The West Bengal State Consumer Disputes Redressal Commission upheld the District Commission’s award to a senior citizen claimant, clarifying that an electrophysiological study (EPS) is an invasive cardiac procedure and cannot be excluded under the policy’s diagnostic exclusion clause. The decision also confirms the Commission’s territorial jurisdiction and the non-preclusive effect of an Insurance Ombudsman order.
Background & Facts
The Dispute
The appellant, National Insurance Co. Ltd., along with its TPA, MD India Health Insurance TPA Pvt. Ltd., appealed against the award granted by the District Consumer Disputes Redressal Commission, Kolkata (Unit-II) in Complaint Case No. CC/363/2022. The respondent, Shri Swapan Majumdar, a senior citizen, had a National Senior Citizen Mediclaim Policy (sum insured Rs 1,00,000) covering the period 31.03.2022 to 30.03.2023.
Key Facts
- 31.03.2022-30.03.2023: Policy period.
- 12.04.2022: Respondent lost consciousness briefly and later consulted a cardiologist.
- 18.04.2022: Cardiologist advised Electrophysiological Study (EPS) with possible Radio Frequency Ablation (RFA).
- Request for cashless authorization submitted to MD India Health Insurance TPA; initial cashless authorization of Rs 50,000 was granted.
- 25.04.2022: Respondent admitted to B.M. Birla Heart Research Centre.
- 26.04.2022: EPS performed; discharge summary noted normal sinus rhythm, dual AV nodal physiology, and inducible atrial tachycardia, recommending RFA with 3D Mapping.
- 27.04.2022: Patient discharged; cashless facility withdrawn on the ground that hospitalization was only for investigation.
- 13.05.2022: Respondent submitted reimbursement claim for Rs 50,584.
- 23.06.2022: Insurer repudiated claim invoking Exclusion Clause 5.16.
- 23.08.2022: Insurance Ombudsman rejected the claim, accepting insurer’s contention.
- 13.08.2024: District Commission ordered respondents to pay Rs 49,119 with 2% interest from filing date, Rs 50,000 compensation, and Rs 5,000 costs, within 45 days.
- 17.08.2026: State Consumer Commission dismissed the appeal and affirmed the District Commission’s order.
Procedural History
- 01.06.2022: Complaint filed as CC/363/2022 before District Consumer Disputes Redressal Commission, Kolkata.
- 13.08.2024: District Commission issued award in favour of the respondent.
- Date not specified: Appeal filed before the State Consumer Disputes Redressal Commission, West Bengal, First Appeal No. SC/19/A/258/2024, under Section 41 of the Consumer Protection Act, 2019.
- 17.08.2026: Judgment delivered by Hon'ble Mr. Rajes Guha Ray, Judicial Member and Hon'ble Mr. Santanu Saha, Member.
Relief Sought
The appellant sought:
- Set-aside of the District Commission’s award.
- Declaration that the Commission lacked territorial jurisdiction.
- Confirmation that EPS falls within Exclusion Clause 5.16 and therefore the claim is barred.
- Costs of the appeal.
The respondent sought affirmation of the District Commission’s award and payment of the ordered amounts.
The Legal Issue
What is the correct interpretation of Exclusion Clause 5.16 of the mediclaim policy - does it exclude reimbursement for an electrophysiological study (EPS) performed as an inpatient invasive procedure, and does the State Consumer Commission have territorial jurisdiction to entertain the appeal notwithstanding the insurer’s change of head-office location?
Arguments Presented
For the Appellant
- The District Commission lacked jurisdiction because the insurer’s head-office had shifted from the address cited in the complaint.
- EPS is a routine diagnostic investigation that can be performed on an outpatient basis; therefore both limbs of Clause 5.16 are satisfied.
- The cashless authorization was initially granted on the premise that EPS would be followed by RFA; the hospital’s failure to provide the 3D Mapping System absolves the insurer of liability for the EPS already performed.
- The Ombudsman’s order bars any further relief under the Consumer Protection Act.
- Reliance on New India Assurance Co. Ltd. v. Dr. Girish M. Wagher, National Insurance Co. Ltd. v. Premjibhai Laxmanbhai Motka, and Sonic Surgical v. National Insurance Co. Ltd..
For the Respondent
- EPS is an invasive intracardiac procedure, not a simple outpatient test; it requires catheterisation, sedation, and continuous monitoring, thus hospitalization was necessary.
- The insurer bears the burden of proving that EPS could have been performed as an outpatient and that the patient’s condition did not require admission; no expert evidence was offered to that effect.
- The Ombudsman’s decision is not a bar under Section 100 of the Consumer Protection Act, 2019.
- The hospital’s lack of a 3D Mapping System does not extinguish the insurer’s liability for the EPS already performed.
- Reliance on medical literature from the Mayo Clinic and the discharge summary to establish the invasive nature of EPS.
The Court's Analysis
The Commission began by examining Section 34(2) of the Consumer Protection Act, 2019, which permits a complaint where the opposite party carries on business or has a branch office in the jurisdiction where the cause of action arises. The appellant’s head-office at 3, Middleton Street, Kolkata was shown to be the centre of its administrative and claims-management functions; no material was produced to demonstrate that business was not carried out from that address. Consequently, the objection to territorial jurisdiction was rejected, and the appeal was deemed maintainable.
"Clause 5.16 does not exclude every procedure merely because it has a diagnostic or evaluative purpose."
The Commission then addressed the pre-clusive effect of the Insurance Ombudsman’s order. It held that the Ombudsman is an alternate grievance-redressal forum; its award does not constitute a judgment of a civil court or a consumer commission and therefore does not invoke res judicata. Section 100 of the CPA 2019 makes the remedies under the Act additional to those available under other statutes, so the complaint remained viable.
On the nature of EPS, the Commission relied on the Mayo Clinic description and the discharge summary, concluding that EPS involves insertion of catheters into the heart, intracardiac electrical recording, and possible delivery of electrical stimuli. This makes the procedure invasive and intracardiac, even though its purpose is diagnostic. The Commission emphasized that invasiveness defeats the first limb of Clause 5.16, which requires that the diagnosis or evaluation could have been carried out as an outpatient procedure.
The second limb of the clause - that the patient’s condition did not require hospitalization - was also not satisfied. The treating cardiologist had advised admission, the hospital admitted the patient, and the TPA’s cashless authorization was granted, indicating that hospitalization was deemed necessary. No expert testimony was offered to show that the patient could have been managed on an outpatient basis.
Because the insurer bears the burden of proving both cumulative conditions of the exclusion, and it failed to establish either, the exclusion was held inapplicable. The Commission affirmed the District Commission’s finding that the insurer’s repudiation was unjustified.
Finally, the Commission noted that the hospital’s failure to provide the 3D Mapping System does not shift liability to the insurer; any separate claim against the hospital must be pursued independently.
The Verdict
The appeal is dismissed. The District Consumer Disputes Redressal Commission’s order dated 13.08.2024 is affirmed. The appellant must comply with the directions within 45 days from the date of this judgment, adjusting any amount already paid. No costs are awarded in this appeal.
What This Means For Similar Cases
Territorial Jurisdiction Under CPA 2019
- A consumer forum may entertain a complaint where the insurer’s head-office or any branch that performs claims-management functions is located in the forum’s territorial jurisdiction.
- Parties cannot defeat jurisdiction by later relocating offices; the location at the time of filing is decisive.
Interpreting Diagnostic Exclusions
- Exclusion clauses that contain conjunctive wording (“and”) require the insurer to prove both conditions: outpatient feasibility and lack of need for hospitalization.
- Courts will scrutinise the medical evidence; absent expert testimony establishing outpatient feasibility, the exclusion will not apply.
- Invasive procedures, even if primarily diagnostic, are treated as inpatient services for the purpose of exclusions.
Burden of Proof on Insurers
- The insurer bears the evidentiary burden to demonstrate that a claimed procedure falls within an exclusion.
- Failure to produce expert medical opinion on either limb of the clause results in the exclusion being deemed inapplicable.
- Practitioners should ensure that policy wording is clear and that supporting medical evidence is gathered at the claim stage.
