State Consumer Disputes Redressal Commission
Satyabrata Chatterjee vs United India Insurance Co. Ltd And Ors. on 12 September, 2011
State Consumer Disputes Redressal Commission State Consumer Disputes Redressal Commission West Bengal BHABANI BHAVAN (GROUND FLOOR) 31, BELVEDERE ROAD, ALIPORE KOLKATA 700 027 S.C. CASE No. 35/0/2005 DATE OF FILING: 26/09/2005 DATE OF FINAL ORDER: 12/09/2011 COMPLAINANT Satyabrata Chatterjee Residing at Flat No. B-1, 2nd Floor, 8/23, Bijaygarh, District- Calcutta, PIN 700 032. West Bengal OPPOSITE PARTIES 1. United India Insurance Co. Ltd. Having its additional office at Himalaya House, 6th Floor, 38 B, Chowringhee Road,] Calcutta 700 071. 2. United India Insurance Co. Ltd. Having its registered office at Whites Road, Chennai 600 014. 3. Barnet & Chase Farm Hospital, Well House Lane, Barnet, Herts, EN5 3D J, U.K BEFORE : HONBLE JUSTICE MR. PRABIR KUMAR SAMANTA, PRESIDENT MEMBER : MRS. S. MAJUMDER MEMBER : MR. S. COARI FOR THE COMPLAINANT : Mr. A. K. Sil & Mr. A. K. Mukherjee, Advocates. FOR THE OPPOSITE PARTIES : Mr. S. K Basu, Advocate : O R D E R :
HONBLE JUSTICE MR. PRABIR KUMAR SAMANTA, PRESIDENT The complainant obtained one Overseas Mediclaim Policy on payment of premium from the O.P No.1 insurer effective from 11th June 2004 to 8th October 2004 for the purpose of visiting his son in England.
As a condition of travel the complainant had obtained such Overseas Mediclaim Policy to cover any emergency medical expenses or any accidental hospitalization that may happen during his visit to England. The said Overseas Mediclaim Policy covered the medical expenses that may be incurred in case of emergency including hospitalization save and except heart and circularatory disorders, diabetes and related disorder.
It is also evident from the materials on record that as per policy, pre-condition the complainant got himself checked-up by one Dr. A. K. Mitra, MD (Medicine) who made a thorough check-up of the complainant and certified that the complainant has good health with slight long PR Interval of the heart. The aforesaid Mediclaim Policy was issued in favour of the complainant after the insurer was confronted with the said medical report of Dr. A. K. Mitra upon payment of a premium of Rs. 7,448/-. The said policy inter alia covered the emergency medical expenses due to illness to the extent of one lakh US Dollar. However, it excluded the medical expenses incurred directly due to heart and circulatory disorder and diabetes and related disorders and any consequences attributable to be accelerated by or arising therefrom as per the medical history stated in the Proposal Form and/or reports attached thereto.
The complainant suffered acute distress owing to severe abdominal pain for a few days in the beginning of July during his stay in England for which he was treated there by a local National Health Service doctor. He diagnosed that the complainant was suffering from acute constipation and prescribed laxatives. In fact, on the night of 2nd July the complainant was admitted to the Emergency Section of Barnet and Chase Farm Hospital with severe abdominal pain. The doctors in the Emergency Section again diagnosed his condition as arisen out of constipation and released him after treating with laxatives. On the next morning on 3rd July 2004, the complainant was re-admitted to the self-same hospital with increasing pain in the abdomen. In the hospital the complainant underwent laparotomy and repair of ruptured leaning abdominal aortic aneurysm. Post operation the complainant was admitted in the Intensive Treatment Unit (ITU). On 5th July 2004 the complainant underwent the second operation of laparotomy and evacuation of haematoma, placement of abdominal mesh and vacuum dressing. Since the 2nd operation the complainant started recovering after being treated in the ITU and thereafter in the General Ward. That for the complete treatment of the complainant the hospital raised a bill of U.K. Pound of 57,411 (Fifty Seven Thousand four hundred eleven Pounds) only. That due to non-settlement of the hospitals bills the hospital authority directly requested Coris Paris Insurance, an agent of the opposite party to settle the claim. The said claim was not settled by Coris Paris Insurance, agent of the Insurer. Subsequently, it was verbally informed by Coris Paris that the claim was rejected as the disease of the complainant was pre-existing. Because of such information Mr. Richard Bird, (the treating surgeon) M. S; FRCS on 13/10/2004 in writing expressed his opinion that the ruptured abdominal aneurysm was not a pre-existing condition of the complainant prior to his departure from India.
