DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.17/2008
Sh. Sanjay
S/o Late Sh. B. S. Sharma
B-6, Press Apartment,
23, I.P. Extension,
Delhi-110092 ….Complainant
Versus
1. Max Devki Devi Heart & Vascular Institute
Regd. Office: 2, Press Enclave Road,
Saket, New Delhi-110017
2. M/s Royal Sundaram Alliance Insurance Co. Ltd.
Through its Regional Manager
Northern Regional Office: Signature Towers,
9th Floor, Tower 2, South City-1
NH-8, Gurgaon-122001 (Haryana) ……Opposite Parties
Date of Institution : 14.01.08 Date of Order : 05.07.16
Coram:
Sh. N.K. Goel, President
S. S. Fonia, Member
O R D E R
S. S. Fonia, Member
Succinctly narrated, the case of the Complainant is that he obtained a Mediclaim Insurance Policy from OP No.2 in the year 2003 and kept it renewed and it was got renewed vide policy bearing No. HO00005280000 103-W101 valid from 19.12.06 to 18.12.07 after paying premium of Rs.3907/-. He states that the policy was taken by him on the assurance given by OP No.2 that the said policy would be useful in all the hospital needs of the Complainant. In the month of July, 2007 he felt some heaviness in his chest area and became normal. Considering it to be an effect of acidity he did not pay much attention. Again he felt occasional pain in the same region and underwent TMT on 03.09.07 and the result was said to be positive for heart disease. Thereafter, he underwent CT Angiography on 10.09.07 at Mahajan Imaging Centre, New Delhi. He was diagnosed and informed about 90% blockage in the heart. Thereafter, he visited and got admitted in the hospital of OP No.1 on 12.09.07 and on the same day he underwent coronary angiography and thereafter PTCA and stent under the supervision of Dr. Ashok Seth. At the time of admission, he opted for cashless facility but the same was declined for the reasons not known to him. Accordingly, he made advance payment of Rs.21,000/- through Credit Card. After remaining in hospital for 2 days he was subsequently discharged on 14.09.07 after treatment. At the time of discharge, he paid balance of payment of Rs.2,79,739/- including advance amount. At the time of discharge he was handed over discharge summary by OP No.1 dated 14.09.07 (copy Annexure-4). He further states that in the discharge summary it was erroneously mentioned that he was a known case of coronary artery disease and was having “Non-critical coronary artery diseases (25.07.02).” He immediately wrote a letter to OP No.1 and also to Dr. Ashok Seth about the error in discharge summary and accordingly mentioned that it was only in July, 2007 that the Complainant for the first time had felt some uneasiness in the chest area. This letter was sent by registered post on 15.09.07 (Copy Annexure-5 & 6). The Complainant states that till date the said letter is un-replied. Thereafter, he filed a claim before the OP No.2 on 22.09.07 for reimbursement of his medical expenses to the tune of Rs.2,79,739/- (copy Annexure-7). The said claim of the Complainant was rejected vide letter dated 19.10.07 by OP No.2 on the ground that the claim lodged by the Complainant was not admissible “since the member was having coronary artery disease since 25.07.2002 and present ailment was complication of pre-existing CAD.” (Copy annexure-8). He has described it as absurd, afterthought only to thwart the possibilities of the Complainant in getting reimbursement of his medical expenses. Treating the conduct of the OPs as illegal, unjustified and without due and proper application of mind, he has moved this forum for redressal of his grievances with the following prayers:-
- Direct the OPs to pay to the Complainant the claim amount of Rs.2,79,739/-,
- Direct the OPs to pay an amount of Rs.5 lacs towards mental agony and harassment caused to the Complainant,
- Direct the OPs to pay to the Complainant Rs.50,000/- as cost of the litigation,
- Direct the OPs to pay interest @ 24% on the abovesaid amounts.
OP No.1 in the written statement has inter-alia denied all the allegations made by the Complainant specifically denying that “there was any error in discharge summary dated 14.09.07 and reiterated that true contents, scope and connotation of the discharge summary, the document itself may kindly be perused. Anything contrary to, less than or more than the contents of the said document is denied.” OP No.1 has further stated that the Complainant accompanied by his brother Mr. Ajay Kumar had come in the hospital for admission on 12.09.07 and gave family history of ischemic heart diseases as also stated to have non-critical artery disease on 25.07.02. The entire medical record of the Complainant has been annexed with the reply and marked as Annexure OP-1. OP No.1 has prayed for dismissal of the complaint.
OP No.2 has also filed written statement denying admissibility of the claim being preexisting disease qua the discharge summary by relying upon the relevant condition of the policy. OP No.2 has prayed for dismissal of the complaint.
Complainant has filed rejoinders to the written statements of OPs.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Maj. Gen.(Retd.) H. S. Mangat, Executive Trustee of OP No.1 and affidavit of Sh. S. Srinivasan Dy. General Manager of OP No.2 have been filed in evidence on behalf of the OPs.
Written arguments have been filed on behalf of the parties. We have heard the arguments on behalf of the parties and have also gone through the file very carefully and dispassionately.
Now, we advert to admissibility of complaint and relief prayed for?
Admittedly, the Complainant obtained a mediclaim insurance policy bearing No. HO00005280000 from OP No.2 from 19.12.06 to 18.12.07 after paying premium of Rs.3907/- which was initially taken in the year 2003 (copy Annexure-1). On 12.09.07 he was admitted in the hospital of OP No.1 and discharged on 14.09.07 (copy annexure-4). As per the discharge summary, he is stated to be known case of coronary artery disease and was having “Non-critical coronary artery diseases since 25.07.02. As per Annexure OP-1 in the form for cashless payment (Copy Mark ‘A’ ) commencement of ailment is mentioned as 25.07.02 and past medical history is mentioned as angina. This form has been signed by the brother of the Complainant. The Complainant in order to circumvent the insurance policy of exclusion i.e. pre-existing disease tried to pressurize OP No.1 to correct the discharge summary under the garb of correction. However, he was oblivious of the fact that the OP No.1 had already retained the copy of Application Form for cashless facility which has been Annexed as Annexure OP-1 (Mark A) which clearly brings the past history of the disease dating back to 25.07.02. It is a matter of common knowledge that discharge summary issued by the hospital reflects the history given by the patient only. More so, discharge summary is immaculate and clearly typed. Hence, we have no reason to disbelieve the discharge summary issued by OP No.1.
We have also perused the medical insurance policy especially the exclusions in para (d) of the policy wherein pre-existing diseases are defined as any diseases, illness, existing prior to the commencement of the date of the policy. As per evidence on record, the Complainant had past history of heart diseases which disqualifies him from reimbursement of the medical expenses incurred for treatment of heart diseases. Complainant has suppressed this fact while taking the policy in 2003 and get it renewed. Accordingly, we hold that the OP No.2 has rightly rejected the claim as well as OP No.1 has established existence of pre-existing disease. No deficiency in service is proved either against OP No.1 or OP No.2. Complaint is accordingly dismissed with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(S. S. Fonia) (N. K. Goel)
Member President
Announced on 05.07.16.
