Haryana

Ambala

CC/120/2022

Rajiv Kumar Taneja - Complainant(s)

Versus

Tata AIG General Insurance Co Ltd - Opp.Party(s)

Udai Singh Chauhan

20 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	120 of 2022
Date of Institution	:	11.04.2022
Date of decision	:	20.05.2024

 

Rajiv Kumar Taneja S/o Sh. Nand Lal, Age about 50 years R/o 2219, Near Gurudwara, Village & Tehsil Barara, District Ambala.

       ……. Complainant

                                                Versus

1. TATA AIG General Insurance Company Ltd. through its Office, Branch Office, 3rd floor Shanti Complex, Jagadhari Road, Opp. Civil Hospital, Ambala Cantt, 133001.
2. TATA AIG General Insurance Company Ltd., Lotus Tower, 1st floor, community center, New Friends Colony, New Delhi-110025.

                                                                                       ….….  Opposite parties

Before:       Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Udai Singh Chauhan, Advocate, counsel for the complainant.

                    Shri Mohinder Bindal, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the amount of Rs.1,92,750/- incurred on treatment of the complainant alongwith interest @18% per annum.
2. To pay compensation to the tune of Rs.50,000/- for mental agony and harassment.
3. To pay cost of litigation of Rs.55,000/-.

OR

Grant any other relief which this Hon’ble Commission may deems fit.

2.             Brief facts of the case are that the complainant availed the housing loan of Rs.25 lacs from TATA CAPITAL vide sanction letter dated 31.01.2017, Annexure C-7.  At the time of sanctioning loan, the complainant also got insured by the TATA CAPITAL from its subsidiary company i.e. from the OPs for securing the home loan in case of any eventuality. The policy was named as TATA AIG HOME GUARD Plus and the complainant got an insurance policy from the OPs vide policy no. 0235352324, date of commencement 10.02.2017 valid for the period from 10.02.2017 to 09.02.2020, after paying premium of Rs.75002/-. The premium payment mode was single premium and the sum assured is Rs.22,82,530/-. The complainant was medically checked by the medical officer of the OPs and after seeking their reports the policy was issued. As per the policy, the complainant is entitled for claim in case of any critical illness. In the first week of January, 2019, the complainant suffered Chest pain and breathing difficulty and consulted a local doctor, who advised to consult some senior cardiologist in any reputed hospital. The complainant informed the authorized agent of the OPs and asked the procedure if in any case the doctor advises for any treatment. The authorized agent of the OPs had advised to get the medical check-up done from Alchemist Hospital at Panchkula as the same is on the panel of the OPs, in case doctor advises for any treatment or surgery, then the complainant will be entitled to get cashless facility from the Alchemist Hospital. As per the advice, the complainant went to Alchemist Hospital on 21.01.2019 and consulted Doctor Arvind Kaul who immediately admitted the complainant for day care and advised certain investigations i.e. E.C.G., T.M.T. The OPs were immediately informed regarding the admission of the complainant in the hospital. After certain tests and investigation, the complainant was diagnosed with "CORONARY ARTERY DISEASE ANGINA ON EXERTION CLASS II". The complainant was admitted for the treatment and was discharged on 22.01.2019. The complainant asked for cashless facility. But the hospital advised approval for cashless facility would take considerable time and the stenting is required to be done immediately, otherwise there was risk of the life. The hospital also told and assured that the entire expenses will be reimbursed by the OPs. In this situation, the complainant had to pay the amount with the hope that the amount incurred will be reimbursed. The complainant has spent a sum of Rs.1,92,750/- for his treatment as advised by the hospital. After discharge from the hospital, the complainant submitted all the required papers, bills to the OPs for approval of claim and reimbursement, but instead of approving the claim, the OPs had sent letter dated 25.03.2019 repudiating the claim on false and flimsy grounds only to avoid the liability. The complainant approached the OPs to get the amount reimbursed as the complainant was fully covered under the policy and thus the OPs are legally liable to pay the amount to the complainant. The OPs rather than acting swiftly based on the submissions made by the complainant, kept on lingering the matter on one pretext or the other. Thereafter, due to the pandemic induced lockdown the complainant could not pursue the matter with the OPs as the doctor had advised not to move outside in such a situation since he was immune compromised and easily susceptible to subsequent waves of covid-19. Hence, the present complaint.
3.           Upon notice, the OPs appeared and filed written version raising preliminary objections to the effect that this complaint is not maintainable and liable to be dismissed in limine; the complainant has not approached this Commission with clean hands as he has suppressed the material facts, cause of action etc. On merits, it has been stated that the claim raised by the complainant under critical illness clause of the policy was duly entertained in due course on being presented and the entire case with all set of papers was gone through by the concerned expert and specialized team of the answering opposite party. After scrutinizing and elaborating the submitted claim documents, it was found that the insured/complainant consulted Dr. V.K. Gupta for chest pain who advised the complainant to go for TMT.  During the TMT, the complainant started having chest pain with ST elevation in lead II, III, aVF, V4, V6 after 6 minutes exercise and thus the exercise was stopped whereupon ECG changes settled within 3 minutes. Thus he was advised Coronary Artery Angiography (CAG) due to TMT changes. Thereafter the complainant was admitted in Alchemist Hospital, Panchkula on the same day and CAG was done and double vessel disease was revealed. Accordingly PTCA to Right Coronary Artery (RCA) and Left Circumflex Artery (LCX) was done at the same time. The complainant was thereafter discharged on the next day i.e. 22.01.2019 being fully fit to be discharged. It was further observed by the concerned official of the OPs that the claim of the complainant does not fall within the purview of the Critical Illness insurance coverage schedule of the policy in question as claimed by the complainant and as such his claim was denied and he was duly informed about the fate of his claim. For the clarification and evaluation, it is submitted that as per Part D dealing with coverage, the 'Critical Illness benefits under the policy has been defined as under:

“….Section 1. Critical Illness Benefit: while this policy is in force, the company shall provide the benefit in one lump sum as stated in the schedule of benefits <> subject to the provisions, conditions and limitations contained herein or which may be endorsed hereinafter if the insured is diagnosed to be suffering from or undergoing for the first time of the surgical procedure as defined under Covered Critical Illness herein below and if all the following conditions are satisfied.

 

a. The insured person experiences a critical illness specifically listed and defined in this policy, and

b. The Critical Illness experienced by the insured is the first incidence of that Critical Illness; and

c. The signs or symptoms of the Critical Illness experienced by the insured person commenced beyond waiting period of more than 90 days following the issue date of the certificate of insurance or inception date, whichever is later, and

d. None of the General or specific limitations or exclusions specifically contained in this policy applies.

e. Covered Critical Illness: A Critical Illness shall mean any one of the following critical illness and it is subject to fulfillment of all conditions as defined above of this benefit and as applicable particularly to each critical illness as defined below:

 

C1. Cancer of specified severity. C2. Kidney Failure Requiring Dialysis. C3. Multiple Sclerosis with persisting symptoms. C4. Major Organ/Bone marrow Transplant. C5. Open Heart/Replacement or Repair of Heart Valves. C6. Open Chest CABG. C7. Stroke Resulting in Permanent Symptoms. C8. Permanent Paralysis of Limbs. C9. First Heart Attack of Specified Severity. All these critical illness has been clarified and defined in detail. Since the relevant being related to the present case falls near to C6 & C9 which says as:

 

C6. Open Chest CABG: This clause relates to heart surgery wherein Angioplasty and/or any other intra-arterial procedures and key-hole or laser surgery has been excluded thus totally irrelevant and against the case of the complainant. Clause 9 relates to First Heart Attack-of Specified Severity: which says that "The first Occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:

 

1. History of typical clinical symptoms consistent with the diagnosis of acute Myocardial Infarction (for e.g. typical chest pain)

2. New characteristic electrocardiogram changes

3. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers. The following are excluded:

1. Non ST segment elevation myocardial infarction (NSTEMI) with elevation of Troponin 1 or T

2. Other acute Coronary Syndromes;

3. All type of angina pectoris..”

 

Thus by appreciating the specific wording and clauses, it is observed that the heart procedure falls under the Critical Illness only when the insured suffers heart attack of specified severity with death of a portion of the heart muscle with other illness characteristics and diagnosis as denied and then he undergoes a heart procedure but the case and illness of the complainant lacks all the ingredients and requirements and specifications of the Critical illness thus does not falls under the category and not entitled to any compensation under the policy for his alleged treatment/illness which he got prior to any myocardial infarction and loss to heart muscle etc. The complainant was duly informed about the fate of his claim vide detailed letter dated 25.03.2019. The complainant being very much aware of the limitations and coverage of the policy and about the fate of his claim but in order to put undue pressure filed this false complaint by exploiting the process of law. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.

