CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

  Udyog Sadan, C – 22 & 23, Institutional Area

          (Behind Qutub Hotel)

   New Delhi – 110016

    Case No.136/20

Mehar Bakshi

D/o Sh. Gopesh Bakshi

R/o H.No.317, Sector-4

Vaishali, Ghaziabad

Uttar Pradesh-201012.…..COMPLAINANT

Vs.

Star Health and Allied

Insurance Co. Ltd.

Off:23, Himalaya House

Kasturba Gandhi Marg

Connaught Place

New Delhi-110001.…..RESPONDENTS

Date of Institution-25.09.2020

Date of Order- 03.05.2024

             O R D E R

RITU GARODIA-MEMBER

1.  The complaint pertains to deficiency in service by OP in repudiating the medical claim of the complainant.

2. Facts outlined in complaint:    The petitioner was born on 07.05.2018 in Yashoda Super speciality Hospital, Koshambi.  The father of petitioner provided all documents and medical record to OP insurance agent.  The petitioner was assigned a policy No.P161116/01/2019/001608 covering a period from 20.06.2018 to 19.06.2019.

3. On 20.07.2018, the petitioner faced some respiratory problem. She was admitted in Yashoda Super speciality Hospital wherein she was diagnosed with bronchiolitis/aspiration pneumonia, late onset sepsis with shock/anaemia.  On 24.07.2018, the petitioner was taken to Max Super Speciality Hospital, Patparganj, wherein she was diagnosed with hypoxic ischemic encephalopathy, polycythemia and thrombocytopenia.

4. OP denied the payment of mediclaim of the petitioner.  The complainant prays for the payment of claimed amount of Rs.33,364/- towards payment made at Yashoda Super speciality Hospital and Rs.3,44,041.69 towards payment made at Max Super Specialty Hospital alongwith with compensation of Rs.5,00,000/- for mental agony and harassment and Rs.50,000/- for litigation expenses.

5. OP submits in its reply that the insured availed Family Health Optima Insurance Plan vide Policy No.P161116/01/2019/001608 covering a period from 20.06.2018 to 19.06.2019 for a sum insured of Rs.5,00,000/- covering Mr. Gopesh Baksi-self, Mrs. Vandana Bakshi- spouse and one dependent baby Mehar Bakshi.  The terms and conditions of the policy were explained to the complainant at the time of proposing the policy. 

6. The insured preferred pre-authorisation request in the second month of the policy towards treatment of baby for acute viral myocarditis at Max Super Speciality Hospital, Patparganj, from 24.07.2018 to 31.07.2018.  A query was raised on 24.07.2018 and the insured was asked to submit the following documents:

1. Letter from treating paediatrician regarding any history of congenital anomaly in this child.
2. Clarify whether this child had any NICU admission.
3. Birth discharge summary with paediatric notes
4. Antenatal scan reports
5. ECHO and all relevant investigation

7. On perusal of the documents submitted, the pre-authorisation request for cashless treatment was rejected vide letter dated 25.07.2018. It is evident from the past treatment records of Yashoda Hospital that the insured infant was under treatment before policy inception, which the insured failed to disclose in the proposal form which amounted to concealment of material facts.

8. OP further submits that the insured submitted the claim form seeking reimbursement of hospitalization expenses for viral myocarditis for Rs.3,44,042/-.  The claim of the insured was rejected vide letter dated 31.03.2019.

9. The complainant has filed rejoinder.  It is specifically stated that OP was negligent in not investigating the medical history of the petitioner before enrolling her into the policy.  It is further submitted that OP has itself accepted in its reply that the petitioner was treated in Max Super Speciality Hospital, at Patparganj, for acute viral myocarditis, which is related for the inflammation of heart muscle whereas as per the statement of OP, the petitioner was treated for –

1. Hypoxic ischemic encephalopathy
2. Polycythemia
3. Thrombocytoenia

10. The petitioner has filed the evidence by way of affidavit and exhibited the following documents:

1. Copy of legal notice is exhibited as Exhibit PW1/1.
2. Copy of reply of legal notice is exhibited as Exhibit PW1/2.
3. Copy of policy is exhibited as Exhibit PW1/3.
4. Copy of birth certificate is exhibited as Exhibit PW1/4.
5. Copy of Max Super speciality hospital bills are exhibited as Exhibit PW1/5.
6. Copy of bills of Yashoda hospital is exhibited as Exhibit PW1/6.

11. OP has filed the evidence by way of affidavit and exhibited the following documents- 

1. The copy of policy terms and conditions is marked as Exhibit R-2.
2. The copy of proposal form  is marked as Exhibit R-3
3. The copy of Portability Form and Policy Schedule are marked as Exhibit R-4.
4. The copy of Pre-authorization Request Form is marked as Exhibit R-5.
5. The copy of query dated 24.07.2018 is marked as Exhibit R-6.
6. The copy of Pre-authorization rejection letter is marked as Exhibit R-7.
7. The copy of Field Visit Report is marked as Exhibit R-8.
8. The copy of Claim Form is marked as Exhibit R-9.
9. The copy of Discharge Summery of Yashoda Hospital is marked as Exhibit R-10.
10. The copy of Lama Summary dated 23.07.2018 is marked as Exhibit R-11.
11. The copy of Discharge summary of Max Hospital is marked as Exhibit R-12.
12. The copy of Laboratory Investigation Reports is marked as Exhibit R-13.
13. The copy of final bill is marked as Exhibit R-14.
14. The copy of repudiation of letter is marked as Exhibit R-15.
15. The copy of Billing Assessment Sheet is marked as Exhibit R-16.
16. The copy of intimation letters of policy cancellation is marked as Exhibit R-17.
17. The copy of Endorsement Schedule is marked as Exhibit R-18.
18.  CD of TVC Recording is marked as Exhibit R-19.

