Complainantby filing this complaint has alleged that complainant himself along with his wife and son are members of the Group Mediclaim Policy being No.1207003412500000003 issued by the insurer the op the New India Assurance Co. Ltd. when complainant no.2 is working in the Life Insurance Corporation of India as Administrative Officer and the family premium in respect of the above Group Mediclaim Policy was collected by the Life Insurance Corporation of India and the employer of the complainant had been deducted the annual family premium from the salary of the employees and remitted to the account of the op no.1 to cover the Domicilliary and hospitalization treatment.  All pre-existing diseases are covered by the policy and the copy of the said policy is also filed with the complaint.

          Fact remains the complainant no.1 became unconscious and fell on the ground on 09.04.2012 when the son of the complainant took her to Dr. Debasish Banerjee, MD (Med.)and the said doctor on clinical examination could not ascertain the cause of the sudden unconsciousness and immediately advised the patient to be admitted to a hospital and on the advice of the doctor she was admitted to Renaissance Hospital on the same date and the doctor on admission conducted various medical tests/x-ray/CT Scan consistent to determine her illness and ultimately diagnosed her disease as Hyponatrimia& RTI. Ultimately complainant was released from the hospital on 14.04.2012 and further she was admitted on 09.04.2012.

          Complainant no.2 informed the past history of illness of the complainant no.1 to the doctor as Schizophrenia and accordingly in the discharge certificate the doctor noted under the heading Final Diagnosis: 1) ….Generalise Convulsion in a case of Schizophrenia, 2) …..Hyponatrimia (corrected), 3)…RTI.  The primary treatment for admission to the hospital was Hyponatrimia which has been corrected is clearly evident from the discharge certificate.      

          After discharge the complainants submitted the claim with the op no.1 through the said employer on 24.04.2012 for Rs.29,634/- along with all original bills, medical tests reports etc. as required for the purpose.  But op no.1 vide its Office Note dated 07.08.2012 informed that “the said claim is repudiated for Schizophrenia as written in the Discharge Certificate”.

          In the above circumstances complainant has also filed a representation with the Regional Manager, New India Assurance Co. Ltd. vide a letter dated 30.10.2012, but all his request was ultimately rejected.  Moreover the doctor who treated the complainant no.1 was not a Psychiatist but was a doctor of medicine.  But he treated the medical part of the treatment and on the basis of principal treatment she was recovered.

          In the above circumstances, for negligent and deficient manner of service of the op, complainant suffered tremendous pain and agony and also prayed for release the said amount and compensation.

          On the contrary op Insurance Company by filing written statement submitted that complainant was diagnosed with Generalised Convulsion in a patient of Schizophrenia, Hyponatrimia& RTI and not with Hyponatrimia& RTI alone and thus the statement made by the complainant in regard to diagnosis supra is a fragmented, convoluted and clouded statement and is far from truth and it is specifically stated that Hyponatrimia is a condition which may occur in different diseases including in a patient of Schizopherenia.  So, it was concluded that the complainant was suffereing from Schizophrenia which led to physical conditions called Hyponatrimia& RTI.

          Further nowhere in the discharge certificate or in any submitted medical paper, it is noted that the patient was not treated for Schizopherenia but as it appears that the diagnosis is Generalized Convulsion in case of a patient of Schizopherenia and that indicates that the patient was in a state of Convuslion arising out of Schizopherenia and not for further cause and accordingly as per terms and conditions of the self-contained in the said Mediclaim Policy the claim was repudiated.  So, there was no fault and deficiency on the part of the and prays for dismissal of this case.

Decision with reasons

          Practically after considering the complaint and written version and also the arguments as advanced by the Ld. Lawyer for the op and further relying upon the terms and conditions of the policy it is found that practically op repudiated the claim as per terms and conditions 4.6 of the Policy because in the treatment sheet it is specifically mentioned that the patient BuluBiswas was suffering from Schizopherenia  and that lady suffered from Hyponatrimia& RTI and for which TPA and the op Insurance Co. as per terms of the Policy 4.6 repudiated the claim and it is the claim of the op that practically Hyponatrimia was caused generally to Schizopherenia patient and it is co-related symptom in respect of a patient of Schizophereniafor which the repudiation was made.

