DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No. 88/2016
Sh. Ramesh Suri
S/o Late Sh. K. L. Suri
R/o C-98, 3rd Floor,
Greater Kailash, Part-I,
New Delhi ….Complainant
Versus
- Reliance Health Insurance,
Having its registered office at:
D3, P3B, District Centre, Saket,
New Delhi-110017
Also at:
Plot No.A3, A4, A5, Sector 125,
Noida, U.P. 201301
- Max Super Speciality Hospital
1, 2 Saket, New Delhi-110017
- Fortis Memorial Research Institute,
Sector-44, Opposite Huda City Centre,
Gurgaon, Haryana-122002
….Opposite Parties
Date of Institution :23.03.16 Date of Order :24.12.18
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
Ms. Kiran Kaushal, Member
ORDER
Member - Kiran Kaushal
Briefly put the case of the complainant is:-
- Sh. Ramesh Suri, Complainant took a health/medical insurance policy floated by Religare Health Insurance, hereinafter referred to as OP No.1. The complainant paid an amount of Rs.17,524/- to the OP-1 as premium for the health cover. After this payment the complainant was made to undergo medical examination by OP No.1 and was diagnosed to be suffering from hypertension. OP No.1 charged Rs.4,381/ to cover the above ailment. The complainant made a total payment of Rs.21,905/- as premium for the policy for a period 20.09.14 to 19.09.15. Vide the email dated 11.10.14 the complainant received the soft copy of the policy certificate dated 10.10.14 alongwith the premium acknowledgment, key policy information, policy terms and conditions and claim process with the assurance that the physical copy of the policy would be forwarded within 10 days. The physical copy of the policy was received more than 20 days after its issuance. The print of the soft copy of the policy is annexed as Annexure C-1.
- Around February, 2015 the complainant felt that his walk was becoming unstable. He visited his regular General Physician and not finding any considerable improvement the complainant visited Sir Ganga Ram Hospital on 20.04.15 where he was advised MRI of the spine and the brain. The complainant underwent the MRI of the Dorsal Spine and of the brain with whole spine screenings from Mahajan Imaging. The reports and the receipts of the same are annexed as Annexure C-4.
- For the second opinion the complainant went to Max Super Speciality Hospital, Saket (OP No.2) and the doctors there diagnosed the problem as “Spinal Dural AVF” with congestive dorsal myelopathy. Copy of the diagnoses by the Dr. Shakir Hussain is annexed as Annexure C-4.
- The complainant on 17.05.15 went to the hospital of OP No.2 and underwent all the tests prescribed by Dr. Shakir Hussain. Finally the procedure was performed on 18.05.15. However, after the procedure the complainant was unable to move, waist downwards.
- On 19.05.15 certain other tests confirmed Occluded Fistula. The complainant complained of deterioration. Therefore on 26.05.15 an MRI was repeated which revealed dorsal cord congestion and reappearance of perimedullary flow fluids. On 27.05.15 MRA spine was performed which revealed recurrence of fistula. The specialist advised the complainant to undertake surgery to deal with spinal Dural AVF to facilitate the neurological recovery. After performing the surgery the complainant was discharged and the discharged summary of OP No.2 is filed as Annexure C6.
- It is next pleaded that the complainant sought cashless facility treatment, which was denied by the OP-1 as it rejected registration of the claim. Dr. Shakir Hussain, the specialist attended to the complainant and issued a certificate dated 22.05.15 certifying that the ailment of the complainant did not fall in the category of spinal disorders. Copy of the certificate issued by Dr. Shakir Hussain is annexed as Annexure C7. The complainant forwarded the said certificate to OP No.1 despite this the claim of the complainant was not registered. On 24.05.15 the complainant protested against wrong classification of his disease and consequently wrong rejection of his claim by OP No.1. Copy of the email is annexure C-8.
- On 30.05.15 the complainant was admitted at Fortis Memorial Research Institute, Gurgaon (OP No.3) wherein the complainant again sought cashless facility treatment which was declined by OP No.1. The complainant underwent another surgery in the hospital of OP No.2. Discharge summary of the same is filed as Annexure C10.
- On 07.09.15 the complainant lodged a claim with the OP No.1 for reimbursement of the total amount of Rs.6,78,268/- being the medical expenses incurred by the complainant. Vide letter dated 18.09.15 OP-1 informed the complainant that they were not registering the claim since the present ailment for which the admission has been done is not payable as per the clause ‘Care 4 (1)(B) (I) (I)’ of the policy. As per the letter of OP-1 the said clause is as follows:
“. Care 4.