4.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CW1/A alongwith documents as Annexure C-1 and C-10 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs tendered affidavit of Amit Chawla, Authorized Signatory of the OPs Company-TATA AIG General Insurance Co. Ltd., Registered Office, Noida as Annexure OP-X, alongwith documents as Annexure OP-1 to OP-7 and  closed evidence on behalf of the OPs.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by not making payment of the amount spent by the complainant on his treatment, despite the fact that treatment was taken by him during subsistence of the policy in question, the OPs are deficient in providing service and adopted unfair trade practice.
7.           On the other hand, learned counsel for the OP while reiterating the averments made in the written version submitted that the liability of the OP under the policy in question arises, had the complainant suffered heart attack with the severity/symptoms  i.e. heart attack of specified severity with death of a portion of the heart muscle with other illness characteristics and related heart procedure, whereas, in the present case, the complainant took treatment for the disease i.e. Coronary Artery Disease (CAD), Angina on Exterion Class-II, TMT Positive, CAG-Double Vessel Disease, PTCA/Stent to RCA, LCX, which was not covered under the policy in question.    
8.           Neither the issuance of the policy in question in favour of the complainant by the OPs nor the fact that the complainant took treatment from Alchemist Hospital i.e. CAG-Double Vessel Disease, PTCA/STENT to RCA, LCX nor the fact that the claim of the complainant has been repudiated by the OPs vide letter dated 25.03.2019, Annexure C-6, on the ground that he did not suffer any Myocardial Infarction as defined under the policy in question are in dispute. Under these circumstances, the moot question which falls for adjudication is as to whether the claim of the complainant was rightly repudiated by the OPs or not. It may be stated here that it is clearly coming out from the Discharge Summary dated 21.01.2019, Annexure C-4 that the complainant was finally diagnosed as :- Coronary Artery Disease (CAD), Angina on Exterion Class-II, TMT Positive, CAG-Double Vessel Disease, PTCA/Stent to RCA, LCX.  It is significant to mention here that a very similar nature of case and facts, wherein also the insurance company while relying upon very similar terms and conditions repudiated the insurance claim of the insured, fell before the Hon’ble State Commission, New Delhi in Appeal No.09 of 2010 decided on 01.02.2010,  titled as ICICI Prudential Life Insurance Company Limited Versus Anil Kumar Jain, wherein, while negating the repudiation of claim by the insurance company, the Hon’ble State Commission allowed the complaint of the complainant. However, REVISION PETITION No. 1234 OF 2010 filed by the ICICI Prudential Life Insurance Company Limited before the Hon’ble National Commission was allowed vide order dated 15.02.2017 and the consumer complaint was dismissed by holding as under:-

“……… As per Note 1 Clause ( c) of main Clause C- Critical Illness Benefit, heart attack has been defined as under:-

          ”Heard Attack- The death of a portion of heart muscle as a result of inadequate blood supply as evidenced by an episode of typical chest pain, new electrocardiographic changes and by elevation of the cardiac enzymes.  Diagnosis must be confirmed by a consultant physician.”

As per medical report and Medico –Legal opinion, insured underwent an ECG, which was reported as ‘normal’.  The patient underwent CPK and CK-MB tests which are diagnostic of heart attack and even these were within the normal range and further observed that in medical parlance, Unstable Angina and Myocardial infarction (heart attack) are two distinct entities.  In the former, there is reduced blood supply to the heart and in the latter there is complete cessation of blood supply to the heart.  Thus, it becomes clear that insured’s treatment does not fall within the purview of heart attack defined in the policy pertaining to Critical Illness Benefit Rider.  Learned State Commission while dismissing appeal observed in para 12 & 14 as under:-

          “12. This Commission is wholly in disagreement with the view, that because of non- fulfillment of aforesaid condition, the complainant will not be entitled for compensation from the Insurance Company.  It is manifest that the respondent suffered a serious Heart Ailment and an artery was found blocked and a stent was placed. It was a very serious condition and if such a Heart Ailment is not compensable, what other disease, will be required for grant of reimbursement.  It is not open to the Insurance Company to place conditions which are unlikely to be fulfilled with a view to create a device to escape payment of compensation. It  amounts to defrauding and cheating the customer.  It is not open to Insurance Company to provide such particulars and details of the disease which quite often do not appear and which may provide a ground to the Insurance Company to avoid payment of compensation symptoms appearing in all kinds of Heart Ailment cannot always be the same, and merely because all symptoms are not 100% the same, the Insurance Company cannot avoid compensation.  The ailment suffered by the respondent was highly serious and life threatening and the spirit and purport of the agreement must be assumed to be such, as to provide for such serious disease of Heart.”

          “14. Judicial ethics becomes obliterated where there is fraud and deception.  The obsequious insertion of such detail which may not et noticed, and be glossed over, and put in place with a view to act as an embargo when a demand for compensation is made, is not ethical in itself and the cry of ethics must rebound and hit back the Insurance Company itself.”

Learned State Commission had no authority to rewrite terms & conditions of the policy as held by Hon’ble Apex Court in II (2013) CPJ 1(SC)- Export Credit Guarantee Corpn. Of India India Ltd.  Vs. Garg Sons International; and in such circumstances, merely because opposite party has placed certain conditions which are unlikely to be fulfilled, insured cannot get benefits of the policy when his treatment is not covered by the policy.….”

9.           In the present case also, it is clearly coming out from the discharge summary, Annexure C-4 that the complainant suffered Coronary Artery Disease (CAD), Angina on Exterion Class-II, TMT Positive, CAG-Double Vessel Disease, PTCA/Stent to RCA, LCX and was treated in the said hospital.  In the case of ICICI Prudential Life Insurance Company Limited (supra), it has been observed by the Hon’ble National Commission that in medical parlance, Unstable Angina and Myocardial infarction (heart attack) are two different entitles. Thus, it becomes clear that insured’s treatment does not fall within the purview of heart attack defined in the policy pertaining to Critical Illness Benefit Rider. As such, by placing reliance on the aforesaid judgment, passed by the Hon’ble National Commission, it is held that by repudiating the claim of the complainant, the OPs cannot be held deficient in providing service.
10.           For the reasons recorded above, this complaint stands dismissed with no order as to costs. Certified copies of the order be sent to the parties concerned, as per rules.  File be annexed and consigned to the record room.

 Announced:- 20.05.2024

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President