Order-17.
Date-09/10/2015.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that complainant has a group Mediclaim Policy issued by National Insurance Co. Ltd., under which the Heritage Health T.P.A. Pvt. Ltd., has been conducting the claim settlement placed by the complainant.
The policy has been issued in the name of Jogendra Kumar Jaiswal, the prime insured, Mina Jaiswal and Adarsh Jaiswal having sum insured Rs.1,50,000/- for Jogendra Kumar Jaiswal, Rs.2,50,000/- for Mina Jaiswal and Rs.1,50,000/- for Adarsh Jaiswal and the policy effective from 15-09-2013 to 14-09-2014 and 15-09-2011 to 14-09-2015 having policy no.154300/48/14/8500004150.
During subsistence of the policy Mina Jaiswal was admitted in Fortis Hospitals on 19-07-2014 under the treating Dr. Raza Dhar for the treatment of chief complaints of dry hoofing cough accompanied by wheezing of and for the last 5 years along with progressive shortness of breath trouble to lie down due to cough. The insured was treated under the said doctor and was discharged from the Hospital on 25-07-2014 with an advice for restricted salt.
During the period of hospitalization the total expenses has been paid Rs.89,491/- and complainant after release his wife lodged the claim to the OP along with proper claim on 31-07-2014 but on 27-08-2014 the TPA of the insurance company wrote a letter to the complainant to submit certain papers to process the matter of reimbursement and accordingly the complainant complied the letter dated 27-08-2014 on 28-08-2014. Thereafter, insurance company did not take any step for reimbursement of the claim which lodged on 31-07-2014 and ultimately reported that it is genetic problem. So, claim was repudiated but not settled and considering the above act on the part of the OP insurance company. Complainant was completely suppressed because it was not a genetic problem and it is their only case to repudiate the said mediclaim and for which negligent and deficient act of the OP complainant filed this case before this Forum praying for redressal of the mediclaim and compensation etc.
On the other hand, the National Insurance company by filing written statement has submitted that no doubt policy was valid from 15-09-2013 to 14-09-2014 and complainant’s wife was admitted to Fortis Hospital on 15-09-2014 for Fibrotic Interstitial Lung disease and subsequently discharged on 25-07-2014. No, doubt the claim was submitted along with all documents but as per Clause 4.11 the Exclusion Clause genetic disorder, stem cell surgery complainant is not entitled to get any claim. It is further submitted that it was genetic disorder because Mina Jaiswal’s daughter also died in 2008 due to attack of ILD genetic disease. So, it was genetic disease no doubt for which claim was repudiated, so, there is no illegality on the part of the OP and no doubt parties of the policy or any product are directly covered by the policy condition and any exception on the ground of equity as per provision of law cannot given and also relying upon the ruling reported in 2013 (4) CPR 165 NC and in the above circumstances, OP has prayed for dismissal of this case.
Decision with Reasons
On comparative study of the compliant and the written version and also considering the argument as advanced by the Ld. Lawyer of the OP and also the ground for repudiation as mentioned by the OP we have gathered that the only question is whether interstitial lung disease is genetic or not. In this context, after studying the particular research work of the doctors of Chest and Lung of Pennsylvania Medical Institute and College it is found that their confirmed opinion is interstitial lung disease includes a group of disease that have thickening of the supporting tissues between the air sacs of the lungs and this thickening is due to a variety of causes. But it cannot be stated how and under what circumstances that disease attacks the patient.
But as per their research work – the most common symptom of interstitial lung disease are a dry cough and shortness of breath.
Disease of interstitial lung disease is recognized on imaging studies as a thick lace(sponge), sometimes symmetric and in other types, scattered and irregular.
Several terms related to interstitial lung diseasehave been used to describe this condition, including interstitial pneumonia. However, since pneumonia is usually associated with an infection, some doctors choose to use the term interstitial pneumonitis to refer to inflammation in the interstitial space since many of the causes of this inflammation are not infections. Interstitial fibrosis is the term used to refer to the scarring of the lungs that can result from prolonged interstitial inflammation.
Interstitial lung disease can be acute (coming on suddenly) or chronic (occurring over time). But no specific cause for such disease can be actually determined to the effect that it is a genetic disease.
Moreover, the said researcher doctors also confirmed the cause is not known (idiopathic), but exposure to medications or toxins or environmental toxins are the causes of such disease. So, considering the opinion of the researchers work doctors and their final opinion after diagnosing the diseases they have confirmed that the prognosis of interstitial lung disease depends on the precise cause but some cases interstitial lung disease do not have and identifiable cause and are referred to as idiopathic(cause is not known). So, considering the opinion of the researchers work doctors and their literature about diagnosis of interstitial lung disease we are confirmed that it is not a genetic disease.
Considering that fact and relying upon the opinion of the research doctor of Pennsylvania Medical Institution we are convinced to hold that the observation of the OP that it is genetic disease is completely baseless and without any foundation and for which the Forum cannot accept the repudiation of the OP but some factors are there for settling the matter by the OP when repudiation is not reasonably legal. So, for settlement if we give a chance to OP they shall have to take time to settle the claim so, the matter should be settled by this Forum by not giving any chance to the OP to linger this matter and to give the complainant relief at this stage. In the result, the repudiation as made by the OP is found uncalled for, illegal, unjust and the opinion of the OP that the complainant’s wife suffered from genetic disease is completely baseless and without any foundation. No doubt, the claim was for Rs.89,491/- but as per clause if it is calculated invariably admission charge and non-medical service charge cannot be given under any circumstances, so, after taking all these factors of the bill a sum of Rs.70,000/- is released as final settlement of the claim and OP shall have to pay the same to the complainant within one month from the date of this order along with litigation cost of Rs.5,000/- that is total Rs.75,000/- and if it is not paid in that case penal damage at the rate ofRs.100/- per day shall be assessed and accordingly this complaint is allowed on contest.
Hence,
Ordered
That the case be and the same is allowed on contest with a cost of Rs.5,000/- against the OPs.
OP1 particularly, shall have to pay a sum of Rs.70,000/- treating it as the mediclaim as made by the complainant is finally settled by declaring the repudiation as made by the OP is baseless and without any foundation. Particularly, OP1 shall have to pay the entire decretal amount of Rs.75,000/- i.e. including the litigation cost, compensation etc. within one month from the date of this order, in default, and in case of disobeyance of the Forum’s order penal interest at the rate ofRs.100/- per day shall be assessed till full satisfaction of the decree and if it is collected it shall be deposited to this Forum.
Even if it is found that OP is reluctant to comply the order in that case penal action u/s.25 read with Section 27 of the C.P. Act shall be started against them for which further penalty and fine shall be imposed.
