Order-16.
Date-30/06/2015. .
This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that complainant along with his family members including his daughter Rupanjana Singha are the holder of mediclaim policy under the OP and complainant insured himself along with the members of his family including the said daughter by such mediclaim policy in the year 2003 and since then he has been contributing premium to the OP in terms and condition of the said policy year to year.
Fact remains Mr. Rupanjana Singha was admitted to Woodlands Multi-Speciality Hospital Ltd. on 09-01-2014 with a history of Angioneurotic Edema (?? Drug Induced) thereafter, she was treated conservatively by the doctors of Woodland Multi-Speciality Hospital and discharged on 16-01-2014 and at the time of discharge the Hospital Authority produced the total bill for service provided amounting to Rs.63,540/- which was paid by the complainant under proper receipt.
Thereafter, complainant submitted claim for the said treatment of her daughter to the OP vide claim control No.NI-6-144187 but most unfortunately OP repudiated the claim vide their letter dated 30-09-3014 wherein OP has mentioned that patient was under psychiatric treatment and Angioedema occurs due to taking of psychiatric drugs and as per Clause 4.10 of the mediclaim policy psychiatric related treatment cost is not payable and that is why it was repudiated. But it is the specific allegation of the complainant that such sort of decision on the part of the OP is completely false, fabricated and without any support of medical science and there is no definite proof that allergy problem occurred to the daughter for consumption of any drug and in the hospital no psychiatric related treatment was given or induced.
Fact remains policy started form 2009 and it is still in force and there was no such psychiatric problem of the daughter of the complainant at any point of time or prior to starting of the policy Angioneurotic Edema to a particular patient may occur for medicine and it is totally depended upon the medical practitioners and there is no scope for a patient party to give such opinion about this. In fact complainant’s daughter Rupanjana Singha was treated for his sudden attack of rash and swelling all over the body and for which went to Calcutta Hospital, then SSKM on 08-01-2014 and also treated at R.G. Kar Medical College and Hospital on 09-01-2014. Thereafter, she was admitted to Woodland Multi-Speciality Hospital on 09-04-2014 for treatment of serious allergic condition but not for any psychiatric treatment. Dr. Spandan Bhaduri, M.D. (Medicine) while suggested urgent admission to Woodland Multi-Speciality Hospital on 09-11-2014 observed that patient had been suffering from rash, swelling etc. So, it is crystal clear that with a view to avoid payment have dared to design false explanation and reason. The complainant is a bona fide consumer and practically for rejection of the claim complainant has suffered much and such a rejection is without any basis and practically it was rejected without any medical ground and such sort of act is no doubt unfair practice for which complainant prays for redressal.
On the other hand, insurance company has admitted that Rupanjana Singha is a policy holder being policy no.100500/48/13/ 8500003743 and she preferred a claim being No.NI-6-144187 for her demand on 09-08-2014 from Woodland Multi-Speciality Hospital no doubt complainant submitted a claim discharge certificate and treatment sheet and it was found that there was a history of acute Urticaria with Angioedema history of taking psychiatric medicines namely lamotrigine and after OPD consultation in RG Kar Medical College and Hospital, doctor clearly mentioned to stop the psychiatric medicines and also noted to avoid tab, Lamotrigine in particular as definite suspicious factor for the complainants. So, considering that document it was found that drugs as taken by the complainant was psychiatric medicine. So, it is clear that Angioneurotic Edema is a psychiatric problem and patient is a known case of psychiatry on lamotrigin and a ripiprazole since past one and half months and the record of treatment as produced by the complainant supports that complainant was suffering from psychiatric disorder for 45 days prior to admission to Woodland Multi-Speciality Hospital and for which the matter was adjudicated and the claim was repudiated and as per insurance policy complainant is not entitled to get any reimbursement for any psychiatric treatment of his daughter for which the claim is repudiated and, in fact, there is no laches deficiency on the part of the OP.
Decision with Reasons
On comparative study of the complaint and the written version and arguments as advanced by the Ld. Lawyers of both the parties and also considering the report and repudiation made by the insurance company dated 30-09-2014 it is found that repudiation is made holding that complainant is a psychiatric patient and treatment is a psychiatric treatment and as per their observation Angioedema occurs due to ingestion of psychiatric drugs and for which Clause 4.10 of National Mediclaim Policy psychiatric related treatment cost is not paid.
Fact remains that both the Ld. Lawyers actually failed to produce any authentic book or any sort of literature regarding the definition of Angioedema and Angioneurotic Edema for which after hearing the Ld. Lawyers we have collected different literature of different Universities. Professors of University of Cincinnati Ohio and from the different literature of Dr. Jonathan Bernstein, M.D., Dr. Cristopher Lindsell, Ph.D. we have gathered that Angioedema is not a psychiatric disease and they have classified that Angioedema is classified as either hereditary or acquired. Acquired Angioedema can be immunologic, non-immunologic, or idiopathic. It is usually caused by allergy and occurs together with other allergic symptoms and urticaria and it may also occur as a side effect for certain medications, particularly ACE inhibitors. As per those doctors sign and symptoms of Angioedema is nothing but the skin of the face normally around the mouth and the mucosa of the mouth and/or throat as well as the tongue, swell over the period of minutes to hours. The swelling can also occur elsewhere typically in the hands and the swelling can be itchy or painful. There may also be slightly decreased sensation in the affected areas due to compression of the nerves. Urticaria (hives) may develop simultaneously in severe cases.
Further it is specifically opined that Angioneurotic Edema is a genetic form of Angioedema. Persons with it are born lacking an inhibitor protein called C1 esterase inhibitor that normally prevents activation of a cascade of proteins leading to the swelling of Angioedema. Patients can develop recurrent attacks of swollen tissues, pain in the abdomen and swelling of the voice box (larynx) which may compromise breathing. The diagnosis is suspected with a history of recurrent Angioedema. It is confirmed by finding abnormally low levels of C1 esterase inhibitor in the blood. Treatment options include antihistamines and male steroids (androgens) that can also prevent the recurrent attacks.
Medical doctors and world famous authors have also confirmed that Angioedema can be due to antibody formation against A1INH. It is an autoimmune disorder. This acquired angioedema is associated with the development of lymphoma.
The use of ibuprofen or aspirin may increase the probability of an episode in some patients and the use of acetaminophen typically has a smaller, but still present, increase in the probability of an episode and doctors have opined that to prevent Angioedema the use of androgens such as danzol, oxandrolone or methyltestosterone is required. These agents increase the level of aminopeptidase P, an enzyme that inactivates kinins(specially bradykinin) which are responsible for the manifestations of Angioedema.
It is specifically mentioned that cetrizine is a commonly prescribed antihistamine for Angioedema. Some patients have reported success with the combination of a nightly low dose of cetrizine to moderate the frequency and severity of attacks, followed by a much higher dose when an attack does appear. Severe Angioedema cases may require desensitization to the putative allergen, as mortality can occur. Chronic cases require steroid therapy, which generally leads to a good response. In cases where allergic attack is progressing towards airway obstruction, epinephrine may be life-saving.
These doctors have also confirmed that most patients have an average of one episode per month, but there are also patients who have weekly episodes or only one or two episodes per year. In most cases angioedema develops over a period of 12-36 hours and then subsides within 2-5 days after medication and there is no chance to predict when and where the same will occur what is impossible for doctors.
