Delhi

North East

CC/85/2017

SH. RISHI PAL BAHL - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

08 May 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 85/17

 

In the matter of:

 

	Rishi Pal Bahl R/o A-139, Gali No.3, Rama Garden, Karawal Nagar, Delhi-110094.	Complainant
	Versus
1.         2.	The Oriental Insurance Co. Ltd Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002. Through its Chairman & Managing Director   Medi Assist India TPA Pvt. Ltd Tower D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore- 560029	Opposite Parties

 

DATE OF INSTITUTION:     JUDGMENT RESERVED ON:               DATE OF DECISION      :

10.03.2017 08.05.2019 08.05.2019

 

N.K. Sharma, President

Ms. Sonica Mehrotra, Member

 

Order passed by Ms. Sonica Mehrotra, Member

 

ORDER

1. Briefly stated, the facts giving rise to the present complaint as culled out by the complainant are that the complainant is a government servant employed with Punjab National Bank and has been availing of mediclaim / health insurance cashless policy of OP1 since 2010 through tie-up of his employer bank PNB with OP1 to provide mediclaim insurance scheme to all its employees from time to time. Complainant has submitted that before filing of the present complaint, OP1 had earlier also harassed him in 2014 when he had undergone treatment / surgery at Fortis Hospital, Gurgaon for head injury and OP1 had rejected his request for cashless facility despite policy being cashless and complainant had to pay Rs. 6,95,222/- on his own at the time of discharge and after a long battle with OP1, OP1 had finally reimbursed Rs. 5,00,000/-. The cause of action giving rise to the present complaint are that the complainant had renewed the said policy vide policy no. 272900/48/16/4104 with OP1 through its TPA, OP2 w.e.f. 08.06.2015 to 07.06.2016 for a total sum assured of Rs. 5,00,000/- against payment of premium of Rs. 6,830/- inclusive of service tax. The complainant was admitted at Fortis Hospital, Vasant Kunj, New Delhi on 12.05.2016 with complaint of headache and vertigo since two weeks and loss of appetite and sleep and was diagnosed with “SAH Coiled Acom Aneurysm” by the treating Doctor of the said hospital and was kept under observation by the doctors there. The complainant informed OP2 on the same day of admission i.e. 12.05.2016 in order to obtain approval of OP1 for mediclaim and on 13.05.2016, OP2 sought information from complainant regarding medical treatment being extended to him by the doctor in Fortis hospital which information promptly supplied by the complainant vide e-mail. From 12.05.2016 till 14.05.2016 the complainant underwent various lab tests viz CBC, Creatinine, Plasma, Serum, NCCT head, angiography of brain for addressing complaint of headache and vertigo and after successful angiography, the complainant was discharged from the hospital on 14.05.2016 in stable condition. However on date of discharge, OP2 denied to extent cashless facility to the complainant against the mediclaim policy vide e-mail on grounds that admission was for evaluation of headache only which could have been managed on OPD basis for which cashless facility cannot be extended and expressed its regret in this regard. The complainant felt aggrieved by this belated, illegal and unlawful denial by OP2 which took three long days to sit on the judgment for his treatment which could have been done on OPD basis as per them. Therefore, the complainant was forced to make the payment of Rs. 77,141/- raised by the hospital vide bill no. IPCS 961165 dated 14.05.2016 against medical expenses, room rent, drugs, consumables, investigations, doctor charges etc. Subsequent to the discharge from the hospital, when the complainant filed the claim for reimbursement of medical bills with OPs, the same was rejected by OP2 vide e-mail dated 18.06.2016 in keeping with their past conduct of arbitrary repudiation on unjustified and illegitimate grounds of repudiation under policy exclusion clause 4.10 taking defence of “No Active Line of Management warranting hospitalization and admission sought mainly for investigations”. The complainant issued a legal notice to OP1 and OP2 dated 25.06.2016 through his legal counsel demanding reimbursement of Rs. 77,141/- against mediclaim policy, which was replied by OP2 vide reply dated 13.07.2016 taking defence of exclusion clause 4.10 of Family Floater Mediclaim Policy. Thereafter, complainant registered a complaint with Insurance Regulatory and Development Authority of India (IRDA) dated 04.07.2016 against OPs but the same resulting in futility and subsequently made a reminder complaint dated 20.08.2016 to IRDA but to no avail. Lastly, the complainant was constrained to file the present complaint before this Forum alleging deficiency of service, illegal and negligent act of OPs, causing undue harassment and mental and physical torture / agony to the complainant and prayed for issuance of directions against the OP1 to reimburse the claim amount of Rs. 77,141/- to the complainant alongwith 24% interest p.a. thereon from 14.05.2016 till realization, payment of Rs. 1,00,000/- as compensation for mental tension, pain and agony caused to the complainant by OPs and cost of litigation.

