PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

                                                           CONSUMER COMPLAINT NO.140/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Smt. Madhusmita Panda,

W/O-Sri. Padman Kumar Tripathy

R/O-Burla, Tripathy Classes, PO/PS-Burla, Sambalpur

Dist-Sambalpur-768017.                                                         …….…......Complainant.

                                    -Vrs.-

The Branch Manager, Star Health and Allied Insurance Company Limited,

 2^nd Floor, Quality Mansion Nayapara,

Dist-Sambalpur-768001.                                                         …………........Opp.Party

Counsels:-

1. For the Complainant         :- Sri. P.K. Nath & Associates
2. For the O.P.                        :- Sri. B.K. Purohit, Adv.

Date of Filing:12.09.2023,Date of Hearing :27.02.2024, Date of Judgement : 15.04.2024

  Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complainant is that health policy insurance No. P/191214/01/2021/003681 for Rs. 5.00 lakhs was taken by Complainant for her family for the period 22.10.2020 to 21.10.2021 and paid premium of Rs. 21,654/- to cover accident and health related issues. On 02.01.2021 when the Complainant felt suffocated with chest, neck lower back pain etc. for checking and treatment went to Sanjeebani Hospital, Dr. Byomakesh Dexit, Cardiologist Echocardiogram and Electrocardiography along with Angiogram tests made. Angiogram was done on 10.01.2021, wherein it was detected high pulse rate and irregular function of heart.

Third round check-up was done on 17.01.2021 by Dr. Byomakesh Dixit but when could not got any solution the Complainant was referred to Dr. Anupam Jena, Cardiologist, Pradyumna Bal memorial Hospital, KIMS. The Complainant was admitted on 21.01.2021 in KIMS. The doctor advised for RFA operation of heart. The O.P. was informed for cash less treatment but the O.P. regreted denying cashless with reason “longstanding aliment and Complaint failed to produce all disease related documents.” The O.P. advised to submit all documents for reimbursement.

Dr. Anupam Jena conducted Radio frequencies Ablation(RFA) operation, frequent PVS, Drug Refractory, CAG normal coronaries and successful Ablation of PVC in RV OT. Problem was detected and the Complainant discharged on 24.01.2021. The hospital authority charged Rs. 2,47,000/-

Claim No. 2188609 made and the O.P. sort for original bills and treatment papers. It was submitted but the O.P. not settled the claim. Being aggrieved complaint was filed.

2. The O.P. in reply submitted that policy is admitted. The Complainant was admitted in KIMS on 21.01.2021 and discharged on 24.01.2021 for treatment of SINUS TACHYCARDIA VENTICULAR BIGEMINY. Due to uncertainly in treatment cashless was not allowed but the claim was submitted later on:

The Complainant was having pre-existing disease sinus Tachycardia Ventricular beigeminy since 22.10.2020 prior to inception of the policy and was undergoing treatment since January 2021. From ALTATION REPORT dated 22.01.2021 the patient was having recurrent history of palpitation SOB (Shortness of Breath), Presyncope frequent PVC which was also ascertained from ECG report dated 06.08.2005. Prior to policy inception the Complainant was suffering from sinus Techycardia and it was not disclosed while taking the policy. As per exclusion clause the Complainant has violated policy terms and conditions. The repudiation made is proper and the Complainant is not entitled for any relief.

3. Perused the documents filed by the Complainant.

1. Policy No. P/191214/01/2021/003681 or the period 22.10.2020 to 21.10.2021.
2. Query on cashless treatment dated 20.01.2021.
3. Denial of Pre-authorisation request for cashless dated 21.01.2021.
4. KIMS bills for payment.
5. Discharge Summary of KIIMS.
6. Ablation Report dated 22.01.2021
7. Coronary Angiography Report dated 22.01.2021.

The O.P. filed the following documents:

1. Copy of policy insurance with schedule and terms.
2. Copy of proposal.
3. ECG report dated 06.08.2005
4. Ablation Report dated 22.01.2021
5. Declaration letter of Dr. B. Dixit.
6. Cashless rejection letter.

