JUDGMENT Per Jagroop Singh Mahal, Member 1. In nutshell, the facts as set out in the complaint are that the complainant had availed Overseas Travel policy issued by OPs after finding him fit for travel on medical examination. The complainant left for Canada on 26.8.2008. However, on 8.11.2008 he suffered ischemic stroke and was admitted at the Foothills Medical Centre, Calgary, Alberta, Canada. The family members of the complainant duly informed M/s Coris International Mumbai that the complainant had suffered an ischemic stroke. Foothills Medical Centre Calgary Alberta, Canada took up the matter and dealt with M/s Coris Internatioal Mumbai and the opinion of the attending doctor about the cause of the stroke was conveyed to M/s coris International, Mumbai. A certificate was also issued by the neurologist attending to the patient opining that he had suffered an ischemic stroke and to the best of his knowledge, the stroke was not caused due to cardiac disease. The certificate dated 22.11.2008 issued by Mr. G.M.Klein, stroke Neurologist is attached as annexure P-5. On 17.11.2008 a letter was sent to the OP No.1 requesting expeditious processing of the claim but OPs did not pay the claim. Left with no alternative, complainant had to be discharged and evacuated to India as he could not afford payment of high expenses incurred on the medical treatment at Canada. After his discharge, the hospital raised a bill to the tune of Canadian dollars 55,523.14. The complainant then returned to New Delhi on 25.11.2008 after purchasing a new business class ticket for himself and his attendant costing Rs.4,74,000/- because of his medical condition and was admitted to Max Institute of Neuro Sciences where he was attended by Dr.Rajeshwar Reddy. On treatment and examination, Dr.Reddy also issued a certificate stating therein that the present condition of the complainant had no relation to the heart ailment for which he had undergone treatment in the year 1999. The complainant had to incur Rs.1,54,908.33 on his treatment in the Max Hospital. The complainant thereafter received letter dated 19.12.2008 from the Heritage Health TPA Pvt. Ltd. stating therein that the present complaints were attributable to the past medical history of the complainant which stood excluded from the scope of the policy coverage and as such no benefit could be given under the policy. It was alleged that the rejection of claim was not based on proper investigation and findings of the medical panel were not sustainable being without application of mind. The complainant then got served legal notice on 14.1.2009 calling upon OPs to reimburse the claim amount as the illness suffered by him was not due to cardiac disease and no material fact was suppressed at the time of opting for the overseas medi-claim policy and the findings of the doctors at Foothills Medical centre, Calgary, Canada as well as Max Hospital, New Delhi were clear and categoric that the illness was not attributable to cardiac disease. All efforts made by the complainant could get no tangible result, hence, alleging deficiency in service on the part of OPs, complainant filed this complaint before the Commission. 2. Upon issuance of notice the OPs appeared and contested the complaint. In the reply, it was inter-alia stated that the complainant had taken an overseas medi-claim policy from the OPs for the period from 25.8.2008 to 22.11.2008 and it was specifically provided on the first page of the policy itself that the insurance was subject to specific exclusion of all medical expenses incurred directly due to coronary artery disease and standard exclusion heart and circulatory disorders, overage exclusions and any consequences attributable to, accelerated by or arising therefrom as per the medical history stated in proposal form. The treatment chart of the Calgary medical institute from where the complainant had taken treatment clearly shows that the complainant had Coronary Artery Bypass Graft (CABG) few years ago in 1999 and he was treated for the coronary artery disease and heart disorder and consequences attributable to, accelerated by or arising therefrom and in this view of the matter as per medical opinion annexure R-3 the claim was not payable. It was further stated that the ischemic stroke is another name of a heart stroke/heart disease for which complainant had already undergone surgery in December,1999, so his claim was rightly repudiated as per terms and conditions of the policy. A prayer was made for dismissal of the complaint. 3. Parties adduced their respective evidence by way of affidavits and documents. 