He further declared by his said letter that the complainant was admitted with ruptured abdominal aortic aneurysm which condition was not diagnosed by Dr. A. K. Mitra who examined the complainant for the purpose of Overseas Mediclaim Policy. The only complication which the complainant had at the time of obtaining the Insurance Policy was of prolonged PR interval found on ECG. By a subsequent letter dated 16th December 2004 said Mr. Bird further made medical analysis of the complainants condition. He stated that the complainant suffered from an abdominal aortic aneurysm which is a part of the arterial system, but he further stated that this condition was not related to disorders of the heart nor specifically to circulatory disorders related the heart and hence should not be excluded by classifying as heart and circulatory disorders. Hence the complaint case for direction upon the O.P Insurer to make payment of the aforesaid amount of U. K. Pound 57,411 in equivalent Indian currencies.
The specific defence of the Insurance Company is that the insured was admitted for treatment mainly for ruptured abdominal Aortic aneurysm which is a part of circulatory disorder and it comes clearly under the specific exclusion clause of the Policy. It has accordingly been contended that the claim of the complainant could not be settled because it fell under the specific exclusion clause of the policy i.e exclusion of expenses incurred directly due to heart and circularatory disorder.
The insurer has disputed the medical analysis and/or the opinion expressed by Mr. R. Bird in his letter dated 13th October 2004 and has further stated in specific that the rupture of abdominal Aortic aneurysm is a part of circulatory disorder. To fortify its stand the insurer has also filed an experts opinion of a senior cardiologist Dr. C. K. Chatterjee. The complainant submitted a questionnaire to said Dr. C.K. Chatterjee in connection with his opinion. Dr. Chatterjee had replied to the same by an affidavit.
On the basis of the said opinion of Dr. C. K. Chatterjee and his affidavit as above in reply to the questionnaire submitted by the complainant, it has strongly been contended that the disease which the complainant suffered and for which he underwent surgical procedure falls under the circulatory system disorder which is excluded under the Policy.
It is evident from the materials on record that Mr. R. Bird has filed a supporting affidavit by way of giving reply to the questionnaire put to him by the insurer in connection with his opinion that the ruptured abdominal Aortic aneurysm suffered by the complainant was not related to heart or circulatory disorder. It is also on record on affidavit by Mr. Nicholas Law, Consultant Vascular and General Surgeon at Chase Farm Hospital in which the complainant underwent an aneurysm repair has also been filed on behalf of the complainant.
Authoritative Medical literature has described abdominal Aortic aneurysm as under :
An abdominal aortic aneurysm is a dilation (widening or bulge) of a portion of the aorta, usually at a weak spot in the aortic wall. If an abdominal aortic aneurysm ruptures (bursts) it can be fatal. Surgery can repair the aorta-this can be emergency surgery if the aneurysm ruptures or elective (planned) surgery if a patient has an aneurysm that is large and the risk of rupture is high.
About aortic aneurysms What is the aorta?
The aorta is the largest artery in the body. It carries all the blood that is pumped out of the heart and distributes it via its many branches, too all the organs of the body. The aorta projects upwards from the heart in the chest and then arches downwards traveling through the chest (the thoracic aorta) and into the abdomen (the abdominal aorta).
