Narayan Lal Gujar vs Cigna Ttk Health Insurance Company Limited

Avm J. Rajendra, Avsm, Vsm (Retd.) Member

The present First Appeal has been filed under Section 19 of the Consumer Protection Act, 1986 (“the Act”) against the Order dated 06.12.2018 passed by the learned Rajasthan State Consumer Disputes Redressal Commission, Jaipur (“the State Commission”), in Consumer Complaint No. 127 of 2016, wherein the Complaint filed by the Complainant (Appellant herein) was dismissed.

For Convenience, the parties in the present matter are being referred to as mentioned in the Complaint before State Commission. “Narayan Lal Gujar” (Since deceased) is identified as Complainant or Insured. "CIGNA TTK Health Insurance Co. Limited" is referred to as the Opposite Party or Insurer (OP in short) in this matter.

There was a delay of 18 days in filing the Appeal No. 175 of 2019. For the reasons stated in IA/1856/2019, vide order dated 24.07.2019, the delay was condoned.

Brief relevant facts of the case are that the Complainant obtained an online policy (No. LTPRCC200000124) on 24.06.2015, a Life-Style Protection- Critical Care Basic Health Insurance Policy from the OP Insurer, with a sum assured of Rs.50,00,000/-. The policy was effective from 24.06.2015 to 22.06.2016. Upon payment of the Rs.30,039/- premium from the Complainant's Savings Bank Account at HDFC Bank via Debit Card, the OP issued the insurance policy online. The policy promised a payout of Rs. 50,00,000/- for critical diseases during its duration.

On 01.12.2015, the Complainant experienced chest pain and sought medical attention at Amritkaur Hospital Byawar. No abnormality was detected. On 03.12.2015, he suffered severe chest pain and was diagnosed with Acute MI (Myocardial Infarction) or a heart attack at Govt Amritkaur Hospital Byawar and was admitted from 03.12.2015 to 09.12.2015 for treatment. Upon recovery, he filed a claim for the insured amount of Rs.50,00,000/- under the policy. All necessary formalities were completed as required by the OP Insurer. Subsequently, the OP conducted ECO & ECG from Pratap Memorial Hospital, Ajmer, and a 2D Echo from Mediscan Diagnostic, Ajmer during the claim investigation. However, the OP repudiated the medical claim vide letter dated 29.04.2016, citing mismatch between ECG submitted by him and the one conducted during the claim investigation. The OP alleged that his documents to be forged, fabricated and intended to deceive. He contended that the OP's rejection was baseless, unlawful, and denied rightful payment for the critical disease covered by the policy.

Being aggrieved due to the deficiency in service on the part of the OPs/Insurer, he filed Consumer Complaint No. 127 of 2016 before the State Commission, sought Rs.50 Lakhs with interest @ 9% p.a. from the date of filing of the claim till its realization; Rs.50,000/- as compensation and Rs.33,000/- as litigation costs.

In reply, the OPs denied the claim stating that the Lifestyle Protection Critical Care Basic Health Insurance Policy obtained by the Complainant did not cover the claimed ailment. As per the terms of the policy, it covers only specific severe conditions related to heart attack (Myocardial Infarction) where muscle damage occurs due to inadequate blood flow to the heart. There is no evidence to substantiate any muscle damage or insufficient blood flow in his heart, resulting in severe chest pain or MI. While the discharge ticket mentioned Acute MI, lack of medical examination reports confirming this condition raised doubts about the alleged heart attack. The recommendation for Angiography to confirm heart muscle damage was not pursued by him, despite being essential for diagnosing the disease. This and absence of suitable treatment following medical advice suggested that there was no heart attack and there was no heart muscle damage. The tests such as ECG and 2D ECHO before claim settlement demonstrated normal heart functioning, which did not align with the changes indicated in the ECG reports filed by him.

Additionally, the OP/Insurer sought opinion from Dr. Sanjay Rajdev, a cardiology consultant at Seven Hills Hospital, Mumbai who confirmed the absence of symptoms indicating a heart attack or any cardiac abnormalities in him. Based on the evaluation of medical reports and expert opinions, the Insurer contended that there was no substantiation for a severe heart attack or Acute Myocardial Infarction suffered by the Complainant, as no corresponding medical treatments like Angioplasty or bypass surgery were undertaken, which would be typical in such cases.

