DATE OF FILING: 02.02.2011
BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI
Dated this the 29th day of August, 2011
Present:
SRI.LAIJU RAMAKRISHNAN PRESIDENT
SMT.BINDU SOMAN MEMBER
C.C No. 21/2011
Between
Complainant : E.A.Rahim,
Ekkarakudiyil House,
Adimali P.O, Adimali,
Idukki District.
(By Adv: Shiji Joseph)
And
Opposite Parties : 1. Medi Assist TPA Rt Limited, 400,
Chandralayam, Kurisupalli Road,
Temple Lane, Ravipuram,
Kochi.
2. The Branch Manager,
Oriental Insurance Company Limited,
Elenjickal Mathew Memorial Plaza,
A.M Road, Kothamangalam. (Both by Adv: K.Pradeepkumar)
O R D E R
SRI.LAIJU RAMAKRISHNAN(PRESIDENT)
The complainant availed a mediclaim policy from the 2nd opposite party through the Ist opposite party. The policy was issued until 2010 and the coverage was for Rs.50,000/-. In the year 2010, due to the instigation of the agent of the opposite party, the complainant increased the coverage from Rs.50,000/- to Rs.2,00,000/-. On 18.05.2010, the complainant suffered a severe heart attack and was treated at Lissie Hospital, Ernakulam. There the complainant had undergone angioplasty and for that the complainant had spent Rs.1,75,709/- . The complainant paid that amount and filed a claim for the same. On 8.12.2010 the complainant got a cheque for Rs.45,000/- along with a settlement advice from the Ist opposite party. In the settlement advice, the Ist opposite party stated that the reason for reduction of the claim amount from Rs.1,75,709/- to Rs.50,000/- is because the complainant enhanced the claim to Rs.2,00,000/- from Rs.50,000/- on 10.07.2009 and in the medical report, there is 80% and 90% block in two vessels, hence the claim was restricted to Rs.50,000/- and deducting 10% commission from Rs.50,000/-. So the cheque for Rs.45,000/- was given to the complainant. On 23.12.2010 the complainant issued a notice to the opposite parties and the cheque was also returned to the Ist opposite party. The 2nd opposite party replied for the lawyer notice sent by the complainant stating that as per the policy conditions 4.1 to 4.3, the claim shall be denied on the ground of the pre-existing disease. In order to attract clause 4.1 to 4.3 of the conditions of the policy, the ailment must be pre-existing either treated or untreated. In this case the heart attack caused to the complainant is not a pre-existing disease and never done any treatment for the same. The complainant never had any pre-conditions for heart attack such as high B.P, diabetics, cholesterol and family history. The complainant never had the life style such as cigarette smoking or never used liquor. Hence the policy condition is not applicable to the complainant and the complainant is entitled for the full amount. The Ist opposite party deducted 10% of the awarded amount. The deduction of 10% of the award amount is illegal and without any authority. The unauthorised deduction of claim amount caused considerable pain and financial difficulties to the complainant and a compensation also claimed by the complainant to the tune of Rs.25,000/-. So this petition is filed for getting an amount of Rs.1,75,709/- with interest and also for compensation.
2. As per the written version filed by the Ist and 2nd opposite parties, it is stated that the complainant has no cause of action against the opposite parties. This petition is not at all coming under the jurisdiction of this Forum. The complaint is barred under the Arbitration and Conciliation Act, 1996 because as per clause 5.1.2 of the contract of insurance, it is specifically contracted that "If any dispute or difference shall arise as to the quantum to be paid under the policy such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties or if they cannot agree upon a single arbitrator within thirty days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996". The Ist opposite party is an independent third party administrator of medi-claims appointed as per the directions of the IRDA. It is true that the then existing policy with coverage of Rs.50,000/- was enhanced to Rs.2,00,000/- for the period 30.07.2009 to 29.07.2010 onwards vide policy No.441702/48/2010/971. But it was not at the instigation of the agent. As per exclusion clauses 4.1, 4.2 and 4.3, enhanced portion of the present claim is excluded from coverage. The complainant filed a claim of Rs.1,75,709/- towards hospitalization for the treatment of coronary artery disease at Lissie Hospital, Cochin from 18.05.2010 to 22.05.2010. While scrutinizing the submitted claim documents, it was observed that the complainant initially admitted to Morning Star Medical Centre, Adimali on 18.05.2010 for treatment of left side chest pain radiating to the left upper limb. From there he was referred to Lissie Hospital, Ernakulam. Being a high value claim and the sum insured enhanced to Rs.2,00,000/- from Rs.50,000/- at the last renewal, the indoor case papers were requisitioned from the Morning Star Medical Centre, Adimali where the initial admission was made. It is revealed from the indoor case papers that the insured was a known case of Hypertension of irregular treatment and it is noted that the B.P reading at the time of admission was 170/120 mm of Hg and pulse rate 42/mt. Dyslipidema was also noted in the diagnosis. Hypertension has two year exclusion in the policy. Hence the enhanced sum of Rs.1,50,000/- at the last renewal, which was 10 months back is not eligible for reimbursement as per exclusion clause 4.3 in the policy. The insured shall bear 10% of the claim as per the terms and conditions of the policy. Considering the terms and conditions of the contract of insurance, the present claim of the complainant was eligible for an amount of Rs.45,000/-. So there is no deficiency in the part of the opposite party.