. I (B) (I) (I) 2 years waiting period: Treatment of spinal disorders is covered after 2 years of continuous policy coverage.”
- Aggrieved by the circumstances above the complainant prayed for reimbursement of Rs.5 lakhs out of Rs.6,78,268/- being the medical expenses incurred during hospitalization of the complainant alongwith interest @ 18% per annum and pay Rs.5 lakhs for mental agony and harassment. It is further prayed that the OP No.1 be directed to pay Rs.50,000/- as the cost of litigation.
2. OP-1 and OP-2 resisted the complaint by filing their written statements however, OP-2 was dropped from the array of parties vide 16.02.2017. Since OP-3 has been dropped the written statement filed on behalf of OP-2 and the replication for the same will not be discussed by the Forum.
2.1 OP-1 in its written statement raised preliminary objections regarding concealment and misrepresentation of fact by the complainant.
2.2 It is further averred that the claim of the complainant was denied vide letter dated 31.05.2015 as per the policy terms and conditions under clause for 4.1(b)(i) as the ailment from which the complainant was suffering is a spinal disorder and the same is covered within the ambit of waiting period clause of the policy terms and conditions. It is, thus, submitted by OP that before the issuance of the insurance policy each and every clause of the terms and conditions of the insurance policy was satisfactorily explained to the complainant and the policy was issued only after having consent of the complainant. It is next stated that having admitted to these terms and conditions the complainant now cannot claim benefit from the exclusion.
2.3 It is next stated that as per the report dated 19.05.2015 and 30.05.2015. It is mentioned that the complainant suffers from degenerative spondy lotic changes seen in the lumbar spine with disc degeneration and marginal end plate steophytes, suggestive of vascular myelopathy that is the abnormality of spinal cord. Therefore, OP-1 raising the objections has prayed for the complaint to be dismissed with exemplary cost.
2.4 OP-2 resisted the complaint by filing its written statement and raised preliminary objection stating that there is no cause of action as such against OP-2. Neither any allegation has been made nor any relief sought against OP-2. Therefore, the complaint is bad for misjoinder of parties and OP-2 should be dropped under Section 12(3) of the Act. However, adverting to the facts, the diagnosis made by private doctors is denied for want of knowledge. The opinion by Dr. Shakir Hussain dated 13.5.2015 exhibited as C5-A is stated to have been made at his private clinic. In subsequent paragraphs the treatment provided at hospital of OP-2 and Discharged Summary has been admitted.
2.5 It is further submitted that the complainant was informed by the hospital authorities prior to hospitalization that the processing and disbursement of cashless or Mediclaim facility, as well as acceptance/ rejection of the claim is a matter between the insured patient and the insurance company. It was further informed that OP-2 has absolutely no role or responsibility in the sanction or rejection of the claim. Therefore, it is submitted as OP-2 does not have any role and no relief is claimed by the complainant against OP-2, the complaint is liable to be dismissed.
3. Replication to the written statement of OP-1 and OP-2 are filed wherein the complainant has reiterated the averments made in the complaint and controverting the statements made therein.
4. Evidence by way of affidavit is filed on behalf of the complainant. Evidence of Ms. Ramnique Sachhar working as Corporate Manager, legal for Religare Health Insurance is filed on behalf of the OP No.1. Affidavit of Dr. Sandeep, Deputy M.S. Max Super Specialty Hospital has been filed with written statement ofOP-2.
5. Written arguments have been filed on behalf of the complainant and OP No.1 are filed.
6. We have gone through the material placed on the record and heard the submission of the complainant. None appeared on behalf of the OPs to argue their case despite providing them opportunity.
7. Having heard the submission of the complainant and perusing the material available on the record thoroughly it is observed that the question before the Forum which requires adjudication is whether the claim of the complainant for cashless treatment or reimbursement was wrongly rejected by OP No.1. OP No.1 repudiated the claim stating as under:-
“we hereby inform you that we are not registering your claim since the present ailment for which admission has been done.
For ease of your perusal we have listed the reason for denial below:
. Care 4.
. I (B) (I) (I) 2 years waiting period: Treatment of spinal disorders is covered after 2 years of continuous policy coverage.”
