B.D. MEHNDIRATTA vs NEW INDIA ASSURANCE CO. LTD.

OUT of the claim of Rs. 1,23,622/- preferred by the claimant against the Mediclaim policy issued by the respondent the appellant has already been paid Rs. 53,000/-. However, his claim of Rs. 63,300/- towards the cost of a device known as C-PAP ventilator support advised by the doctors was declined by the District Forum vide impugned order dated 10.12.2001 on the ground that such a claim is barred by condition No. 3.2 of the insurance policy. Feeling aggrieved the appellant has preferred this appeal.

CLAUSE 3.2 pertains to post-hospitalisation expenses and is as under: "3.2. Post-Hospitalisation Relevant medical expenses incurred during period upto 60 days after hospitalisation on disease/illness/injury sustained will be considered as part of claim as mentioned under item 1.00 above." The claim of the appellant in this regard repudiated by the respondent on the basis of the report of a panel doctor of the respondent to the effect that claim in respect of C-Pap fell beyond the scope and terms and conditions of the insurance policy.

Facts giving rise to this appeal, in short, are that appellant suffered high blood pressure and was admitted in the Aashlok Hospital on 5.2.1998 and was diagnosed as suffering from sleep-apnoea syndrome. He remained hospitalised for seven days and was discharged with the advice to get treatment such as coronary angiography and C-Pap ventilatory support as life procedure management. Within a week he purchased C-Pap valuing Rs. 63,600/-.

ADMITTEDLY the device of C-Pap is a life support system. Now the question arising for determination is whether the amount spent for purchasing this device come within the ambit of medical expenses incurred during the period upto 60 days after hospitalisation on disease/illness/injury sustained by the insured.

IN support of his plea that the expenses incurred in purchasing the aforesaid device were expenses towards the disease the appellant suffered from, the medical opinion of Aashlok Hospital has been produced by the appellant which is as follows: "This is to certify that Mr. B.D. Mehndiratta, whose signature is given below, is suffering from Obstructive Sleep Apnoea. I first saw the patient in February, 1998 at Aashlok Hospital, New Delhi when we diagnosed this condition. Obstructive Sleep Apnoea is a life threatening condition for which using C-Pap system overnight is essential and a life saving device which he has to take as treatment throughout his life. If the patient does not use C-Pap he is at risk of sudden death or at least repeated admissions for respiratory cardiac failure as a result of OSA."

According to the Counsel for appellant the said device was purchased by the appellant on 18.2.1998 which was well within 60 days after hospitalisation. In our view the interpretation of condition No. 3.2 of the insurance policy entitles the appellant to claim medical expenses incurred during the period of 60 days after hospitalisation on the disease/illness/injuries sustained by the insured as the said device formed part of the expenses on the disease he suffered from and was hospitalised and was purchased within 7 days after hospitalisation. On the contrary the contention of the Counsel for the respondent is that only that treatment for the disease for the purpose of medical expenses is permissible by this condition which contains for 60 days after hospitalisation whereas device in question useable for life long and was not a part of treatment in the form of medicines or tests etc. and at the most proportionate amount may be awarded.

THE appellant suffered from a disease known as Obstructive Sleep Apnoea. This is such a disease which was curable or remediable only through the device in question as this disease in the opinion of the doctor is life threatening condition and the C-Pap system has to be used overnight as part of treatment of the disease. If the patient does not use this device he puts himself at risk of sudden death or repeated admissions of respirator cardiac failure. We have thus to provide a meaningful interpretation to condition No. 3.2 of the insurance policy keeping in view the nature of the disease and the cure or remedy for the same. THE disease and the treatment after hospitalisation should have nexus with each other. Surviving after having received treatment for the disease in question without the use of C-Pap system and, therefore, to say that the expenses incurred towards purchasing this device were not the medical expenses incurred on the disease in question is denying the reality or shirking the factual aspect of the matter.

IN our view the only requirement of fulfilment of the condition No. 3.2 is that medical expenses on the disease which includes expense on such device which prevents the future onslaughts of the disease should be incurred upto 60 days after hospitalisation and in the instant case the appellant purchased the device within 7 days and, therefore, he was entitled to receive the benefit of the condition No. 3.2 of the policy. In view of the foregoing reasons we allow the appeal, set aside the impugned order. In the result, the claim of the appellant for Rs. 63,600/- is allowed. However, we are not awarding the interest in view of the peculiar nature of the facts of the case as well as the fact that interpretation of the term of condition of the policy involved dissectory approach.

Bank Guarantee/FDR, if any, furnished by the appellant be returned forthwith.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to record room. Appeal allowed.