Haryana

Ambala

CC/26/2017

Ajey Mehta - Complainant(s)

Versus

NIC - Opp.Party(s)

Tarun Mehta

21 Aug 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 26 of 2017.

                                                          Date of Institution         : 18.01.2017.

                                                          Date of decision   :  21.08.2018

 

Ajay Mehta son of lte Sh.Gian Sagar Mehta, aged about 55 years house No.6047, Jamuna Dass Building, Ambala Cantt-133001.

 

……. Complainant.

                                      Versus

 

1. The National Insurance Company Limited, NIC, DO-Ambala Cantt. 106, Railway Road, Ambala Cantt-133001.

2. Medsave Healthcare (TPA) Ltd. SCO-66, Second Floor, Sector 40-C, Chandigarh-160036.         

                                                                             ….…. Opposite parties.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER                             

 

Present:       Sh.Tarun Mehta, counsel for complainant.

                   Sh.Dev Batra, counsel for OPs.

 

ORDER

                   The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with the averments that   complainant and his wife had been taking mediclaim insurance policy from OP No.1 since 2003 and continuously had got mediclaim policy No.420400/ 48/15/8500000053 for a sum of Rs.3 lacs on 07.05.2015 having validity from 07.05.2015 to 06.05.2016. The cover note No.421112312121 dated 06.05.2015 in consideration of premium for a sum of Rs.11065/- was issued for the policy in question. In the second week of September, 2015 the complainant had fever body-ache & sore throat with cough which increased within 2/3 despite taking home remedies and rest. Thereafter he visited Dr.C.K.Mittal, Mittal Nursing Home, Ambala Cantt. on 17.09.2015 and after investigation the disease Dengue was detected and he was immediately referred to Fortis Hospital, Mohali for further management. On 17.09.2015 the complainant was taken to Fortis Hospital in Ambulance and was admitted there in emergency. The necessary information was also provided to the hospital corporate department for cash less treatment but on 19.09.2015 it was conveyed to the complainant that the insurance company has denied extending cash-less treatment on the ground that The liability of the insurance company under this policy is not determinable at present from the details provided to us regarding the history of the insurance and disease. Cashless is denied under exclusion clause 4.21 treatment arising out of disease due to misuse of alcohol or intoxicating substance are not payable in policy.  The complainant remained in hospital for about 10 days and was discharged on 26.09.2015 with follow up treatment. On 09.10.2015 the complainant filed claim besides giving all the original record of the disease for payment and further submitted fibro scan report in original with request for payment of claim of bill amount already submitted and the claim was registered on 20.11.2015 as claim file No.20160108BO09R3A752 for payment undertaken by the OPs out of the expenses incurred by complainant and the complainant had sent letter dated 30.01.2016 submitting all the information required by OP No.2 from time to time. The complainant also submitted fibro scan report in original with request for payment of claim of bill already submitted vide letter dated 17.06.2016. The claim of the complainant was not settled for 7/8 months despite completing all the formalities by the complainant.  The insurance company did not pay any heed to the letter dated 17.06.2016. The insurance company being a statutory authority is engaged in the business of insurance for providing protection of the interest of the consumer. The complainant repeatedly requested the insurance company to settle the claim as he had paid the entire amount of Rs.4,31,991 to the Fortis Hospital after denial of cashless facility besides spending Rs.2960/- at Ambala before admission in Fortis Hospital and Rs.21079/- were spent after discharging the follow up visits, medicines & tests  but inspite of repeated requests the insurance company has not paid any amount. The act and conduct of the OPs clearly amounts to deficiency in service on their part. The complainant has tendered affidavit Annexure CX and documents Annexure C1 to Annexure C12, Annexure C12/A to Annexure C-12/O, Annexure C13, Annexure C13/A, Annexure C14, Annexure C14/A, Annexure C14/B and Annexure C15.

2.                          On notice OPs appeared and filed their joint reply wherein it has been submitted that the complainant has not followed the terms and conditions of the policy and has committed the breach of terms and conditions No.4.21 and 5.11 of policy. The case was investigated by the team of insurance company and during investigation hospital has refused to provide the indoor case papers of the patient and as per investigation report claim was repudiated under Clause 5 NIC 5.4. The terms and conditions of the policy are binding on both the parties in letter and spirit in view of article 299 of the Constitution of India. No blanket policy is issued by the insurance company. As per TPA the Cashless was rejected/ denied as per Clause 4.21 Treatment arising out of disease due to misuse of Alcohol or use of intoxicating substance are not payable in policy. Further as per the discharge summary the insured was treated for Dengue, UGI Bleed, Pan Gastritis with Erosive Duodnitis, Alcohol liver disease, diabetes mellitus Type II having history of chronic smoking and alcohol consumption. Also at the time of investigation, hospital authorities refused to co-operate and show IPD records for cross verification. It was further detailed by TPA that the company shall not be liable to make any payable under the policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person action on his behalf.  There is no deficiency in service on the part of insurance company as the claim was repudiated on the recommendation of TPA. Moreover, the medical history chart of the patient reflects otherwise and as per same the patient was suffering from Alcohol Liver Disease, Diabetes Mellitus Type II history of chronic smoking and alcohol consumption. The repudiation of the claim of the complainant was made after going through the claim papers. Other contentions have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OPs have tendered affidavits Annexure RX, Annexure RY and documents Annexure R1 to Annexure R8.

3.                We have heard learned counsel for the parties and gone through the case file very carefully.

4.                The case of the complainant is that the complainant and his wife had been taking mediclaim insurance policy from OP No.1 since 2003 and continuously had got mediclaim policy No.420400/ 48/15/8500000053 for a sum of Rs.3 lacs on 07.05.2015 having validity from 07.05.2015 to 06.05.2016. The cover note No.421112312121 dated 06.05.2015 in consideration of premium for a sum of Rs.11065/- was issued for the policy in question. In the second week of September, 2015 the fell ill and therefore, he visited Dr.C.K.Mittal, Mittal Nursing Home, Ambala Cantt. on 17.09.2015 and after investigation the disease Dengue was detected and he was immediately referred to Fortis Hospital, Mohali for further management. On 17.09.2015 the complainant was taken to Fortis Hospital and took treatment by spending an amount of Rs.3 lacs but the OPs had declined the claim amount on the ground that The liability of the insurance company under this policy is not determinable at present from the details provided to us regarding the history of the insurance and disease. Cashless is denied under exclusion clause 4.21 treatment arising out of disease due to misuse of alcohol or intoxicating substance are not payable in policy.  The complainant remained in hospital for about 10 days and was discharged on 26.09.2015 with follow up treatment. In total the complainant had spent an amount of Rs.4,31,991 to the Fortis Hospital after denial of cashless facility besides spending Rs.2960/- at Ambala before admission in Fortis Hospital and Rs.21079/- were spent after discharging the follow up visits, medicines & tests  but inspite of repeated requests the insurance company has not paid any amount.

5.                          On the other hand the counsel for the OPs has argued that as per discharge summary Annexure R4 issued  by Fortis Hospital. The discharge summary showing Alcohol Liver disease and further it is not mentioned in the discharge summary that infected liver due to Dangue and even doctor C.K.Mittal who was examined in this court has never clearly stated in his cross-examination that patient was  not having alcohol liver disease. The counsel for the OPs further argued that it is duty of the complainant to summon the doctor of the Fortis hospital to clarify qua their observation as patient was not chronic smoker and alcohol consumer. As per medical term Dangue not medicated except painkiller given to the  patient and long list of the medicines mentioned in the discharge summary shows some antibiotics, vitamin K,D for stomach ulcer, acidity to prevent the cancer, liver kidney and gall bladder etc.Medical term qua Dangue  alcohol liver disease, WGI Bleed etc. to the details of medicines, prescribed at the time of discharge and as per the policy clause 4.21 it is clearly mentioned that treatment arising out of disease due to misuse of alcohol or use of intoxicating substance are not payable in policy.  He relied upon the case law titled as Pardeep Kriplani Vs. New India Insurance Company Ltd. decided on 07.09.2017 by Hon’ble National Commission in RP No.2617 of 2016.

6.                          After hearing both the parties even for the sake of arguments addressed by counsel for the OPs if it is presumed that patient was chronic smoker and alcoholic but he had no immediate problem related to liver disorder before the onset this episode of illness. As per the record and statement of C.K.Mittal, who was examined in the court, he specifically mentioned in his affidavit that the patient was suffering from high fever, body ache & sore throat and cough. It is clear on the file that Dr.C.K.Mittal initially investigated and found to be patient of Dengue fever and had referred her to higher institute and patient remained under treatment in Fortis Hospital for 10 days and during stay in hospital. The hospital issued the discharge summary and in the column of course it has been mentioned Patient admitted with Acture Fibrile illness and GI bleed (Dengue shock syndrome). He was investigated outside and found dengue positive with thrombocytopenia (Platelet count 35thou/ul). On admission he was altered sensorium and shock. Initial blood investigations showed acute kidney injury and severe liver dysfunction, MODS. He was rectscitated with IV fluids. He was kept in ICU under observation and was started on RT aspiration. Pantocid infusion, somatostatin infusion, IV antibiotic Inj Cefriaxone, Iutrup,  syrup Sucralfate and other supportive treatment. His dengue serology was positive. He was transfused 1 unit of platlet aphresis for thrombocytopenia. USG whole abdomen showed mild hepatomegaly with fatty liver with mild ascitis. UGI endoscopy was done under Dr. Mohinish Chhabra which showed Grde A esphagitis. Haemorrhagic pangestritis, erosive Duodenitis. He developed he matoma over right groin. Vascular surgery opinion was taken under Dr.Rahul Jindal. USG Doppler B/L lower limb showed atherosclerotic changes in bilateral lower limb arteries. He had epicodes of malena and ooze from right groin. His Hb dropped to 8.4 and platelet count dropped to 24thou/uL. He was transfused 1 unit of PRC and 1more unit of platelet apheresis. Ivenous ammonia was 90 and LFts were severely deranged. His igM anti HAV and igM HEV were negative. Liver fibroscan  showed S3 steotosis and F4 fibrosis. Patient was containing constructive management. TPN was given for nutritional supportive. His blood and urine cultures were sterile. His HbA1C was regular and blood sugar monitoring was done and insulin was given  accordingly. Patient had an episode of PSVT/AF was given Amiodarone infusion to which he responded well. Inj Magnesium sulphate was given for hypomagnesemia and Inj KCL for Hypokalemia. Patient gradually showed improvement, he started accepting orally and subsequently his RT was removed. He had H/o productive cough with mild blood tinged sputum. CT chest showed moderate pleural effusion bilaterally (right>left) with bilateral basal atelectasis, patchy ground glass opacities and consolidation in bilateral lung fields? Pulmonary hemorrhages? infective etiology. CT whole abdomen showed mild hepatomages diffuse edematous GB wall thickening with mild perichoiecystic fat standings, thickening of pre-renal fascia with adjoining fat strandings, minimal free fluid in pelvis, diffuse calcification in abdominal aorta and bilateral common iliac   arteries with 40-50 % luminal narrowing in right common iliac artery and 70-80 % luminal narrowing in left common artery. Patient was shifted to ward on 24.09.2015 after he became clinically stable. His LFT’s started improving, 2D ECHO showed 56 % LVEF with RWMA of LV. Repeat CECT showed improvement and there were no signs of pulmonary hemorrhage. Now patient is being discharged in stable condition with follow up.

