DATE OF FILING :10.08.2010
BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI
Dated this the 28th day of February, 2011
Present:
SRI.LAIJU RAMAKRISHNAN PRESIDENT
SMT.SHEELA JACOB MEMBER
SMT.BINDU SOMAN MEMBER
C.C No.168/2010
Between
Complainant : M.V. Jacob,
Kadhalikandathil House,
Thommankuthu P.O,
Thodupuzha- 685 581,
Idukki District.
(By Advs: Able.C.Kurian, Naiju Ravindranath & M.M.Lissy)
And
Opposite Parties : 1. The Bajaj Allianz Life Insurance Co. Ltd.,
Registered and Head Office, GE Plaza,
Air Port Road, Yerawada,
Pune – 411 006.
2. The Chief Executive Officer,
Bajaj Allianz Life Insurance Co. Ltd.,
Registered and Head Office, GE Plaza,
Air Port Road,
Yerawada,
Pune – 411 006.
3. The Bajaj Allianz Life Insurance Co. Ltd.,
Calicut Branch, 11/41 B,
M Sons Arcade, Cherootty Road,
Calicut – 673 001.
4. The Bajaj Allianz Life Insurance Co. Ltd.,
C.R Complex, Near Bypass Junction,
Nut Street,
Vatakara – 673 104,
Kozhikode District.
5. The Bajaj Allianz Life Insurance Co. Ltd.,
Thodupuzha Branch,
Sundaram Towers,
Temple Byepass Road,
Thodupuzha – 685 584.
(By Adv: Babichen.V.George)
O R D E R
SRI.LAIJU RAMAKRISHNAN(PRESIDENT)
The insurance consultant of the opposite parties named one Mr.Icy Varghese and his colleague approached the complainant in the month of September 2005 and promised various benefits of the insurance policies of the Ist opposite party. It was informed that the Ist opposite party started insurance business in India in the year 2002. The complainant was also informed that for a premium payment of Rs.45,000/- as one time payment or in 3 yearly instalments, a unit linked policy named Bajaj Allianz unit gain will be issued which includes Accidental Death Benefit Rider, Critical Illness Rider and total/partial permanent disability coverage. The complainant was also given certain brochures detailing the various benefits of the insurance policies of the Ist opposite party. The complainant remitted the first premium of Rs.15,000/- on 28.09.2005 and a premium receipt was issued by the 3rd opposite party. The complainant further paid a sum of Rs.35,000/- immediately on 4.10.2005 as top up premium and a receipt was also issued by the 3rd opposite party. The policy issued to the complainant includes accidental death benefit, critical illness benefit, total/partial disability benefit apart from the other guaranteed benefits under the policy. It is also submitted that as per the proposal accepted by the opposite parties and schedule of the policy, the complainant is entitled for critical illness benefit. The critical illness coverage is also mentioned in the policy itself and the first among it is first heart attack. On 25.07.2008 the complainant's brother was admitted in St.Mary's Hospital, Thodupuzha. On the said date the complainant experienced severe chest pain while in front of the hospital and subsequently he got fainted and he was immediately taken to the causality and after preliminary procedures he was suddenly shifted to Intensive Coronary Care Unit of the hospital. The consultant cardiologist after examination confirmed that he has suffered a heart attack and it was diagnosed that Acute non ST Elevation, Myocardial Infarction and hypertension. The ECG was recorded and various tests were conducted and required medicines were administered. The Cardiologist observed that there was acute coronary syndrome and cardiac enzymes were positive for myocardial infarction. The complainant had no previous history of any heart ailment and was suffering a heart attack for the first time. On 28.07.2008, when the condition of the complainant was slightly improved, the Consultant Cardiologist referred the complainant to Lakeshore Hospital and Research Centre, Ernakulam for conducting Coronary Angiography and further treatment. The complainant had incurred an expense of Rs.7,192/- at the St.Mary's Hospital. The complainant was shifted directly from the intensive care unit of St.Mary's Hospital, Thodupuzha to the Lakeshore Hospital and was admitted there on 28.07.2008. Coronary Angiogram was conducted on him on 29.07.2008. The diagnosis was that Type II Diabetes, CAD, Class-II Angina, Now Lateral Wall NSTEMI and after conducting the tests the final impression is that there is Type II Diabetes, CAD, Class II Angina, Now Lateral Wall NSTEMI Severe Stenosis of MID LAD and LCX. The consultant Cardiologist recommended PTCA + STENTING TO LAD, PTCA + STENTING TO LCX. Since the condition of the complainant requires urgent treatment, Percutaneous Transluminal Coronary Angioplasty was conducted on the complainant on 30.07.2008 itself. The complainant had mild angina during LCx angioplasty but he tolerated the angioplasty. The condition of the complainant improved