Order-15.
Date-13/07/2015.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that her husband Partha Pratim Chatterjee was a legal practitioner who had a mediclaim policy namely ‘Individual Health Insurance Policy’ being policy No.030600/48/13/97/00004269 with the OP1 and continued the same without any break by paying the premium regularly and renewed the said policy for the period from 21-11-2013 to 20-11-2014 and the policy covered the health of his own, spouse and his daughter for a sum assured of Rs.2,25,000/- per member.
Suddenly on 21-04-2014 complainant’s husband fell seriously sick and was admitted in the ILS Hospital, the OP3 with complain of severe abdominal pain with frequent vomiting and frequent loose motion with fever and expired on 22-04-2014 because of ‘severe sepsis with septic shock with acute renal failure’ as stated in the discharge summary dated 22-04-2014. Despite request for cashless facility by the Hospital for its beneficiary Partha Pratim Chattopadhyay, the insured OP2/TPA deliberately rejected to extend cashless facility vide its e-mail dated 22-04-2014 stating that “as patient is known alcoholic and the present condition is related to alcohol abuse, cashless authorization is not payable” which is absolutely false and arbitrary and after receiving the said letter complainant became stunned and being suffered from financial crisis she humbly requested the OP1 Insurance Company to release the reimbursement of medical expenses vide a letter dated 28-04-2014 but OP did not pay any heed.
It is further stated by the complainant that her husband was non-alcoholic during his lifetime and therefore in a fit of anger, she immediately rushed to the Hospital and expressed her grievances about their wrong perception and Hospital Authority after admitting their own mistake accordingly rectified the same by issuing a certificate declaring and confirming that “it was wrongly mentioned that the patient was a ‘known alcoholic’ instead of typing ‘non-alcoholic’ since from the hospital records it was later found that there was no history as such about the patient …. accordingly the discharge summary stood amended ….” and this amended certificate issued by the Hospital Authority was immediately submitted to the Insurance Company, OP1 by the complainant for their kind consideration for the settlement of her claim.
Thereafter, complainant immediately submitted claim form by claiming Rs.82,865/- under claim I.D. No.0320010008830701 and policy no.030600/48/13/97/00004269 along with all medical reports, medical bills, receipts, discharge summary etc. issued by the Hospital in connection with the treatment of her husband, the insured with the Insurance Company, the OP1 but OP1 rejected her claim on flimsy ground vide their repudiation letter dated 19-09-2014 stating its inability to entertain the claim under clause 4.9 of the Mediclaim Policy and in response to the said complainant sent a letter dated 10-10-2014 for reconsideration to the Insurance Company but unfortunately the Insurance Company replied by a letter dated 13-10-2014 stating that the document issued by the Hospital rectifying the mistake in discharge summary did not seem reasonable or acceptable under normal circumstances.
Complainant further ventilated her grievances about non-settlement of her claim to the Grievance Redressal Cell but they also clearly stated in its e-mail communicating that the case was examined and as per policy condition, the claim is not payable under the policy and so, the decision taken by the operating office is found in order.
Thereafter, complainant communicated several times with the OPs but they kept mum about the steps for payment of the genuine claim of the complainant and though the complaint is absolutely genuine and lawful one but the action of repudiation on the part of the OPs on arbitrary and inappropriate ground is not only wrongful and illegal but also against the guidelines of IRDA and therefore, finding no other alternative complainant filed this complaint before this Forum praying for reimbursement, compensation, cost etc.
On the other hand, OP United India Insurance Co. Ltd. by filing written statement submitted that the OP already denied all allegation made against the insurance company except which has documentary proof and OP has nothing to say in reply against para 2 to 8, 13 and 14 which are matter of record and the complainant ought to have proved the same by filing original documents for inspection of the OP. Further it is submitted that the claim of the complainant was rejected as per terms and condition of the policy by TPA on the basis of the document produced by the complainant except this OP stated nothing but denied the allegations and prayed for dismissal of this case.
Decision with Reasons
On proper consideration of the complaint, written version and also considering the vital documents which was filed by the complainant along with claim case it is found that there was a noted history made by the doctor at the time of examination at the hospital that the patient was known-alcoholic, known-diabetic and known-hypertensive and in fact about known case of diabetic and hypertension there was no denial and truth is that complainant has tried to prove that by procuring a document from ILS Hospital, subsequently, that word ‘known’ shall be ‘non’. Truth is that the patient was admitted on 21-04-2014 diagnosis was made on 21-04-2014 at 8.12 a.m. and that patient died on 22-04-2014 at 1.15 a.m. that means within 17 hours he died.