Complainant has attached copy of letter dated 29.06.2014 address to OP1 with respect to non process of his mediclaim against previous policy for the period 2013-14, copy of PNB Oriental Royal Mediclaim Policy Schedule / Cover Note alongwithprospectus containing salient features of the policy and terms and conditions, copy of discharge summary dated 14.05.2016 issued by Department of Neuro Surgery Fortis Hospital, Vasant Kunj New Delhi with respect to the complainant alongwith medical investigation record in the nature of lab investigations, NCCT headand brain angiography, copy of consolidated inpatient bill dated 14.05.2016 issued by Fortis Hospital with respect to the complainant and copy of receipts of payment made there against to the tune of Rs. 10,000/-, Rs. 56,000/- and Rs. 11,141/- paid by complainant in cash and through credit card, copy of repudiation e-mail dated 18.06.2016 issued by OP2 to the complainant rejecting the claim under policy exclusion clause 4.10, legal notice dated 25.06.2016 issued by complainant to respective CMDs of OP1 and OP2 alongwith postal receipts, copy of reply by OP2 dated 13.07.2016 and copies of complaints dated 04.07.2016 and 20.08.2016 lodged by complainant against OPs with IRDA.

2. Notice was issued upon the OPs on 17.03.2017. Despite service effected on OP1 and OP2 on 24.03.2017 and 26.08.2018 respectively, none appeared on their behalf and were therefore proceeded against ex-parte vide orders dated 17.07.2017 and 12.02.2018 respectively.
3. Ex-parte evidence by way of affidavit and written arguments were filed by complainant on 12.02.2018 and 27.03.2018 respectively.
4. Complainant was issued directions vide order dated 10.07.2018 by this Forum to file a comprehensive medical literature on the disease SAH Coiled Acom Aneurysm. In compliance of the said directions the complainant filed the same on 04.10.2018 alongwith policy terms and conditions.

For proper adjudication/ assessment of the present case, it is pertinent to examine what is SAH. SAH is abbreviation for Subarachnoid Hemorrhage and is a life threatening type of brain stroke caused by bleeding into the space surrounding the brain. SAH can be caused by ruptured aneurysm, AVM or head injury and has less than half of survival rate.Symptoms are sudden onset of severe headache, nausea and vomiting, stiff neck, photophobia, blurred / double vision, loss of consciousness and seizures. One of the causes, Aneurysm is a balloon like bulge or weakening of an artery wall that ruptures, releasing blood into the subarachnoid space around the brain. It is a cause of 5 to 10 percent of strokes and can be diagnosed through CT scan, lumbar puncture, angiogram or MRI. The disease can be treated surgically of through medication depending on underlying cause of bleedings and extent of damage to the brain. Medication can be given to alleviate headache and to prevent or treat seizures and surgery in case of SAH from ruptured aneurysm by way of surgical clipping or endovascular coiling. Recovery and prognosis are highly variable and largely dependent on severity of an initial SAH. The after effects of such a disease even post surgery in the nature of common problems faced by such patients amongst others, relevant to the complainant’s case are side effects of medication producing nausea, change in appetite, fatigue due to los of sleep and most commonly headaches.

