State Consumer Disputes Redressal Commission
Icici Prudential Life Insurance Co. ... vs Smt. Anamika Mishra on 9 June, 2015
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
WEST BENGAL
11A, Mirza Ghalib Street, Kolkata - 700087
First Appeal No. FA/1340/2013
(Arisen out of Order Dated 07/11/2013 in Case No. CC/269/2012 of District Kolkata-II)
1. ICICI Prudential Life Insurance Co. Ltd.
15, Ganesh Chandra Avenue, 3rd Floor, P.S. Bowbazar,
Kolkata - 700 013.
2. ICICI Prudential Life Insurance Co. Ltd.
Chakraborty Ashok Nagar, Ashok Road, Kandivali(E),
Mumbai - 400 101. ...........Appellant(s)
Versus
1. Smt. Anamika Mishra
W/o Dinesh Kumar Mishra, AG-333, Satelite Manor
Krishnapur Hanapara, Kestopur, Kolkata - 700 102. ...........Respondent(s)
BEFORE:
HON'BLE MR. DEBASIS BHATTACHARYA PRESIDING MEMBER
HON'BLE MR. JAGANNATH BAG MEMBER
For the Ms. Soni Ojha , Advocate
Appellant:
For the
Mr. Ashish Chakraborty., Advocate
Respondent:
ORDER
Date: 09-06-2015 Sri Debasis Bhattacharjee This appeal emanates out of Order dated 07-11-2013, passed by the Ld. District Forum, Kolkata Unit II in C. C. No. 269/2012, by which the complaint case has been allowed on contest against the OPs. Being aggrieved by and dissatisfied with the same, OPs thereof have preferred this appeal.
Case of the Complainant, very shortly, is that she lodged a mediclaim with the OP for a sum of Rs. 1,50,000/- against her treatment at Apollo Gleneagles Hospital. However, vide its letter Page 2 of 9 dated 28-05-2010, the OPs repudiated her claim on the ground that criteria were not fulfilled, hence no benefit payable. Although she sent protest letter against the same, no positive response came through from the side of the OPs. She moved a petition before the Insurance Ombudsman, Kolkata for redressal of her grievance. After hearing both sides, the Ombudsman allowed ex gratia payment of Rs. 30,000/-. Hence, the complaint case.
OPs disputed such claim of the Complainant stating that in the event a life insured is diagnosed to be suffering from any one of the specified critical illnesses, the benefit payable should be to the extent and subject to the fulfillment of the conditions specified for each critical illness and subject to the policy being in force on the date of diagnosis. Clause 2.1 (c) of the terms and conditions runs as follows:
"Any cerebrovascular incident resulting in permanent neurological deficit and including infraction of brain tissue, hemorrhage and embolisation from an extra cranial source. Diagnosis has to be confirmed by a neurologist and by typical clinical symptoms and by CT scan or MRI of the brain. Evidence of neurological deficit for at least 3 months has to be produced."
From the above clause, it is clearly manifested that if the above mentioned conditions are fulfilled, only then the policyholder is entitled for the benefit under the subject policy.
In the present case, on the basis of the claim and medical documents submitted by the Complainant herself it was revealed that the Complainant was diagnosed of 'Subarachnoid Hemorrhage due to ruptured aneurysm' and there was no symptom of permanent neurological deficit in the Complainant. In order to take benefit under the above clause, the Complainant had to prove with medical documents confirmed by a neurologist that the cerebrovascular incident had resulted into permanent neurological deficit which she Page 3 of 9 has failed to prove in this case. Accordingly, the claim of the Complainant was rightly repudiated.
The Ld. District Forum decided the case in favour of the Complainant directing OPs to pay Rs. 1,50,000/- as insurance benefit together with compensation and litigation cost of Rs. 15,000/- and Rs. 10,000/-, respectively.
Decisions with reasons Ld. Advocate for the Appellants has submitted that in terms of clause 2.1 (c) of the policy in question, evidence of neurological deficit for at least 3 months has to be produced. However, no such evidence has been put forth by the Respondent. In fact, in order to remove any ambiguity and to authenticate and substantiate the fact that the disease was congenital, they sought the opinion of Dr. C. H. Asrani, medical expert who opined that the neurological deficit was drowsiness and not weakness/paralysis etc. The Respondent has been shown to have recovered from the same. It is also evident from the discharge report that the Complainant was alert and stable at the time of discharge. As the Respondent did not meet the prerequisite conditions mentioned in the terms and conditions, the Appellants rightly repudiated the claim. The Respondent has failed to adduce any evidence to show that she had actually undergone 'permanent neurological deficit' as defined under clause 2.1(c) of the terms and conditions of the policy. So, the claim of the Respondent was rejected. Thereafter, the Respondent moved the Insurance Ombudsman and as per its order, the Appellants complied with the said order by sending a cheque for an amount of Rs. 30,000/- to her, but for some obscure reasons, she did not encash the same and instead moved a complaint case before the Ld. District Forum. The Ld. District Forum erred in holding that illness of the Complainant was critical and comes under the purview of definition 'stroke' as per terms and conditions of Clause 2.1(c). It further erred in holding that period of neurological deficit is not the subject matter to justify repudiation. As such, the impugned order be set aside.