When the patient Partha Pratim Chatterjee was admitted in the hospital his complain was abdominal pain with frequent vomiting since yesterday night and frequent loose motion since today morning at 4 a.m. also low grade fever for today 3 a.m. and significant findings is known alcoholic and known case of portal hypertension known diabetic on oral anti-hyperglycemic medication and all relevant investigations were done and attached with the file and subsequently death certificate was issued by the ILS Hospital on 22-04-2014 and antecedent of cause of death is hypertension and type II Diabetes Mellitus. In the significant findings it is noted known case of portal hypertensions and known diabetic on oral anti-hyperglycemic medication and prior to that known alcoholic. When this report was received by the complainant’s family members they did not challenge it and, in fact, the complainant’s husband was suffering from acute portal hypertension and type II DM for which he also suffered from severe sepsis with septic shock and for renal failure and in the medical discharge summary it is noted acute renal failure is due to severe metabolic acidosis known case of portal hypertension and type-II DM that means the deceased suffered from such known case of hypertension, known case of diabetes and invariably it was found that the patient had a known case of alcoholic for which it is noted as known case of alcoholic. Truth is that Dr. Arvind Kr. Ojha actually examined patient and treated him and fact remains knowing about the said death certificate, findings of the doctors etc. that claim was submitted by the complainant. Thereafter, the said claim was repudiated vide letter dated 19-09-2014 and by that letter dated 22-04-2014 it was reported that the claim was rejected on the ground it was a known case of alcoholic and entire condition is also related to alcoholic use and for which the cashless authorization is not payable, that letter was issued on 22-04-2014 that is after the date of death of the patient. When that matter was reported by the OP to the complainant, complainant must have to file forthwith the certificate for the correction of certificate but peculiar factor is that as per request and pressure of the complainant already Dr. Ojha issued one addendum to discharge summary dated 22-04-2014 stating that known alcoholic shall be read as non-alcoholic but in that addendum there is no date. Most interesting factor is that Dr. Nibedita Chatterjee on behalf of the ILS Hospital, Dum Dum tried to convince that known alcoholic was due to mistake, if that is the fact then in the significant findings known is always used before the words alcoholic, hypertension diabetes, if there is actually such history. But if there is no case of any alcoholic history of any patient there is nothing to mention but only it is mentioned when it is a known case of alcoholic. We have gathered in so many cases in such a manner on the death of a patient different nursing home only to please their customers changed the certificate in such a manner and that is the mal-practices of the hospital authority, in fact, this Forum cannot rely upon such document which has been subsequently issued by the ILS Authority. Truth is that death was caused due to hypertension and at the same time for diabetes and that was the cause of death and at the same time there are certain matters what we have observed. On the very date on 22-04-2014 TPA reported hospital authority and the complainant that the cashless benefit was refused on the ground that known case of alcoholic and also known case of hypertension and diabetes and death was caused due to that but peculiar factor is that on that date nothing was done but every was manipulated by the ILS authority. What even it may be, we, have gathered that anyhow the patient died but we are not in a mood to think over his past habits but fact remains death was due to hypertension and high blood sugar but that matter was not disclosed at the time of purchasing the policy. Truth is that on 22-04-2014 the patient died and no doubt as per policy condition the claim is not payable when the fact is that about the health status of the complainant it was not discussed in Forum of policy and as per clause 2/2 for treatment of hypertension, type II diabetes mellitus no claim shall be entertained for domiciliary hospitalization benefit and in the present case practically complainant was hospitalized and was there for 17 hours to 18 hours but not full one day and it is proved that cause of death was nothing but hypertension and diabetes. As he was a known patient of so on that ground also the complainant is not entitled to get any benefit of claim even if we disregard the known case of alcoholic but after considering certain medical journals it is found that diagnosis as made simply proves renal failure which was caused with severe metabolic acidosis only on the ground of known case of portal hypertension and type II DM and in view of the above facts and circumstances, it is proved that practically the repudiation was justified but considering the death and treating the treatment as conservative hospitalization for only 16 hours and further relying upon the argument as advanced by the OP’s Ld. Lawyer and also relying upon the judgment passed in RP No.4447 of 2012 passed by National Consumer Dispute Redressal Commission dated 07-01-2015 we find that it cannot be disputed that insured was suffering from portal hypertension and diabetes Mellitus Type-II for long years and admittedly policy was taken for the period from 21-11-2013 to 20-11-2014 but complainant died on 22-04-2014. Therefore, it is proved that complainant obtained insurance policy by concealing the material fact pertaining to its previous ailment and the insured was well aware about his health problem which was not disclosed and had the insured disclosed its previous ailment it would have affected the decision of the insurance company whether to accept the proposal for insurance or not. Therefore in our considered view the insurance companies are justified in repudiating the claim.
Fact remains in the repudiation letter one clause was noted but for that reason other clauses can also be invoked but regarding settlemet of the claim all the conditions, terms of the policy shall be applicable and this Forum cannot go beyond the terms and condition of the policy and cannot show any mercy or equity in favour of the insured. Further the subsequent so called rectified certificate of the doctor is not relevant particularly when the insurance contract was obtained by the insured concealing his previous ailment that is portal hypertension and DM-II and truth is that antecedent of the death is hypertension and DM-II and in view of the above discussion we find that there is no material irregularity in repudiating the claim of the complainant by the OP and in fact complainant has failed to prove any negligence and deficient manner of service on the part of the OP but anyhow at the time of advancement of argument Ld. Lawyer of the OP submitted that as because it is a death case at best for conservative hospitalization only pharmacy charges may be allowed but no other charges can be allowed but anyhow that charges also cannot be allowed in view of the clause 4.8 but anyhow the Ld. Lawyer for the OP submitted that as because there is no deficiency, negligent on the part of the OP then invariably complainant cannot get any relief.
No doubt after considering the whole matter it is found that complainant is not entitled to get any relief because the insured who died did not disclose that he had been suffering from hypertension and DM and as per death certificate that is the cause of his death. So, in view of the judgment as referred, complainant is not entitled to get any relief when negligence and deficiency on the part f the OP is not at all proved but even then considering the death of the insured we are directing the OP to release a sum of Rs.35,000/- as final amount treating the entire claim as finally settled by this Forum but no other amount can be awarded in this case and for which the necessary order is being passed directing the OP to handover that amount by showing corporate social responsibility at once.
Hence,
Ordered
That the complaint succeeds in part on contest but without any cost against the OP1 and dismissed without any cost against OPs2 and 3.
OP1 is directed to handover a sum of Rs.35,000/- to the complainant treating the claim of the complainant as finally settled by this Forum when negligence, deficiency on the part of the OP is not proved.
If OP1 fails to comply the order in that case penal action shall be started for implementation of the order.