after the procedure. The complainant was discharged from the hospital on 1.08.2008 with advice to continue medication and a review after two weeks. The total hospital bill of Lakeshore Hospital was Rs.1,47,374/-. The complainant was admitted again on 3.08.2008 due to the problems associated with the heart attack. He was treated as inpatient from 3.08.2008 to 6.08.2008 and got improved after medical treatment. He was discharged in a stable condition on 6.08.2008. The complainant had incurred a total expense of Rs.11,424/- at that time. As a result of the heart attack suffered by him on 25.07.2008, he had spent Rs.1,65,990/- as hospital expenses. After discharging from the hospital, the complainant contacted the 5th opposite party, which is the local branch. The insurance company later issued the required claim form. The complainant filed a claim before the insurance company claiming critical illness benefits as provided in the insurance policy and to refund the amount payable under the policy. He also produced a certificate of hospital treatment along with all the relevant records including report of Diagnostic procedures and all medical bills issued by both of the hospitals referred above. The complainant had submitted all records as requested by the opposite parties. The opposite parties by a letter dated 30.10.2008 addressed to the complainant declined the critical illness claim under Policy No.11572096 on the life of the complainant. It is alleged in the letter dated 30.10.2008 that the illness suffered by the complainant is not covered under critical illnesses mentioned in the policy terms and conditions and hence the critical illness claim has been rejected as non-admissible. The complainant was also advised to refer to the policy conditions for the critical illness claim. The complainant after getting proper advice regarding the sustainability of the claim re-submitted the claim application requesting to reconsider the claim for critical illness benefits along with all the relevant records. The complainant is entitled to get an amount of Rs.1,00,000/- as critical illness claim under the insurance policy from the opposite parties. So this petition is filed.
2. In the written version filed by the opposite parties, it is admitted that the complainant availed a policy from the opposite parties. It is true that the complainant's claim stating his claim may by honored as his illness falls within the first heart attack which is one of the eleven critical illnesses mentioned in the policy. But on going through the records and documents brought by the complainant and after detail scrutiny it was found that the illness of the complainant is not first heart attack according to the features specified in the policy schedule. So it is not correct that the complainant filed a claim before the opposite party claiming critical illness benefits as provided in the insurance policy and to refund the amount payable under the policy. The claim was rejected by the opposite party as the disease suffered by the insured is not covered under the eleven critical illnesses mentioned in the policy terms and conditions. On perusal of the various documents and medical reports pertaining to the case of the complainant, the opposite party has arrived at the conclusion that the submitted documents did not indicate any myocardial infarction. The decision had been taken well after the consultation with the Chief Medical Officer. It is also done when the complainant requested for the reconsideration of the rejection of the claim. This opposite party has rejected the claim on the strong basis that the produced documents by the complainant were not confirmed with the statement given that the insured had suffered Fist Heart Attack. The reasons for the conclusion may be read as follows :
1. Insured was diagnosed of CAD NSTEMI Double Vessel disease, which is not covered under coronary artery disease (CADS) requiring surgery
2. Class II Angina is excluded under First Heart Attack
3. Comments of cardiac enzymes were positive for myocardial infection was not supported by any specific test to ascertain the same
4. The ECG record do not indicate ST elevation
5. Coronary Angiogram report indicates lateral wall NSTEMI (Non ST Elevation Myocardial infection)
6. SGOT indicated possibility of alcoholism
7. SCK MB test did not confirm myocardial infection
The records produced by the complainant never go to show that the illness suffered by him is first heart attack. The expenditure bills produced include the expenses of Angiogram and Angioplasty since the non surgical techniques are excluded as per policy document. So the opposite parties are not at all liable to pay Rs.1,00,000/- to the complainant.
