IN THE DISTRICT CONSUMERS’ DISPUTES REDRESSAL FORUM AT MYSORE<br /> <br /> PRESENT: 1. Shri.D.Krishnappa<br /> B.A., L.L.B - President <br /> 2. Smt.Y.V.Uma Shenoi<br /> M.Sc., B.Ed., - Member<br /> 3. Shri. Shivakumar.J.<br /> B.A., L.L.B., - Member<br /> <br /> CC 388/08 DATED 26.03.2009<br /> ORDER<br /> <br /> Complainant Prahalad Karanum, S/o Late K.Narayana Rao, R/at No.2870/1, 10th Cross, 6th Main Road, V.V.Mohalla, Mysore-570002.<br /> (By Sri.C.S.Amar., Advocate)<br /> Vs. <br /> Opposite Parties 1. Branch Manager, Oriental Insurance Company Ltd., D.O.H. 2903, 1st Floor, New Muslim Hostel, Complex-1, Main, Saraswathipuram, Mysore-09<br /> 2. Incharge Manager, Heritage Health Service Pvt. Ltd., No.1102, Raheja Chambers, Free Press Journal Road, Nariman Point, Mumbai-400002.<br /> (By Sri.Jaganath Suresh Kumar., Advocate for O.P.1 and O.P.2 - EXPARTE)<br /> <br /> Nature of complaint : Deficiency in service<br /> Date of filing of complaint : 04.12.2008<br /> Date of appearance of O.P. : 13.01.2009<br /> Date of order : 26.03.2009<br /> Duration of Proceeding : 2 MONTHS 13 DAYS<br /> <br /> <br /> <br /> PRESIDENT <br /> <br /> <br /> <br /> MEMBER<br /> <br /> <br /> MEMBER<br /> <br /> <br /> Sri.D.Krishnappa,<br /> President<br /> <br /> 1. The grievance of the complainant who has filed this complaint against the opposite parties is, that he had visited USA during December 2006 and returned to India on 03.05.2007. That before leaving India he had obtained an Overseas Mediclaim Policy from first opposite party for a sum of 5,00,000/- US dollars by paying a premium of Rs.31,759/-, a total premium and the policy was valid from 07.12.2006 to midnight on 04.06.2007. Before he took the Mediclaim policy his health condition was fully checked up by the doctor who has given a certificate, certifying that he was in good health. During his stay in USA his health condition became worse and got admitted to Alexian Brothers St. Alexius Medical Center and was an inpatient from 28.02.2007 to 08.03.2007 and incurred a total expenditure of 52,686.78 US dollars. Then he approached the first opposite party several times for reimbursement of that amount, but the second opposite party vide his letter dated 23.05.2007 stating that policy carries specific exclusion for heart and circulatory dis-orders has repudiated his claim. Therefore, he by attributing deficiency to the opposite parties and collusion between them has prayed for a direction to the opposite parties to pay him Rs.19,50,000/- as against the total amount he is entitled Rs.26,18,405.10 by restricting his claim.<br /> <br /> 2. The second opposite party who is duly served with the notice of this complaint has remained absent is placed exparte. The first opposite party has appeared through his advocate and filed version contending that their liability under the policy is strictly as per the terms, conditions, exclusions and endorsements contained in the policy and has stated that policy excludes All heart and circulatory dis-orders and the same is incorporated in the policy and the doctor who examined the complainant before the inception of the policy given the report that complainant was havi9ng hypertension for the last 10 years and was under treatment for the said ailment. That the second opposite party is an independent company registered under the Companies Act is a third party administrator. Any claim of a person taking an Overseas Mediclaim Policy from them with all documents will be forwarded to second opposite party who handles all the claims arising under the policies. That second opposite party has team of doctors who scrutinize every mediclaim and decide on merits. That they came to know that the complainant preferred a claim with the second opposite party in connection with the treatment, the complainant had at USA and that the second opposite party after considering specific exclusion under the policy and by taking opinion of the doctors have turned down the claim of the complainant. Medical records of St. Alexius Medical Center of USA reveal that the complainant had Hyponatremia secondary to nausea and vomiting, related increased ADH HCTZ use and volume depletion and that reveal that hyponatremia which is related use of HCTZ a medication used for the treatment of hypertension, which is excluded from the scope of the policy. This opposite party further denying other allegations of the complainant has stated that there is no cause of action for the complainant and further denying their liability has prayed for dismissal of the complaint.<br /> <br /> 3. In the course of enquiry in to the complaint, the complainant and the Divisional Manager of the first opposite party have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. The complainant has produced a mediclaim policy, letter of repudiation issued by the second opposite party, hospital records where the complainant took treatment at USA including the bills. The first opposite party has produced copy of the proposal form given by the complainant, copy of the policy, terms and conditions of the policy. The counsel for the complainant has filed written argument. Heard the counsel for both the parties further and perused the records.<br /> <br /> 4. On the above contentions, following points for determination arise.<br /> 1. Whether the complainant proves that the first and second opposite parties have caused deficiency in their service in repudiating his claim for reimbursement of the medical expenditure on the ground that the complainant had suffered heart and circulatory dis-orders, which are excluded under the policy?<br /> 2. To what relief, the complainant is entitled to?<br /> <br /> 5. Our findings are as under:-<br /> Point no.1 : In the Negative.<br /> Point no.2 : See the final order.