4. It is the admitted case of both the parties that the Complainant was initially under the supervision of Dr. Byomakesh Dixit and then shifted to Dr. Anupam Jena, Cardiologist, KIIMs, Bhubaneswar. The Complainant was admitted in KIIMs from 21.01.2021. to 24.01.2021 and during the period policy No. P/191214/01/2021/003681 was in force.

The allegation and rejection of claim No. 2188609 of the Complainant by O.P. is due to suppression of facts about the pre-existing disease since 2005 which is observed from Ablation report dated 22.01.2021 and ECG report dated 06.08.2005. The Complainant has violated the policy terms conditions. Although in the list of documents the O.P. mentioned E.C.G. report of 2005 but not filed any report except the ECG graphs and from graphs it can not be ascertained that the graphs belong to the Complainant of the year 2005. Likewise the O.P. not filed any repudiation letter of the claim and even not mentioned on which dated the claim was repudiated.

Taking into consideration the pleading of the parties and documents submitted following issues are framed:

1. Whether the Complainant suppressed the pre-existing disease SOB and vilated the insurance contract?
2. What relief the Complainant is entitled to get?

Issue No.1: Whether the Complainant suppressed the pre-existing disease SOB and violated the insurance contract?

The Complainant was admitted in KIIMs under the supervision of Dr. Anupam Jena being referred by Dr. B. Dixit, Cardiologist, Sanjeevani Hospital on 22.01.2021. The doctor conducted frequent PVC, Drug Refractory, CAG-Normal Coronaries and Ablation of PVC in RV OT(Posterior Walls and Lower point). The discharge Summary of Dr. Jena Clearly reflects the Complainant was operated through surgery/course in the hospital: CAG & Successful Ablation of PVC in RV OT (Posterior Walls and Lower point) on 22.01.2021 and during discharge advised to follow up review after one month in cardiology OPD. The ablation report dated 22.01.2021 reflects recurrent history of palpitation SOB, Presyncope and frequent PVC. Learned advocate for O.P. submitted that the insured has suppressed the pre-existing disease and violated the terms and condition of policy thereby repudiation is proper. In this respect filed Bajaj Allianz Life Insurance Co. Ltd. & others Vs. Dalbir Kaur Case 2020 ACJ-3009 of the hon’ble Supreme Court.

In the other hand the Complainant submitted that Health/Medical Insurance Policies did not cover pre-existing conditions and complications arising there from. Rejection of policy, when the insured is her-self unaware of any conditions prior to her treatment then in such case the repudiation is not proper. The Complainant cited Manmohan Nanda Vs. United India Assurance Co. Ltd & another (2022) 4 SCC-582.

A mediclaim Policy is generally taken by an insured to seek indemnification in report of a sudden illness or sickness which is not expected or imminent. In such case the sudden illeness or ailment is not excluded from the policy. Accordingly, duty is casted upon the insurer to indemnify the insured for the expenses incurred thereon.

In the present case the O.P. has not filed any documentary evidence to prove the pre-existing disease.

Secondly the treating physician in discharge note clearly opined that the insured was under his treatment for ventricular Bigeminy is a cardiac arrhythmia single ectopic heat or irregular heartbeat. In ventricular bigeminy, a sinus beat is shortly followed by premature ventricular contraction (PVC) a pause, another normal beat and then another PVC. It is related with the heart. Previously it was not aware of by the insured. In such condition the issue goes in favour of the Complainant. Although the repudiation letter has not been filed, the repudiation is not proper.

Issue No.2 What relief the Complainant is entitled to get?

Taking into circumstances of the case the Complainant is entitled for the relief claimed for as the OP not applied its mind while rejecting the cashless and also the final settlement of claim.

Accordingly, the following order is passed:

ORDER

          The complaint is allowed on contest against the O.P. The O.P. is directed to pay Rs. 2,47,000/- with 7 % interest w.e.f. dated of discharge i.e. 24.01.2021 within one month of this order failing which the O.P. shall be liable to pay 12% interest per annum till realisation. The O.P. is liable for compensation amounting to Rs. 50,000/- and litigation expenses of Rs. 10,000/-

Order pronounced in the open court on 15^th day of April 2024

Supply free copies to the parties.