The learned State Commission dismissed the complaint with following observation: -

“As per the complainant, he got insured on 24.06.2015, which was in respect of serious illness, paid premium of Rs.30,039/- and policy issued. On 03.12.2015, severe pain became in chest. He was admitted in Amrat Kaur Hospital Byawar, where found Acute MI, which is disease relating heart ailment. He remained admitted in Amrat Kaur Hospital w.e.f. 03.12.2015 to 09.12.2015. ECO has been done from Pratap Memorial Hospital Ajmer on presentation of claim and 2D ECO Test got conducted from Mediscan Diagnostic Ajmer, which found normal. Due to which claim rejected.

Following provisions are for insurance benefits in the health policy of the Policy Holder/insured person:-

Critical illness cover

If an insured person is diagnosed to be suffering from a critical illness (as defined below) while the policy is in force, we will pay the sum insured subject to the following conditions:-

The critical illness, which the insured person is suffering from, occurs or manifests itself during the policy period as a first incidence; and

The insured person survives for at least 30 days from the date of diagnosis of the critical illness.

For the purpose of this policy critical illness shall mean any illness Medical Event of surgical procedure as specifically defined below whose signs or symptoms first commence at least 90 days after the inception of policy period.

There are following provisions for compensation on being heart disease to the Policy Holder/ Insured person:-

First Heart Attack of Specific 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 are the diagnosis for this will be evidenced by all of the following criteria;

a. A history of typical clinical symptoms consistent with the diagnosis of Acute myocardial infarction (for e g typical chest pain)

b. New characteristic electrocardiogram charges; and

c. Elevation of infarction specific enzymes Troponins or other specific biochemical markers

i. Non-ST-segment elevation myocardial infarction (NSTB ml) with elevation of Troponin I to T.

ii. Other acute coronary syndromes;

iii. Any type of angina pectoris.

These provisions are admitted by both the parties, when the Complainant discharged from Byawar Hospital on 09.12.2015, advice has been given therein for Angiography and advised for seeing to Cardiologist. Angiography is a such test regarding heart disease, result can be out from it that what is problem in heart and what treatment should be done, whether will be done Angiography or bypass surgery, it all is decided by Cardiologist. After discharge from the Hospital, the complainant neither did angiography nor consulted with Cardiologist but he started living normally after discharge from the Hospital. ECG and 2D ECO Tests have been done after claim, which found normal, accordingly no heart disease found.

In this situation, the claim filed by the complainant and the same rejected, there is no defect of any kind. Hence, the complaint is liable to be rejected.

ORDER

Hence, the complaint of the complainant is rejected.

(Extracted from True Translated Copy)

Being aggrieved by the impugned order, the Complainant (Appellant herein) filed this present Appeal seeking the following:

(a). That this Hon'ble Commission may be pleased to set aside the impugned order dated 06/12/2018 passed by the Hon'ble State Commission and allow the present appeal and further direct the Respondent /opposite party to release the claim of the Appellant for an amount of Rs. 50,00,000/- (Rs. Fifty Lacs Only).

(b). That this Hon'ble Commission may be pleased to grant interest @ 18% p.a. on the claim / insured amount from the date of filing of claim with the Respondent/ Opposite party till the realization;

(c). That this Hon'ble Commission may be pleased to direct the opposite party to pay Rs. 2,00,000/- as costs of litigation expenses to file the present Appeal as well as previous complaint;

(d). That the Hon'ble Commission may be pleased to summon the record of the Ld. State Commission necessary)

(e). To pass any other or further order(s) in favor of the Appellant and against the respondent /OP may deem fit In the facts and circumstances of the case in the Interest of justice.

In the Appeal, the Appellant raised the following key issues:

(a) The State Commission incorrectly concluded that he, post-hospital discharge, did not undergo angiography or consult a Cardiologist but resumed normal activities.

(b) The State Commission overlooked the opinion of Dr. Sanjav Rajdev that in the initial ECG an acute anterior wall ST segment elevation myocardial infarction and that unless treated immediately, the infarct-related artery typically opens in an hour.

(c) The claim rejection was based on an investigation by Claimprobe Consultancy Services, appointed by OPs, determining the complainant suffered a heart attack at 8:30 am and arrived at the hospital by 9:00 am. This contradicts Dr. Rajdev's assessment that timely treatment prevented residual damage in the subsequent ECG after the Appellant's arrival.

(d) The State Commission failed to acknowledge the critical "Golden hour" post-heart attack, typically lasting 80-90 minutes from onset, crucial for minimizing damage.

(e) The State Commission overlooked discrepancies in the OP’s reply and the basis for claim rejection, primarily centered on alleged submission of forged documents by the Appellant.

