DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. NO. 109/16

Shri. Anil Jain

H. No. 1, IInd Floor,

East And Enclave,

Laxmi Nagar, Shakarpur,

Delhi- 110092

….Complainant

Vs.    

1. Religare Health Insurance Co. Ltd.

Through its Manager

Having Regd. Office at

D3, P3B, District Centre,

Saket, New Delhi- 110017

2. Max Super Specialty Hospital

Through its Managers

Regd. Office:- 108 A, Indraprastha Extn.

Patpar Ganj, Delhi- 110092

                                                                                 …Opponents

Date of Institution: 03.03.2016

Judgement Reserved on: 09.09.2019              

Judgement Passed on: 16.09.2019

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

Order By: Harpreet Kaur Charya (Member)

JUDGEMENT

           Jurisdiction of this forum has been invoked by Shri. Anil Jain, the complainant alleging deficiency in service and unfair trade practice against Religare Health Insurance Co. Ltd., (OP-1) and , Max Super Specialty Hospital (OP-2) under Section 12 of the Consumer Protection Act, 1986.

Briefly stated the facts of the present complaint are that the complainant and his family were covered under mediclaim policy bearing no. 10004891 issued by OP-1 for the period from 31.10.2014 to 30.10.2015. Complainant has stated that he had been maintaining his mediclaim policy since 31.12.2012, continuously without break.

The complainant was hospitalized at Max Hospital, OP-2 on 03.05.2015 for the complaint of chest pain and was discharged on 06.05.2015. Request for cashless was rejected, due to which complainant had to pay Rs. 2,37,427/-. Claim for reimbursement was lodged with OP-1, vide claim no. 90104782. Complainant’s claim was repudiated without any intimation. This fact came to his knowledge when he contacted the customer care, where he was asked to download the repudiation letter from website. The said claim was rejected on the baseless ground

“Clause 4.3 (a) (xxiv) -Act of self destruction or consumption, use, misuse or abuse of tobacco, intoxicating drugs”.

           Despite submitting certificate issued by Dr. Anil Bhat, MD, DM Senior Consultant, Cardiologist with OP-2, which was of dated 22.08.2015, where it had been specifically mentioned that “A history of smoking has no medical evidence that it is sole cause of myocardial infarction” which was ignored by OP. Even after complying with all requirements and several representations, the claim of the complainant was not settled.

The complainant has alleged that there was gross negligence on part of           OP-1, which had resulted in harassment and mental agony. Feeling aggrieved the complainant has prayed for directions to OPs to pay Rs. 4,37,426/- being            Rs. 2,37,426/- expenses for treatment of complainant and Rs. 2,00,000/- as compensation on account of mental agony, humiliation and loss of time and money.

           The complainant has annexed photo copy of policy documents, copy of discharge summary copy of hospital bills, print of repudiation letter downloaded from the website of OP, doctor’s report dated 06.05.2015 another letter dated 22.08.2015, copy of proposal form and photocopy of voter ID with the complaint.

           Written Statement was filed upon service of notice in the present complaint on behalf of OP-1 through Ms. Ramnique Sachar, Corporate Manager (Legal). They have taken several pleas in their defence such as: there was no cause of action in favour of complainant and against them; the complaint was frivolous. It was submitted that policy bearing no. 10004891 for the period 31.10.2012 to 30.10.2013 was issued to the complainant and since then the mediclaim insurance policy were renewed and lastly for the period from 06.11.2015 to 05.11.2016. Admission of the complainant with OP-2 was not disputed. It was further submitted that the cashless request for the treatment of severe chest pain was rejected, as on investigation, it was found that the complainant had the history of smoking which he had declared to OP-2 where the complainant had declared that he had been smoking for past 6 to 7 years and had left smoking for last one year only. Even in the nursing admission assessment the complainant had accepted that he was into smoking. Besides that OPD papers issued by OP-2 dated 14.05.2015 mentioned the complainant as “ex-smoker”. So, relying on above mentioned documents, the repudiation letter dated 20.06.2015 was issued as there was breach of Clause 4.3 of policy terms and conditions, which is:-

           4.3 Permanent Exclusions:

a. Any claim in respect of any insured person for arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions.

xxiv.) Act of self destruction or self inflicted injury, attempted suicide or suicide while sane or insane or illness or injury attributed to consumption, use misuse or abuse of the tobacco, intoxicating  drugs and alcohol or hallucinogens.

