State Consumer Disputes Redressal Commission
National Insurance Co. Ltd. vs Vineet Mahajan & Anr. on 6 May, 2019
IN THE STATE COMMISSION: DELHI
(Constituted under Section 9 of the Consumer Protection Act, 1986)
Date of Decision:06.05.2019
First Appeal No.575/2016
(Arising out of the order dated 26.08.2016 passed in Complaint Case No.
186/2015 by the District Consumer Disputes Redressal Forum (Central),
Kashmere Gate, Delhi)
National Insurance Co. Ltd.,
National Legal Vertifcla (NLV),
2E/9, Jhandewalan Extension,
New Delhi -110005. .....Appellant
Versus
1. Vineet Mahajan,
S/o Shri Ravinder Mahajan,
2. Smt. Shruti Mahajan,
W/o Shri Vineet Mahajan,
BOTH RESIDENT OF
77-C/6, Mukesh Nagar,
Circular Road, Delhi -110032. ....Respondent
CORAM
Justice Veena Birbal, President
Ms. Salma Noor, Member
1. Whether reporters of local newspaper be allowed to see the judgment?
2. To be referred to the reporter or not?
Justice Veena Birbal, President
1. This is an appeal under Section 15 of the Consumer Protection Act, 1986 (in short, the "Act") against order dated 26.08.2016 passed by the Consumer Disputes Redressal Forum (Central) Delhi (in short, the "District Page 1 of 8 Forum") in Complaint Case No.186/2015 whereby the aforesaid complaint has been allowed and appellant/OP is directed as under:
1) Pay to the complainants as sum assured of Rs.3 lacs as reimbursement of the expenses incurred for the treatment of complainant No.2.
2) Pay to the complainants a sum of Rs.30,000/- as compensation of pain and agony suffered by them.
3) Pay to the complainant a sum of Rs.5,000/- as cost of litigation.
2. Briefly facts relevant for the disposal of the present appeal are that a complaint under Section 12 of the Act was filed by the respondent herein i.e. the complainant before the District Forum stating therein that respondents/complainants had taken a mediclaim insurance policy from appellant/OP, which was effective from 22.07.2014. The sum assured under the policy was Rs.3,00,000/- for each of the respondents/complainants. It was stated that during the subsistence of the policy, respondent No.2/complainant No.2 was admitted in Max Hospital, Patparganj, Delhi wherein she was diagnosed as a case of Post-partum Cardiomyopathy, pneumonia with massive pleural effusion with sever sepsis with septic shock. She was admitted on 12.12.2014 and was discharged on 22.12.2014. A sum of Rs.5,51,387.87 was incurred on her treatment. Respondents/complainants had informed the appellant/OP about admission in the hospital and requested for cashless facilities, which was denied. It was stated that after discharge, a claim was filed before the Page 2 of 8 appellant/OP, however, the same was not settled. Finding deficiency in service on their part, respondents/complainants filed a complaint before the District Forum seeking the total value of claim alongwith compensation and litigation costs.
3. Complaint was opposed by the appellant /OP by filing written statement, wherein the issuance of mediclaim policy in favour of the respondents/complainants and sum assured therein was admitted. It was stated that the policy was issued subject to its terms and conditions. It was stated that the claim was repudiated as respondent No.2/complainant No.2 was suffering from post-partum cardiomypathy, which was related to pregnancy. It was stated that such a claim was not payable under Clause 4.7 of the policy. Appellant/OP had prayed for dismissal of the complaint.
4. Rejoinder was filed by the respondents/complainants wherein it was stated that clause 4.7 of the policy is not applicable in the present case. Respondents/complainants had reiterated the averments made in the complaint.
5. Both the parties filed evidence by way of affidavits. After hearing the parties and considering the documents on record, i.e. Ex. CW 1/8 to CW
-1/8, Ld. District Forum held that respondent No.2/complainant No.2 had suffered from right side pneumonia with pleural effusion which had led to septicaemia. It was further held that the same was not related to or termed as a disease arising from or traceable to pregnancy. Accordingly, ld. District Forum allowed the complaint and directed the appellant/OP to pay the sum Page 3 of 8 assured alongwith compensation and costs of litigation, as has been stated above.
6. Aggrieved with the aforesaid order present appeal is filed.
7. Ld. counsel for appellant/OP has submitted that prior to admission in Max Hospital respondent No.2/complainant No.2 had delivered a child at Dr. Hedgewar Arogya Sansthan on 01.11.2014 and the delivery was normal. It is contended that thereafter due to problem of breathlessness she was admitted in Max Hospital, Patparganj, Delhi where she remained admitted on 12.12.2014 and was discharged on 22.12.2014. It is contended that Ld. District Forum ignored the final diagnosis of respondent No.2/complainant No.2 as Post Partum Cardio myopathy, which is diagnosis recorded in the discharge summary dated 22.12.2014 Ex. cw- 1/3 issued by Max Hospital. It is contended that aforesaid discharge summary shows that for evaluation of breathlessness, echo was done, which revealed global hypokinesia with LVEF - 35-40% with mild MR & minimum pericardial effusion and cardiologist opinion was taken. It is further submitted that in view of post partum period, gynaecologist opinion was also taken. It is contended that patient was evaluated and assessed for post partum cardiomyopathy and cardiologist and gynaecologist opinion were also taken and the patient was accordingly treated. It is contended that District Forum has not correctly appreciated the material on record. It is submitted that the impugned order is liable to be set aside.