(f) The State Commission failed to consider the findings of Claimprobe Consultancy Services who verified the treatment records, met with doctors and presented relevant records. The OPs did not dispute their authenticity, affirming the heart attack and claim eligibility. It overlooked the record that he at Jawaharlal Nehru Chikitsalay went through follow up.

In his arguments, the learned counsel for Appellant reiterated the grounds of the appeal and argued the State Commission failed to consider Dr. Sanjav Rajdev's opinion. This formed basis for rejection of the policy by the OPs. He stressed the crucial patient's medical history, which holds significant importance for his treatment. The claim was rejected on the accusation of fraud. However, the burden to substantiate the allegation of fraud remained unfulfilled by the OPs. The learned Counsel highlighted the report of Claimprobe Consultancy Services indicating that the Appellant experienced heart attack at 8:30, reaching the hospital by 9:00, subsequently receiving Streptokinase (a medicine for blockage removal). This treatment led to no residual damage as evidenced in second ECG. Further, he referenced the criticality of the "Golden Hour" in limiting heart muscle damage and enhancing recovery, which, as per research, played a pivotal role. He alleged that the said investigation agency engaged by the OP did not annex all necessary documents of the Complainant providing evidence of occurrence of a heart attack.

The learned Counsel for Respondent argued that there is no substantiated evidence of the Complainant suffering from an actual heart disease, given the absence of consultations with a cardiologist or angiography, pivotal in diagnosing such conditions. Further, as outlined in Clause II of the insurance policy's terms and conditions, it specifically covers critical illnesses, including the first heart attack, subject to predefined severity criteria. Key points stressed were the discharge ticket from the Govt hospital, which purportedly did not confirm the occurrence of a myocardial infarction or heart attack, and the alleged disregard to doctors' post-discharge advice. Mention was made of the second ECG and 2D ECHO test results, showing no signs of a myocardial infarction, along with Dr. Sanjay Rajdev's contention that the two ECGs did not correspond to the same individual. The absence of timestamps and dates on diagnostic tests was highlighted, and lack of documented consent from the Appellant for administering Streptokinase, a medication carrying serious side effects, was noted. Further, the absence of signatures from medical personnel on medical records, all written in a uniform handwriting by a single individual, was found implausible. The purchase invoices for allegedly administered medications were absent. He asserted that the submission of the alleged 1st ECG report occurred only following the Commission's order and was not initially included in the Appeal. The Appellant failed to summon crucial witness from the Govt hospital to validate the claim regarding the critical/golden hour.

We have examined the pleadings and associated documents placed on record and rendered thoughtful consideration to the arguments advanced by the learned Counsels for both the Parties.

The primary issue in the case is rejection of the insurance claim for medical expenditure for suffering heart attack, citing absence of necessary medical conditions with respect to the alleged heart attack suffered by the insured. The insurer denied this claim based on medical evidence citing absence of certain corresponding features with respect to the same. The dispute centers on whether the medical claim falls within the coverage of the insurance policy.

The Appellant has stated that he suffered heart attack at 8:30 AM on 03.12.2015 and was rushed to hospital. There he received Streptokinase (a medicine for blockage removal) immediately within the critical "Golden Hour", which limited the heart muscle damage and enhanced the recovery process. Due to this, there was no residual damage as evidenced in the 2nd ECG. However, the claim for medical reimbursement of bills for treatment for heart attack was rejected on the accusation of fraud. It is the stand of the Respondent there is no substantial evidence of the Complainant suffering from heart attack and thus the claim was repudiated.

It is an established fact that the first ECG taken immediately after the alleged heart attack is without timestamps and dates on diagnostic tests. There was no consent document that was taken from the Appellant for administering Streptokinase, a medication carrying serious side effects. The discharge ticket from the Govt hospital did not confirm the occurrence of a myocardial infarction or heart attack. The doctors' post-discharge advice for undergoing angiography, which is essential in diagnosing such case was disregarded by the Appellant. The first and second ECGs did not match as opined by Dr. Sanjay Rajdev bringing out that the two ECGs do not correspond to the same person. The second ECG and 2D ECHO test results showed no signs of a myocardial infarction. There were no signatures of medical personnel on medical records and all were written in a uniform handwriting by a single individual. The purchase invoices for medicines allegedly administered were not brought on record. All these aspects which form a chain of events formed basis for the order of the learned State Commission.

In view of the foregoing discussions, we are considered view that the Order of the State Commission does not suffer from any illegality. The FA No. 175 of 2019 is, therefore, dismissed.

All pending application, if any, stand disposed of accordingly.