OP-1 had also sought an opinion of independent doctor to ascertain if there was any correlation between smoking and CAD. As per the opinion of that independent doctor, it was opined that “smoking is a major cause of atherosclerosis- a buildup of fatty substance in the arteries. Atherosclerosis occurs when the normal lining of the arteries deteriorates, the wall of the arteries thickens and deposits of fat and plaque block the flow of the blood through the arteries. In coronary artery disease the arteries that supply the blood to the heart become severely narrowed, decreasing the supply of the oxygen rich blood to the heart, especially during times of the increased activity. Extra strain on the heart may result in chest pain and other symptoms. When one or more of the coronary arteries are completely block, a heart attack may occur.”

The complaint filed by the complainant before the insurance ombudsman vide complaint no. DEL-G-037-1516-0162 was dismissed on 08.10.2015. The fact that had been concealed by the complainant. It was also stated that the complainant was bound by policy terms and conditions and had signed the declaration in the proposal form. Rest of the contents of the complaint have been denied.  

They have annexed the board resolution dated 10.06.2016 as                  Annexure OP-1, policy cover note (Colly.) Annexure OP-2, discharge summary dated 06.05.2015 as Annexure OP-3, cashless/ spot investigation report as Annexure OP-4 alongwith nursing admission assessment, pre authorization of cashless hospitalization rejection letter is Annexure OP-7, claim rejection letter dated 20.06.2015 as Annexure OP-8, terms and conditions as Annexure OP-9, independent expert opinion is Annexure OP-10, order of insurance ombudsman dated 08.10.2015 is Annexure OP-11 and copy of the proposal form dated 29.10.2012 is Annexure OP-12.

           OP-2 filed their Written Statement. They have submitted that the complainant had not alleged any deficiency in service against them; complaint was bad for misjoinder of parties. It was submitted that, it was OP-1 who was to process the claim of the complainant, thus acceptance/ rejection was matter between OP-1 and the complainant, OP-2 had no responsibility in acceptance/ rejection of claim. They have submitted that the complainant was admitted on 03.05.2015 with “the history of chest pain and Retrosternal Discomfort” and as far as past history was concerned the patient did not give any past history of diabetes, hyper tension, PTB (Pulmonary Tuberculosis) and/ or CAD (Coronary Artery Disease). It was further submitted that the complainant had earlier gone to some other hospital where he was diagnosed with ACS and was given loading dose to anti platelets and statin and ECG was done at ER. After informed consent CAG- SVD and PTCA (DES) to LAD procedure was done and finally the complainant was discharged on 06.5.2015.

           The fact of issuance of certificates for and on behalf of Dr. Anil Bhat was admitted. Rest of the contents of the complaint have been denied.

           In the replication to the Written Statement of OP-1 and Written Statement of   OP-2, the complainant has controverted the submissions made by them and has reaffirmed the contents of his complaint.

           Complainant has filed evidence by way of affidavit and has deposed on oath the contents of his complaint. He has relied upon the annexures annexed with the complaint.

           Dr. Loveleen Sharma, Deputy Med. Superintendent of OP-2 was examined, where they have stated that OP-2 was totally committed in providing best possible care to its patients and the settlement of the claim was solely discretion/ matter between complainant and OP-1. She has re-affirmed the submissions made in their Written Statement.

