Order-15.
Date-16/06/2015.
Complainant Shambhu Nath Das by filing this complaint submitted that he is a Sr. Citizen about 67 years and his wife an elderly lady is under coverage of Miediclaim Insurance of National Insurance Company Ltd.On 09.02.2013 Smt. Manju Das was admitted in the Bangur Institute of Neurosciences as paying-patient with Multi-infract state with seizure disorder (GTCS) is known hypertensive and diabetic with depression and polyarthritis and after full recovery she was discharged on 23.02.2013.
For the treatment of insured Manju Das the benefit of Mediclaim Insurance was availed of and as such soon after her admission to the hospital as per the terms and conditions of the mediclaim insurance policy the matter was informed to the op as there was no existence of cashless treatment tie up in between the ops and the Bangur Institute of Neurosciences.So the cost of the treatment of insured-2 amounting to Rs. 18,129/- was spent only by complainant and following the terms and conditions of the continuing Mediclaim Policy of Insurer on 16.03.2013 the claim for reimbursement of cost of treatment of Manju Das was lodged to the op no.3 the nominated TPA of insurer in the pre-scheduled Format of Insurer.
On receipt of the reimbursement claim, initially none ops, op no.3 took no action whatsoever for consideration and disposal of the alleged claim.But after lapse of 6 months or so from the date of receipt of the alleged reimbursement claim op no.3 vide its letter dated 03.09.2013 advised insured to submit the duly received original final bill issued by the treating hospital and soon after receipt of the said communication of op no.3 complainant submitted the desired documents.But even after that the insurer and its designated TPA did not take any action.
In the meanwhile to get assertive status of the alleged claim of complainant one RTI Application dated 20.09.2013 was preferred through NGO “Consumers’ and Elderlys’ Rights Protection Society” and soon after the said recourse of action was taken and op no.2 vide letter dated 25.09.2013 admitted that complainant holds the insurance policy in question since 10.03.2003 but purportedly denied receipt of alleged claim of complainant and also denied to disclose other information and being dissatisfied with the reply to RTI Application for Cryptic Reply in its communication dated 25.10.2013 another application addressed to op and in respect of age of insured no.2.Complainant submitted on 29.12.2013 an Affidavit sworn on 19.121.2013 before Ld. 1st Class Judicial Magistrate as proof of age of insured Manju Das.
But after that the matter was decided and op repudiated the claim after lapse of 10 months stating the reason that Clause 4.8 of Mediclaim Insurance Policy it was repudiated.So, in the above circumstances, complainant has prayed for redressal on the ground that the said rejection is completely illegal and against the spirit of terms and conditions of the said policy.
On the other hand op by filing written statement submitted that in writing that the entire complaint is false and fabricated.Fact remains that the said policy was valid from 26.02.2012 to 25.02.2013 and the insured Manju Das was admitted at Bangur Institute of Neurosciences on 09.02.2013 with known cause of Hypertension with Diabetic with sudden altered behaviour, decreased fluency of speech, difficulty in finding words, repeating the starting words, inability to recognize family members, inappropriate talks, sometimes auditory hallucinations, pain in left shoulder and considering the behaviour and abnormality, metabolic ancephalopathy was considered, but it was ruled out due by normal electrolytes and biochemistry test results, possibility of wernick’s aphasis was also considered.However imaging did not show any abnormality, finally psychiatric consultation was taken and the case was diagnosed as depressive episode and the patient was conservatively treated for the same with SSRI (Selective Serotonin Reuptake Inhibitor) and other supportive medication.On scrutiny of the claim it is observed that the patient with known case of Hypertensive and Diabetic was admitted at Bangur Institute of Neurosciences and in previous occasion in the year 2008 seizure disorder was detected having past history of Type-2 Diabetes Mellitus and Hypertension as per medical certificate submitted by the insured and also considering all documents and reports, it is found that it is a case of psychotomatic treatment and it comes under the purview Exclusion Clause 4.8 when finally it was diagnosed by hospital from the time she was hospitalized.So, there was no negligence and deficiency on the part of the op and further as per Judgement of Hon’ble Supreme Court, it is settled principle of law that as per terms and conditions of the policy parties shall be be guided and practically complainant suppressed his previous existence of Psychomatic problem and mental disorder and for which the present complaint should be dismissed as repudiation is legal and valid.
Decision with reasons
On an comparative study of the complaint and written version, it is found that Manju Das aged about 61 years female (insured) was admitted at Bangur Institute of Neurosciences on 09.02.2013 and from the report of the discharge summary, it is clear that she had been suffering from the said disease (Multi-infract state with seizure disorder GTCS) since 2008.But that matter was not disclosed at the time of opening the policy which is also proved and subsequently after proper clinically tests of the consumer it was found that it was a case of psychiatric problem.So, psychiatrist consultation was done and she was diagnosed and at present the patient was treated for SSRI (Selective Serotonin Reuptake Inhibitor) and patient was conservatively treated. So, Manju Das was released with direction to continue the different type of examinations and Professor A. Senapati and Dr. Nishal examined her and issued the discharge summary.Now the question is whether the said incident took place for the first time in case of the present patient Manju Das or not.But in this regard we have gathered from the discharge summary that Manju Das also suffered from same diseases, Multi-infract state with seizure disorder in the year 2008.