3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to ?
4. The evidence consists of the oral testimony of PW1 and Exts.P1 to P8 marked on the side of the complainant and the oral testimony of DW1 and Exts.R1(series) and R2(series) marked on the side of the opposite parties.
5. The POINT :- The complainant produced affidavit and deposed as PW1. PW1 availed a Happy Family Floater policy from the opposite party for an amount of Rs.50,000/- and it was enhanced to Rs.2,00,000/- on 29.07.2009, Ext.P1 is the policy schedule issued by the opposite party. The policy and its conditions were also produced and marked as Ext.P2. On 18.05.2010 due to chest pain he was taken to Morning Star Hospital, Adimali and from there he was referred to Lissie Hospital, Ernakulam and on diagnosis it was found that he was suffering from interior myocardial infarction, double vessel block and for that angioplasty was done at Lissie Hospital, Ernakulam. The treatment records for the same from Lissie Hospital, Ernakulam were produced and marked as Ext.P3(series). The complainant spent Rs.1,75,709/- for the treatment there and a claim was filed for the same. But the opposite party sent a cheque for Rs.45,000/- on 8.12.2010. The reason stated for the rejection of the claim was that the sum assured was increased to Rs.2 lakhs from Rs.50,000/- on 30.07.2009, and as per CAG report, there is double vessel disease (80% and 90% stenosis), hence the enhanced sum is not admissible. So the claim is restricted to Rs.50,000/- deducting 10% as commission. The letter for settlement advice for Rs.45,000/- is marked as Ext.P4. So a lawyer notice was issued to the opposite parties, office copy of the same and its postal receipts are marked as Ext.P5(series). The opposite party issued a reply notice stating that it is a pre-existing disease. On perusing the documents from the Morning Star Hospital, Adimali, the complainant was suffering from hypertension of irregular treatment. Hypertension has 2 year exclusion in the policy, hence the enhanced sum of Rs.1,50,000/- at last renewal 10 months back is not eligible for reimbursement as per policy exclusion 4.3. After deducting the 10% co-payment in the policy, the claim was settled as Rs.45,000/-. Ext.P7 is also a letter issued from the 2nd opposite party for the same. PW2 is a doctor who examined the complainant at Lissie Hospital, Kochi. PW2 deposed that Dr.Rony Mathew was the Senior and Head of the Department of Cardiology in Lissie Hospital was treated the complainant. He was also assisting him at the hospital. On perusing Ext.P3 treatment records, it is revealed that the patient is a non-diabetic and non-hypertensive. He had a first heart attack on 18.05.2010. On perusing the records it was his first heart attack and no previous history of heart attack. Angioplastic surgery was done on the patient. Two stents were implanted on him. A patient without diabetic and hypertension can cause heart attack. Stress can also cause heart attack at once. There is no pre-existing conditions or previous history necessary for the cause of heart attack. It can cause to persons not having family history of heart attack. The Assistant Manager of the 2nd opposite party deposed as DW1. The policy copy and conditions are produced and marked as Ext.R1(series). The copy of medical record of PW1 at Morning Star Hospital, Adimali are produced and marked as Ext.R2(series). As per the records filed by the opposite party as Ext.R2(series), it is clear that the complainant was a patient of hyper tension and was under treatment for the same. On cross examination of the learned counsel for the complainant, DW1 deposed that on perusing Ext.R2(series) records, it is revealed that the complainant was having irregular treatment for hyper tension. While the counsel for the complainant specifically interrogated that from which date onwards the complainant was irregular treatment as per Ext.R2, DW1 answered that it is a prescription of the doctor and she cannot understand the same. It is also deposed that as per the treatment records on 18.05.2010 the patient was affected with heart attack. As per exclusion clause 4.3 of the policy conditions, the claim was rejected by the opposite party.