Ld. Advocate for the Respondent strongly opposed such Page 4 of 9 contention of the Appellants and stated that medical reports on record sufficiently prove that she suffered stroke. Such illness being covered under the policy in question, she is entitled to get insurance benefit. From such perspective, there is no infirmity with the impugned order. The award passed by the Ld. District Forum being a just and reasoned order, the same be upheld.
Ostensibly, the 'Health Assurance' policy issued by the Appellants in favour of the Respondent was meant to reimburse medical treatment costs incurred by the Insured for six critical illnesses, viz., Cancer, Heart Attack, Stroke, Heart By Pass surgery, Kidney failure and major Organ Transplant (as recipient).
The pivot of instant dispute revolves over the fact whether or not her illness qualifies as 'Stroke' to be eligible to get reimbursement of treatment costs incurred by the Respondent.
Citing Clause 2.1(c) of the terms and conditions of the policy, it is contended by the Appellants that an Insured is entitled to reimbursement of treatment costs if it is established that the Insured has suffered permanent neurological deficit, including infarction of brain tissue, hemorrhage, and embolisation from an extra cranial course and such diagnosis has been confirmed by a Neurologist, and last but not the least, such neurological deficit existed for at least three months. Although it is evident from the CT scan report that the Respondent suffered hemorrhage, and that presence of hypodense in bilateral frontal lobe is suggestive of infarct, she did not conform to the third parameter, i.e., her neurological deficit did not last three months. For obvious reasons, therefore, the instant claim of the Respondent has been rightly repudiated by the Appellants.
Ld. Advocate for the Appellants also tried to make light of the situation stating that her neurological deficit was drowsiness and not weakness/paralysis etc. As per the discharge certificate, the Respondent was alert and stable at discharge indicating that her neurological deficit had disappeared after surgery for evacuation of clot and clipping of aneurysm.
Page 5 of 9We must state here that there always remains many a slip between the cup and the lip. So, it is probably not fair to equate a 'reasonably alert' state of health of a person with '(fully) alert' condition. Nowhere in the discharge certificate was it mentioned that at the time of discharge, the Respondent was in a stable condition. In fact, it was mentioned in the discharge summary that, 'At the time of discharge, she was reasonably alert, obeying commands and speaking words and short sentences. She had started taking a pureed diet orally. She had a catheter-in-situ.' It is also evident from the document on record that such was the condition of the Respondent on 26-03-2010 that she could not put her signature on the Claim Statement Form: Health Claims for which she put her thumb impression and the same was endorsed by Dr. Rajendra Misra, MBBS MS., FRCS. Lastly, the gravity of the situation can be ascertained from the following letter written by Dr. Harsh Jain dated 04-02-2011, who treated the patient.
"Dear Dr. Gudhka, This is with reference to the claim of Mrs. Anamika Mishra (Policy No. 06009328).
This patient had come to our hospital (Apollo Gleneagles, Kolkata) with a severe subarachnoid haemorrhage from a ruptured anterior communicating artery aneurysm (Date of admission - 14-02-2010). She underwent microsurgical clipping (Date of Surgery - 15/02/2010) and had a very stormy course in the ICU and ward, as a result of the severity of the bleed. Eventually, however, she made a very good recovery and is now leading a normal life. She would be considered a triumph of good medical and surgical treatment.
However, her claim was refused on the grounds that she did not have any deficit at the 3-month stage and hence did not qualify as a 'stroke' according to the insurer's guideline.Page 6 of 9
Surely, as an experienced clinician, you would see the fallacy of this argument. Here on the one hand, we have a patient who nearly died from severe brain haemorrhage, whom we managed to save, with a very good functional result, and they are denying that her condition was not serious enough. This is an unbelievable situation and I am sure you can use your good offices to convince the provider to the contrary and honour the claim.
I will be very grateful if you could kindly get back to me on this.
Besh wishes, Sd/-
Dr. Harsh Jain"
There can be no manner of doubt that a treating doctor is the best judge to give proper account about the state of health of his patient on any given day. That apart, keeping in mind the fact that Dr. Jain is an expert in the field of Neurology; on the other hand, Dr. C. H. Asrani, a DNB (Family Medicine); MBBS, in the parlance of Neurology, the opinion of the former would always prevail over the latter.
Be that as it may, the Appellants banked upon the 'Central Nervous System Questionnaire' form filled up by Dr. Harsh Jain dated 19-05-2010 where prevailing mental status of the patient was described as, 'Alert, oriented, normal speech' to prove that the Respondent did come round before the threshold limit of three months and thereby, did not fulfill the criterion stated in the terms and conditions of the policy.