3. The point for consideration is whether there was any deficiency in service on the part of the opposite parties, and if so, for what relief the complainant is entitled to ?
4. The evidence consists of the oral testimony of PWs 1 and 2 and Exts.P1 to P22 marked on the side of the complainant and the oral testimony of DW1 and Exts.R1 and R2 marked on the side of the opposite parties.
5. The POINT :-The complainant produced evidence as PW1. PW1 paid a huge premium to the opposite party as Rs.50,000/-. Ext.P1 is the receipt for the Ist premium paid to the opposite party for Rs.15,000/- dated 28.09.2005. Ext.P4 is the receipt for the payment of the topup premium done by the PW1 on 4.10.2005 for an amount of Rs.35,000/-. The opposite party issued a life insurance policy to the complainant which is marked as Ext.P3, in which it is mentioned about the Critical Illness Benefit in page CIB-1 of the policy, in which includes a diagnosis confirmed by a medical practitioner appointed by the company. As per Clause 1, it is written that First Heart Attack, the specification regarding the first heart attack is that the death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis should be based on all of the following :
a history of typical chest pain, if any
new and recent electrocardiographic changes indicating myocardial infarction
elevation of cardiac enzymes
diagnosis based on the elevation of Troponin-I Test alone shall not be considered diagnostic of a heart attack.
Angina or chest pain are especially excluded.
On 25.07.2008 the brother of the complainant was admitted in St.Mary's Hospital, Thodupuzha. On the said date PW1 experienced severe chest pain while in front of the St.Mary's Hospital and subsequently he got fainted and immediately he was taken to the causality and suddenly shifted to intensive coronary care unit of the hospital. The consultant cardiologist after examination confirmed that PW1 had suffered a heart attack and it was diagnosed that there was Acute Non ST Elevation, Myocardial infarction and hypertension. The ECG was recorded and various tests were conducted and required medicines were administered. The cardiologist observed that there was acute coronary syndrome and cardiac enzymes were positive for myocardial infarction. After that he was referred to the Lakeshore Hospital, Ernakulam and discharge summary dated 28.07.2008 from the St.Mary's Hospital, Thodupuzha is marked as Ext.P5. An ECG was recorded at the St.Mary's Hospital on 25.07.2008 and ECG Report of the complainant is marked as Ext.P6. Another ECG report of the complainant dated 25.07.2008 is marked as Ext.P7. The complainant spent Rs.7,192/- at the St.Mary's Hospital, Thodupuzha. The medical bills issued for the same is marked as Ext.P8(series). Then he was admitted in the Lakeshore Hospital on 28.07.2008 and coronary angiogram was conducted on 29.07.2008. The Coronary Angiogram report from the Lakeshore hospital is marked as Ext.P9. The consultant cardiologist recommended PTCA + STENTING TO LAD, PTCA + STENTING TO LCx. Since the complainant's condition requires urgent treatment, percutaneous transluminal coronary angioplasty was conducted on PW1 on 30.07.2008 and it is a part of the treatment for heart attack. The Percutaneous Transluminal Coronary Angioplasty Report dated 30.07.2008 is marked as Ext.P10. The discharge summary dated 1.08.2008 issued from the Lakeshore Hospital for the treatment of PW1 is marked as Ext.P11. The discharge Bill along with the detailed bills dated 1.08.2008 issued from the Lakeshore Hospital are marked as Ext.P12(series).The complainant was again admitted on 3.08.2008 due to the problems associated with the heart attack and treated as inpatient from 3.08.2008 to 6.08.2008. The discharge summary dated 6.08.2008 issued from the Lakeshore Hospital is marked