7.                          As per the above column of course in the Fortis hospital it is clear that the patient was suffering with Dengue Fever with acute fibrile illness and GI bleed. (Dengue shock syndrome). He was investigated outside and found Dengue positive. The patient was given life saving treatment in the hospital to save the life of the patient as per treatment record Annexure R4 and patient had associated with GI Bleed and doctor Mittal has categorically stated in his statement that the symptom in patient was not due to alcohol in use because Fibroscan (Annexure C12N)  dated  02.04.2016 show that Elasticity measurement (Liver Stiffness) value  is 3.7 Kpa- FO Fibrosis because chronic liver disease due to accessible alcohol is never revert and show FO fibrosis.

8.                          It is also clear from the statement given by Dr.C.K.Mittal, suggestion put by the doctor that patient was not suffering from Dangue disease is highly astonished that as Dr.C.K.Mittal and treating doctor of Fortis hospital have clearly mentioned in their treatment to effect that patient was suffering from Dangue disease and further more there is no evidence that the Dangue disease occurred due to intake of alcohol and smoking. Moreover, as per the admitted pleadings of the parties complainant got the medical policy in the year 2003 and same has been renewed continuously upto 2015. Had the patient/complainant was such a habitual drinker and chain smoker then must have suffered liver disease much before 2015 and must have been treated for such disease. There is no such case of the OPs that the complainant as ever treated for liver disease from 2003 to 2015. Further, OPs even did not place copy of any such policy containing the alleged clause on the basis of which claim of the complainant has been disallowed. Furthermore, willful violation of terms of policy the ops were supposed to prove that complainant was suffering with the liver disease due to habitual drinking of alcohol and chain smoking in 2015. When the medical policy was obtained in the present case. The counsel for the OPs also placed on record medical literature for causes of Alcoholic liver disease Alcoholic liver disease occurs after years of heavy drinking. Over time, scarring and cirrhosis can occur. Cirrhosis is the final phase of alcoholic liver disease. Alcoholic liver disease does not occur in all heavy drinkers. The chances of getting liver disease go up the longer you have been drinking and more alcohol you consume. You do not have to get drunk for the disease to happen. The disease is common in people between 40 and 50 years of age. Men are more likely to have this problem. However, women may develop the disease after less exposure to alcohol than men. Some people may have an inherited risk for the disease. Outlook (Prognosis) Alcoholic liver disease is treatable if it is caught before severe damage. However continued excessive drinking can shorten your lifespan  but this literature is not helpful to the case of the OPs as the causes mention therein does not attract the disease suffered by the complainant.

9.                          Keeping in view the above facts and circumstances we are of the confirmed view that the OPs have wrongly repudiated the claim of the complainant and the repudiation letter Annexure C15 dated 21.04.2017 is quashed as the above said disease was occurred during the subsistence of the policy in question having validity from 07.05.2015 to 06.05.2016 as per cover note Annexure C1 which was issued for Rs.3 lacs only. Though the complainant has incurred an amount of Rs.4,31,991/- shown in the bill attached with the complaint but the policy was limited upto Rs.3 lacs, therefore, complainant is only entitled for this amount.  The OPs directed to pay the awarded amount and to comply with the following directions within a period of 30 days from the date of receipt of copy of this order:-

1. To pay Rs.3,00,000/-  as per Annexure C1 alongwith interest @ 9 % per annum from the date of filing of complaint till its realization.
2. To pay Rs.10,000/- on account of cost of litigation etc.

 

Copy of this order be supplied to both the parties free of costs.  File be consigned after due compliance

ANNOUNCED ON:      21.08.2018

                                               

(PUSHPENDER KUMAR)                                  (D.N.ARORA)                                    MEMBER                                        PRESIDENT