5. During the course of oral arguments, this Forum had put a specific question to the counsel of complainant in the light of the discharged summary issued by Fortis Hospital of complainant’s case being that of “Follow-up of SAH Coiled Acom Aneurysm” having being admitted for “further evaluation and management” having undergone NCCT head and cerebral angiogram that what was the “active treatment for the ailment during the hospitalized period” given to the complainant between 12.05.2016 to 14.05.2016. The counsel for complainant could only at best put forth his case for admission of complainant for headache and vertigo and loss of appetite and sleep for which he was advised admission by the doctor of Department of Neuro Surgery, Fortis Hospital Vasant Kunj New Delhi where he was treated for past SAH Coiled Acom Aneurysm disease suffered by him in 2014 and when asked about medication, if any administered to the complainant, there was none on record for the treatment.
6. A close look at the two discharge summaries issued by Fortis Hospital reveal the complainant to be a follow-up case of SAH. Coiled Acom Aneurysm with past history of endovascular coiling of Acom Aneurysm done under GA in May 2014 at Fortis Gurgaon and was admitted for complaint of headache and vertigo for further evaluation and management towards which NCCT head and cerebral angiogram was done which did not reveal any abnormality as both showed well Coiled Acom Aneurysm and complainant was discharged in satisfactory condition with no neurological deficit with “avoid stress” advice. It is therefore clear from the discharge summary that the complainant’s case was that of follow up and for further evaluation and management. For determining the “evaluation and diagnosis”, what has to be seen is the purpose of admission and nature of treatment given and its effect. In the present case, clearly no “active treatment” was given to the complainant but was admitted / referred to as a “follow up case”. Nothing significant in terms of past history and mere reference to past surgery of endovascular coiling of Acom Aneurysm under GA in 2014 is referred in the discharged summary. The chief complaints as mentioned in the discharged summary are common after effects of SAH as have been exhaustively discussed in the forgoing para particularly headache, loss of appetite and sleep and are recurring in nature.
7. Therefore, in view of the nature of disease suffered by the complainant and its after effects despite surgery coupled with the discharge summary referring to the complainant’s case as a follow-up case of his past disease for further evaluation and management, it becomes quite clear that the complainant’s case is hit by exclusion clause 4.10 of Oriental Bank Mediclaim Policy, with Family Floater which excludes “Expenses Incurred at Hospital or Nursing Home Primarily for Evaluation / Diagnostic Purposes which is not followed by Active Treatment for the Ailment During the Hospitalized Period”. The Hon’ble National Commission in Bhupinder Kumar Vs Bajaj Allianz Life Insurance Co. Ltd and Anr. I (2018) CPJ 307 (NC) had held in the light of discharge summary reports issued by the hospital that petitioner was admitted for evaluation of coronary artery status and therefore come under exclusion clause of not being covered under Critical illness thereby upholding the judgment of Hon’ble State Commission Punjab which had set aside the order of District Forum which had allowed the complaint.  Judgment relied upon by the complainant is not relevant in the particular case as there is no dispute with respect to the issuance of policy in the present case by OP, the same having being admitted in its reply to legal notice and earlier correspondence too.
8. In light of the aforementioned discussion, it becomes quite clear that notwithstanding that the illness of the complainant was not serious or diagnosis or course of action taken by Fortis Hospital by way of recommending admission was incorrect or uncalled for, the admission of the complainant was a follow-up case of SAH (his past disease) with complaints typical of after effect of such a disease and was therefore admitted for further evaluation and management and hence his mediclaim entitlement cannot be sustained and resultantly his complaint is not maintainable and dismissed accordingly with no order as to costs.  
9. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
10.   File be consigned to record room.
11.   Announced on  08.05.2019

 

(N.K. Sharma)     President

(Sonica Mehrotra)  Member