as Ext.P14. So a total expense of Rs.11,424/- was incurred by the complainant on 6.08.2008 and the detailed discharge bill is marked as Ext.P15. So the complainant spent a total of Rs.1,65,990/- as hospital expenses and also spent a huge amount for purchasing medicines after discharge from the hospital, besides the aforementioned hospital expenses. The certificate of hospital treatment dated 8.09.2008 issued by Dr.Anandkumar.V, Consultant Cardiologist, which was produced to the opposite party for the refund of the amount is marked as Ext.P16. PW1 submitted all the relevant records requested by the opposite parties. But the opposite parties repudiated the same by declining critical illness claim by a letter dated 30.10.2008, which is marked as Ext.P17. The opposite parties failed to mention any valid reason for rejection of the claim. The complainant after getting proper advice regarding the sustainability of the claim re-submitted the claim application requesting to reconsider the claim for critical illness benefits along with all the relevant records. The copy of the letter dated 31.12.2008 issued by PW1 to the insurance company is marked as Ext.P18. Another letter was issued on 18th March, 2009 by the opposite party confirming their earlier decision of rejection of the claim is marked as Ext.P19. The diagnosis of Dr.Mathew Abraham at St.Mary's Hospital, Thodupuzha and consultant cardiologist of Lakeshore Hospital were based on all the above criteria mentioned in the policy conditions. The Consultant Cardiologist Dr.Mathew Abraham at St.Mary's Hospital issued a certificate dated 19.10.2009 stating that he had a Myocardial Infarction for the first time, which is marked as Ext.P21. Troponin-I Test was conducted on PW1 and the result for the same is marked as Ext.P22.
6. PW2 is a doctor who is working at St.Mary's Hospital, Thodupuzha, who is MD in General Medicine. PW2 admitted that they have issued Ext.P5 discharge summary from the hospital and in the diagnosis it is stated that Acute Non ST Elevation, Myocardial Infarction, Diabetic Hypertension and Post MI Management. PW2 deposed that on perusing the documents PW1 was treated for the first heart attack. The clinical history is written as chest pain – one hour. It is detected that the person was having heart attack from the history told by the person or from the enzyme test conducted. Ecocardiogam was also done in the hospital. A particular type of pain is caused for the heart attack and it can be understand by interrogation and the patient was fainted down. It is also recorded in the hospital records that he was advised to shift to the Lakeshore Hospital, Ernakulam for further treatment. As per the Ext.P11 certificate issued from the Lakeshore Hospital, it is written that the cardiologist Dr.Mathew Abraham stated that PW1 caused the first myocardial infarction/Heart attack on 25.07.2008. So Troponin - I test was also done which was conducted for the variation of the cardiac enzymes. On perusing Ext.P9 Coronary Angiogram Report, PW2 stated that the patient has caused heart attack on that day. On cross examination of the learned counsel for the opposite parties, PW2 stated that in the definition of first heart attack written in Ext.P3 policy, typical chest pain and elevation of cardiac enzymes were included. The death of the heart muscles were happened in the patient in this case. The enzymes positive means there is death in the heart muscles. The Troponin – I test is not the only test for deciding heart attack. As per Ext.P14, final diagnosis TYPE 2 DIABETS MELLITUS, SYSTEMIC ARTERIAL HYPERTENSION,CAD – RECENT LATERAL WALL NSTEMI, POST PTCA + STENTING TO LAD AND PTCA TO LCx(30.07.2008) PRESENT PROBLEM ACUTE GASTROENTRITIS DEHYDRATION, HYPOTENSION, ACUTE RENAL FAILURE – RECOVRED, HYPERKALEMIA – RECOVERED.
