State Consumer Disputes Redressal Commission
Raman Kumar vs Apollo Munich Health Insurance on 30 January, 2018
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No. 590 of 2017
Date of Institution : 10.08.2017
Date of Reserve : 17.01.2018
Date of Decision : 30.01.2018
Raman Kumar, 92, Kot Baba Deep Singh Nagar, Jalandhar,
Punjab, Presently 162, Aman Nagar, Jalandhar.
....Appellant/Complainant
Versus
1. Apollo Munich Health Insurance Company Limited, 2nd and
3rd Floor, ILABS Centre, Plot Number 404-405, Udhyog Vihar,
Phase III, Gurgaon-122016, Haryana through its Managing
Director.
2. Apollo Munich Health Insurance Company Limited, SCO No.
146, 2nd Floor, Feroze Gandhi Market, Ludhiana-141 001 through
its Branch Manager.
....Respondents/Ops
First Appeal against the order dated
7.2.2017 of the District Consumer
Disputes Redressal Forum, Ludhiana.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member.
Shri Rajinder Kumar Goyal, Member
First Appeal No. 590 of 2017 2
Present:-
For the appellant : Sh. P.K. Kukreja, Advocate
For the respondents : Sh. Sachin Ohri, Advocate
GURCHARAN SINGH SARAN, PRESIDING JUDICIAL MEMBER
ORDER
The appellant/complainant (hereinafter referred as complainant) has filed the present appeal against the order dated 7.2.2017 passed by the District Consumer Disputes Redressal Forum, Ludhiana (hereinafter referred as the District Forum) in consumer complaint No. 124 dated 27.2.2015 vide which the complaint filed by the complainant was dismissed.
2. Complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short 'the Act') against the respondents/opposite parties (hereinafter referred as Ops) on the averments that he purchased online health insurance policy from Ops for sum insured of Rs. 5,00,000/- bearing policy No. 10002766 for the period 11.2.2012 to 10.2.2013. During the substance of the abovesaid policy, on 26.12.2012, the complainant suffered heart attack and was treated at Dayanand Medical College & Hospital, Ludhiana for CAD-Unstable Angina, which leads the heart attack. As per the terms and conditions of the policy in case of acute illness, the complainant is entitled to lumpsum amount of Rs. 5,00,000/- from the Ops. Duly covered under the definition of critical illness, the complainant lodged his health insurance policy claim with Ops but surprisingly, Ops First Appeal No. 590 of 2017 3 repudiated the claim on flimsy ground by virtue of decision dated 17.12.2014 sent to the complainant on 31.12.2014. The inference drawn by the Ops with regard to the illness of the complainant is wholly based upon conjecture and surmises. Before filing the present complaint, legal notice dated 17.1.2015 was served upon the Ops. Alleging deficiency in service on the part of Ops, complaint was filed by the complainant before the District Forum seeking payment of Rs. 5,00,000/-, sum insured alongwith compensation of Rs. 50,000/- and litigation expenses of Rs. 11,000/-.
3. Upon notice, Ops appeared and filed their written reply taking preliminary objections that the complaint is not maintainable as the policy was purchased from Jalandhar and no cause of action had arisen in favour of the complainant against Ops at Ludhiana; the claim filed by the complainant is false, frivolous and vexatious, therefore, it is not maintainable, therefore, complaint is liable to be dismissed. In brief facts, issuance of the policy for the period 11.2.2012 to 10.2.2013 was issued. The complainant was admitted with D.M.C. & Hospital, Ludhiana with a complaint of chest pain and provisional diagnosis was unstable angina and request for cashless claim was received with an estimate of Rs. 15,000/- Queries were raised on 27.12.2012 stating that "kindly provide all past treatment records of heart disease with duration certified by treating doctor, with present positive investigation report". The complainant provided written certificate of Dr. N. Aslam in which it was stated that complainant was diagnosed as a First Appeal No. 590 of 2017 4 case of Unstable Angina, therefore, possibility of pre-existing condition could not be ruled out, therefore, cashless facility was not extended and complainant was advised to submit the claim for possible reimbursement. The complainant thereafter submitted a claim form on 2.2.2013 for a sum of Rs. 18,952/-. The Ops after reviewing the medical documents made a payment of Rs. 14,663/- vide cheque bearing No. 184330 dated 13.3.2013 from HDFC bank. Thereafter the complainant lodged another claim of Rs. 5 Lacs. On reviewing the documents, it was noted that disease CAD-Unstable Angina does not qualify the definition of critical illness. With regard to condition of first heart attack of specific severity, it required the following criteria:-
"A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial infarction(for e.g. typical chest pain)."
