State Consumer Disputes Redressal Commission
Achanta Gopinath, S/O. Krishnaiah ... vs United India Insurance Company Ltd. ... on 6 January, 2012
BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD. FA 823 of 2010 against C.C. 19/2010, Dist. Forum-III, Hyderabad Between: Achanta Gopinath, S/o. Krishnaiah Age: 56 years, Business R/o. D-71, Madhura Nagar Hyderabad. *** Appellant/ Complainant. And United India Insurance Company Ltd. Divisional Office-IX, 206 & 207, Sapthagiri Towers Begumpet, Hyderabad Rep. by its Divisional Manager. *** Respondent/ O.P Counsel for the Appellant: M/s. U. Pratap Rao Counsel for the Respondent: M/s. S. Sravan Kumar CORAM: HONBLE SRI JUSTICE D. APPA RAO, PRESIDENT & SMT. M. SHREESHA, MEMBER FRIDAY, THIS THE SIXTH DAY OF JANUARY TWO THOUSAND TWELVE ORAL ORDER:
(Per Honble Sri Justice D. Appa Rao, President) ***
1) Appellant is unsuccessful complainant.
2) The case of the complainant in brief is that he being a member of Telugu film producers council he was covered by medi-claim policy for the period between 21.6.2008 and 20.6.2009. While so he was diagnosed that he was suffering from coronary artery disease (CAD), and as such underwent coronary angiogram which revealed triple vessel disease. On enquiry he learnt that advanced treatment was available at Oxymed Hospital Pvt. Ltd., Chennai. In the investigation it was found that he needed Enhanced External Counter Pulsation (EECP). Accordingly he underwent EECP treatment between 13.6.2009 and 8.7.2009.
He spent Rs. 1, 45,188/- towards treatment. When he submitted the claim form it was returned on the ground that EECP was not admissible under the policy. Later he submitted the claim to the insurance company for fresh appreciation as other insurance companies were settling the claims for the above treatment. However, it was repudiated on 24.8.2009. There upon he issued legal notice followed by complaint claiming Rs. 1,45,188/- with interest @ 24% p.a., from the date of claim till the date of payment together with damages of Rs. 1 lakh, and legal expenses of Rs. 2,000/- in all Rs. 2,47,188/-.
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3) The insurance company resisted the case. While admitting issuance of policy however it alleged that policy risk covered was hospitalization as per standard medi-claim policy, and the special peril was pre-existing disease and special exclusion was domiciliary hospitalization. The complainant has still to pay Rs. 96,000/- to the hospital. He did not submit the bill for Rs. 5,188/- said to have been spent towards pharmacy. The bill for Rs. 4,000/- paid towards 3 DCCG test was not admissible, and the same was excluded. EECP is a mechanical procedure in which long flatable cuffs are wrapped around patients both legs. This is accomplished with the assistance of a computer so that cuffs deflate just as each heart beat begins, and inflate just as each heart beat ends. Milking action on the leg cuffs would increase blood flow to the coronary arteries. EECP effectively pumps the blood into the coronary arteries. Indeed an invasive procedure that does the same thing. It reduces cardiac ischemia in patients with coronary artery disease.
EECP is administered as a series of outpatient treatment for seven weeks in 35 sessions. They are aimed at provoking long lasting beneficial changes in the circulatory system. However, Artery Clearance Therapy (ACT) is an alternative treatment which attempts to remove plaque build up in the arteries. It involves intravenous infusions of therapeutic doses of vitamins, minerals and amino acids over a period of 3 to 6 months. It helps in reducing the risks due to high blood pressure, high cholesterol and blood clots. The policy covers expenses on hospitalization for a minimum period of 24 hours. He did not stay 24 hours in the hospital, and as such he was not entitled to the amount under the policy. The fact of repudiation was informed to the complainant. Since it was beyond the scope of the policy, the complainant was not entitled to any amount, and therefore prayed for dismissal of the complaint with costs.
4) The complainant in proof of his case filed his affidavit evidence and got Exs. A1 to A11 marked while the insurance company filed Ex. B1.
5) The Dist. Forum after considering the evidence placed on record opined that the treatment undertaken by him is not covered by terms and conditions of the policy, and therefore he was not entitled to any amount, and consequently dismissed the complaint.
6) Aggrieved by the said order, the complainant preferred the appeal contending that the Dist. Forum did not appreciate either facts or law in correct perspective. The Dist. Forum had concluded that the insurance company had no right to say that the complainant had taken different treatment other than the treatment covered under the policy. It ought to have awarded Rs. 96,000/- payable to the hospital directly and balance to him instead of dismissing the complaint in its entirety.
7) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
8) It is an undisputed fact that the complainant being a member of Telugu film producers council he was covered by medi-claim policy for the period between 21.6.2008 and 20.6.2009. In the policy there is a categorical mention that the risks covered are hospitalization as per standard medi-claim policy, and the special peril for pre-existing disease and special exclusion for domiciliary hospitalization. It is also not in dispute that Oxymed Hospital Pvt.
Ltd. revealed that the complainant had underwent angiogram in a private hospital on 15.5.2009 and was diagnosed that he was suffering from TVD (Triple Vessel Disease), and suggested to undergo CABG ( Coronary Artery By-Pass Surgery). This treatment was approved by Food and Drug Administration and recognized by the Govt. of India for which the Govt. of Tamil Nadu has been offering the same under Tamil Nadu Chief Ministers Cashless Scheme through STAR Health Insurance entity. After due evaluation the hospital authorities have commenced ACT (Artery Clearance Therapy) for 13 sittings and EECP for 35 sittings for a period of 25 days between 13.6.2009 and 8.7.2009. The EECP package charge was Rs. 1, 19,000/- and therapy package was Rs. 17,000/-.
He had paid Rs. 17,000/- towards therapy and Rs. 23,000/- towards EECP. Still he had to pay Rs. 96,000/- to the hospital. The complainant represented that an amount of Rs. 96,000/- which he had to pay to the hospital be paid directly to the hospital as the policy covers such an ailment.
9) The insurance company repudiated the claim on two grounds (i) the procedure EECP and ACT are not covered under the policy (ii) he was treated as an out-patient all through and a minimum a period of 24 hours hospitalization is need in order to claim the amount covered under the policy. It may be stated herein that the procedure in treating the CABG through EECP is not excluded under the terms of the policy. There may be a variety of procedures in order to treat a particular ailment. Obviously that is the reason why while mentioning the treatments they were described by giving examples. The list is not exhaustive but only descriptive in nature. The insurance company could not contradict the version of the complainant when he stated that the treatment through EECP is approved by Food and Drug Administration and recognized by the Govt. of India for which the Govt. of Tamil Nadu has been offering the same under Tamil Nadu Chief Ministers Cashless Scheme through STAR Health Insurance entity. The said hospital in Ex. A9 dt. 8.7.2009 made it clear that it is an advanced treatment. The insurance company intends to give its own version by stating that it is only an alternative treatment and might be adopted for treating, however it cannot be compared with other treatments in vogue. This is not based on any medical literature or experts opinion. The insurance company did not file any affidavit evidence authenticating the procedure submitted by it in its counter or EECP is not approved form of treatment for the ailment suffered by the complainant. It is fleeting averment, and does not specifically mention as to why the complainant was not entitled to this treatment or the amount spent towards the treatment under the above said procedure. The insurance company cannot contend that said treatment is not covered under the terms of the policy. If that were to be so the procedures for any of the ailments are not mentioned in the terms of the policy. The insurance company could not prove that the procedure underwent by the complainant in Oxymed Hospital, Chennai is not approved form of treatment nor such a treatment would not come under the terms of the policy. Therefore this contention has no legs to stand.
10) The other contention that was raised is that he did not stay in the hospital for a period of 24 hours, and therefore he was not entitled to the benefits covered under the policy. Clause-2.3 makes it clear that :
2.3 Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, i.e, Dialysis, Chemotherapy, Radiotherapy; Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), D & C, Tonsillectomy taken in the Hospital / Nursing Home and the Insured is discharged on the same day, the treatment will be considered to be taken under hospitalization Benefit. This condition will also not apply in case of stay in hospital of less than 24 hours provided
a) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals.
b) Due to technological advances hospitalization is required for less than 24 hours only.
11) In the light of the above the contention that the complainant did not stay in the hospital for a period of 24 hours, and therefore he was not entitled to the benefits under the policy has no basis, and undoubtedly EECP is technologically advanced treatment where hospitalization is required for less than 24 hours was mentioned in Ex. A9. Therefore this contention also pales into insignificance. The repudiation was unjust as the claim was in accordance with the terms of the policy. Evidently the complainant paid Rs. 40,000/- as against the bill for Rs. 1,36,000/-. He has no objection for payment of Rs. 96,000/- directly to the hospital authorities.
12) In the result the appeal is allowed setting aside the order of the Dist. Forum. Consequently the complaint is allowed in part directing the insurance company to pay Rs. 1,45,188/- and out of said amount an amount of Rs. 96,000/- be paid directly to Oxymed Hospital Pvt. Ltd., Chennai, and balance of Rs. 49,188/- to the complainant. The complainant is also entitled to interest @ 9% on Rs. 49,188/- from the date of complaint viz., 26.11.2009 till the date of realization together with costs of Rs. 5,000/-. Time for compliance four weeks.
1) _______________________________ PRESIDENT
2) ________________________________ MEMBER 06 /01/2012 *pnr