8. On the other hand, ld. counsel for the respondents/complainants has argued that order passed by the District Forum is correct. It is Page 4 of 8 contended that respondent No.2/complainant No.2 had suffered right side pneumonia with pleural effusion which led to septicaemia and had taken treatment for the same and the said disease was not connected in any manner with the pregnancy nor the same can be alleged to have arisen from pregnancy. It is contended that there are medical certificates i.e. Ex. CW - 1/8 to CW -1/10 on record produced by the respondents/complainants which were given by the doctors of the hospital wherein respondent No.2/complainant No.2 was admitted and had taken treatment and for which bills were raised. It is contended that in the aforesaid medical certificates it is clearly stated that respondent No.2/complainant No.2 was admitted in the hospital with severe breathlessness with cough and fever and was provided treatment for pneumonia. In support of stand taken, medical certificates are also filed. It is stated that aforesaid certificates clearly show that disease for which respondent No.2/complainant No.2 had taken treatment was not connected with pregnancy in any manner as has been alleged.
9. We have heard the counsel for the parties and perused the material on record.
10. Repudiation Clause 4.7 of the policy as relied upon by appellant/OP is as under:
"4.7 Pregnancy - Treatment arising from or traceable to pregnancy/childbirth including caesarean section, miscarriage, surrogate or vicarious pregnancy, abortion or complications thereof including changes in chronic conditions arising out of pregnancy other Page 5 of 8 than ectopic pregnancy which may be established by medical reports."
11. Ld. counsel for appellant/OP has also relief upon discharge summary dated 22.12.2014 Ex. CW-1/3 of respondent No.2/complainant No.2 issued by Max Hospital. The relevant portion of the same is as under:
"FINAL DIAGNOSIS:
POST PARTUM CARDIOMYOPATHY (LVEF-35-40%) PNEUMONIA (RIGHT) WITH MASSIVE PLEURAL EFFUSION SEVERE SEPSES WITH SEPTIC SHOCK (RECOVERED) REASON FOR ADMISSION: breathlessness, fever and cough HISTORY OF PRESENT ILLNESS: Patient presented with complaints of increasing breathlessness since 1 week. She also complained of cough since same duration associated with fever.
COURSE IN HOSPITAL: Patient was admitted with above mentioned complaints in emergency. In view of severe respiratory distress (cause right side massive pleural effusion) urgent inter costal drain was put in right pleural cavity and sent for detailed investigation. She was started on I/V antibiotics, bronchodilators, non invasive support, oxygen enriched air, fluid resuscitation and other supportive treatment. For evaluation of breathlessness, her ECHO was done which revealed global hypokinesia with lVEF-35-40% with mild MR and minimal pericardial effusion and cardiologist opinion was taken. In view of persistent hypotension, multiple inotropic supports were started. In view of falling saturation on NIV support, patient was intubated on 14-12-2014. All cultures were sent of which vaginal swab culture revealed E. Coli and treatment was modified accordingly. Her USG abdomen was suggestive of moderate asicites with multiple retro peritoneal lymph nodes. pleural fluids reports suggestive of lymphocytic, exudative in nature with high ADA (cytology for malignant cell was negative), Page 6 of 8 ATT was started. In view of deranged KFT, nephrologist opinion was taken and advice incorporated. In view of post partum period gynecologist opinion was also taken. Patient was gradually improved with the treatment and was exctubated on 18-12-2014 and right sided inter costal drain was also removed. Hematologist opinion was taken for persistently low leukocyte count. Patient improved and was shifted to ward. Now patient is being discharged in stable condition to follow up in OPD.
12. Ld. counsel has submitted that aforesaid document clearly shows that respondent No.2/complainant No.2 was diagnosed with post partum cardiomyopathy (LVEF 35-40%), pneumonia (right) with massive pleural effusion several sepsis with septic shock. It is contended that post partum cardiomypathy, is connected to pregnancy, as such appellant/OP is not liable to pay for treatment.
13. We have gone through the discharge summary Ex. CW-1/3 reproduced above in detail. It is clearly mentioned therein under the heading „History of Present Illness‟ that patient was admitted due to increase breathlessness since 01 week and was having complaint of cough in that period which was associated with fever. The aforesaid document shows that course provided to her in hospital was related to severe respiratory distress. The treatment provided to her in the hospital was mainly for the said disease. Medical certificates on record given by the doctor who provided treatment to her as well as on behalf of hospital i.e. Ex. CW -1/8 to CW -1/10 show that cardiomyopathy was an incidental finding and not a cause leading to her problem. The patient had septicaemia and the cause for the same was right side pneumonia with massive pleural Page 7 of 8 effusion. Respondent No.2/complainant No.2 had taken treatment for a disease which was not falling under Clause 4.7 of the policy.
14. In view of the above, we find no illegality or infirmity in the impugned order. Accordingly, appeal stands dismissed.
15. A copy of this order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum for information. The record of the District Forum be also sent forthwith.
Thereafter, the file be consigned to record room.
(Justice Veena Birbal) President (Salma Noor) Member Tri Page 8 of 8