Therefore, there was no history of dyspnoea, palpitation, cough, fever or fatique/syncope. The medical literature provides signs and symptoms for heart attack as under;-
"a) Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back.
b) Nausea, indigestion, heartburn or abdominal pain.
c) Shortness of breath. (Dyspnoea)
d) Cold sweat.
e) Fatique.
f) Light-headedness or sudden dizziness."
First Appeal No. 590 of 2017 5
Therefore, the condition of the complainant did not fulfill symptoms of heart attack as there was no tightness, no nausea, no shortness of breath (Dyspnoea), no cold sweat, no fatique / syncope, no light-headiness. The electrocardiogram should show to have:-
"a) Acute inferior myocardial infarction ST elevation in the inferior leads II, III and aVF Reciprocal ST depression in the anterior leads
b) Acute anterior myocardial infarction * ST elevation in the anterior leads VI - 6, I and aVL * reciprocal ST depression in the inferior leads
c) Acute posterior myocardial infarction * (hyperacute) the mirror image of acute injury in leads VI- 3 * (fully evolved) tall R wave, tall upright T wave in leads VI - 3 * usually associated with inferior and/or lateral wall MI However, after going through the ECG finding of the complainant, it does not fulfill the symptom of heart attack. With regard to elevation of Infarction specific enzymes, Troponins or other specific biochemical markers, the medical literature provides as under;-
"Cardiac enzyme studies measure the levels of enzymes and proteins that are linked with injury of the heart muscle. These include the enzyme creatine kinase (CK), and the proteins troponin I (TnI) and troponin T (TnT). Low levels of these enzymes and proteins are normally found in your First Appeal No. 590 of 2017 6 blood, but if your heart muscle is injured, such as from a heart attack, the enzymes and proteins leak out of damaged heart muscle cells, and their levels in the bloodstream rise. Because some of these enzymes and proteins are also found in other body tissues, their levels in the blood may rise when those other tissues are damages. Cardiac enzyme studies must always be compared with your symptoms, your physical examination findings, and electrocardiogram (EKG, ECG) results."
Therefore, medical documents of the complainant establish that cardiac enzymes values are not raised and were in normal limits. On the basis of these findings, the Ops rejected the claim and it was duly communicated to the complainant. Therefore, the complaint filed by the complainant is false, frivolous and vexatious and is not covered under the terms and conditions of the policy. Complaint is without merit, it be dismissed.
4. Before the District Forum, the parties led their respective evidence.
5. In support of his allegations, the complainant had tendered into evidence his affidavit Ex. CA and documents Exs. C1 to C-16. On the other hand, Ops had tendered into evidence affidavit Ex. RA and documents Ex. Op1 to OP9.
6. After going through the allegations in the complaint, written reply filed by the OPs, evidence and documents brought on the record, the District Forum vide impugned order observed that it is a case of myocardial infarction and is not a case of critical First Appeal No. 590 of 2017 7 illness as defined in Section 8 of definition 4 of the terms and conditions of the policy. Simple diagnose of CAD-Unstable Angina falls in exclusion clause, therefore, the claim was rightly repudiated and the complaint be dismissed.
7. Aggrieved with the order passed by the learned District Forum, the appellant/complainant has filed this complaint for setting aside the impugned order and allowing the complaint as prayed for.
8. We have heard the learned counsel for the parties and have carefully gone through the record of the case.
9. It was argued by the counsel for the appellant/complainant that insurance policy Ex. C-1 is of Life Insurance Corporation of India and not the policy issued by the Op. The impugned order passed by the District Forum is against the facts and evidence brought on the record. Therefore, it is not maintainable in the eyes of law. The case of the complainant dully falls under the definition of critical illness as defined under Section 8(4), therefore, the order passed by the District Forum is liable to be set-aside. Whereas on the other hand, the counsel for the respondents/Ops Mr.Sachin Ohri, Advocate argued that the District Forum has given a detailed findings how the case of the complainant is not covered under Section 8(4). Therefore, the order be affirmed.