          Whereas the Ld. Lawyer for the complainant submitted that Schizopherenia patient may suffer from some other diseases like hypertension, RTI, UTI and other diseases but for that reason if a Schizopherenia patient is treated by any medicinist in that case it shall not be presumed and cannot be presumed that other vital diseases are caused due to suffering of any patient from Schizopherenia and in the present case practically this Schizopherenia patient suffered from Hyponatrimia which had been corrected by the doctor and that is evident from the discharge certificate and further the doctor who examined the present patient BuluBiswas got the history that the BuluBiswas had been suffering from Schizopherenia which is admitted fact and it was within the knowledge of the Insurance company also.

          But fact remains that the present doctor treated the present patient BuluBiswas particularly for the disease of Hyponatrimia& RTI and fact remains when she was admitted to hospital she had been suffering from Convulsion including Hyponatrimia and for which in the final diagnosis doctor opined – Generalized Convulsion in case of a patient of Schizopherenia – Hyponatrimia and further diagnosed Hyponatrimia& RTI.  Fact remains Hyponatrimia was corrected after treatment and so the entire decision of the op is completely baseless and without any foundation.

          In this regard we have gone through the Medical Literature and Medical Book i.e. Encyclopedia of the Medical terms and the details of the diseases wherefrom we have gathered that Hyponatrimia is an Electrolyte Disturbances in which the Sodium concentration in the Serum is lower than normal. (Hypo= low; natraemia = sodium in blood) Sodium is the dominant extracellular cation and cannot freely cross the cell membrane.  Its homeostasis is vital to the normal physiologic function of cells.  Normal serum sodium levels are between 135 and 145 mEq/L.  Hyponatrimia is defined as a serum level of less than 135 mEq/L and is considered severe when the serum level is below 125 mEq/L) and as per said Encyclopediain the vast majority of cases Hyponatrimia occurs as a result of excess body water diluting the serum sodium.

          Further Hyponatrimia is most often a complication of other medical illnesses in which excess water accumulates in the body at a higher rate than can be excerted (for example in congestive heart failure, syndrome of inappropriate antidiuretic hormone, SIADH, or polydipsia).  Sometimes it may be a result of overhydration.

          Lack of sodium is virtually never the cause of Hyponatrimia, although it can promote Hyponatrimia indirectly.  In particular, sodium loss can lead to a state of volume depletion, with volume depletion serving as signal for the release of ADH (anti-diuretic hormone).  As a result of ADH-stimulated water retention, blood sodium becomes diluted and Hyponatrimia results.

          Practically Researchers found, for instance, that 13% of the athletes who finished the 2002 Boston Marathon were in a clinically Hyponatremic condition.

          Considering the entire history of the disease of Hyponatrimia and the sign and symptoms we have gathered that there is no nexus in between the Hyponatrimia and Schizopherenia and she was suffering from Hyponatrimia and most of the time cause of Hyponatrimia cannot be detected.  But it is found that even the world famous athletes suffered from Hyponatrimia after completion of their run or race in the Boston Marathon 2002, then it cannot be said that all the athleteswere suffering from Schizopherenia for which it was found that after completion of their race they were suffering from Hyponatrimia.  But truth is that Hyponatrimia practically causes for excess water accumulation in the body at higher rate than can be extracted and sometimes it may be a result of over hydration and after study of the definition terms signs, causes of the Hyponatrimia from the literature and Encyclopedia we have gathered that there was no nexus in between the diseasesHyponatrimia andSchizopherenia for which it is proved that lady was suffering from Hyponatrimia and fact remains from the discharge certificate it is found that the doctor treated the lady for correction of her Hyponatrimia and that was corrected as because the lady had his past history of Schizopherenia and lady is suffering from Schizopherenia no doubt but for that reason the doctor treated her forHyponatrimia but gave dose of medicines which had been taken by the lady for years together for Schizopherenia and that was noted.  But the doctor did not treat the lady BuluBiswas for her Schizopherenia as she had been treated by other doctor.  But she was treated by the present doctor at Renisance Nursing Home for the disease of Hyponatrimia which has no connection with the disease of Schizopherenia.