The normal diameter of the abdominal aorta is about 2 to 3 cm (about 1 inch) What is an aortic aneurysm ?
An aortic aneurysm is a thin weakened section of the wall of the aorta that bulges outward. Most aortic aneurysms occur in the section of the aorta that passes through the abdomen and are called abdominal aortic aneurysm. A few occur in the part of the aorta in the chest that is near the heart and are called thoracic aortic aneurysms.
As the wall of the aneurysm is weaker than a normal artery wall it may not withstand the pressure of blood inside. This may cause it to rupture (burst).
The chance of an abdominal aortic aneurysm rupturing depends on the size of it.
Symptoms :
If an aneurysm is in your abdomen, symptoms may include :
a pulsating feeling in your abdomen.
abdominal pain back pain.
Complications :-
If an abdominal aortic aneurysm becomes very large and ruptures (bursts) it can cause excruciating pain in the abdomen and back. A ruptured abdominal aortic aneurysm causes severe internal bleeding which is often fatal unless emergency surgery is carried out to repair the rupture.
Causes :-
The main cause of an aortic aneurysms is atherosclerosis. This is a condition in which fatty deposits are laid down in the walls of arteries. The deposit is called an atheroma. This weakens the wall and makes the walls less elastic and weaker as a result.
All about Heart & Vascular Aneurysm What is an aneurysm ?
An aneurysm is a building, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning greater than 50 per cent of the normal diameter (width). An aneurysm may occur in any blood vessel, but is most often seen in an artery rather than a vein.
An aneurysm may be located in many areas of the body, such as blood vessels of the brain, the aorta (the largest artery in the body), the intestines, the kidneys, the spleen, and the vessels in the legs. The most common location of an aneurysm is the aorta, which carries oxygenated blood from the heart to the body. An aneurysm can be characterized by its location, shape and cause.
References :- (1) Author Walter A Tan, MD, MS, Assistant Professor of Medicine (Cardiology) and Radiology, Director of Vasuclar Medicine Program, Departments of Medicine and Radiology, Division of Cardiology, University of North Carolina at Chapel Hill. ;
(2) Author Martin G Radvany, MD, Clinical Assistant Profession Radiology and Nuclear Medicine, Uniformed Services University of Health Sciences, Chief, Interventional Radiology Service, Department of Radiology, Brooke Army Medical Centre.
(3) Author Venerando Seguritan, MD, Staff Radiologist , Radiology, The Radiology Group. Inc. It has been specifically stated by Mr. Nicholas Law, Consultant Vascular and General Surgeon at Chase Farm Hospital on oath as under :-
An abdominal aortic aneurysm is classified as a peripheral arterial condition and is not related to any pre-existing cardiac condition. In both OPCS and the BUPA procedural codes pathology relating to the peripheral arterial system, which includes abdominal aortic aneurysms, is classified quite independently from all cardiac conditions. A ruptured abdominal aortic aneurysm should not therefore be considered as a part of a pre-existing cardiac disorder.
Mr. Richard Bird in his supporting affidavit to the opinion expressed by him in the form of reply given on oath to the questionnaire put to him by the insurer has clearly stated as under in reply to :-
Question No. 10.
The circulatory system is a general term which includes the heart, great vessels, all the arteries, all the veins including both the pulmonary, vascular and portal beds. It is similar to the term alimentary tract which includes the mouth, stomach, small bowel, large intestine and anus. Similarly dental treatment, or for a duodenal ulcer would not be considered a pre-existing condition for the other parts of the alimentary tract.
And question No. The witness statement of Richard Bird, 03.11.2008 states Point 5 Abdominal aortic aneurysm is part of the arterial system, it is not related to the heart specifically nor to circulatory disorders relating to the heart. Further the OPCS code (WHO classification) separates the heart from the peripheral circulation. The aorta and abdominal aortic aneurysms are part of the OPCS classification for peripheral circulation. The aneurysm should not therefore be classified under heart and circulatory disorder.
