State Consumer Disputes Redressal Commission
National Insurance Co. Ltd. vs Sushil Mohini Gupta on 11 February, 2019
IN THE STATE COMMISSION: DELHI
(Constituted under Section 9 of the Consumer Protection Act, 1986)
Date of Decision: 11.02.2019
First Appeal No. 426/2014
(Arising out of the order dated 28.03.2014 passed in complaint case No. 657/2011 by the
District Consumer Disputes Redressal Forum (West), Janakpuri, New Delhi-110058)
In the matter of:
National Insurance Company Ltd.
Regional Office No.2,
2 E/9, Jhandewalan Extension
New Delhi-110051 ..........Appellant
Versus
Smt. Sushil Mohini Gupta
R/o C-24, 65, Janak Puri,
New Delhi-110058. ........Respondent
CORAM
JUSTICE VEENA BIRBAL - PRESIDENT
SALMA NOOR - MEMBER
1. Whether reporters of local newspaper be allowed to see the judgment?
2. To be referred to the reporter or not?
SALMA NOOR - MEMBER
1. Present appeal is preferred against the order dated 28.02.2014 passed by the Ld. District Consumer Disputes Redressal Forum, Janakpuri, in complaint case no. 657/2011 whereby the complaint of the respondent/complainant has been allowed.
2. Briefly stated case of the respondent/complainant before the Ld. District Forum was that she was holder of a "Varistha Medical Policy"
No.361801/48/10/8500005034 for the period 25.01.2011 to 24.01.2012 and the total sum assured was Rs.3lacs, consisting of Rs.1lac towards coverage of hospitalization and Rs.2lacs coverage towards critical illness. The policy was Page 1 of 7 designed to cater to the needs of senior citizens. It was stated that Coronary Artery Surgery was covered under the critical illness. Besides Hospitalization Benefits were also covered which included cost of pacemaker alongwith other allied hospital/medical treatment expenses e.g. Room Boarding expenses, Nursing Home fees of Surgeon. It was stated that on 13.08.2012 respondent/complainant had undergone Coronary Artery Surgery on the advice of Dr. Anshul Jain, Cardiologist at Action Medical Institute, Paschim Vihar, New Delhi. The total medical bill of treatment was Rs.2,73,739/-. It was stated by the respondent/complainant that as per policy terms and conditions she was eligible for cashless treatment at the hospital but appellant/OP did not approve the same. It was stated that the total cost of the treatment was Rs.2,73,739/- but appellant/OP paid only Rs.40,000/-.
3. It was further stated that respondent/complainant was not allowed to leave the hospital until all the payments were made. Husband of respondent/complainant tried to contact the appellant/OP-1 but received no effective response from their side. Respondent/complainant wrote a letter on 23.08.2011 followed by reminder dated 12.09.2011 but there was no response from appellant/OP-1. Thereafter, a legal notice dated 24.09.2011 was served to appellant/OP-1 still no payment was made. Aggrieved by the conduct of the appellant/OP-1, respondent/complainant filed a complaint before the Ld. District Forum with the following prayers:-
a. OP should be directed to pay the balance of medical treatment bill of app.Rs.2,34,000/-.
b. OP should be directed to pay Rs.50,000/- toward unwarranted mental agony and harassment mooted to the complainant and her husband who is 83 years Page 2 of 7 old and had to run pillar to post for realization of claim, which has not been paid till date.
c. Interest charges @18% from the date of discharge from the Hospital i.e. 21.08.2011 till realization of the amount.
4. Reply was filed by appellant/OP-1 stating therein that claim was settled as per terms and conditions of the Insurance Policy. It was submitted that as per discharge summary issued by Sri. Balaji Action Medical Institute, respondent/complainant was admitted in the hospital on 12.08.2011 and discharged on 21.08.2011 with a history of two episodes of syncope where PPI (DDDR) was implanted under medical advice. It was further stated that the disease for which the respondent/complainant was treated by the hospital did not fall under the critical illness definition of Insurance Policy. Hence, claim was not admissible against critical illness for which sum insured was Rs.2 lacs.
It was further stated that claim papers of respondent/complainant were submitted to Third party Administrator (TPA) and her claim was settled by the TPA for Rs.97,000/- against sum insured for Rs.1 lac in full and final settlement of the claim strictly considering the terms and conditions of the policy. Hence any further liability to pay the claim amount was not covered under the policy. The appellant/OP 1 had denied deficiency in service as was alleged.
5. Respondent/complainant had filed rejoinder wherein it was stated that as per prospectus given alongwith the Varistha Medical Policy mentioned that Coronary Artery Surgery was covered under critical illness cover as per section II and cost of pace maker under Hospitalization was payable. It was stated that appellant/OP was having its own concept of critical illness. It was stated that Page 3 of 7 Webster‟s Encyclopedic Unabridged Dictionary defines it as "patient‟s condition unstable and abnormal vital signs and other unfavorable indicators as loss of appetite or unconsciousness." Respondent/complainant denied that her claim was not admissible against „critical illness‟ for which sum assured was Rs.2 lacs. Respondent/complainant had reiterated the contents of complaint.
