DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 24th day of June, 2024
Present : Sri. Vinay Menon V., President
: Sri. Krishnankutty N.K., Member Date of Filing: 29/10/2021.
CC/183/2021
K.N. Kajahussain,
S/o. Noor Muhammed,
Gopika House, Ramanathapuram,
Palakkad – 678 001. - Complainant
(By Adv. K.B. Sujith)
Vs
The Branch Manager,
M/s. Star Health & Allied Insurance Co. Ltd.,
R.K. Building, Opp. Chitturkavu,
Chittur, Palakkad – 678 101. - Opposite party
(By Adv. M/s. P. Ratnavally & Kiran G Raj A)
O R D E R
By Sri. Vinay Menon V., President
- Skeletal pleadings requisite for judicial appreciation of disputes are that the complainant and his family are the beneficiaries under a health insurance policy issued by opposite party. Complainant suffered cardiac issue leading to hospitalization and surgery in two hospitals. Claims raised for indemnification of expenses incurred in both these hospitals were repudiated on the ground of pre-existing diseases. Complainant was not suffering from any pre-existing disease. Aggrieved by the repudiation of claim, this complaint is filed seeking consideration of the claims raised along with compensation and incidental expenses.
- OPs filed detailed version stating that they had, upon verification of the medical records submitted by the complainant, directed the complainant to obtain a letter from the treating doctors clarifying some queries which were not forwarded to the OP even after repeated reminders. It was under these circumstances that the opposite party had repudiated the claim on the grounds of non-submission of required documents and not disclosing pre-existing disease.
- The following issues were framed for consideration:
- Whether the condition suffered by the complainant was pre-existing?
- Whether there is deficiency in service or unfair trade practice on the part of OP?
- Whether the complainant is entitled to any of the reliefs sought for?
- Any other reliefs?
4. (i) Documentary evidence of complainant comprised of proof affidavit and Exhibits A1 to A5. Complainant was examined as PW1.
Marking of Ext. A2, A3 & A5 are objected to on the ground that they are photocopies. Since this Commission not bound by Indian Evidence Act and as the OP has no case that the said documents are forged or fabricated, said objections are over ruled.
(ii) O.P. filed proof affidavit and marked Ext.B1 to B9. Marking of Exts.B5 & B8 are
objected to on the ground that the complainant had not received the said letter. We are of the opinion that non receipt of a letter cannot eschew the evidentiary value of a document. Hence, they are taken on record.
(iii) Documents called for and produced by OP are marked as Exts.C1 series.
(iv) Documents called for from LIC are marked as Exts.X1 and X2.
Issue No.1
5. Facts are admitted that the complainant was hospitalized for treatment pertaining to acute coronary syndrome-evolved inferior wall myocardial infarction (ACS – IWMI). He had underwent coronary artery angiography. He was admitted thereafter in AIMS for treatment of triple vessel coronary artery disease and sinus rhythm. Complainant had underwent surgery in AIMS. Upon receipt of the claim and medical records, the OP had issued a query letter dated 3/8/2021 seeking the following documents:
1) Letter from treating doctor stating the exact duration of TVCADS and when it was first diagnosed;
2) First consultation details;
3) Previous history of CAD TVD; and
4) Previously taken ECG, ECHO, CAG.
Subsequent reminders issued also went unheeded. It is in these circumstances that the O.P. had repudiated the claim.
6. The definition clause in Ext. B1 (Page 10) defines a pre-existing disease as follows:
“Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice/treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.”
7. In this case, the complainant has been hospitalized in two hospitals, first one being the Thankam Hospital, Palakkad. Since the treatment availed in AIMS is a follow-up of the treatment in Thankam Hospital, details of AIMS can be considered as corollary to the treatment carried out in Thankam Hospital.
8. Ext.A2 is the discharge summary issued from the Thankam Hospital. Period of hospitalization was from 13/4/2021 to 17/4/2021. The presenting complaints as shown therein is reproduced below:
“45 years old male. Type 2 DM – Newly detected, family H/O CAD, H/O burning chest discomfort on 12/4/2021 at 12 noon followed by extreme fatigue. H/O extreme tiredness past one day”.
9. The question that is to be considered is whether this condition i.e. coronary artery disease (CAD) was pre-existing or not. Admittedly this condition is not shown as a pre-existing condition in Ext. B2 proposal form as on 29/9/2020. As per the definition of pre-existing disease, for the purpose of issuing a policy, it should be any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice/treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.
10. Even though Ext. A2 discharge summary shows that the condition as one that had started on 12/04/2021, a day prior to hospitalization in Thankam hospital, the OP was not satisfied with this explanation. Hence, they sought for clarification by way of issuing Exts.B5 and B8. Per OP, they had also issued other reminders which were dated 1/9/2021 and 16/9/21. Inspite of issuance of Ext.B5 & B8 and reminders, the OPs had not produced the details. Therefore O.P. repudiated the claim.
11. At the behest of OP, the LIC of India had produced two sets of documents which were marked as Exts. X1 and X2. Ext. X1 is a policy issued by LIC to the complainant. Ext. X2 is a set of medical records of medical checkup underwent by the complainant for availing Ext.X1 policy. These medical examiner’s confidential report is dated 23/9/2020. On that day, the complainant underwent ECG, Computerized TMT, Haemogram test, routine urine analysis and special biochemical tests. It is after considering all these test results that the medical examiner’s confidential report is prepared.
