Date of filing : 25.9.2017
Judgment : Dt.27.11.2018
Mrs. Balaka Chatterjee, Member
This petition of complaint is filed under section 12 of the C.P.Act, 1986 by Arnab Banerjee alleging deficiency in service against opposite parties (referred as OP hereinafter) (1) Managing Director, National Insurance Company, (2) Anil Kumar Barija, (3) Mr. M.V.Subhramanium, (4) Mr. Joginder Paul, (5) Mr. Soumitry Chowdhury, (6) Mr. Ranjiv Roy and (7) Tarun Chakraborty.
Case of the Complainant in brief is that the Complainant obtained a Health Insurance Policy of being No.100400501610006351 issued by the National Insurance Company Limited for the Complainant, along with his wife and daughter and renewed the policy every year by paying premium regularly till date and, subsequently, increased the insured sum amount from Rs.2,00,000/- to Rs.5,00,000/- in 2012 and paid the same till 2017, which was duly received by the OPs. The Complainant has stated that he had suffered from severe chest pain on 6th June, 2017 and got admitted to Lilavati Hospital in Mumbai and doctors of the said Hospital namely Dr. Nitin Gokhale and Dr. Yash Lokhandwala found that the Complainant had been suffering from Arrhythmia and was in need of immediate support of pacemaker and, therefore, the Complainant got the pacemaker implanted in his chest and thereafter released from the Hospital on 13.6.2017.
It is stated by the Complainant that on 21.6.2017 he submitted the claim with the OP for reimbursement of the amount which he had spent for his treatment but the claim was repudiated by the OP. Insurer vide letter dated 17.08.2017 on the ground that the Complainant suffered from genetic disease, which was not covered under the Policy as per terms of exclusion Clause No.4.11. It is further stated by the Complainant that thereafter he requested OP No.4 for review the claim submitting two certificates issued by Dr. Nitin Gokhale and Dr. Yash Lokahandwala explaining that Arrhythma was not a genetic disease but that request yielded no fruitful result and the Complainant again requested the OP No.3 to settle the claim but that too went in vain and, therefore, finding no other alternative, the Complainant by filing the instant Consumer Complaint prayed for direction upon the OP to pay claimed amount along with compensation and litigation cost which is Rs.6 lakhs as cost of operation Rs.2 lakhs as compensation and Rs.1 lakh as litigation cost.
The Complainant annexed photocopies of Policy document, Receipt dt.15.9.2016, Policy Schedule, Premium Certificate, Claim Form, Query letter issued by Heritage Health Insurance TPA Pvt. Ltd. Prescription dt.6.6.2017 issued by Dr. Nitin S. Gokhale Certificate dt.31.7.2017 issued by Dr. Nitin S. Gokhale, letter dt.10.8.2017, 17.8.2017 issued by Senior Divisional Manager of National Insurance Company Ltd. repudiating claim of the Complainant.
The OP Nos.1 to 5 contested the case by filing written version denying and disputing all the allegations made out in the petition of complaint stating inter alia, that the Complainant was admitted in Lilavati Hospital for treatment of Hypertrophic Cardiomyopathy and after careful examination of documents enclosed to claim form the TPA rejected the claim of the Complainant o n the ground that hypertrophic Cardiomyopathy is genetic in origin and as per exclusion clause No.4.11 of the National Mediclaim Policy repudiated the said claim. The OPs have further stated that after examining the documents filed with the claim the RCRC stated that “Vertriculae Trachycardia is a sign and not a disease. Its identifiable cause in this case is hypertrophic cardiomyopathy. No other cause is found in documents. ICD implant is not done in a healthy heart. It is only done in presence of structural disease which is unfortunately attributable to a genetic disorders and not covered under policy as they are excluded under clause 4.11. Therefore, claim cannot be re-considered for payment and is recommended for repudiation as per clause 4.11”.
The Insurance Company referred the matter to a Senior Consultant Intervention Cardiologist namely Dr. Aftab Khan who in his advice dt.7.8.2017 also opined that hypertrophic cardiomyopathy is genetic disease. It is further stated by the OPs that as genetic disorders are not covered under the policy so repudiation of claim is absolutely lawful.
Accordingly, the OPs pray for dismissal of the case.
The OPs annexed photocopies of policy document, provisional repudiation letter issued by Heritage Health Insurance TPA Pvt. Ltd., Medical Officer Reviews, letter dt.27.7.2017 issued by National Insurance to the Complainant.