6. Both the parties had led evidence by way of their respective affidavits and also filed written arguments. The Ld. District Forum after hearing the parties had held as under:-
"We hereby order that claim of the complainant be settled, treating her ailment as critical illness and reimbursement be made accordingly after making fresh calculations and adjustments of the amount already paid alongwith interest at the rate of 6% per annum from the date of filing of the complaint till realization of the amount. A compensation of Rs.25,000/- is awarded to the complainant for the inconvenience and hardship caused to her."
7. Aggrieved by the aforesaid order of Ld. District Forum, present appeal is filed by appellant/OP-1.
8. Respondent/complainant filed reply to the appeal.
9. We have heard counsel for parties and perused the material on record.
10. Ld. Counsel for appellant/OP has contended that present was a case of implantation of pacemaker and not of coronary artery bypasses graft (CABG) which is for different kind of coronary artery disease. It is contended that policy in question does not include pace maker implantation as such appellant/OP had rightly repudiated the claim. It is contended that District Forum has arbitrarily ignored the terms and conditions of the policy including critical illness as is mentioned in Section II of the policy.
Page 4 of 7
11. On the other hand, Ld. Counsel for Respondent/complainant has contended that pacemaker was implanted after surgery as per medical advice and the same falls under the category of critical illness and the District Forum has rightly allowed the complaint.
12. It is admitted position that respondent/complainant had taken policy in question from appellant/OP. It is also admitted position that respondent/complainant had heart ailment due to which she remained admitted at Sri Balaji Action Medical Institute, Pashchim Vihar, New Delhi from 12.08.2011 to 21.08.2011. As per discharge summary dated 21.08.2011 issued by aforesaid hospital, respondent/complainant was admitted in aforesaid hospital with h/o two episodes of syncope. She was evaluated extensively-MRI Brain, HUTT test, ECG, Holter, Carotid Dopler & Echo were one. She was noted to be LBBB. She was taken up for CAG+/-EPS. Coronary Angiography showed normal coronaries. During EPS respondent/complainant had asystole and then 2:1 AV blockes as such Permanent Pacemaker was implanted i.e. PPI (DDDR).
13. As per contention of appellant/OP implantation of PPI (DDDR) is not covered under critical illness. Critical illness cover is given in Section II of policy which is reproduced as under:
"Section II: Critical Illness Cover:
The company shall pay to the Insured Person, the compensation as set against such Insured Person's name in the Schedule; should and Insured Person be diagnosed, during the period of insurance set in the schedule, as suffering from a critical illness, symptoms (and/or the treatment) which were not present in such Insured Person at any time prior to inception or this Policy.
Definitions Stroke.....
Cancer.....Page 5 of 7
Renal Failure.....
Major Organ Transplant.....
Multiple Scierosis.....
Coronary artery surgery.
........The actual undergoing of open chest surgery for the correction of two or more coronary arteries, which are narrowed or blocked, by coronary artery bypass graft (CABG). The surgery must have been proven to be necessary by means of coronary angiography. Angiography and/or any other intra-arterial procedures are excluded from this definition......
.................
................."
14. As noted above respondent/complainant was a heart patient and was admitted in hospital with h/o two episodes of syncope. All the requisite tests were done and was noted to be LBBB i.e. Left Bundle Branch Block. During EPS she had asystole and then 2:1 blockes due to said reason PPI (DDDR) was implanted. PPI is implanted when there is irregular heart beat. Irregular heart beat may cause cardiac arrest. PPI is implanted for regular blood supply to the heart. Implantation of pacemaker is a surgical process which had to be surgically placed into the chest of respondent/complainant due to her critical condition. PPI (DDDR) i.e. pace maker was implanted to prompt the heart to beat at a normal rate. It is an artificial device that electrically stimulates the heart‟s muscle to cause it to contract to initiate a heartbeat. It is a small, lightweight electrical device surgically placed inside in the upper chest area. PPI/DDR was implanted to regulate blood supply of the heart which means she was suffering from critical illness. Further the surgery was done on the advice of Dr. Anshul Jain, Cardiologist at Action Medical Institute, Paschim Vihar, New Delhi. In view of the above discussion, we are of the view that Page 6 of 7 appellant/OP had wrongly repudiated the claim on the ground that the same does not fall under critical illness definition of insurance policy.
15. We find no reason to disagree with the reasoning given by Ld. District Forum in allowing the complaint.
16. We find no substance in the appeal filed by the appellant/OP-1, in result appeal is dismissed and the order of the Ld. District Forum is upheld.
17. A copy of the order as per the statutory requirement be forwarded to the parties free of charge and also to the concerned District Forum. Thereafter, the file be consigned to record room.
(Justice Veena Birbal) President (Salma Noor) Member (fatima) Page 7 of 7