As per the complainant, he was admitted in Morning Star Hospital, Adimali on 18.05.2010 while he felt severe chest pain. From Morning Star Hospital, Adimali he was referred to Lissie Hospital, Cochin. It was diagnosed from Lissie Hospital, Kochi that the complainant was suffering from inferior wall myocardial infarction with double vessel block and for that Angioplasty was done at Lissie Hospital, Ernakulam. Ext.P3(series) medical records from Lissie Hospital also shows the same. PW2 who is a doctor who examined the complainant at Lissie Hospital, Kochi. On perusing Ext.P3(series) treatment records that the patient is a non-diabetic and non-hypertensive as per the records. He had a first heart attack on 18.05.2010. It was his first heart attack and no previous history of heart attack was noted. Angioplastic surgery was also done on the patient. Two stents were also implanted on him. A patient without diabetic and hypertension can cause heart attack. Stress can also cause heart attack. There is no pre-existing conditions or previous history necessary for the cause of heart attack. But as per DW1, they have perused the treatment records of Morning Star Hospital, Adimali and on perusing that records DW1 deposed that complainant is having irregular treatment for hyper tension. She also deposed that she is not aware the date on which the irregular treatment was commenced because it is a doctor's treatment record and she cannot understand the same. It is also stated that on perusing Ext.R2(series) medical records, the opposite party rejected the claim stating that there is pre-existing disease to the complainant. In Ext.R2(series) it is written that K/C HTN and irregular treatment as a question mark. But there is no mention of irregular treatment for hyper tension written in Ext.R2(series) records and the matter was not at all explained by any of the doctors who examined the patient in Morning Star Hospital, Adimali or in Lissie Hospital, Ernakulam. There is no previous history of heart attack or myocardial infarction or hyper tension diagonised on the complainant as per the medical records. The only deposition of DW1 that on perusing Ext.R2(series) she revealed that the patient is having irregular treatment for hypertension. She also deposed that she cannot understand the prescription of the doctor. So what prevented the opposite party to produce the evidence of the doctor who examined the complainant at Morning Star Hospital, Adimali to prove that the complainant is having any pre-existing diseases. The opposite party never produced these medical records for perusing the same, while the doctor who examined the complainant at Lissie Hospital, Ernakulam was examined as PW2. So we think that the copy of the medical records does not reveal that the complainant is having pre-existing disease of hypertension and he was in irregular treatment. If any dispute regarding the same that ought have been proved by the opposite party with a medical practitioner or any doctor who examined the complainant at Morning Star Hospital, Adimali or Lissie Hospital, Ernakulam.
PW2 is a doctor who examined the patient at Lissie Hospital, Ernakulam deposed that there is no pre-existing disease to the complainant and he is not having any hypertension and is not having any history of smoking, alcohol etc. He had the first myocardial infarction/heart attack on 18.05.2010. The Ext.R2(series) medical records were never shown to the doctor by the opposite party while cross examining PW2, for proving the records produced by them.
So we think that the allegation of the opposite party that the complainant was having pre-existing disease and he is not liable for the amount claimed as per exclusion clause 4.3 of the policy conditions is not at all believable. The opposite party never proved the same. So the repudiation of the amount is a gross deficiency from the part of the opposite party. It is admitted by the opposite party that a claim for an amount of Rs.1,75,709/- was filed by the complainant as per Ext.P4. The treatment records of Lissie Hospital, Kochi and Ext.P3(series) also shows that Angioplastic surgery was done on the patient and two stents were implanted on him. It is also admitted by the opposite party that the complainant is having a medi-calim Happy Family Floater policy for an amount of Rs.2 lakhs and he was promptly paying the premium for the same. Ext.R1(series) also shows the same. So the opposite party is liable to pay the amount claimed by the complainant.
Hence the petition allowed. The opposite parties are directed to pay an amount of Rs.1,75,709/- with 12% interest from the date of this petition to the complainant as per Ext.R1(series) policy and Rs.2,000/- as cost of this petition within one month of receipt of a copy of this order, failing which the outstanding amount shall carry further 12% interest per annum from the date of default.
Pronounced in the Open Forum on this the 29th day of August, 2011
Sd/-
SRI. LAIJU RAMAKRISHNAN(PRESIDENT)
Sd/-
SMT.BINDU SOMAN(MEMBER)
APPENDIX
Depositions :
On the side of Complainants :
PW1 - E.A.Rahim
PW2 - Dr.Nidhin Parrit
On the side of Opposite Parties :
DW1 - K.C.Kavitha
Exhibits:
On the side of Complainant:
Ext.P1 - Happy Family Floater Policy Schedule
Ext.P2 - Photocopy of Happy Family Floater Policy with conditions
Ext.P3(series) - Treatment Records issued from Lissie Hospital, Ernakulam
Ext.P4 - Photocopy of Settlement Advice for Rs.45,000/- issued by the Ist opposite party
Ext.P5(series) - Office copy of Lawyer Notice dated 23.12.2010 issued by the complainant and its postal receipts
Ext.P6 - Reply notice dated 21.01.2011 issued by the Ist opposite party
Ext.P7 - Letter dated 31.12.2010 issued by the 2nd opposite party
Ext.P8 - Authorization letter dated 13.07.2011 issued by Dr.Rony Mathew, Department of Cardiology, Lissie Hospital, Kochi
On the side of Opposite Parties:
Ext.R1(series) - Happy Family Floater Policy with conditions
Ext.R2(series) - Photocopy of Medical Record of the complainant at Morning Star Medical Centre, Adimali
