Order-15.
Date-03/04/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short is that the Complainant is a Policy holder along with other members of his family under Max Bupa Health Insurance Co. Ltd. (OP No. 1A and 1B) having policy no. 30441244201500 with coverage from 08.07.2015 to 07.07.2016 and Policy No. 30441244201601 from 08.07.2016 to 07.07.2018,on renewal for 2 years with cashless facility. There was no illness of any of the covered persons during the initial policy from 08.07.2015 to 07.07.2016 and the policy holder had no claim. On 5th August, 2016 the spouse of the complainant Smt. Purba Das Ganguly an insured coverage person fell ill and she was admitted at Apollo Gleneagles Hospital, 58,Canal Circular Road, Kolkata (OP No. 2). O.P.-2 suggested few pathological and clinical tests and diagnosed the disease as “Syncope and collapse” and she went on treatment as inpatient in the said hospital. According to hospital authority, hospital obtained authorization of insurance treatment for the package of Rs.55,000/- of which OP No. 1 (a) & 1 (b) disallowed Rs.25,000/- and allowed Rs. 30,000/- without showing any reason to OP No. 2 for such disallow. Further test at the hospital and MRIrevealed existence of “ARVD”, a medical term related to Heart disease. A person of Insurance Company also visited the hospital and held talk to the patient and asked her name etc. Hospital authority advised ICD implantation as early as possible to avoid imminent life danger. OP No. 2 also told verbally that it may cost around Rs.9,50,000/-. The Hospital authority also sent estimated cost for the treatment including the plans of ICD to the Insurance Company. The Complainant alleges that the Hospital authority informed him that the Insurance Company have cancelled/withdrawn their authorization for cashless treatment and advised the Hospital Authority to collect the amount of Rs.30,000/- which is Insurance Company approved earlier. The OP No. 1 (a) & 1 (b) alleged that the condition of the patient is genetic in nature as per terms and clause No. 4 (e) (xxxi), genetic disorderresulting from a defect in the Genes is not allowed under coverage. It is stated by the Complainant that the patient did not have the disease since birth and ARVD may have developed during the passage of years and can never be said that it has developed due to genetic disorder of defect in gene. Hospital authority thereafter informed the Complainant that the hospital shall not be allowed to undergo treatment on cashless and demanded full cost of the treatment so far amounting to Rs.81,047/-. The Complainant had no other alternative but to take discharge of the patient on 12.08.2016. The Insurance Company did not inform the policy holder to withdrawal of cashless policy. It is alleged that the Insurance Company cannot deny the cashless treatment of the hospital on the ground of genetic disorder. It is stated that patient had never any pre-existing cardiac complaint. The Complainant alleges that the withdrawal of authorization from the hospital for cashless treatment tantamount to deficiency of service and which is illegal, arbitrary. It is stated that Insurance Company illegally stopped cashless treatment of the Policy holder by withdrawing the authorization it extended to hospital for treating the patient. It is stated that the Complainant had to pay an amount of Rs.81,047/- towards expenses for the treatment at the hospital and has prayed for refund of the said amount and other relief in terms of prayers in the play.
OP No. 1 has contested the case in filing w.v. contending inter alia that the case is not maintainable in its present form and prayer. It is stated that there has been no deficiency of service committed by this OP, which can entail no relief as claimed in the complaint. It is stated that on 05.08.2016 OP No. 1A received a request for cashless facility from OP No. 2 i.e. Hospital, in which the Complainant’s wife was admitted for treatment of Syncope and collapse THD. Certain documents were furnished to IOP No. 1 and OP No. 1(a), initially approved Rs.30,000/- on the basis of the available document and expressly stated that final approval can be given upon the discharge summary and final bill being presented to OP No. 1A.On 16th August, 2016, OP No. 1A received a revised treatment plan for the insured person from OP No. 2 along with certain medical documents from which it transpires that the diagnosis of the insured person is “Arrhythmogenic Right Ventricular Dysplasia” (ARVD)and the patient was diagnosed ARVD. It is stated that ARVD is genetic disorder which is caused due to abnormality or defect in Genes. Clause 4(e) (xxxi) of the Insurance Policy excludes any genetic disorder resulting from a defect in the genes as a permanent exclusion from the policy. In the light of such fact, due to diagnosis of a genetic disorder , OP No. 1(a) was constrained to issue denying authorization and was further constrained to withdraw earlier authorization. It is stated that denial of cashless treatment cannot be construed as a deficiency of service. This OP has prayed for dismissal of the instant proceedings.
OP No. 2 has also contested the case in filing w.v. contending inter alia that the instant complaint is not maintainable against the hospital. It is stated that the Complainant has not alleged any allegation or deficiency whatsoever as against the hospital. It is also stated that the OP No. 2 has received entire cost of treatment from the patient party and no amount has been received from OP No. 1, Insurance Company. It is stated that the Complainant has not prayed for relief from this OP. This OP has also prayed for dismissal of the case against it.
Point for Decision
- Whether the Ops have been deficient in rendering service to the Complainant ?
- Whether the Insurance Company rightly negated / withdrawn the cashless benefit of the wife of the complainant ?
- Whether the complainant is entitled to get relief as prayed for ?