7. The 5th opposite party produced evidence as DW1. As per DW1 on going through the records and after detailed scrutiny it was found that the illness of the complainant was not according to the features specified in the policy. Ext.R1 is the Claim Note prepared by the opposite parties by referring the various records of the complainant's disease. On receiving the claim form of the complainant, the claim was registered at the company and an expert opinion was prepared by considering the opinion of the expert doctors of the medical team of the company and a claim note, Ext.R1 was prepared, which was prepared as per the detailed investigation done by the opposite parties. The opposite party prepared an office note in which all the recommendations of the officers of the opposite parties are mentioned and copy of the same is marked as Ext.R2. In Ext.P1 it is written that total/partial permanent disability, critical illness and accidental death benefit to the policy. In Ext.P3 policy schedule, first heart attack and coronary artery disease requiring surgery are written as two different critical illnesses. On cross examination of the learned counsel for the complainant, it is admitted by DW1 that World Health Organization is prescribing diagnostic procedures for heart attack, Cancer and AIDS. IN Ext.P3 policy, page CIB-1, it is written that typical chest pain if any is not mandatory.
8. As per the opposite party, it is admitted that the complainant availed a policy of Rs.50,000/- from the opposite party and also providing critical illness benefits for the first heart attack. But in the case of the complainant, on going through the records and documents brought by the complainant and after detail scrutiny it was found that the illness of the complainant was not first heart attack according to the features specified in the policy schedule. The reasons for the conclusion is read as follows :
1. Insured was diagnosed of CAD NSTEMI Double Vessel disease, which is not covered under coronary artery disease (CADS) requiring surgery
2. Class II Angina is excluded under First Heart Attack
3. Comments of cardiac enzymes were positive for myocardial infection was not supported by any specific test to ascertain the same
4. The ECG record do not indicate ST elevation
5. Coronary Angiogram report indicates lateral wall NSTEMI (Non ST Elevation Myocardial infection)
6. SGOT indicated possibility of alcoholism
7. SCK MB test did not confirm myocardial infection
It was finalised by the medical team of the opposite party and as per the expert opinion of the doctors of the opposite party. After consulting the expert doctors a report and a claim note was prepared which is marked as Ext.R1. But it is not mentioned that who are the expert doctors consulted by the opposite parties for getting an expert opinion for preparing Ext.R1 and Ext.R2 office notes. The opposite party never produced any of the expert doctors before the Forum to substantiate their contention. No experienced or qualified persons certified that the patient was not caused the first heart attack as per the conditions of the policy.
9. As per the complainant, he availed an insurance policy from the opposite party by paying a huge amount of Rs.50,000/- and at the time of availing the same Ext.P3 policy was issued by the opposite party. It is clearly mentioned in Ext.P3 policy page CIB-1 that critical illnesses to be covered includes the first heart attack.
10. So the only dispute is whether it was first heart attack ?
The complainant was admitted in St.Mary's Hospital, Thodupuzha due to severe chest pain and he was referred to Lakeshore Hospital, Ernakulam for further treatment and a total amount of Rs.1,65,990/- was expended for the same. So he is entitled to get the critical illness benefit of Rs.1,00,000/- from the opposite parties. PW2, who is a Senior Medical Practitioner in St.Mary's Hospital, Thodupuzha. On perusing the treatment records of the complainant PW2 stated that Ext.P11 discharge summary issued by the doctor from the Lakeshore Hospital, Ernakulam, it is written that history and examination of the patient – the patient was referred by Dr.Mathew Abraham MD DM, Chief Cardiologist, St.Mary's Hospital, Thodupuzha and detected that he has a history of acute coronary syndrome on 25.07.2008. It means that patient was the first heart attack/myocardial infarction on 25.07.2008. It is also deposed by PW2 that there is death has been caused to the heart muscles of the patient and Troponin - I test was also conducted on the patient. In Ext.P3 policy issued by the opposite party, the specification regarding the first heart attack is history of typical chest pain and elevation of cardiac enzymes, that was also happened in this case. It is submitted by the learned counsel for the complainant that the most modern test for detecting heart ailment is Troponin-I. In Ext.P21 certificate issued by Dr.Mathew Abraham, Consultant Cardiologist, St.Mary's Hospital, Thodupuzha, it is very clearly stated that the patient had a Myocardial infarction for the first time on 25.07.2008 and he was referred to Lakeshore Hospital, Ernakulam on 28.07.2008.
