National Insurance Ordered to Pay Rs. 1.25 Lakh as Mediclaim

On a complaint filed by Consumer Education and Research Society (CERS) and Sanat K. Desai (82), Ahmedabad, the Ahmedabad City (Additional) Consumer Disputes Redressal Forum ordered the Kolkata and Ahmedabad offices of National Insurance Company Ltd. and MD India Healthcare Service (P) Ltd., Ahmedabad, to pay Desai Rs. 1,25,000 with interest at six per cent per annum from 16 October 2007 until payment. Besides, the Forum directed the opposite party to pay him Rs. 1,250 as cost.

Desai had taken a Mediclaim policy in 1996-1997 and renewed it every year; the last renewal was for the year from 5 July 2007 to 4 July 2008. During the policy period, he suffered a pain on his left hand and, when it persisted for three weeks, he consulted Dr. T. K. Patel who referred him to Dr. Tejas Patel.

Dr. Tejas Patel took a cardiogram, a 2D echo test and recommended further pathological investigation. Desai was admitted to the SAL Hospital on 29 June 2007 for an angioplasty and was discharged the next day. Desai incurred an expenditure of Rs. 2,18,048 on his treatment but submitted the Mediclaim for Rs. 1,00,000 plus Rs. 25,000 cumulative bonus, being the amount of the policy. He submitted the claim papers along with copies of medical treatment, tests and cash memos. The discharge summary issued by the SAL Hospital dated 30 June 2007 clearly indicated his final diagnosis as “unstable angina CAD” (coronary artery disease).

The opposite party rejected the claim. Desai approached CERS and together, they complained to the Forum, charging the company with “totally arbitrary, unjust and illegal” repudiation and “deficiency in service”.

The opposite party stated that “the complainant is suffering from hypertension / blood pressure since 35-40 years and (was) admitted to the SAL Hospital for treatment of a coronary artery disease, which is a direct complication of hypertension / blood pressure”. Therefore, on grounds of `pre-existing disease’, the company rejected his claim.

The complainants pointed out that hypertension is not a disease and that it is a condition where the blood pressure is constantly higher than normal.

The Forum observed that, by rejecting Desai’s claim, the opposite party had taken on itself the onus of establishing the history of his hypertension and its connection with his last treatment at the SAL Hospital. The opposite party had failed to establish the connection between hypertension and CAD, the Forum added. In fact, Desai had submitted an affidavit by way of evidence from Dr. Tejas Patel who had treated Desai for the pain in his left hand. Dr. Patel had certified, “As per medical science, it is not necessary that a patient of coronary artery disease has to be hypertensive. Coronary artery disease can occur without hypertension”.

The Forum concluded on 6 February 2010 that the opposite party was guilty of deficiency in service and ordered it to pay the complainant Rs.1,25,000/- with interest and cost.

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