Haryana

StateCommission

A/1137/2015

National Insurance Company Limited - Complainant(s)

Versus

S.C. Bhatia - Opp.Party(s)

23 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      1137 of 2015

Date of Institution:        31.12.2015

Date of Decision :         23.01.2017

 

National Insurance Company Limited, through its Manager, 1 & 5 BP, 5C, Railway Road, NIT, Faridabad through its Divisional Manager, Railway Road, NIT, Faridabad.

                                      Appellant-Opposite Party No.1

Versus

 

1.      S.C. Bhatia s/o Sh. Ram Lal, Resident of 92, Sector-8, Faridabad, Haryana.

Respondent-Complainant

2.      M/s Vipul Med TPA (Third Party Claim Administrator) Corporation through its Manager/Director, R/o 515, Udyog Vihar, Phase-V, Gurgaon, Haryana, through its Branch Office, YMCA, Faridabad.

                                      Respondent-Opposite Party No.2

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                                                                                                         

Argued by:          Shri J.P. Nahar, Advocate for appellant.

                             Shri Tanmoy Gupta, Advocate for respondent No.1.

                             None for respondent No.2 (service dispensed with).

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          National Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party No.1 is in appeal against the order dated September 14^th, 2015 passed by District Consumer Disputes Redressal Forum, Faridabad (for short ‘the District Forum’) whereby complaint filed by S.C. Bhatia-complainant (respondent No.1 herein) seeking benefits with respect to Hospitalization Benefit Policy was accepted on the following terms:-

“9.     Opposite Party No.1 is directed to pay the sum insured of Rs.2,00,000/- (Two lakh only) along with interest @ 9% p.a. from the date of filing of this complaint till realization of amount within 30 (thirty) days from the date of receipt of this order to the complainant. Opposite party No.1 is also directed to pay Rs.5500/- as compensation towards mental agony, harassment alongwith Rs.2200/- as litigation expenses to the complainant.”    

2.                Briefly stated the facts of the case are that the complainant-respondent No.1 purchased  Hospitalization Benefit Policy (Annexure-A) for the period March 26^th, 2010 to March 25^th, 2011 from the Insurance Company-Opposite Party No.1/appellant. The policy was in continuity of the earlier policies which commenced with effect from March 23^rd, 2009.

3.                On August, 10^th, 2010 the complainant suffered chest pain. He approached Sarvodya Hospital, Sector-8, Faridabad. After angiography, he was referred to Dr.R.K. Caroli where he took treatment from August 21^st, 2010 to January 6^th, 2011.

4.                On January 19^th, 2011 the complainant visited Escorts Heart Institute & Research Centre, Okhla Road, New Delhi where he was diagnosed Ischemic Heart Disease patient. The complainant remained admitted in the said hospital from January 19^th, 2011 to January 22^nd, 2011 and Coronary Angiography (Non Ionic Dye) was done on 20^th January, 2011. The complainant alleged to have spent Rs.4,30,000/- on his treatment. Claim being filed, the Insurance Company-appellant did not pay the amount on the ground that the disease for which the complainant was treated, was not covered under the policy vide Clause 4.1. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed before the District Forum.

5.                The opposite party No.1/Insurance Company contested complaint by filing written version wherein it reiterated the fact stated in the preceding paragraph of this order and prayed for dismissal of the complaint.  Opposite Party No.2-Vipul Med TPA did not contest the complaint and it was proceeded exparte.

6.                After evaluating the pleadings and evidence of the parties, the District Forum vide impugned order allowed complaint directing the Insurance Company as detailed in paragraph No.1 of this order.

