Date of Filing: 16/08/2014

Date of Order: 14/02/2017

ORDER

BY SRI.SYED ANSER KHALEEM, PRESIDENT

1.     This is the complaint filed under Section 12 of the Consumer Protection Act, 1986 against the Opposite Parties (herein referred in short as O.Ps) alleging the deficiency in service and prays for direction to the O.Ps to pay a sum of Rs.7,30,836/- to the complainant.

2.     The brief facts of the complaint are that, the complainant is a resident of Bangalore since 10 years, and in the normal course, her husband, Mr. V.Srinivas Parthasarathy Reddy has taken the Heath Insurance policy in the month of November-2012, i.e., M/s.  Religare Health Insurance Company Ltd., this Health Insurance Cover/policy and the same was renewed in the month of November 2013.   It is further stated that the complainant after having suffered episode of giddiness, visited cardiologist, Dr. K.Meenakshi, M.D., D.M. (Cardio) at Chennai, who after clinical and other tests opined that the features as mentioned in the relevant Test Reports were consistent with Hypertrophic Cardiomyopathy and that it would be advisable for the complainant to undergo implantable Cardioverter-defibrillator (ICD) implantation. The complainant therefore visited Apollo Hospital in Chennai and underwent different Tests in preparation for the recommended ICD implantation.

3.     The complainant further states that, having availed the facility of Heath cover from the O.P/Insurance company informed M/s. Apollo Hospitals about the Health Cover, and M/s. Apollo requested for pre- authorisation so that complainant could avail the benefit of cashless hospitalisation. The Insurance Company by its communication dated 16.05.2014 wrote to M/s. Apollo Hospital, requesting amongst others, for the aetiology of Hypertrophic Cardiomyopathy. The authorities at M/s. Apollo Hospital, without consulting complainants’ cardiologist, Dr. K.Meenakshi, wrote back to the O.P/Insurance Company erroneously reporting that Hypertrophic Cardiomyopathy was a genetic disorder seen in some families which can cause sudden cardiac arrest and that in the past complainant’s father and her brother.   O.P in response to the letter dated    16-05-2014 informed the  Apollo Hospital that the cashless hospitalization cannot be approved because the proposed treatment was a treatment for congenital Anomaly and was excluded from coverage in terms of 4.3 (A)(xi) of the policy terms and condition.

4.     The complainant further states that Dr. A.M. Karthigesan from M/s. Apollo Hospitals issued certificate dated 17.05.2014 stating that Hypertrophic Cardiomyopathy it neither congenital nor birth defect/ disease and that complainant was diagnosed as suffering from Hypertrophic Cardiomyopathy  only about a few months back after repeated episodes of giddiness strangely and O.P insurance company had refused cashless hospitalization previously on the ground that Hypertrophic Cardiomyopathy was a congenital/birth defect, by its Letter dated 17.05.2014.

1. The provisional Diagnosis was “other acute ischaemic heart disease”.
2. The cashless facility was being denied because Hypertrophic Cardiomyopathy is a genetic ailment.    

5.     That the complainant states that, Dr. K. Meenakshi has issued certificate dated 18.05.2014 stating that complainant was diagnosed as suffering from hypertrophic Cardiomyopathy only 3 months prior because episodes of giddiness and that hypertrophic Cardiomyopathy is neither congenital heart disease nor birth defect.  The complainant forwarded this certificate along with appropriate request to O.P. on 20.05.2014 for allowing cashless hospitalization.  But O.P. refused cashless hospitalization stating that complaints disease is genetic.

6.     The complainant further states that she underwent ICD implantation procedure without benefit of cashless hospitalisation and incurred expenses to the tune of Rs.5,30,836/- complainant issued legal notice dated 23.05.2014 and the O.P. issued unattainable reply denying the reimbursement benefits. Hence this complaint.

7.     Upon issuance of notice O.Ps No 1 and 2 appeared through its counsel and filed its version. In the version O.Ps denies the averments made by the complainant in the complaint. Further contended that the complaint is false malicious, in correct and malafide one and is nothing but abuse of the processes of the law and hence contended that complaint is neither maintainable in law nor in facts and prays for dismissal of the complainant.

8.     Further O.P. 1 & 2 contended that they are regulated by Insurance Regulatory and Development authority (IRD).  It is further stated that on receiving the preauthorization request, this O.Ps. had requested the hospital authorities to provide the additional documents and the medical records with regard to the past history of the complainant and raised the query for Etiology of the disease.  The O.Ps. further stated that the Hospital authorities have given the reply stating that the patient has family history of sudden cardiac arrest.   It is stated that Hypertrophic cardiomyopathy along with family history is Autosomal Doninant which is Genetic in nature and congenital diseases are not covered under the policy.  The O.Ps. further stated that as the Etiology of disease is such that it depends on the genetic makeup which is by birth, hence the preauthorization request was rejected.  It is further stated that the congenital anomalies can be defined as structural or functional anomalies, including metabolic disorders, which are present at the time of birth and in the case on hand, the statement of the hospital authorities clearly indicates that the complainant was suffering from a congenital anomaly and the same is coming under the exclusion of the policy.  Further O.P. after receiving the entire medical records of the complainant, this O.P. has also obtained  the expert opinion  and as per the expert opinion, this is a case of HCM (Hypertrophic Cardiomyopathy)  non obstructive type with family H/o sudden cardiac arrest, syncope (may be due to HCM).  He has further stated that Hypertrophic Cardiomyopathy is a condition that is usually passed down through families (inherited).  It is further stated that in view of the above expert opinion, it is clear that the complainant is suffering from congenital anomaly and the same is not payable as per the terms and conditions of the policy and hence the O.P. prays for dismissal of the complaint.