On the contrary, Dr. C. K. Chatterjee in his expert opinion has merely stated that it is anatomically and physiologically true that human heart is the main pumping organ which pumps out blood first to aorta (the main artery) and its various branches and then receive blood viaenacavae (This is called Cardiac and Circulatory system). Mr. Chatterjee the complainant was suffering from pain in abdomen due to rupture (leaking of aorta aneurysm) which is very much part of circulatory system. Hence the illness falls under circulatory disorder and accordingly he opined that the claim can not be allowed.
In view of the pleadings of the parties and on the basis of the materials on record, namely the opinions of the experts available in this case, it is now necessary to decide whether ruptured abdominal aortic aneurysm was due to heart and circulatory disorder or as a consequence attributable to be accelerated by or arising therefrom slight prolonged PR interval as found on the ECG.
Upon careful analysis of all the opinions as above and more particularly of Dr. C. K. Chatterjee, we are of the view that Dr. C. K. Chatterjee has given a generalized opinion without specifically establishing that the complications suffered by the complainant namely abdominal aortic aneurysm was because of heart and circulatory disorder that had occurred to the complainant, or in other words, some heart and circulatory order of the complainant had resulted in such ruptured abdominal aortic aneurysm or had resulted in consequence attributable to be accelerated by or arising therefrom slight long PR interval of the heart of the complainant as found on ECG before taking of the insurance cover by the complainant. Only because heart is the main pumping organ which pumps out blood for survival of the living being through various arteries while is called the circulatory system does not imply that rupture of the abdominal aortic wall was due to some defect of circulatory disorder. Dr. Chatterjees opinion as above does not establish that.
Dr. C. K. Chatterjee has nowhere specifically opined that abdominal aortic aneurysm is a kind of heart and/or circulatory disorder. He has rather opined that because of rupture of aortic aneurysm there may be failure of circulatory system but he did never opine that because of any heart and circulatory disorder rupture of aortic wall had occurred. The medical authorities as quoted herein above also do not suggest the therapy that if there is rupture of abdominal aortic wall it would be taken for granted that the patient had heart and circulatory disorder.
We also do not feel confident to rely solely upon the opinion expressed by Dr. C. K. Chatterjee for twofold grounds. First : Dr. C. K. Chatterjee is a panelled doctor of insurer which fact has not been denied by the insurer as well as the Dr. C. K. Chatterjee himself. Secondly, the medical authorities as above and the experts opinions of both Mr. Richard Bird,, MD, FRCS and Mr. Nicholas Law, Consultant Vascular and General Surgeon sound much stronger and more specific than the generalized opinion of Dr. C. K. Chatterjee.
For the reasons as aforesaid, we are of the view that the complainant is entitled for emergency medical expenses incurred for his treatment at Barnet and Chase Hospital in England for repair of ruptured abdominal aortic aneurysm. It has not been disputed by the insurer that the hospital bill for a sum of U.K Pound 57,411 was raised for such purposes.
We are therefore of the view that the complainant is entitled to the aforesaid amount in equivalent Indian currencies.
The complaint case is thus allowed by directing the O.P No.1 insurer to pay to the complainant the equivalent sum in Indian rupees of U.K Pound 57,411 along with a sum of Rs. 1,00,000/- (One Lac) by way of compensation for the harassment caused to him for not settling the claim of the complainant on the basis of the insurance cover issued to him by the O.P No.1. The O.P No.1 insurer will further pay a sum of Rs. 10,000/- (Ten thousand) by way of litigation cost. All such payments shall be made by the O.P No.1 to the complainant within a period of forty-five (45) days from the date of making of this order. In default of making payment of the above amount within the period as aforesaid the same will carry interest at the rate of 10% per annum from the date of making of this order till payment.
The complaint case is thus allowed.
(S. Majumder) (S. Coari) (Justice P.K. Samanta) MEMBER(L) MEMBER PRESIDENT