The Complainant by filing a petition prayed for treating the petition of complaint as affidavit-in-chief. Prayer was allowed. Similarly, OPs also prayed for treating the written version as evidence. Prayer was allowed. Both the parties filed questionnaire and reply respectively.
In course of argument Ld. Advocate for the Complainant narrated the facts as mentioned in the petition of complaint. It is submitted by the Ld. Advocate of the Complainant he has obtained another policy from another company and on filing claim said company reimbursed the claim.
The Complainant has filed written notes of argument which is captioned wrongly as “The written argument filed on behalf of the opposite parties” same appears to be a bona fide mistake.
The Complainant has reiterated that repudiation of the claim by the OP Insurer is very much unlawful and in this connection he relied upon the decision of Hon’ble National Commission reported in (1) 1(2016) CPJ 16B NC [Star Health and allied Insurance Company Ltd. VS Dr. Srinivasa Charyulu & anr.]
(2) (2016)CPJ 23B(CN) (Guj) [Saktish Ramanll Panchal vs New India Insurance Co. Ltd.].
(3) 1(2010) CPJ 514 [ICICI Prudential Life Insurance Company vs Anil Kumar Jain] including other decisions.
Ld. Advocate for the OP Nos.1 to 5 submitted that as per terms of the Exclusion Clause being No.4.11 any disease of genetic origin is not covered under the insurance policy and, therefore, repudiation of the claim is very much lawful and, hence, the OPs have no deficiency in providing service. This Op relied upon the decision reported in (1) 1(2016) CPJ 16B NC [Star Health and allied Insurance Company Ltd. VS Dr. Srinivasa Charyulu & anr.]
(2) (2016)CPJ 23B(CN) (Guj) [Saktish Ramanll Panchal vs New India Insurance Co. Ltd.].
(3) 1(2010) CPJ 514 [ICICI Prudential Life Insurance Company vs Anil Kumar Jain] and many other citations.
Points for determination
- Whether repudiation of claim is justifiable?
- Whether the Complainant is entitled to relief as prayed for?
Decision with reasons
Point No.1
Admittedly, the Complainant along with his wife and daughter obtained a Health Insurance Policy being No.100400501610006351 issued by the OP, Insurer. Admittedly, the said policy has been renewed and in force. There is no dispute as to the statement that the Complainant fell ill and the Complainant claimed to have obtained Health Insurance Policy from the National Insurance Company and renewed the same every year and in 2012 increased the Insurance amount from 2 lakh to 5 lakh. In support of such contention filed photocopy of Policy documents.
The Complainant has stated that he was admitted in Lilavati Hospital on 6th June, 2017 and had pacemaker implanted in his chest, thereafter filed claim form to the OP National Insurance Company for reimbursement of expenditure incurred by him for implantation but the OP, by a letter dt.17.8.2017 repudiated the claim of the Complainant on the ground that treatment received by the Complainant for such disease which is genetically existed within the Complainant.
The OP have stated that as per their rules the Insurance Company sent the claim file to the TPA and as per recommendation of the Doctor of the TPA the claim was repudiated.
On perusal of provisional repudiation letter dt.14.7.2017 issued by Heritage Health Insurance TPA Pvt. Ltd., it appears that ground taken for repudiation is “As per discharge certificate of ‘Lilavati Hospital and Research Centre’ patient was admitted for treatment of Hypertrophic Cardiomyopathy. As evident from prescription of Dr. Nitin S. Ghokhale patient is known case of Hypertrophic Cardiomyopathy. Present illness due to cause of complication of Hypertrophic Obstructive Cardiomyopathy which is genetic in origin. Hence, this claim is not admissible and stands repudiated………………………”.
However, it appears from certificate issued by the treating Doctor i.e. Dr. Nitin S. Gokhale that “Ventricular trachycardia which occured is not a genetic disease. It is a sequel of hypotraphic cardiomyopathy (hcm). It may also occurs in patients do not have hcm”.
It further appears from the certificate issued by another treating doctor i.e. Dr. Yash Lokhandwala where he opined “I have been treated Arnab Banerjee since the last 4 months. He had Hypertrophic Cardiomyopathy and Ventricular Tachycardia. His condition is not congenital. It must be covered by medical insurance”.