Evidence by way of affidavit was filed on behalf of OP-1, where they have got examined Shri Ankit Shankar Bhardwaj, Manager (Legal), who has reaffirmed the contents of their Written Statement and have got exhibited the authority letter dated 19.04.2017 as Ex.OP1/A, policy documents from 2013- 2014, 2014-2015, 2015-2016 and 2016-2017 as Ex.OP1/B(Colly.), the discharge summary has been exhibited as Ex.OP1/C. He also got exhibited the cashless investigation report and nursing admission assessment as Ex.OP1/D& Ex.OP1/ E respectively. Copy of OPD paper dated 14.05.2015 is Ex.OP1/F, cashless denial letter dated 06.05.2015 and claim rejection letter are Ex.OP1/G & Ex.OP1/H. Terms and conditions of the policy, independent expert opinion alongwith proposal form are Ex.OP1/I to Ex.OP1/K. Copy of the order of insurance ombudsman is Ex.OP1/L.

           We have heard the arguments on behalf of Ld. Counsel for Complainant and Ld. Counsel for OP-2. Perusal of the complaint reveals that the issue in dispute is the non-reimbursement of claim of Rs. 2,47,426/- for treatment filed by the complainant with OP-1 during the subsistence of his mediclaim policy. The said claim was rejected on the grounds of violation of Clause 4.3 a (xxiv) of policy terms and conditions.

It has been argued by the Ld. Counsel for Complainant that OP-1 did not consider the letter dated 06.05.2015 issued on behalf of Dr. Anil Bhat, where it has been categorically stated that “Patient does not give past h/o smoking as per our case sheets. And to our knowledge patient does not give history of smoking presently or in past” The said Annexure-E which is letter dated 06.05.2015 issued on behalf of Dr. Anil Bhat, which has been relied upon by the complainant is in contradiction with Annexure-F, which is again another letter dated 22.08.2015 issued by Dr. Anil Bhat that being so these letters cannot be relied upon

           On the other hand OP-1 has placed on record cashless/ spot investigation report i.e. Ex.OP1/D, where it has been mentioned under column “Detail:- Smoking-6-7 years but patient leave smoking last year ”.  Further, if we look at Ex.OP1/E, which is nursing admission assessment of date 03.05.2015, 08:00PM, where the answer under head “Do you smoke? Is affirmative. Thus, it seems that the letter issued by Dr. Anil Bhat which is Annexure-F is in contradiction with their own record which was prepared during the period for which the complainant was hospitalized. The letter dated 06.05.2015 i.e. Annexure-E has been signed on behalf of Dr. Anil Bhat, which is binding on Dr. Anil Bhat, therefore, it is observed that letter dated 22.08.2015 i.e. Annexure-F, is an afterthought and has no sanctity as Dr. Anil Bhat is interested witness.

           OP-1 has also placed on record an independent expert opinion                     i.e. Ex.OP1/I, where it has been observed that “Sustained smoking habit over a period of time causes CAD (Coronary Artery Disease), SVD (Small Vessel Disease)”. Therefore, OP has successfully discharged the onus that the CAD and smoking have co-relation, and it was the complainant who was in violation of policy terms and conditions.

           Hence, in the facts and circumstances of the present complaint there is clear cut breach of Clause 4.3 (a) (xxiv) of policy terms and conditions and OP-1 has rightly repudiated the claim of the complainant. No deficiency in service can be said to be on the part of OP-1.

           Now, we have to see whether OP-2 was deficient in providing services. We have gone through the entire complaint. There is not even a single whisper of allegation of deficiency in service against OP-2. They have been unnecessarily dragged into litigation. That being so, the complaint is dismissed qua OP-2 being devoid of merits subject to cost of Rs. 5,000/- to be paid to OP-2.

           Therefore, the present complaint is dismissed being devoid of merits with order to cost of Rs. 5,000/- to be paid by complainant to OP-2 within 30 days from the date of receipt of this order by the complainant.

           Copy of the order be supplied to the parties as per rules.

           File be consigned to Record Room.

            (HARPREET KAUR CHARYA)                                                            (SUKHDEV SINGH)

                 Member                                                                                  President