<br /> <br /> REASONS<br /> <br /> 6. Point no. 1:- The fact that the complainant had taken an Overseas Mediclaim Policy from the first opposite party, the policy was valid from 07.12.2006 to midnight of 04.06.2007 and that the second opposite party is the third party administrator health services is not in dispute. Similarly, that health policy taken by the complainant was covering for a sum 5,00,000/- US dollars is also not in controversy. The complainant contending to had suffered from ill-health while he was in USA was under treatment during December 2006 that is during the validity period of the insurance policy is not disputed by the opposite parties and that the complainant incurred 52,686.78 US dollars as medical expenditure is also not in dispute. But, the problem started when the claim of the complainant for reimbursement of the aforesaid medical expenditure was repudiated by the second opposite party vide their repudiation letter dated 23.05.2007. The second opposite party administrator of health services by contending that “The policy carries specific exclusion of all medical expenses incurred due to past history, ailments and any consequences attributable to accelerated by or arising there from as per the medical history.” Further stated that the policy carries specific exclusion of heart and circulatory dis-orders and therefore they are not liable to reimburse the money. The complainant questioning this repudiation of the second opposite party has come up with this complaint. Therefore, this Forum is required to find out whether repudiation of the claim of the complainant for the reason assigned by them amounts to deficiency or whether the opposite parties have acted under the conditions of the policy.<br /> <br /> 7. Admittedly, the medical policy issued in favour of the complainant contain excluded diseases, which says “This policy excludes all heart and circulatory dis-orders.” The learned counsel representing the complainant in support of his contention in the written arguments and also orally submitted that the complainant though was a patient of hypertension, but that is nothing to do with the disease, for which the complainant has taken treatment, by further stating that hypertension is a common phenomena with most of the people and that is not a disease and thus submitted for allowing the complaint. The complainant and the first opposite party have also produced reports of St. Alexius Medical Center of USA where the complainant took treatment from 02.08.2007 till he was discharged. These diagnosis assessment and reports of the hospital where the complainant took treatment are produced by the complainant himself and they are not in dispute. Wherein the doctors of St. Alexius Medical Center, USA have noted down the past history of the complainant as hypertension on hydrochlorothiazide and it is further recorded that the complainant was taking medicines including hydrochlorothiazide. Further the case sheet produced by the complainant reveal that the complainant had past history of hypertension on a beta blocker and thiazide and the doctors of USA hospital diagnosed the disease of the complainant as hyponatremia and the same was complicated by on going administration of thiazide diuretic at home. If the case sheet of St. Alexius Medical Center it is observed that emsis probable cause of hyponatremia along with antihypernatremia medicines and the complainant problem was assessed as hyponatremia secondary to nausea and vomiting related increased ADH HCTZ use and volume depletion. HCTZ is often used in the treatment of hypertension, congestive heart failure symptomatic adema prevention on kidney stones. It is not in dispute that the complainant was taking for a long period HCTZ and its use for a long period found to have led to hyponatremia.<br /> <br /> 8. The counsel appearing for the complainant in support of his arguments that hypertension is not a disease and it do not amounts to heart disease has relied on a decision reported in I (2008) CPJ page 258 and he has also relied upon the decisions reported in CPJ 2008 (III) page 423 of Delhi State Consumer Dispute Redressal Commission, I (2007) CPJ page 57 of NC, I (2007) CPJ page 260 of Punjab State Consumer Dispute Redressal Commission, and III (2007) CPJ page 320 NC. But, none of these decisions relied upon by the counsel for the complainant are helpful to the case on hand. Because in those cases, the contention of the insurance company that the complainant had pre-existing disease has been rejected by the State and National Commissions as the insurance company had not proved those consumers were suffering with any pre-existing diseases, by producing acceptable materials. In the case on hand prior to the inception of the policy the complainant was subjected to medical test by the second opposite party and found that the complainant had hypertension for quite long period and was also under medication policy was issued excluding heart and circulatory dis-orders. This exclusion, which is incorporated in the policy itself, was within the knowledge of the complainant. It is not the case of the complainant that he did not have this hypertension since long time and he was getting it in intermittently. On the contrary, as revealed from the medical records, the complainant has long history of hypertension and was under medication at home. It is further stated in the medical records of the complainant, that taking of ADH and HCTZ has resulted in hyponatremia, which is nothing but circulatory dis-order and heart disease. Suffering with hypertension for quite long period can be held has heart disease and that since has been excluded under the terms of the policy, the complainant is not entitled for reimbursement of the expenditure he has incurred for such disease and therefore repudiation of the claim by the opposite parties cannot be termed as deficient. As the result, we answer point no.1 in the negative and thereby pass the following order:- <br /> ORDER<br /> <br /> 1. The Complaint is dismissed.<br /> 2. Parties to bear their own costs.<br /> 3. Give a copy of this order to each party according to Rules.<br /> <br /> (Dictated to the Stenographer, transcribed by her, transcript revised by us and then pronounced in the open Forum on this the day 26th March 2009)<br /> <br /> <br /> <br /> <br /> <br /> (D.Krishnappa) <br /> President <br /> <br /> <br /> <br /> (Y.V.Uma Shenoi)<br /> Member<br /> <br /> <br /> <br /> (Shivakumar.J.)<br /> Member<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />