Date of filing: 27.06.2013.
Date of disposal: 21.05.2014.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: Sri A. M. L. Narasimha Rao, B.Sc., B. L., President
Smt N. Tripura Sundari, B. Com., B. L., Member
Wednesday, the 21st day of May, 2014
C.C.No.113 of 2013
Between:
Gogineni Venkateswara Rao, S/o late Nageswara Rao, Hindu, Aged about 66 years, Properties and Business, R/o.D.No.68-4-13, Nallurivari Street, Patamata, Vijayawada.
….. Complainant
And
Star Health & Allied Insurance Company Ltd., Rep: by its Branch Manager, Branch Office at D.No.40-1/1-17, Adars Nagar, Opp: Chennupati Petrol Bunk Road, Moghalrajpuram, Vijayawada.
. … Opposite Party.
This complaint coming on before the Forum for final hearing on 6.5.2014, in the presence of Sri Narra Nageswara Rao, advocate for complainant; Sri Nori Sridhar, advocate for opposite party and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble President Sri A. M. L. Narasimha Rao,)
1. This complaint is filed under Section 12 of Consumer Protection Act, 1986 for a direction to the opposite party to pay Rs.2,50,000/- under mediclaim policy, to pay Rs.1,00,000/- as compensation and to pay interest and costs.
2 The averments of the complaint in brief are as follows:
That complainant had taken a medical insurance policy from the opposite party for the period from 24.9.2011 to 23.9.2012. The complainant renewed it for the next year under policy No.131211/01/2013/002549. The complainant was hale and healthy. He did not suffer any illness prior to 9.10.2012. On that day the complainant suddenly had reeling sensation and he was uncomfortable. He was admitted in Sentini hospital on 9.10.2012 and after examination he was diagnosed to have HOCM Severe Intra Ventricular and LVOT Gradients Mild HR HTN (DNO). The complainant was discharged on 12.10.2012 and the hospital charged a sum of Rs.42,000.82 ps for treatment. Later the complainant was admitted in Ayush, NRI, LEPL Health Care Pvt., Ltd., Vijayawada on 1.11.2012. Cardiologists Dr. K. Gopala Krishna and Dr.P.S.S. Chowdary examined the complainant. The doctors had performed surgery adopting the procedure of FFR to LAD and PTCA + STENT (EES, 1.11.2012). The complainant was discharged on 3.11.2012. The hospital had charged a sum of Rs.2,09,410.29 ps for the treatment and pharmacy. The complainant spent about Rs.2,51,000/- for the treatment apart from medicines. The opposite party has to reimburse the said amount as per the terms of the policy. The complainant made a claim. The opposite party had rejected the claim on the ground that the complainant was suffering from heart diseases prior to issuing policy. It is a false plea raised by the opposite party. The opposite parties used to get the applicant thoroughly examined by panel doctors before issuing policy. The complainant was thoroughly examined by Navarang Diagnostic, Vijayawada and reports were issued to the opposite party before issuing policy. There is deficiency in service on the part of the opposite party and they are bound to pay the insurance amount and compensation.
3. The opposite party filed version admitting the issue of policy and denying the allegations made in the complaint and further stating as follows:
On receipt of the claim the medical team of the opposite party referred the complainant’s claim to specialist. He opined that the patient’s pre medical ECG shows the evidence of existence of heart disease prior to inception of medical insurance policy. The present ailment of the insured patient is a pre-existing disease. As per the exclusions of the policy the company is not liable to pay the claim amount in respect of pre existing diseases until 48 months of continuous coverage from the inception of policy. Therefore the claim was rightly repudiated. The complainant did not disclose about his illness in the proposal form and did not give proper answer to the questions. Therefore the complainant is not entitled to the amount claimed and the opposite party is not liable to pay any amount.
4. The complainant filed his affidavit which is received as deposition of PW.1. The opposite party filed affidavit of one C. Krishna Sagar an employee of the opposite party. Exs.A1 to A8 are marked on behalf of the complainant and Exs.B1 to B9 are marked on behalf of the opposite party.
5. Heard the arguments advanced by the learned counsel for both the parties. The opposite party had filed written arguments after hearing is closed.
6. The points that fall for determination are:
- Whether the complainant was suffering from pre-existing disease and had knowledge of such disease by the time of taking policy and if the claim if does not lie on the ground of ailment being pre-existing disease?
- Whether there is deficiency in service on the part of the opposite parties?
- Whether the complainant is entitled to the amounts claimed?
Points 1 and 2:
7. The complainant had admittedly taken a medical insurance policy from the opposite party which has been in force from 24.9.2011. The alleged illness and admission of the complainant in the hospital was on 9.10.2012. It is during the 2nd year after taking the policy. The complainant was diagnosed to have some heart problem and he took treatment in Sentini hospital spending Rs.42,000/-. He was again admitted in Ayush NRI LEPL Health Care Private Limited and he had undergone surgery there. It seems stent was fixed and the complainant was discharged on 3.11.2012. The complainant said to have spent Rs.2,51,000/- for the treatment in Ayush NRI LEPL Health Care Private Limited. The complainant made a claim it was rejected on the ground pre-existing disease and suppression of that fact. Since the policy is admitted and the complainant undergone treatment and amount spent is not disputed, the opposite party has to establish that the complainant was suffering from pre-existing disease and it was within the knowledge of the complainant and he suppressed the fact.
8. The opposite party placed material under Ex.B1 to B9 in support of their contention. Ex.B1 is the proposal form wherein he had answered in negative for all the questions relating to the health. So the complainant admittedly has not mentioned he has pre-existing disease. He did not say he had taken treatment earlier. In the repudiation letter Ex.B5 it is stated that the medical team of the opposite party had referred the claim to specialist who opined that the insured patients pre medical ECG shows LBB LVH with strain which evidences existence of heart disease prior to inception of medical insurance policy. The photocopy of discharge summary obtained from Sentini hospital is marked as Ex.B7. Only one paper of two sheets is filed. It is not known what is mentioned in other sheet. The sheet Ex.B7 contain the details of discharge diagnosis, hospital course and some of the investigations namely CK-MB, RFT (RENAL FUNCTION TEST), SERUM ELECTROLYTES. The other investigations are not entered in the sheet of Ex.B7. It is mentioned that the complainant was admitted complaining of reeling sensation nausea and gastritis for one day. It is also mentioned that on investigations he found to have elevated cardiac enzymes. Patient underwent CAG on 9.10.2012 found to have advised PTCA + Stent – LAD (covering major septal). There is nothing in this discharge summary as to any earlier ailment or symptoms expressed by the complainant at the time of admission in Sentini hospital on 9.10.2012.
9. It is one thing to say that the complainant must have had the heart disease by the time of taking policy and it is yet another thing to say that the complainant had knowledge of his having some hear problem. Unless the problem is exhibited by some symptom or feeling there was no reason for the complainant to know that he had some ailment relating to heart and needed medicine or treatment. Merely because one specialist had expressed one opinion on looking into an ECG it cannot be readily said that the complainant had knowledge of his having heart problem by the time of taking the first policy.
10. Ex.A5 is the copy of 1st sheet of discharge summary issued by Ayush hospital. In the clinical summary mentioned in Ex.A5 it is noted as under: “A 65 year old male is admitted for FFR. He is neither a diabetic and nor a hypertensive. He has been hospitalized recently (8.10.2012) for syncope and found to have HCM, abnormal ECG and positive Trop T. His coronary angiogram has reavled SVD (70% mid LAD disease). Nothing is mentioned in this clinical summary as to the complainant had approaching any hospital or doctor earlier and the complainant had symptom or ailment prior to his admission in the hospital. Therefore the documents states that the complainant does not have any pre-existing disease or at least the complainant had no knowledge of any such pre-existing heart problem. The opposite party had filed a memo on 14.5.2014 subsequent to closing of the hearing stating that the complainant has not any document or discharge summary for Sentini hospital after discharge from the hospital and therefore the complainant may be directed to file the discharge summary of Sentini hospital. As observed Ex.B7 is a part of the discharge summary given by Sentini hospital. Ex.A4 shows the list of documents said to have been enclosed for the claim made by the complainant. They include discharge summary. However it is not mentioned that the discharge summary was obtained from Sentini hospital and submitted to the opposite parties. If the discharge summary sent by earlier with claim was insufficient then itself the opposite party should have asked him, to submit complete discharge summary obtained from Sentini hospital. Now asking of such summary at fag end of the proceedings cannot be appreciated.