7.                Learned counsel for the appellant-Insurance Company assailed the order of the District Forum raising plea that the complainant was suffering from heart disease for the last two years and therefore as per Clause 4.1 of the policy, nothing was payable by the Insurance Company. In support, reference was made to Clause 4.1 of the policy, which reads as under:-

“4.1   All diseases/injuries which are pre existing when the cover incepts for the first time. However, those diseases will be covered after four continuous claim free policy years. For the purpose of applying this condition, the period of cover under Mediclaim policy taken from National Insurance Company only will be considered.

          pre-existing disease like Diabetes and Hypertension will be covered from the inception of the policy on payment of additional premium by the insured.”

8.                Learned counsel for the appellant referred to Discharge Summary (Annexure A/4) showing the Date of Admission: 19.01.2011 and Date of Discharge: 22.01.2011. Under the heading of ‘History of Presenting Illness’ the doctor has mentioned as under:-

“Patient is normotensive, diabetic, non-smoker and has no family history of Ischaemic heart disease. He presented with complaints of angina on exertion (class II) for last 2 years, increasing for last 1 year. TMT done was positive. He was admitted to this hospital for stabilization and further management.”

 9.               Under the heading ‘Course in the Hospital’ the treating doctor mentioned as under:-

“Patient underwent coronary angiography and PTCA + stents (XIENCE X 3) to LAD LCX/OM on 20.01.2011 with good end result and no residual stenosis or flap. The procedures were uncomplicated and well tolerated. His general condition at the time of discharge is satisfactory.”

10.              In the Discharge Summary (Annexure A/4) it has been mentioned that Angiography (non lonic Dye) was done on 20.01.2010.  Learned counsel for the appellant submitted that going  back two years from the date of admission in the hospital, that is, 19.01.2011, the disease was prior to the purchase of the policy and therefore it fell under the Exclusions Clause 4.1 being a pre-existing disease.

11.              On the other hand learned counsel for the respondent No.1-complainant submitted that the doctor has wrongly mentioned history of two years, whereas in fact the complainant was admitted in the said hospital on 19.01.2011; he was advised to undergo coronary angiography which was done on 20.01.2011. The certificate dated 22^nd January, 2011 issued by Dr. (Prof.) Upendra Kaul, Fortis Escorts Heart Institute reads as under:-

“This is to certify that Mr. S.C. Bhatia Ehirc No.397200 admitted here in Escorts Hospital with a complaint of angina on exertion (class II) on 19/1/11.

The patient was advised to undergo coronary angiography which was done on 20/1/11 revealed double vessel disease and further advised to undergo percutaneous transluminal coronary angioplasty with stenting done on the same day (20/1/11) using 3 Xience stents to LAD, left circumflex and OM.”

12.              There is no mention in the above said certificate that the complainant was suffering from heart disease prior to that date, i.e. when he was admitted in the hospital.  Besides ‘Revised Discharge Summary’ (Annexure A-6) has been placed on record the relevant part of which reads as under:-

                   “Course in the Hospital:

Patient has represented that he underwent coronary angiography on 20.01.2011, not on 20.01.2010 and he is having angina on exertion for last 6 months, not for last 2 years. Based on the affidavit, a revised discharge summary has been issued accordingly on 20.05.2011.”

13.              Thus, going back six months, it cannot be termed that the complainant was suffering from heart disease prior to the date of purchasing of the policy and therefore complainant’s claim was not covered under Clause 4.1 of the policy. 

14.              To determine as to whether the disease suffered by the complainant was a pre-existing disease, learned counsel for the appellant-Insurance Company has drawn inference on the initial Discharge Summary where the brief history was mentioned to be since 2 years.  Mere inadvertent wrong entry cannot be taken as ground by the Insurance Company for the purpose of declining the claim when the period was corrected by the hospital itself. Taking it positively, the period being corrected six months, the disease could not be termed as pre-existing and therefore, the complainant was entitled to the benefit of policy. Thus, no case for interference in the order of the District Forum is made out. 

15.              In view of the above, the appeal is dismissed being devoid of merits.

16.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced: 23.01.2017

(B.M. Bedi) Judicial Member

(Nawab Singh) President

 

CL