10. So we think that the complainant had a first heart attack on 25.07.2008 and it is included in the critical illness benefit of Ext.P3 policy of the opposite party and he is entitled to get the compensation as per the policy for critical illness which is for Rs.1 lakh.
Hence the petition allowed. The opposite parties are directed to pay Rs.1,00,000/-as per Ext.P3 policy to the complainant with 12% interest from the date of this petition and Rs.2,000/- as cost of this petition within one month of receipt of a copy of this order, failing which the amount shall carry 12% per annum from the date of default.
Pronounced in the Open Forum on this the 28th day of February, 2011
Sd/-
SRI. LAIJU RAMAKRISHNAN(PRESIDENT)
Sd/-
SMT. SHEELA JACOB(MEMBER)
Sd/-
SMT. BINDU SOMAN(MEMBER)
APPENDIX
Depositions :
On the side of Complainant :
PW1 - M.V. Jacob
PW2 - Dr.Joy Paul
On the side of Opposite Parties :
DW1 - James Luis
Exhibits:
On the side of Complainant:
Ext.P1 - First Premium Receipt dated 28.09.2005 for Rs.15,000/- issued by the opposite parties
Ext.P2 - Photocopy of opposite party's letter dated 1.10.2005 addressed to the complainant
Ext.P3 - Life Insurance Policy issued by the opposite parties
Ext.P4 - Topup Premium Receipt dated 4.10.2005 for Rs.35,000/- issued by the opposite parties
Ext.P5 - Discharge Summary dated 28.07.2008 issued from the St.Mary's Hospital, Thodupuzha
Ext.P6 - E.C.G Report of the complainant dated 25.07.2008 from the St.Mary's Hospital, Thodupuzha
Ext.P7 - Another E.C.G Report of the complainant dated 25.07.2008 from the St.Mary's Hospital, Thodupuzha
Ext.P8(series) - Medical Bills(16 Nos) issued from the St.Mary's Hospital, Thodupuzha
Ext.P9 - Coronary Angiogram Report dated 29.07.2008 issued from the Lakeshore Hospital, Ernakulam
Ext.P10 - Percutaneous Transluminal Coronary Angioplasty Report dated 30.07.2008 issued from the Lakeshore Hospital, Ernakulam
Ext.P11 - Discharge Summary dated 1.08.2008 issued from the Lakeshore Hospital, Ernakulam
Ext.P12(series) - Discharge Bill along with the detailed bills(6 Nos) dated 1.08.2008 issued from the Lakeshore Hospital, Ernakulam
Ext.P13 - Cash Bill dated 1.08.2008 for Rs.824/- issued from the Lakeshore Hospital, Ernakulam
Ext.P14 - Discharge Summary dated 6.08.2008 issued from the Lakeshore Hospital, Ernakulam
Ext.P15 - Detailed Discharge Bill dated 6.08.2008 issued from the Lakeshore Hospital, Ernakulam
Ext.P16 - Photocopy of certificate of hospital treatment dated 8.09.2008
issued by Dr.V.Anandkumar, Consultant Cardiologist, Lakeshore Hospital, Ernakulam
Ext.P17 - Repudiation letter dated 30.10.2008 issued by the opposite parties
Ext.P18 - Complainant's letter dated 31.12.2008 addressed to the 4th opposite party
Ext.P19 - 4th opposite party's letter dated 18.03.2009 addressed to the complainant
Ext.P20 - Policy Envelop
Ext.P21 - Certificate dated 19.10.2009 issued by Dr.Mathew Abraham, Consultant Cardiologist, St.Mary's Hospital, Thodupuzha
Ext.P22 - Troponin-I Test Result issued from the St.Mary's Hospital, Thodupuzha
On the side of Opposite Parties :
Ext.R1 - Claim Note prepared by the opposite parties
Ext.R2 - Photocopy of Office Note prepared by the opposite parties