The ECG report shows that the condition of the complainant’s heart is normal. Clinical finding with regard to cardiovascular system is ‘S1 S2 normal’. The ECG report is seen attested by the cardiologist attached to Rajiv Gandhi Co-op. Hospital, Palakkad.
Further it is also seen that the computerized treadmill test was carried out for 6 minutes and 50 seconds. The report shows that TMT is negative, which connotes that the required heartrate of 150 bpm was achieved without showing any changes in the ECG results.
All these tests were carried out on 23/9/2020. The proposal form, Ext.B2 is dated 29/9/2020 i.e. 6 days after carrying out the tests forming part Ext.X2. Thus, we can see that the complainant was healthy when Ext.B2 proposal was taken immediately subsequent to undergoing Ext.X2 tests.
12. This, in our opinion is a conclusive proof that the complainant was of ample health and was free of pre-existing cardiac disorders.
13. Ext. A2 makes mention of Type-2 DM which was recently discovered. Conspicuously this condition is absent in Ext. X2 medical records, which was availed merely months before hospitalization. But as the O.P. has no dispute regarding DM, we confine the discussions to cardiovascular conditions suffered by the complaint alone.
Issue No. 2
14. Even though we have come to a conclusion that the complainant was not suffering from any pre-existing cardiac diseases, one vital aspect is that even after the opposite party had filed version and stated that they had sought for relevant details from the treating doctor, the complainant had failed to produce these documents. In our opinion even though the complainant states that they are not in receipt of the communications seeking production of documents the OP had sought for, they could have very well produced the letters from treating doctors even after the initiation of this complaint. This a duty on the part of complainant to produce the entire documents as sought for by the insurer so as to alleviate any chances of defrauding the company which is the handler of public money.
15. Exts. X1 & X2 came to our notice only after the OP had taken any solid steps. Only when one appreciates the contents of Ext. X2 can it be found that the complainant had undergone a series of tests prior to preparing the proposal form of LIC. The complainant remained a mute spectator rather than being of any assistance to this Commission in coming to a conclusion in the dispute. Merely opposing the marking of Exts.B5 and B8 on the grounds of non-receipt, when the addresses shown in the said documents are the same as that was given by the complainant, would not do away with their liability to produce documents as sought for by the insurer.
16. The O.P.’s conduct was merely a natural outcome of the conduct of the complainant in not handing over of the details as sought for by the O.P. Conduct of the O.P. is contractually valid. On an over-all appreciation of the attenuating facts, we do not find deficiency in service on the part of OP in repudiating the claim.
Issue No. 3
17. Yet, considering the facts that the complainant had underwent a series of tests which showed him in perfectly good condition with regard to cardio vascular system on 23/9/2021, we are of the opinion that the complainant is entitled to receive the benefits under the policy.
Issue No.4
18. Balancing the observations and findings in Issue Nos.1 to 3, we hold as herein below:
1) The complainant is entitled to the claims raised in both cases of hospitalization, payable in accordance with the terms and conditions of the policy.
2) Since the entire dispute arose as a result of the irresponsible conduct on the part of the complainant, we are not allowing interest on the amounts receivable by the complainant, compensation or cost.
3) The opposite party shall comply with this order within a period of 45 days from the date of receipt of a copy of this order, failing which the O.P. shall pay a solatium of Rs.500 per month or part thereof to the complainant from the date of this order till the date of payment of the amounts as ordered above.
Pronounced in open court on this the 24th day of June, 2024.
Sd/-
Vinay Menon V
President
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 - Original Insurance Certificate
Ext.A2 - O Copy of discharge summary issued from Thankam hospital.
Ext.A3 - Copy of discharge summary issued from AIMS
Ext.A4 – Printout of repudiation letter bearing No.CIR/2022/181226/2804045
dated 4/10/2021
Ext.A5 – Original covering letter dated 27/11/2020 issued to complainant by LIC
Exhibits marked on the side of the opposite party:
Ext.B1 - Copy of family health optima insurance plan terms & conditions & certificate of
insurance
Ext.B2 – Printout of common proposal form
Ext.B3 - Copy of discharge summary dated 17/4/2021 from Thankam hospital
Ext.B4 - Printout out of coronary angiogram report.
Ext.B5 - Copy of communication dated 17/8/2021
Ext.B6 - Copy of repudiation of claim dated 4/10/2021 of claim No.CIR/2022/181226/2804045
Ext.B7 - Copy of discharge summary from AIMS.
Ext.B8 - Copy of communication dated 3/8/2021
Ext.B9 - Copy of repudiation letter dated 4/10/2021 of claim No.CIR/2022/181226/2524626
Court Exhibit:
C1 series - Documents submitted by complainant before OP for raising claim.
Third party documents:
X1 – True copy of LICs Accident Benefit Rider Certificate of insurance and terms and conditions
X2 – Copies of medical examiner’s confidential report and MRI Scans & other medical reports.
Witness examined on the side of the complainant:
PW1 – Kaja Hussain (Complainant)
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