To sum up, the Complainant got admitted to hospital for his treatment. After getting recovered, the Complainant submitted his claim to the OP- Insurer for disbursement of the claim amount dispute with the OPs cropped up regarding disbursement of the claim as the OP Insurer repudiated that claim. As to the ground of repudiation the OPs have stated that the disease “Hypertrophic obstructive cardiomyopathy“ from which the Complainant has suffered is genetic by origin.
On perusal of certificates issued by the treating doctors namely Dr.Nitin S. Gokhale and Dr. Yash Lokhandwala, it appears that both of them in an unequivocal language have stated that the Complainant was not suffering from any disease which was genetic in nature. On the other hand, the OPs have filed opinion of their doctors namely Dr. C. P. Sharma and Dr. Aftab Khan.
Both doctors who had treated the patient/ Complainant certified that the disease from which the patient was suffering is not a disease of genetic origin.
The OPs repudiated the claim holding the said disease was of genetic origin since their doctor opined “Complication of HOCM which is genetic in origin” and Dr. Aftab Khan holds that “in Mr. Arnab Banerjee case, the Vt in the back ground of HCM as a cardiac disease, justifies the use of ICD. HCM is a genetic disease and patients of HCM & VT need ICD implantation to prevent sudden cardiac death”.
On perusal of the opinions of the said doctors stated by OPs, it appears that the said opinion does not necessarily mean that the Complainant was suffering from genetic disease especially when the treating doctor namely Nitin Gokhale opined that “Ventricular trachycardia which occured is not a genetic disease. It is a sequel of hypotraphic cardiomyopathy (hcm). It may also occurs in patients do not have hcm”. Moreover, had the OPs preferred to challenge the opinion of treating doctors, they ought to have prayed for opinion of an expert to be appointed by this Forum. However, the OPs did not make such prayer. Therefore, opinion of the doctors who physically examined and treated the patient are the best persons to say whether HCM is a genetic disease.
In such view of the matter, we hold that the exclusion clause is not applicable to the instant case and therefore repudiation of the claim is not justifiable.
The Complainant has stated that he obtained another Health Insurance policy issued by Oriental Insurance Company Ltd. and after filing claim regarding the ailment in respect of which he has filed claim with the OP – National Insurance Company Ltd. and the said Orientgal Insurance Paramound Health Services & Insurance TPA Pvt. Ltd.
Company settled his claim by disbursing an amount of Rs.3,00,000/- holding that the said ailment is not genetic in origin.
Point No.1 is decided accordingly.
Point No.2
The Complainant has prayed for direction upon the OP Insurer to settle the claim by disbursing an amount of Rs.6,00,000/-. On perusal of the Policy Documents, it appears that the insured sum is fixed as Rs.4,00,000/- apart from Rs.80,000/- as Company Employee Insurance. It is, therefore, evident that upper limit of disbursable amount is Rs.4,00,000/-. Therefore, prayer for disbursement of Rs.6,00,000/- cannot be allowed. Documents on record show that the Complainant spent an amount of Rs.6,41,087/- towards medical treatment for the ailment in respect of which he has filed his claim.
Under such state of affairs, we are of opinion that the Complainant is entitled to get Rs.4,00,000/- as to medical expenses to be disbursed by the Insurer.
Further, the Complainant has prayed for Rs.2,00,000/- towards compensation. The Complainant, however, did not explain that the quantum of loss he had compelled to suffer for which an amount of Rs.2,00,000/- is to be payable by the OP, Insurer. However, it is true that time factor effects value of money under such circumstances we are inclined to award Rs.30,000/- towards compensation.
Further, the Complainant has prayed for Rs.1,00,000/- towards cost of litigation. In our considered view an amount of Rs.10,000/- is just and proper for cost of litigation.
Point No.2 is decided accordingly.
In the result, the Consumer Complaint succeeds in part.
Hence,
Ordered
That CC/563/2017 and the same is allowed in part on contest against OP Nos.1 to 5 and allowed ex-parte against OP Nos. 6 & 7.
The OPs are directed to pay Rs.4,00,000/- towards insured sum to the Complainant within one month from the date of this order.
The OPs are further directed to pay Rs.30,000/- towards compensation and Rs.10,000/- towards cost of litigation within aforesaid period. Failing which the amount shall carry interest @ 6%p.a. from the date of this order till realization thereof.
