Order-20.

Date-02/02/2017.

       Shri Kamal De, President.

This is an application u/s.12 of the C.P. Act, 1986.

Complainant’s case in short is that the Complainant obtained  a Mediclaim coverage under a policy namely, Group   Health Insurance Policy issued by OP No. 1. OP No. 1 is a reputed Private Insurance Company and OP No.2 is  the TPA. The period of coverage was from 05.06.2015 to Midnight 04.06.2016 vide policy No. 0000000002967311 dtd. 05.06.2015. The said policy was issued in the name of the Complainant as to be insured by giving coverage to the. Complainant in the event of any hospitalization benefit / accidental death / loss of limbs / permanent, total disablement during the period of said insurance policy coverage for an overall capital  sum insured  of Rs.2 lacs. The wife of the petitioner, namely Tapati Sandhukhan is a nominee in the said policy. On 17.08.2015 the Complainant felt chest pain and as a result of that he was admitted in Narayana Multispeciality Hospital, Barasat and as per the advice of the Dr. there, the Complainant took admission in “Rabindranath Tagore International Institute of Cardiac Sciences” on 18.08.2015 vide patient ID No. 17600000015675. The Complainant was admitted therein till 30.08.2015. After some medical tests of the Complainant, the doctor advised him for Open Heart Operation. Then Operation was performed on 22.08.2015 and he was under treatment till 30.08.2015. On 30.08.2015 the Complainant was discharged from the hospital. The Complainant during the aforesaid treatment incurred expenditure amounting to Rs.2,20,000/-, apart from Ambulance Charges and other miscellaneous charges. The Complainant thereafter submitted the claim before the OPs. The Complainant also duly intimated the OPs regarding such hospitalization on 16.09.2015. The Complainant contacted the OPs to know the fate of such claim. Surprisingly, after expiry of about few months the OP on 15.03.16, sent a purported letter in favour of  the Complainant that the claim has been closed as ‘No claim’. The Complainant was astonished and made correspondences with the OPs, but to no good.

It is also stated that except the policy certificate no other document  relating to such policy was supplied to the Complainant. The Complainant alleges that the OP has been deficient in rendering services and repudiated the claim illegally and arbitrarily. Hence, this case.

OP No. 1 has contested the case in filing w.v. contending, inter alia, that the instant case is not maintainable in law and in its present form.

It is stated that the Complainant at the time of taking the said policy has understood and agreed with all the terms and conditions of the said policy and Insurance Policy is nothing but a contract between the insurer and the insured. It is also stated that the claim of the Complainant is for treatment of Myocardial infarction with Hypertension and Diabetes mellitus for which bypass (Open Heart Operation) done at Rabindra Nath Tagore Institute of Cardiac Sciences On 22.08.2015. As per the document submitted, it is observed that the Complainant was admitted in the Hospital on 17.5.2015 with the history of ‘Type 2’ Diabetes which is since 3 years and Hypertension which is since one year and as such these are pre-existing in nature and the current ailment is complication of the same. The first policy inception date is 05.06.2015. As per exclusion clause No. 11, the Complainant is not entitled to get the claim. As such, the claim of the Complainant was repudiated through a letter on 15.03.2016 as the claim for hospitalization falls beyond the purview of policy coverage and is not payable.

This OP No. 1 has prayed for dismissal of the case.

OP No. 2 has not contested the case and the case has proceeded ex parte against the OP No. 2.

Point for Decision

1)         Whether the case is maintainable in its present form and prayer?

2)         Whether the OP No. 1 has been deficient in rendering service to the Complainant?

3)         Whether the OP No. 1 repudiated the claim rightly as per Exclusion Clause?

4)         Whether the Complainant is entitled to get relief as prayed for?