Decision with Reasons
We have travelled over the documents on record i.e. photocopy of mediclaim policy and policy documents, photocopy of the certificate of Dr. Sankar Subhra Das dated 11.08.2016, photocopy of discharge record, photocopy of Cardiac MRI, photocopy of discharge and other documents on record.
It appears that Complainant obtained mediclaim policy from OP No. 2 in 2015 and renewed subsequent years and presently valid with effect from 08.07.2016 to 07.07.2018 for Rs.5,50,000/- with cashless benefits covering himself, his spouse and minor son. On 05.08.2016 the spouse of the complainant became ill and was admitted in the OP 2 hospital as per advise of his family physician. After tests and MRI, heart disease was diagnosis is “Syncope and Collapse”. She went on treatment by the doctor at OP-2 hospital under package of Rs.55,000/-. OP No. 1 sanctioned 30,000/- towards cashless benefit against claim of Rs.55,000/-. Subsequently, from other tests including MRI showed ARVD. The treating doctor advised ICD implantation to avoid life danger of the patient and orally told cost of the same would be around 9,50,000/-. The matter was informed to OP No. 1 by the Complainant.The OP No. 1 later on cancelled their cashless treatment of Rs.30,000/- on the plea that the disease is genetic in nature and as such is not admissible for under clause 4(e) (xxxi) of policy terms and conditions. The Complainant had to pay the entire cost of treatment at the time of discharge on 12.08.2016 amounting to Rs.88,047/- to the OP Hospital and obviously the Complainant could not implant IRD to her spouse. The Complainant has prayed for relief as against OP No. 1 alone. Complainant has not alleged any deficiency of service against OP No. 2 hospital.
It is worthy to point out at the very outset that the Complainant has not lodged any claim for reimbursement of hospital expenditure before OP No. 1, but has approached directly to this Forum at the denial of authorization of cashless benefit itself. We find that the claim of the Complainant has been negated on the ground that the Complainant’s wife suffered from “Arrhythmogenic Right Ventricular Dysplasia, shortly, ARVD.
From the medical papers on record, we find that Complainant was diagnosed with ARVD. The discharge summary and other medical documents also reveal that the Complainant was suffering from ARVD. We find that Cardiac MRI report and treating hospital progress report date 10.08.2016 mentioned that the patient was diagnosed ARVD. Clause of the Terms and Conditions of the Insurance Policy reads as follows .
“Permanent exclusions . we will not be liable under any circumstances for any claim in connection with or with regard to any of the following permanent exclusions and any such permanent exclusions as may be specified in the Schedule of Insurance Certificate .
“(xxxi) Generic Disorders
Any genetic disorder relating from a defect in the genes”.
It is also argued from the side of O.P.-1 that as the Complainant’s wife was diagnosed Arrhythmogenic Right Ventricular Dysplasia “ARVD”, which is permanently excluded under the policy, the cashless benefit was withdrawn.
The question is whether ARVD is a genetic disease or not. We have perused different medical literatures and the views of the doctors. It has not been denied by the treating doctor that ARVD is a genetic condition. From the different medical literatures, it appears that ARVC is a genetically transmitted disease. However, the genetics are more complex than any other inherited conditions wherein a single gene abnormally mutation may be causative. It is stated that Arrhythmogenic Right Ventricular Cardiomypathy (ARVC) is a genetically transmitted disease. However, the genetics are more complex than in other inherited conditions wherein a single gene abnormal mutation may be causative. In ARVC, 5 causative desmosomal genes have been identified, but because only 30 percent to 50 percent of patients with ARVC have 1 of these gene abnormalities, it is ssumed that there are other genes not yet identified. Frequently, patients with ARVC have à one genetic defect in the same gene (compound heterozygosity) or in a second complement ary gene (digenic heterozygosity). In addition, a family member may have an ARVC gene defect and have development of the disease or have no or minimal manifestations of the disease.Clinical genetic testing is commercially available. It is beneficial for first degree family members of a person with ARVC to have genetic testing but only if there is a known genetic abnormality in the affected person. If the affected family member (proband) with ARVC does not have a genetic defect identified, then it will not be identified in the family member. Genetic counseling is strongly advised for family members of the proband(J Am Coll Cardiel 2013. 61. 1945-8) (c) 2013 by the American College of Cardiology Foundation.
So, we find that ARVD known also as ARVC is a genetic cause for sudden cardiac arrest. A condition in which the heart stops. ARVC is inherited as an autosomal dominant trait. We also find that cases of ARVD runs in families and genes mostly are responsible for ARVD. Accordingly, we have no hesitation to hold that the claim of the Complainant falls within the permanent execution clause and thus beyond purview of the policy. In Oriental Insurance Co. Ltd. Vs Sami Chem reported at AIR 199 SC 342 the Supreme Court has held that the Insurance Policy between the insurer and the insured represents a contract between the parties and insured cannot claim anything more than what is covered by the Insurance Policy and that being so the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein. Moreover, we find that after rejection of the pre authorization request i.e. denial of cashless treatment the Complainant did not file any claim with the OP. We are afraid, we are constrained to hold that there has not been deficiency of service on the part of the OPs as alleged.
In result the case merits no success.
Hence,
Ordered
That the instant case be and the same is dismissed on contest against the OPs.
No order as to cost