However, we should appreciate that the said form described the state of health of the Respondent as on 19-05-2010 and not 14- 05-2010 when the threshold of three months attained. Nowhere in the said form there is any mention of the fact Respondent was in the pink of her health as on 14-05-2010. So, on the basis of a Page 7 of 9 certificate dated 19-05-2010, it cannot be said with certainty that the Respondent was doing fine on 14-05-2010.
As per the Oxford Dictionary, 'Stroke' means 'A sudden disabling attack or loss of consciousness caused by an interruption in the flow of blood to the brain, especially through thrombosis'. The Oxford Learner's Dictionary defines 'Stroke' as 'a sudden serious illness when a blood vessel (= tube) in the brain bursts or is blocked, which can cause death or the loss of the ability to move or to speak clearly'. 'Stroke' is defined as 'a medical condition in which blood is suddenly blocked and cannot reach the brain, or in which a blood vessel in the brain breaks, often causing a loss of the ability to speak or to move particular muscles' by Macmillan Dictionary. Merriam Webster Medical Dictionary defines 'stroke' as, 'sudden diminution or loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction (as by a clot) of a blood vessel of the brain--called also apoplexy, brain attack, cerebral accident, cerebrovascular accident'.
Going by the above definitions, it appears, duration of neurological disorder of a person cannot be the appropriate parameter to determine whether a particular illness was a stroke or something else. The Appellants have not brought on record any scrap of paper from any medical expert in the field of Neurology to suggest that the illness of the Respondent was not 'Stroke' in medical term. While the Appellants sought to give it a completely new avatar by linking the same with duration of illness, it was of paramount importance that the Respondent was taken into confidence before signing the proposal form to enable her take a judicious decision to opt/back out of such a policy. On going through the copy of proposal form, however, we find that only the benefits illustration of the policy was disclosed to her implying that while signing it she did not get the due opportunity to study the full text of the terms and conditions of the policy, including the definition of 'Stroke' as subsequently communicated to her in the form of policy schedule. We feel, parties to a contract should remain conscious of the full text of the terms and conditions of a contract before signing an agreement. Withholding full text of definitions of important wordings prior to signing a proposal form and merely Page 8 of 9 mentioning the names of illnesses in conventional medical term to a prospective Insured is almost like 'Aswodhama Hoto Iti Gaja', for which the truthful Judhistir had to face hell once. In this case, it was setting a time frame of three months to qualify for indemnification in case of occurrence of 'Stroke'. The Appellants cannot reject a claim citing any particular stipulation in the policy document which was not disclosed to the Respondent before signing the proposal form. As a service provider, Insurer is not supposed to play trick with an Insured, but the other way round. Surely, in this particular case, conduct of the Appellants has fallen vastly short of the standard of probity expected of any customer centric organization.
True, the Respondent had the opportunity to come out of the contract within the free-look period, however, the IRDA (Protection of Policyholders' Interests) Regulations, 2002 mandates that a policyholder has to be informed of such stipulations by sending a forwarding letter to this effect. However, the Appellants have not placed on record any such document to prove that they complied with such regulatory directive. As policy schedule contain innumerable terms and conditions, virtually it is near impossible for a policyholder to take note of each and every aspect of the policy. On the other hand, as a service provider, it was obligatory on the part of the Appellants to remain strict-compliant of such regulatory directive, which for some inexplicable reasons was honoured in its breaches.
While the Appellants themselves are guilty of violating statutory directive, as discussed hereinabove, it is indeed surprising that they repudiated the claim of the Respondent on hyper-technical ground. It was also confirmed when the Insurance Ombudsman, Kolkata granted ex gratia of Rs. 30,000/- in the matter to the Insured. Those who live in glass-houses should not pelt stones at others.
By issuing the health policy, the Appellants sought to indemnify the Insured/Respondent in the emergence of perils on account of any of the six critical illnesses as stated hereinabove. Therefore, it was but natural that they would stick to their stated Page 9 of 9 commitments. By creating distorted definition of diseases, which has got no relevancy in medical term, and that too keeping the Insured totally in the dark about such stipulation, they cannot take helpless consumers for a ride and get away with impunity. The documents on record sufficiently prove that the Respondent suffered 'stroke' going by its conventional medical term and therefore, the Appellants must reimburse the medical cost incurred by the Respondent to the maximum limit of sum assured, i.e., Rs. 1,50,000/-. There is no infirmity with the award passed by the Ld. District Forum in favour of the Respondent. However, considering the facts and circumstances of the case, the Appellants are accorded additional time to comply with the impugned order.
In the result, the appeal succeeds in part.
Hence, ORDERED that the appeal be and the same is allowed in part on contest. Appellants are directed to comply with the impugned order within 40 days from the date of this order, i.d., punitive damage @ Rs. 500/- per day shall be payable from this day till full and final payment is made. The impugned order is otherwise affirmed in toto.
Let a copy of this order be sent to the Ld. District Forum along with the LCR.
JAGANNATH BAG DEBASIS BHATTACHARYA
MEMBER MEMBER