Decision with Reason

We have perused the documents on record i.e. photocopy of Policy documents, photocopy of Group Health Insurance Policy Certificate, photocopy of Certificate of Insurance, photocopy of Policy Annexure,  photocopy of Receipt of Rabindra Nath Tagore  Hospital, photocopy of copies of prescriptions of Rabindra Nath Tagore Hospital, photocopy of Heart Diagram, photocopy of Discharge Summery of Rabindra Nath Tagore Hospital, photocopy of Operation Note of Rabindra Nath Tagore Hospital, photocopy of final bill, photocopy of letter dated 16.09.2015 to OP No. 1 informing about the Open Heart Operation, photocopy of the documents submitted with the OP No. 1 along with letter dated  16.09.2015, photocopy of claim application, photocopy of repudiation letter and other documents on record.

            It appears that the Complainant obtained a subject Group Health Insurance Policy on 10.06.2015 having coverage period from 05.06.2015 to midnight of 04.06.2016. The OP as we find has repudiated the claim, of the Complainant on the ground that he was treated Myocardial infarction with hypertension and Diabetes Mellitus for which bypass (Open Heart Operation / Elective coronary Artery Bypass Grafting X 3 Grafts was done at Rabindranath Tagore Institute of Cardiac Sciences on 22.08.2015. It is stated that the Complainant was surviving with the history of Type II Diabetes for 3 years and Hypertension for one year and these are preexisting  in nature and that current ailment is complication of the same.

            We have perused the surgical discharge summary of Rabindranath Tagore Institute in respect of the Complainant. The diagnosis, as we find is “Left Main Coronary Artery with Double Vessel Coronary disease”.  Operation done for Elective Coronary Artery Bypass Grafting X 3 Grafts (LIMA-LAD, RSVG,-OM1 .RSVG, - PDCx). The history of the present illness reveals that the Complainant was  admitted with the history of chest pain, shortness of breath on exertion-coronary angiography was done at Narayana Multispecialty Hospital, Barasat on 17.08.2015 revealing left main coronary artery with double vessel coronary artery disease. But there is nowhere in such discharge summary that hypertension or diabetes resulted chest pain, shortness of breath or block of main coronary artery. We find that there is previous history of Diabetes, hypertension and he was on medication but nothing is on medical paper or document or in then discharge summery that diabetes mellitus or hypertension caused Open heart surgery or bypass was done for Diabetes mellitus or hypertension. We can not say that blockage of artery has been the result of suffering from hypertension  or diabetes mellitus. We find that Open heart Operation is not within the exclusion clause of the subject policy. The allegation that the Complainant developed artery blockage as he is  a patient of diabetes mellitus or hypertension is frivolous. There is also no such reflection in the discharge summary or even on the medical documents. Even in the discharge summary of Narayani Multispecialty Hospital, we find that the Complainant was admitted there with history of chest pain and AMP palpitation. We find that the patient suffered from sudden severe chest pain, severe restlessness. On medical tests he was diagnosed as “left main coronary artery with double vessel coronary diseases”.

            We think that the liability rests upon the OP in repudiating the claim of the Complainant arbitrarily. The Complainant within the validity of the policy felt chest pain and as a result of that he was admitted at Narayana Multispecialty Hospital at Barasat, subsequently, he took admission at Rabindranath Tagore Cardiac Hospital. Dr. advised him for Open Heart Operation. So, we think that the action on the part of OP that the claim has been closed as ‘No claim’ is arbitrary one.

            We think that the Complainant is entitled to get the claim.

In result, the case succeeds.

Hence,

Ordered

That the instant case be and the same is allowed on contest against the OP No. 1 and dismissed ex parte against the OP No. 2.

            OP No.1 is directed to pay an amount of Rs.2 lacs to the Complainant towards hospitalization benefit apart from litigation cost of Rs.5,000/- to be paid within one month from the date of this order.

In default, the Complainant will be at liberty to put the order into execution and in that event the OP1 shall be liable to pay a penal damage  at the rate of Rs.1000/- per diem to be paid to this Forum till full and final satisfaction of the decree.