12. The Commission has considered the pleadings and material on record.  It is admitted by both the parties that the complainant was covered under Family Health Optima Insurance Plan vide Policy No.P161116/01/2019/001608 covering a period from 20.06.2018 to 19.06.2019 for a sum insured of Rs.5,00,000/-.  It is not in dispute that the complainant was born  on  07.05.2018 at Yashoda Super speciality hospital.  On 23.07.2018, she was taken to Yashoda Super Speciality Hospital for some respiratory problem. Thereafter, she was taken to Max Super Speciality Hospital, Patparganj on 24.07.2018. 

13.  A cashless claim was filed which was repudiated vide letter dated 25.07.2018, relevant portion is as follows :

As per the medical records submitted, it is noticed that the patient admitted for hypoxic ischemic encephalopathy, polycythaemia, thrombocytopenia, and baby was put on mechanical ventilation, VBG was done showed severe metabolic acidosis and treated for same from 07.05.2018 to 16.05.2018 which is prior to policy inception for this baby, which the insured has failed to disclose in the proposal form.This amounts to concealment of a material fact.”

14. A claim was filed which was repudiated vide letter dated 11.8.2018. 
15.  

15. Discharge summery from Yashoda Super speciality hospital mentions date of birth as 07.05.2018 and date of discharge as 16.05.2018 at the time and the insured infant was born. The  relevant portion is as follows :
16.  

Respiratory System:

Baby was put on mechanical ventilation SIMV mode (PIP/PEEP/FlO2-16/6/50).VBG was done showed severe metabolic acidosis with lactate of 10.Full umbilical cord was thromboses which might be the reason of asphyxia, umbilical cord was sent for histopathological report awaited.Respiratory distress was gradually settled and baby was extubated at about 7 hrs of life to room air.Initially baby had slight stridor which was settled over next 24 hrs.Currently baby is breathing comfortably under room air.

Cardiovascular System:

Baby had sinus bradycardia which has improved over next 48-72 hrs of life.”

At admission, sepsis screen and blood culture sent and IV Piptaz and Amikacin started.Blood culture report came sterile and baby improved clinically so IV antibiotics were stopped 2^nd days of life.Baby was re-evaluated for sepsis bcz initial screen was +ve (Thrombocytopenia and very high CRP).Last platelet count was 1 lakh and CRP was 33 on 13.05.2018.”

16. Subsequent discharge summery from Yashoda Super Speciality Hospital shows date of admission as 23.07.2018.  She was discharged on the same day against medical advice.  Diagnosis is as follows: 
17.  

17. Discharge summery of Max Super speciality hospital shows date of admission as 24.07.2018.  Relevant portion of discharge summery is as follows:

“DIAGNOSIS” ACUTE VIRAL MYOCARDITIS

PRESENTING COMPLAINTS:

H/OBREATHLESSNESS SINCE 1 DAY

H/O VOMITING 1-2 EPISODE

CHILD WAS ADMITTED IN OUTSIDE HC SPITA (YOSHODA HOSPITAL) THERE WAS PROGRESSIVE INCREASE IN RESPIRATORY DISTRESS THERE AND CHILD WENT IN SHOCK.HENCE CHILD WAS VENTILATED AND PUT ON VENTILAORY SUPPORT CHILD WAS TRANSFERRED FROM YASHODA HOSPITAL TO MAX HOSPITAL AS PER RELATIVES REQUEST FOR FURTHER MANAGEMENT.”

18. The chronology of event reveals that on the day of birth 07.05.2018, the infant experienced respiratory issues and required mechanical ventilation. Additionally, the infant exhibited sinus bradycardia, indicating an abnormal cardiac rhythm, and tested positive for sepsis during initial screening. Subsequently, the policy was initiated on 20.06.2018. The baby was admitted to Yashoda Super Speciality Hospital on 23.07.2018, where the diagnosis indicated late onset sepsis and provisionally, bronchiolitis. She was discharged on the same day against medical advice. Later, at Max Super Speciality Hospital wherein she was admitted on 24.07.2018, the diagnosis pointed to acute viral myocarditis, with the complainant showing symptoms of respiratory distress, necessitating ventilator support.

19. It's apparent that the complainant/baby had previously experienced the same diseases/issues before the policy's inception. However, these were not disclosed in the proposal form. Consequently, there is no deficiency on the part of the OP, and the complaint is dismissed without any order regarding costs. Order to be uploaded and file be sent to record room.