4. We have heard learned counsel for the parties and gone through the file carefully. It is not disputed that the complainant had earlier undergone coronary artery bypass grafting (CABG) in 1999. The complainant mentioned this fact in the proposal form and as per learned counsel for OPs the said disease was excluded from the purview of the policy Annexure P-1 in which this fact is specifically mentioned. It was argued by the learned counsel for OPs that the present disease arose due to cardiac problem and therefore it was not covered under the policy. In support of his contention, he referred to Annexure P-4 Discharge summary certificate in which it is mentioned that CT head showed a RMCA stroke which according to learned counsel for OPs relates to cardiac disease. This contention is opposed by the learned counsel for complainant. According to the medical literature i.e. MD Consult Preview as downloaded from the internet RMCA stroke means Right Middle Cerebral Artery Stroke which is caused due to obstruction of the blood in the middle cerebral artery supplying blood to the brain. The history of the patient/complainant as recorded by the Foothills Medical Centre, Calgary, Canada which is to the following effect also confirms this diagnosis ; “This 78 year old gentleman visiting from India is normally independent. His past medical history is significant for a CABG a number of years ago, but was only on aspirin since that time. He had no previous strokes. He was well this evening, he was out for dinner with his family. He came back and was last seen normal at about 11p.m. He went to the bathroom to get ready for bed and then the family found him at about 11.30 p.m. on the floor of the bathroom complaining of left-sided weakness. His exam showed that he had a gaze preference to the right, he had a left visual field cut, he had left upper motor neuron seventh. He was dysarthric. He had left pronator drift. Some left mild hemineglect with some extinction, possibly a mild hemisensory disturbance. His NIH stroke scale score was 10. Blood Pressure was around 140 systolic. The CT head showed early ischemic chanes in the right insula. M2, and M3 with an ASPECTS of 7. The CTA showed a right distal M1/dominant M2 branch occlusion. The cortex looks clear. There was possibly an ulcerated plaque at the right ICA bifurcation, but no significant stenosis. IMPRESSION Right MCA stroke with etiology unclear. It looks embolic. He had good antigravity strength on the left, but some hemisensory loss neglect and a visual field cut. The risks and benefits were explained to the family and they were keen to proceed with thrombolysis. An IV TP bolus was given at 1:28 a.m.This gentleman will get a repeat CT in 24 hours and he also needs a cardiac work up. I was at the bedside from 1 a.m. until 2.30a.am.” 5. There is no mention in the treatment chart if the complainant suffered a heart stroke. The symptoms rather refer to a brain stroke. When opinion of the treating doctor was obtained he submitted through Annexure P-5 as follows : “The above named patient is under my care. He has suffered an ischemic stroke. To the best of my knowledge this stroke was NOT caused by cardiac disease.” After his evacuation from Canada, the complainant was admitted in Max Institute of Neuro Sciences, a super specialty hospital at New Delhi. His admission in the Institute of Neuro Sciences also suggests that the illness related to Neurology and not to Heart, otherwise he would have been admitted in the hospital treating with heart problems. Dr.Rajashekar Reddi holding the degree of MD Medicine(PGI Chandigarh) DM (PGI Chandigarh) and DNB Neurology, has opined vide Annexure P-9 as follows ; “This is to certify that Wg.Comdr P.P.Singh (SKDD193360) was admitted here at Max Super Specialty Hospital on 25/11/08 as a case of right MCA infarct with left hemiparesis for evaluation and management. His present condition has no relation to the heart ailment for which he had undergone CABG in 1999.” Not only this, OPs had also obtained the opinion Annexure R-7 of Doctor Ashok Kunnure. He is MD (Bombay) and is not as qualified as Dr.Rajashekar Reddi who issued certificate Annexure P-9. Even according to Annexure R-3 Dr.Ashok Kunnure reported as follows ; “This 78 yrs old man, one day he was out for dinner came back at 11p.m went to bathroom, fell down there. He was noticed by relatives, brought to ER. After admission he was found to have CVA, he was thrombolysed & treated for it.” The diagnosis given by him as per available notes was CVA which mean Cerebrovascular accident and not cardiac arrest/stroke. Annexure R-4 vide which the claim submitted by complainant was rejected by OPs also mentions the diagnosis Cerebrovascular accident. In this manner from the documents produced by complainant or OPs, complainant was not found to have suffered heart stroke and therefore, claim was not excluded from reimbursement. 6. Learned counsel for OPs had then argued that affidavits of doctors who had issued annexures P-5 & P-9 have not been produced and therefore in its absence, these certificates should not be accepted as correct. This argument does not appear to be correct. Even the OP has not submitted the affidavit of Dr.Ashok Kunnure who issued Annexure R-3. Otherwise also, OPs have no where disputed genuineness of these certificates. In fact OPs obtained photocopy of record from the said hospital and the same is Annexure R-2. If Annexure P-5 had not been genuine they would have obtained the certificate from the hospital while obtaining annexure R-2 but it was not done for the reasons best known to them. It was for the OPs to prove that the complainant suffered heart stroke but the documents produced by them