          Most interesting factor is that the TPA doctor refused the claim of the complainant only on the ground that the Hyponatrimia was caused due to Schizopherenia.  Such sort of decision of the TPA doctor is against the principal of Medical Science.  But we are very much sure that TPA are here and there for throttling the claim of the insured and for which sitting in their sophiscated rooms they passed any decision for repudiating the claim and for which they are appointed by the Insurance Companies because they are getting consideration from the Insurance Company and TPAs are being run.  So, no doubt TPAs are run.  Under the seal of the Insurance Co. for the purpose of repudiating the claim and in this case such an unfair path has been taken by the insurance company to take help of the TPA regarding the claim of the present complainant.

          But considering the entire material and historical background of the Hyponatrimia and its signs and symptom and cause we have gathered that complainant though was suffering from Schizopherenia also suffered from Hyponatrimia for some other cause and there was or is no nexus in between Schizopherenia and Hyponatrimia because Hyponatrimia is another type of disease.  Then a mad can suffer from several diseases like Gall Bladder Stone pain or from Kidney failure or from Intestine disfunction but that cannot be related to her mental disorder or madness.  For the sake of the arguments if it is accepted that a person is mad then for all the diseases it cannot be presumed or opined that all other diseases if such said mad has been suffered in that case it shall not be treated as outcome madness and no doubt similar type of opinion has been passed by the TPA doctors who never gone through any such medical book but casually repudiated the same which swallowed by the insurance company and insurance company repudiated the same in this case.

          Considering all the above discussion and also the vital suffering of the complainant from Hyponatrimia we are convinced to hold that practically the doctor at Renanciance Nursing Home treated the lady BuluBiswas for her complicated disease of Hyponatrimia and it can be a result of over hyderationas a result of excess body water diluting the serum sodium and fact remains the said doctor treated her for such disease and corrected the disease and thereafter the complainant was released but she had been suffering from Schizopherenia is undisputed fact.  But we are convinced that there is no relation in between Hyponatrimia and Schizopherenia from which the lady BuluBiswas suffered.

          In the light of the above observation we are convinced to hold that the entire decision of the TPA doctors and also the reason for repudiation of the insurance company is illegal, uncalled for, unwanted and without any medical prove because medical science does not support such a theory as adopted by the TPA doctors the henchmen of the insurance company and for which the complainant is entitled to get entire claim for the treatment of BuluBiswas and op Insurance Co. i.e. New India Assurance Co. Ltd. is liable to pay the entire claim amount of Rs.28,386/- to the complainant as per her mediclaim which was filed before the New India Assurance Co. Ltd. which shall be treated as final and after taking into account that repudiation is illegal and further the complainant is entitled to certain compensation and litigation cost when it is found that with some purpose the repudiation was made by the New India Assurance Co. Pvt. Ltd.

          Thus the complaint succeeds.

          Hence, it is

ORDERED

          That the complaint be and the same is allowed on contest against the op no.1 Sole Op with cost of Rs.6,000/- and same is dismissed against the op no.2 Proforma Defendant without any cost.

          Op no.1 New India Assurance Co. Pvt. Ltd. is hereby directed to pay the mediclaim amount of Rs.28,386/- and also a sum of Rs.10,000/- as compensation for causing harassment, mental pain, agony to the complainant the patient BuluBiswas.

          Op no.1 New India Assurance Co. Pvt. Ltd. is hereby directed to pay and hand over the said amount of Rs.28,386/ (Mediclaim amount) + Rs.10,000/- (compensation as awarded) + Rs.6,000/- (as litigation cost) i.e. total Rs.44,386/- within one month from the date of this order positively and without any fail failing which the op no.1 shall have to pay punitive damages @ Rs.300/- per day till full satisfaction of the decretal amount and even if it is found that op no.1 New India Assurance Co. Pvt. Ltd. is reluctant to comply the order in that case penal action shall be started against them and further penalty of Rs.10,000/- shall be imposed for which the op no.1 New India Assurance Co. Pvt. Ltd. shall be liable.