Considering the journals of those doctors published from University of Cincinnati, Oheo of Cincinnati college of Medicine and also American College of Allergy it is clear that angioneurotic edema is not a disease related to any psychiatric matter at the same time angioneuroedema is not a psychiatric disease but OP has tried to confirm that angioedema is a psychiatric disease but we are confirmed that the opinion of the OP or TPA is completely baseless and without any medical foundation. Fact remains swelling is too much itchy and painful and it is continued for some period for two or three months. It creates some depression of the patient for compression of nerves and decreasing sensation in the affected areas but no way it is a psychiatric problem but in the present case as because the patient is clearly suffering from such disease and his face, tongue, lips and all over body swelling portion were itching, the lady losses some mental stability and that may be occurred. But no doubt from the doctor’s opinion it is found that probably the doctors did not diagnose and as because complainant failed to bear the pain and for which she was mentally depressed but it is not treated as a psychiatric disease when we have already discussed very vividly the angioneurotic edema including the effect of angioedema and its treatment and general symptoms and also the method of medication. So, it is clear that the decision as taken by the OP and TPA regarding the treatment that angioedema is related to psychiatric treatment is completely wrong and practically TPA’s doctor are not aware of the said disease and treatment and symptoms etc. Probably the word is angioneurotic edema and when there is word neurotic in between angio and edema there is a question of treatment of psychiatric patient but after study of the entire article of the doctors it is clear that the neurotic was included in view of the fact due to angioedema, sensation of the affected areas are decreased and for compression of nerves and due to over-itching symptoms the patient feels nervous and for which particular patient is found depressed but for that depression said patient cannot be treated as a psychiatric patient. For the observation of those doctors as already referred we are confirmed that soon after recovery of the said swelling itching pain due to angioedema the patient is always found normal and due to taking medicine for the treatment. There is no question of suffering from any psychiatric disorder and in the present case it is found that patient never suffered from psychiatric disorder due to taking of medicine and, in fact, from the prescription of the doctor etc. we have gathered that some higher doses was prescribed for which she suffered from compression of nerve and as because she suffered from such angioneurotic edema for 40 to 45 days so the sensation in the affected part was decreased for which urticaria developed and for that reason doctors without further pathophysiology referred it for psychiatric treatment, such sort of reference is completely against the opinion of the expert doctors in both of angioneurotic edema and angioedema. So, considering all the above facts we are convinced to hold that repudiation as made by the insurance company and the opinion as made by the TPA in this regard is completely against the fundamental theorization and the treatment of angioedema and angioneurotic edema when that is the fact then we are confirmed that the present complainant is no doubt entitled to get the relief in respect of their mediclaim policy when he was only treating for angioedema or angioneurotic edema which is no way related with psychiatric treatment but we want to see that TPA must have to read more books in future before passing such comments that a patient is suffering from psychiatric disorder and angioedema is a disease from psychiatric disorder on the ground that the patient is a lady and such sort comment of the OP may cause further metal depression but that must not be done, particularly in this case very hapless comment has been made by the OP which is not supported by any world famous doctors who are expert in respect of angioedema or angioneurotic edema and also in respect of the critical allergy, asthma and immunology in this regard it is to be mentioned that by research works it has already been confirmed by American College of Allergy, Asthma and Immunology and the Society for Academic Emergency Medicine, and that was published in the Spring 2014 edition of the journal Academic Emergency Medicine.
For better knowledge of the OPs we have ventilated in this judgment the observation about treatment the decision of the doctors who have already covered 80,000 to 1,20,000/- allergic patient of angioedema in their clinic or research hospital.
In this regard, the case succeeds.
Hence,
Ordered
That the case be and the same is allowed on contest with a cost of Rs.5,000/- against the OPs 1 and 2 insurance company.
OPs are directed to dispose of the claim of the complainant immediately within one month from the date of this order and to pay the amount as would be admissible after considering the discharge bill voucher of the Woodland Multi-Speciality Hospital and it must be completed within one month by the OPs failing which OP shall have to pay a sum of Rs.50,000/- to the complainant forthwith treating the entire claim of the complainant is finally disposed of.
If OP fails to comply the order in that case OP shall be prosecuted u/s.27 of the C.P. Act and for non-compliance of the Forum’s order penal interest at the rateRs.200/- shall be assessed till full satisfaction of the decree and if it is collected it shall be deposited to this Forum.