10. To go through whether the case of the complainant is covered under the term critical illness as defined under Section 8 First Appeal No. 590 of 2017 8 of the terms and conditions, the relevant portion of Section is reproduced as under;-
"Critical Illness means Cancer of specified severity, Open Chest CABG, First Heart attack of specified severity, Kidney Failure requiring regular dialysis, Major Organ/Bone Marrow Transplant, Multiple Sclerosis with Persisting Symptoms, Permanent Paralysis of Limbs, Stroke resulting in Permanent Symptoms......"
It has been argued by the counsel for the appellant that as per the terms and conditions, the first occurrence of myocardial infarction means there will be inadequate blood supply to the relevant area. However, before diagnosing it a first attack of specified severity, it shall be evidenced by the following criteria:-
"iii) First Heart Attack of Specified Severity;
The first occurrence of myocardial infarction which means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria:
• A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain).
• New characteristic electrocardiogram changes. • Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
Excluded are:First Appeal No. 590 of 2017 9
• Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T. • Other acute Coronary Syndromes.
• Any type of angina pectoris.
History of typical critical illness symptoms. Chest Pain, the treatment was taken by the complainant in D.M.C. & Hospital and its discharge summary Ex. C-3 wherein history of the illness has been mentioned as under:-
"History of Illness:43 years male, presented with chief complaints of chest pain one day prior to admission. No history of dyspnoea, palpitation, cough, fever or syncope." and in the final diagnosis, it was mentioned as CAD single vessel disease. Therefore, record of the DMC does not help the complainant in any manner. During the course of arguments, he has referred to another documents Exs. C-11 to C-15 i.e. stress myocardial perfusion study, in which in final impression, it has been referred as under:-
"Haemodynamically significant SVD (RCA Ds).
EF = 52% (at Rest) and 62% (At Stress) with RWMA as described."
The counsel for the Ops has referred to the medical literature i.e. critical illness common definition, which is supported by five criteria, in which the heart attack has been defined as under:-
"* History of typical chest pain,
* New electrocardiogram (ECG) changes proving
infarction;
First Appeal No. 590 of 2017 10
* Diagnostic elevation of cardiac enzyme CK-MB;
* Diagnostic elevation of Troponin (T or I);
* Left ventricular ejection fraction less than 50%
measured 3months or more after the event."
and almost similar observations have been given in the policy terms and conditions. In the record of DMC Ex. C-3 in the history as referred above, there was no history of dyspnoea, palpitation, cough, fever or syncope, which showed single vessel disease, therefore, the counsel for the complainant has failed to mention on the record history of typical chest pain, which is criteria to judge the first heart attack of specified severity. Then he has also failed to refer the characteristic ECG changes because no ECG record or changes noted during the treatment has been referred by the counsel for the complainant in his evidence or from the record of the hospital. He has also failed to refer to the allegation of Infarction specific enzymes, Troponins, or other specific biochemical markers. Mere instable enzymes and CAD is not covered under the definition of critical illness. Counsel for the Ops has referred to the latest judgment of the Hon'ble National Commission 2017 (3) CPR 138 "Bhupinder Kumar versus Bajaj Allianz Life Insurance Co. Ltd. & Anr." In that case also the claim was raised on account of first heart attack and similar provision as in our case was there in the policy of Bajaj Allianz Life Insurance Co. Ltd. and in that case also the Hon'ble National Commission observed that the symptoms as provided under the policy are not there, therefore, the claim of the complainant is not First Appeal No. 590 of 2017 11 covered under the definition of critical illness. This judgment duly covers this case also. Therefore, we are of the opinion that the findings recorded by the District forum are justified and no scope to interfere in the well reason order passed by the District Forum.
11. In view of the above discussion, we do not find any merit in the appeal and the same is dismissed with no order as to costs.
12. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
13. The counsel for the parties/parties are directed to collect free certified copy of the order from the office of the Commission within a period of 15 days from the date of pronouncement.
(GURCHARAN SINGH SARAN) PRESIDING JUDICIAL MEMBER (RAJINDER KUMAR GOYAL) MEMBER January 30, 2018.
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