11. When the opposite party rely upon one opinion of a specialist it is not known why they have not filed such opinion. The opposite party filed Ex.B2 copy of part of ECG slip of one G. Venkateswara Rao dated 21.9.2011 and photocopy copy of ECG report issued by Navarang Diagnostic center, Vijayawada without mentioning name of the patient. The ECG impression is noted as ‘left ventricular hypertrophy with repolorisation of normality’. In the copy of part of ECG slip name of Venkateswara Rao appears to have written in manuscript on the print to be taken from ECG equipment. There is no authenticity of this slip. The slip obtained from Navarang Diagnostic Center, Vijayawada may be the report of ECG taken prior to taking policy as noted in the complaint. The opposite parties do not say if the copy of Ex.B2 obtained by panel doctor of opposite party was given to the complainant and if he was informed that he had left ventricular hypertrophy (LVH). A person having LVH may not find the problem till some symptom exhibited. So no value can be attached to this slip. When the burden is on the opposite parties to establish that the pre-existing disease and when the document filed by both the parties do not support or even indicate that the complainant was suffering from pre-existing disease by the time taking policy it can be said that the opposite party failed to discharge his policy and accordingly it must be held that the complainant is not proved to have pre-existing disease. Then repudiation of claim or rejection of claim is bad. Consequently we hold that there is deficiency in service on the part of the opposite party.
Point No.3:
12. The complainant claiming the amount of Rs.2,51,000/-. The complainant claim is based on the bills submitted to the opposite party. If the rejection remarks and in repudiation letter there is o reference made to any excess claim or entitlement to the lesser amount than the amount claimed. Ex.A7 the record obtained from Sentini hospital and said document show the expenditure of Rs.42,082/-. Ex.A4 contains an invoice for stent showing the cost of the stent Rs.89,250/-. The other bills obtained from Ayush hospital shows expenditure of Rs.749/-, R.219.65 ps, Rs.280.09 ps. IP detailed bill available in Ex.A6 shows a total expenditure of Rs.1,90,000/- after concession. This bill includes the value of stent therefore the total amount of the bill Ex.A6 may be taken as Rs.1,90,000/- the amount spent in Ayush hospital. Then the amounts spent in the hospital comes to Rs.2,32,082/-. The complainant entitled to this amount. The opposite party has not filed the copy of policy showing any other exclusions or deductions from even genuine claim. Therefore the complainant is entitled to the amount of Rs.2,32,082/- and interest thereon at the rate of 9% p.a., from 8.11.2013 the date of repudiation till realization. The complainant shall also be entitled to costs of Rs.3,000/-.
13. In the result this complaint is allowed in part and the opposite party is directed to pay Rs.2,32,082/- (Rupees two lakhs thirty two thousand and eighty two only) to the complainant with interest thereon at the rate of 9% p.a., from 8.11.2013 till realization and to pay costs of Rs.3,000/-. The amounts awarded shall be paid within one month from the date of this order. The complaint for rest of the reliefs is dismissed.
Dictated to steno, N. Hazarathaiah, transcribed by him, corrected by me and pronounced by us in the open Forum, this the 21st day of May, 2014.
PRESIDENT MEMBER
Appendix of evidence
Witnesses examined
For the complainant: For the opposite party:
Gogineni Venkateswara Rao C. Krishna Sagar, Employee of OP
(by affidavit) (by affidavit)
Documents marked
On behalf of the complainant:
Ex.A1 Copy of Star Certificate plus policy schedule.
Ex.A2 Copy of Star Certificate plus policy schedule.
Ex.A3 30.10.2012 Copy of policy intimation details.
Ex.A4 Photocopy of claim form and invoice.
Ex.A5 03.11.2012 Copy of discharge summary.
Ex.A6 01.11.2012 Copy of Cardiology FFR & PTCA report and bills.
Ex.A7 12.10.2012 Copy of discharge summary of Sentini hospital.
Ex.A8 Copy of rejection remarks of policy.
On behalf of the opposite party:
Ex.B1 Photocopy of proposal form of OP.
Ex.B2 Photocopy of ECG report.
Ex.B3 Photocopy of star certificate plus policy schedule.
Ex.B4 Photocopy of star certificate plus policy schedule.
Ex.B5 08.11.2013 Photocopy of letter issued by OP to complainant’s wife.
Ex.B6 05.02.2013 Photocopy of letter issued by OP to complainant’s wife.
Ex.B7 12.10.2012 Copy of discharge summary of Sentini hospital.
Ex.B8 Photocopy of invoice of OP.
PRESIDENT