9.     In order to substantiate the case of the parties and both the parties filed their affidavit evidence. Also heard the Arguments.

10.   On the basis of the pleadings of the parties, the following points will arise for our consideration is:-

                (A)   Whether the complainant has proved

                         deficiency in service on the part of the O.Ps?

(B)  Whether the complainant is entitled to

      the relief prayed for in the complaint?

(C)   What order?

11.   Our answers to the above points are:-

POINT (A) and (B):  In the Affirmative     

POINT (C):       As per the final order

for the following:

REASONS

POINT No.(A)& (B):-

12.   At the outset it is an undisputed fact that, complainant has taken the Health insurance policy from the opposite parties.  It is not in dispute that the complainant underwent treatment for Hypertrophic Cardiomyopathy and incurred medical expenditure of  Rs.5,30,000/-.  Further it is not in the dispute that the O.Ps. did not honour the claim made by the complainant on the ground that Hypertrophic Cardiomyopathy along with family history is Autosomal Doninant which is Genetic in nature and conghenital diseases are not covered under the policy.

13.   The complainant states that the authorities of M/s. Apollo hospitals without consulting her cardiologist Dr. K.Meenakshi and reported erroneously reporting that Hyupertrophic cardiomyopathy was a genetic disorder seen in some families.  Further complainant deposed that Dr. A.M. Karthigesa from M/s.  Apollo hospital issued a certificate dated 17.05.2014 confirming that Hypertrophic Cardiomyopathy is neither congenital nor birth defect but the O.Ps repudiated the claim.  Further it is also deposed in the evidence that the Dr. K.Meenakshi who has earlier given the contrary report also certified that Hypertrophic Cardiomyopathy neither a congenital heart disease nor birth defect.

14.   Per contra O.Ps also contended that they have taken expert opinion contending that Hypertrophic Cardiomyopathy is a genetic one and it excludes as per the insurance terms and conditions.

15. The   crux of the matter whether the Hypertrophic Cardiomyopathy is genetic one or not?. In the evidence the complainant deposed that are two doctors certified that Hypertrophic Cardiomyopathy is neither a congenital heart diseases nor birth defect.  On perusal the document No.5 and 7, it clearly discloses that both the Doctors by name A.M. Karthigesam and Dr. K.Meenakshi certified that Hypertrophic Cardiomyopathy is neither a congenital heart diseases nor a birth defect.  Whereas O.P. contended that as per their expert opinion Hypertrophic Cardiomyopathy is congenital heart disease and genetic one.  It is worthy to note that the burden is lies on the O.Ps to rebute the evidence placed by the complainant.  Also the O.Ps did not examined in the expert i.e., Dr. C.H. Asrani and in absence evidence of expert mere filing of the opinion styled as to whom so ever cannot be helpful to the contention of the O.P.  The object of insurance to cover of the risk arising out of unknown diseases.  The repudiation without any solid grounds by the O.Ps is clear case of deficiency service.

16.   Further on perusing the medical bills i.e., document No.12 at ink page No.53 of the complaint, it clear discloses that complainant incurred medical expenditure of Rs.5,09,828/-  and advanced paid Rs.4,50,000/- and final settlement  i.e., complainant has to pay Rs.59,828/- and totally it comes to Rs.5,69,656/-. Further on perusing the copies of bill from ink page 54 to 68 and all these bills discloses that in addition to above said amount, the complainant incurred additional expenditure of Rs 12,004/-. In total, the complainant incurred expenditure Rs 5,81,660/-. However on perusal of insurance cover details at ink page 10 of the cover page of complaint, it discloses that the sum assured is Rs 5,00,000/- only.  Hence the complainant is entitled for the sum assured as per the insurance coverage. However the O.Ps also not disputed regarding medical expenditure incurred by the complainant. Under the circumstances we are of the considered opinion to direct the O.Ps to pay a sum of Rs 5,00,000/- to the complainant towards the insurance policy coverage, it will meets the ends of justice. Accordingly we answered the point A and B in the Affirmative.

POINT (C):

17.   On the basis of answering the Points (A) & (B) in the affirmative, we proceed to pass the following:-

ORDER

1. The complaint is allowed in part with cost.

2.  Further O.Ps are jointly and severally liable to pay a sum of Rs 5,00,000/- to the complainant towards the coverage of Insurance policy within 30 days from the date of receipt of this order, failing which O.Ps are directed to pay interest at the rate of 9% per annum on the said amount from the date receipt of this order till realization.

3. Further O.Ps are directed to pay Rs.2,000/- towards cost of the litigation expenses.

4. O.Ps are directed to comply the order of this Forum within 30 days and submit the compliance report to this forum within 45 days from the date of receipt of this order.

6. Send a copy of this order to both parties free of cost.

 (Dictated to the Stenographer, transcribed and computerized by him, corrected and then pronounced by us in the Open Forum on this the 14^thDay of February 2017)

MEMBER                 MEMBER                PRESIDENT