Further it is evident from the other documents of the year 2011 she also suffered from similar type of disease.But that was also suppressed but in that case complainant managed to get the reimbursement.But in the present case, it is specifically decided that it is a seizure disorder and she is a patient of psychiatric treatment.But both the sides failed to give any detail of the definition of seizure disorder.So, we consulted some medical books on of seizure disorder and other of University of Merin Medical Centre and wherefrom we have gathered that seizure disorder means one of a mere medical condition that if characterized by electric shock of brain and some seizure disorder are of past history but other or involuntarily hazard and seizure disorders are likely who have their other neuro-disorder and psychiatric disorder of main system.But due to seizure disorder patient is admitted along with permanent mental and physically loss and treatment is nothing but medication although it is difficult to cure it properly.But sometimes brain surgery may be tried.Further from defection of seizure disorder it is found that if one after another seizure happen, in that case, it shall be treated as defectiveness of epelapse.
But after considering the present case, it is found that this lady has been suffering from seizure disorder along with neuro-disorder and psychiatric problem since 2008 and at the time of purchase the policy it was suppressed.But from the present medical report it is clear that lady has been suffering from psychiatric problem and the present treatment was for seizure disorder including psychiatric problem and she was under treatment of Bangur Institute of Neurosciences.So, it is clear that it is specifically assessed for one type of mental disorder.Not only that from the medical report, it is clear that she is known case of seizure disorder since 2008. Though she has no history of stroke or any other thing or no history of trauma headed air discharge etc. and practically prior to such admission, the patient expressed that she is not willing to live in this world and she failed to recognize any one and failed to recover anything.
So, apparently the insured Manju Das is a patient of psychiatric problem, neuro disorder and seizure disorder, that means as per Clause 4.8 the exclusion clause all psychiatric and seizure disorder diseases are excluded in respect of this Mediclaim Policy and in the present case it is found that admission was done for psychiatric problem and also for run down condition.So, the claim as repudiated by the op is found legal in view of the exclusion Clause and in fact the present complainant cannot get any relief when it is decided by the Hon’ble Supreme Court that parties shall be guided by the terms and conditions of the policy and there is no question of giving any extra relief to the insured on the ground of equity or etc. and further it is already decided by the Hon’ble Supreme Court in 1966 3 SCR 500 Constitution Bench that the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves and moreover in the present case we have gathered that op applied their mind by applying the terms and conditions of the policy after proper consideration of the medical report and discharge summary as produced by the complainant and we have also found that in deciding the claim of the complainant there is no illegality and at the same time we have found that there is no deficiency on the part of the op.But fact remains that op asked the complainant to file all the documents lastly that thereafter it was repudiated after considering the documents by applying judicial mind.
In this regards we have also gone through the discharge summary issued by Bangur Institute and also considering their medical documents and particularly the chapters of seizure disorder and University of Merin Medical Centre and we have gathered that it is a very peculiar type of case where neuro disorder generally found in the system of the patient where seizure disorder are more likely to develop.So, seizure disorder and psychiatric problem and stem problem were found in the present case, so we have gathered that it is a known case of seizure disorder and psychiatric problem and other neuro-disorder and it is being continued since 2008 that means at the time of purchase this policy that was not disclosed and in respect of the present claim op investigated the matter in its totality and rightly come to a conclusion that as per clause 4.8 (Exclusion Clause) the complainant is not entitled to get such reimbursement and in this regard the decision of the op is quite correct and justified.
Fact remains that the complainant is a patient of known case of seizure disorder, psychiatric problem and immune system problem and as per finding it is clear that such a disease recurs time to time as per medical experts’ opinion of Merin Medical Centre and such sort of disorder cannot be completely cured but it will revive and sometimes the medicines cannot improve the same but finally such sort of problem cannot be cured but may be kept under control for certain period by medication.
Considering all the above fact and circumstances and materials and considering the nature of disease, we have gathered that it is no doubt a case of psychiatric problem with neuro disorder and seizure disorder.So, as per Clause 4.8 (Exclusion Clause) complainant is not entitled to any relief and in fact there is no deficiency on the part of the op and op rightly rejected it and for which we are inclined to hold that when the complaint bears no merit and claim of the complainant cannot be entertained because it was rightly repudiated by the op on the ground that the insured Manju Das is a known patient of seizure disorder, psychiatric problem, mental disorder and it is being continued since 2008 and as per Medical Books and Research Journal of University of Merin Medical Centre, it is found that the present problem is either hereditary or caused by birth defect because there is no history of sustaining injury to the brain after birth or any stroke or any heart attack.So, it is clear that the patient is a known case with past history of seizure disorder that has been suppressed at the time of purchasing the policy for which this complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed against the op without any cost.