Study of the OP exclusion clause reveals that spinal disorder is covered in the insurance policy after two years of the continuous policy coverage.
8. Arguments of the complainant that all disorders of the spinal cord have not been excluded. It is only the spinal disorders related to bone and joints have been excluded which is based on the principle of Ejusdem Generis (of the same kind or species).
9. However, the forum does not agree with the said argument as the study of the ailments revealed that it is the de-generated ailment viz. arthritis, osteoarthritis, osteoporosis, gout and rheumatism and spinal disorder especially the one with which the complainant is suffering is also of the degenerative nature and the ailments of the degenerative nature are excluded in the insurance policy.
10. It is next the case of the complainant that ailment of the complainant was of the nature of neuro surgery and not spinal disorder. This argument is based on the certificate issued by Dr. Shakir Hussain. Copy of the said certificate is exhibited as Ex. C7.
11. Before going into the contents of the certificate dated 22.05.15 two other findings by the same doctor one prior and another later, give a different picture. The complainant before getting the treatment done at the hospital of OP No.2 visited Dr. Shakir Hussain on 13.05.15 where Dr. Shakir Hussain vide his diagnosis clip exhibited as Ex. C5A has stated that the complainant is suffering from “spinal dural AVF with congestive dorsal myelopathy. Advised: Spinal DSA and endovascular embolization.”
12. Having so advised, the complainant underwent the procedure at the hospital of OP No.2 by Dr. Shakir Hussain whom he had earlier consulted privately at his clinic.
13. Primary and final diagnosis of the complainant as mentioned in the discharge summary exhibit C6 is reproduced hereby for the ready reference:-
PRIMAARY DIAGNOSIS | Sub-acute progressive dorsal Myelopathy Secondary to Spinal Dural AVF with venous Congestive Dorsal Myelopathy, Hypertension |
FINAL DIAGNOSIS | Sub-acute progressive dorsal Myelopathy, secondary to Spinal Dural AVF Post Embolization, Congestive Dorsal Myelopathy Hypertension |
Study of the initial diagnosis of Dr. Shakir Hussain dated 13.05.2015 and discharge summary dated 30.05.2015 exhibit C6 again, bearing the signature of Dr. Shakir Hussain and another Dr. reveals the complainant to be suffering from Spinal Dural AVF Post Embolization, Congestive Dorsal Myelopathy, Hypertension. The study of the primary and final diagnosis reveals that OP-2 had diagnosed the complainant to be suffering from degenerative spinal problem which was also the initial opinion of Dr. Shakir Hussain (exhibit C-5A). Further the word Myelopathy used in diagnosis as per Wikipedia means as under :-
“Myelopathy describes any neurologic deficit related to the spinal cord. When due to trauma, it is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy. The most common form of myelopathy in human, cervical spondylotic myelopathy (CSM), is caused by arthritic changes (spondylosis) of the cervical spine, which result in narrowing of the spinal canal (spinal stenosis) ultimately causing compression of the spinal cord. In Asian populations, spinal cord compression often occurs due to a different, inflammatory process affecting the posterior longitudinal ligament.”
14. Despite Dr. Shakir Hussain having initially diagnosed the complainant with spinal issues and finally in the discharged summary, he again held the same opinion. However, strangely in the certificate issued on 22.05.2015 he has certified that there is no problem with the complainant’s spine as such. This certificate does not tally with the certificates issued prior and later by him. Therefore, the Forum does not find that the certificate issued on 22.05.2015 has any evidentiary value.
15. Exhibit C-7 also seems to reveal that the complainant suffered from disorder of nervous system involving spinal cord due to formation of a shunt. This too reveals that the complainant is suffering from some kind of spinal chord disorder.
16. Therefore, we find not reason to accept the certificate exhibit C7, the same is hereby rejected.
17. On the basis of discussion above, it is evident that the complainant was suffering from spinal disorder which ailment has been specifically excluded from the Health Insurance Policy. The terms and conditions of which were mailed to the complainant on 11.10.2014 itself and a hard copy was subsequently received. The Forum finds no deficiency of service on part of OP-1 as the terms and conditions were provided to the complainant much before his raising the claim or for that matter prior to the occurrence of his ailment and hospitalization. Therefore, we find no merits in the complaint and it is thereby dismissed with no order as to cost.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 24.12.18.
