002, (published in Gazette of India dated 06.04.2002) provides mandatory provision for the hospitals/ doctors to record/maintain Case Summary and Discharge Summary. Neither in Case Summary nor in Discharge Summary of Columbia Asia Hospital or of Sir Ganga Ram Hospital, this fact was noted that the patient was on mild medication, for last 20 years. This handwritten letter dated 17.09.2019 was contrary to the hospital record. Dr. Manjeet Nath Das was arrayed as opposite party-5 in the complaint. He did not dare to file his Affidavit of Evidence, admitting execution of this letter and explaining the circumstance, under which he had written this letter, contrary to the hospital record, maintained in discharge of mandatory provision of law. In the absence of personal affidavit of Dr. Manjeet Nath Das, no reliance can be placed on the letter dated 17.09.2019, in preference of the hospital records, which are maintained in discharge mandatory provisions of law. As such, it is not proved that the deceased Insured had concealed about his disease, in the proposal form. 

42. The treating Dr. Mukesh Kumar has given a certificate stating that the diagnosis Neurocysticercosis in left frontal cortex. He has also stated that there is no relation to any illness in childhood. He has further stated that the complainant does not have any history of anti-epileptic medication in past.

43. OP in its reply states that policy was cancelled on 16.11.2017 after due investigation. In the same reply OP states that complainant has not filed a claim for reimbursement and they are unable to carry out proper investigation as to the genuineness of the claim in the absence of any filing of claim. It is difficult to understand when OP had already engaged an investigator who had filed an investigation report after visiting the hospital and questioning the complainant on the hospital bed, what investigation was remaining. OP had cancelled the claim on 16.11.2017 on the basis of the said investigation’s report. The complainant had disputed this cancellation through emails but OP cancelled the policy. It is again difficult to understand as to how the complainant could file a claim with OP with respect to a cancelled policy.

44. Thus, it can be seen from the chronology of the events that complainant suffered from Status Epileptics which is a seizure activity with a duration of 5 or more. The final diagnosis as well as the certificate of treating doctor shows that complainant suffered from NCC who a parasitic infection caused by Tapeworm.

45. OP has rejected the claim of his pre of epileptic since childhood which relied on progress report dated 08.11.2017. OP has relied on progress report dated 08.11.2017, the progress report at 06:03 shows that the person was drowsy confused and agitated. The progress report at 10:32 am. The same date shows that the complainant was drowsy, sleepy and aferbile on examination and history was taken was epileptic at early childhood. OP has not filed any documents confirming that the complainant was suffering from epileptic either at early childhood or since at early childhood. The history recorded by doctor when a patient is drowsy and sleepy or confused cannot be taken as a gospel truth. In fact OP has not filed an affidavit of Dr. Naveen Jain who is taken the history to the complainant at 10:32 am.

46. Thus in the light of discussion above we find OP guilty of complainant has annexed medical bills by Max Healthcare dated 13.11.2017 amounting to Rs.2,16,220.41/-. Complainant has also filed Pharmacy Bills dated 13.11.2017 amounting to Rs.1277.99/-. Complainant has also filed a follow up with Dr. Mukherji dated 17.11.2017 amount of Rs.1,150/-.

47. Complainant has also filed one follow up bill of Dr. Mukherji in January and Pharmacy bill in March, 2018. These bills cannot be covered for the purpose of admission dated 08.02.2013.

48.  The complainant paid an amount of Rs.2,18,648.4/- for treatment and admission in hospital dated 08.11.2013.

49. In the above discussion, Commission direct the OP to reimburse the claim of complainant and pay Rs. 2,18,648.4/- (2,17,370/-) with interest @ 7% p.a. from the date of filing of complaint till its realization.

50. Payment of Rs.30,000/- as compensation for mental harassment and physical inconveniences.

51. Payment of Rs.10,000/- towards litigation expenses.

52. This order be complied with within 60 days from the date of the order.  This entire amount is payable to the complainant within a period of 60 days from the date of order failing which the entire amount will further carry an interest @9% per annum till it is paid to the complainant.
53. File be consigned to record room.