rather rule out this fact. Whether the certificates produced by the complainant are read into evidence or not even from the evidence produced by the OPs it is proved to be a brain stroke and not heart stroke. One thing more is interesting in this case. Complainant suffered the injury and was admitted in the hospital on 8.11.2008. He remained under treatment till 23.11.2008. The OPs have produced copy of treatment chart Annexure R-2 pertaining only to 8.11.2008, the date on which complainant was admitted in the hospital. As per the medical literature i.e. MD Consult Preview as downloaded from the internet RMCA stroke means Right Middle Cerebral Artery Stroke which is brain stroke and not a heart stroke. The OPs also admitted through Annexure R-3 that it was Cerebrovascular accident. Needless to mention that ischemic stroke does not mean heart stroke and this argument of learned counsel therefore cannot sustain nor disease can be determined simply on the basis of Annexure R-3. Otherwise also, Annexure R-2 nowhere mentions if there was any heart problem to the complainant due to which present disease arose. Learned counsel could not point out any sentence relating to the heart problem in the entire treatment dated 8.11.2008 produced by OPs. In fact Annexures P-5 and P-9 clinch the matter that the present condition of the complainant had no relation to the heart ailment. These documents, therefore, cannot be excluded from evidence. 7. It was also argued by the learned counsel for OPs that infact it was an ischemic heart disease due to which complainant fell down and suffered injury. OPs, however, have not been able to prove from any document or treatment as to how they reached this conclusion. ‘Ischemic’ infact relates to constriction or obstruction in the blood vessel supplying blood to that part of the body. Ischemic stroke could relate to the heart as well as to the brain. It is caused by hardening or thickening of the walls of the blood vessels that go to the heart or the brain. In the present case the entire record produced by the parties show that it was not an ischemic heart disease. This argument of counsel for OPs cannot be accepted. 8. It was also argued by the learned counsel for OPs that in view of clause (d) of Condition NO.10 of the policy Annexure R-1 it was necessary for the complainant to inform Mercury International Assistance and Claims Limited failing which the claim in excess USD 100 could not be allowed to the complainant. The learned counsel argued that since MERCURY has not been informed, complainant is entitled to USD100. We do not find any merit in this argument. No such objection was however taken in the written reply submitted by the OP. Otherwise also in the policy document Annexure R-1 a cross has been put against Mercury and its place Coris International has been mentioned. In para-6 of the complaint it was mentioned by the complainant that the family members of the complainant informed M/s Coris International Mumbai and Foothills Medical Centre Calgary, Alberta, Canada where complainant was admitted and also took up the matter with the said company and cause of stroke was conveyed to them. OPs in corresponding para-6 of their reply did not dispute this fact and contended that it was a matter of record. It, therefore, cannot be said that Mercury/Coris was not informed and claim in excess of USD100 was not payable to the complainant. 9. Annexure P-7 is the bill for 53,358.75 Canadian Dollars paid to the Fothills Medical Centre,Calgary where complainant was treated. Complainant, thereafter took treatment from Max Super Specialty Hospital, New Delhi where he spent Rs.1,54,908.37.As per clause 3 and 4 under Section A of the insurance policy Annexure R-1 his transportation charges shall be paid by the OP. The complainant however could not prove if the OP is liable to pay the charges of an attendant also. When complainant was evacuated air tickets were purchased for Rs.2,37,000/- vide annexure P-8. Complainant is therefore entitled to the said amount in view of the terms of the policy Annexure R-1. 10. Complainant has also prayed for compensation of Rs.50.00 lacs on account of mental and physical harassment in not granting the claim promptly. We are of the opinion that the complainant is not entitled to this amount of Rs.50.00 lacs as compensation on any count as we are allowing interest on the claim amount. 11. In view of the above discussion, we are of the opinion that the present complaint must succeed and the same is accordingly allowed. OPs are directed to pay to the complainant in Indian currency equivalent to the Canadian Dollar 53,358.75 alongwith Rs.2,37,000/- and Rs.1,54,908/- with interest @ 9% p.a. since the date of repudiation i.e. 19.12.2008 till the payment is made to the complainant. OPs shall also pay Rs.5000/- as costs of litigation. If the entire amount is not paid within 30 days from the date of receipt of copy of the order, OPs would be liable to pay interest @ 12% p.a. with effect from today till the amount is actually paid to the complainant.
| | HON'BLE MR. JAGROOP SINGH MAHAL, MEMBER | HON'BLE MRS. NEENA SANDHU, PRESIDING MEMBER | , | | 
