IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 17th day of March, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R, Member
Sri. K.M. Anto, Member
C C No. 116/2020 (filed on 24-08-2020)
Petitioner : Dinesh Kumar,
S/o. Divakaran Nair,
Parayankunnel,
Kallara South P.O.Meenachil
Vaikom – 686632
(Adv. T.A. Sheeja and
Adv. Prasanth S. Pillai)
Vs.
Opposite Parties : 1) Managing Director,
Adithya Birla Health Insurance
Company Ltd. 10th Floor, 6 Tech Park, Nirlom Compound, Gocegarm east,
Mumbai – 400063.
2) The Brach Manager,
Adithya Birla Health Insurance
Company Ltd. Nagambadam,
Kottayam – 686001.
(For Op1 and 2, adv. Saji Isaac K.J
and Adv. Nithin Sunny Alex)
O R D E R
Smt. Bindhu R, Member
The Complaint is filed under Section 35 of Consumer Protection Act, 2019.
The complaint is filed under Section 35 Consumer Protection Act, 2019.
The complainant took a group active health insurance policy on 21-08-2019 in the name of himself and his wife and daughter vide policy no.6119000150000. The policy was valid from 21-08-19 to 20-08-2020 for an amount 1155 as premium per month and the complainant had been paying it regularly. On 13-01-2020, the complainant was admitted to St. Marys Health Care Private Limited, Thodupuzha as inpatient No.2020/225/1 due to coronary artery disease. It was diagnosed as ACS-ST elevation anterior wall myocardial infraction, triple vassal disease, S/P primary PTCA with DES to LAD mild LV disfunction. He was discharged on 16-01-2020. Upon intimation, the opposite parties collected all the original hospital bills and other related documents from the complainant while he was in the hospital and a claim was registered as claim No.1221910055550 on 17-01-2020 for Rs.1,35,000/-. On 28-02-2020, the opposite parties sent a letter demanding certain documents and those documents were submitted by the complainant. Again on 01-04-2020, the complainant was admitted to Bharat Hospital Kottayam and was discharged on 03-04-2020. Again another claim was registered for Rs.1,50,000/-, but the opposite parties rejected both claims on the ground that from the documents it was understood that 2 year waiting period for hypertension and its complication. And hence, the claim could not be allowed. As per request from the opposite parties, the complainant availed a letter from Dr. Mathew Abraham HOD, Cardiology, St. Marys Hospital, Thodupuzha in which it is clearly stated that systemic hypertension is a newly detected one. The complainant had no pre-existing diseases and he was unaware about the waiting period of 2 years. The opposite parties rejected the complainant’s claim without any bonafides. Hence this complaint is filed for getting the insurance amount and compensation.
The opposite parties were noticed and they appeared and filed version.
In the joint version filed by the 1st and 2nd opposite parties, it is contented that the policy is admitted. The policy was issued on the basis of the proposal form submitted by the complainant. But the complainant had suppressed material information which was vital in assessing the undertaking of risk by the opposite parties. The complainant falsely averred that he had submitted all the documents. The complainant was having hypertension as a pre-existing disease and hypertension is noted as a risk factor for the complainant in the discharge summary of St.Mary’s Hospital. Contract of insurance is a contract based on the principle of at most faith, the opposite parties are liable only according to the terms and conditions of the policy. In this case, the complainant has suppressed his condition of systemic hypertension at the time of proposal. According to the conditions of the policy, “WE will not make any payment for any claim in respect of any Insured Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to any pre-existing diseases or any complication mentioned in Annexure II arising from the same, until 24 months from the Start Date of the first Policy with Us”. As per the discharge summary, the pre-existing disease of hypertension was a risk factor and the hospitalization was within 24 months, which is excluded by the Annexure II of the policy conditions. The allegation that the agent of the opposite parties never disclosed the fact of waiting period of 24 months is false. The complainant was aware that the information provided by him in the proposal form would form the basis of the insurance policy and that the information provided by him on behalf of the insured are true and complete to the best of his knowledge . As the complainant has made false declaration suppressing material facts the policy had become void ab-initio. An insured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. The complainant was legally bound to disclose the fact pertaining to his pre-existing medical conditions. Since the claim of the complainant fell within 24 months from the start date of 1st policy, the claim was rejected by letter dtd.21-03-2020. The BP of the complainant seems normal at the time of admission read along with noting in the discharge summary regarding risk factor of hypertension would show that hypertension was a pre-existing disease at the time of admission. Letter dtd.06-03-2020 issued by St.Mary’s Hospital does not show that hypertension was detected at the time of admission on 13-01-2020.
With a view to re-assess the claim of the complainant, the opposite parties send a letter dtd.26-09-2020 requiring the complainant to submit the 1st consultation paper for hypertension. Inspite of the multiple reminder, there has been no response from the complainant. It is very important for the opposite parties to evaluate the history of hypertension for processing the claim request. The complainant is not entitled to Rs.1,50,000/-. Hence the complaint is liable to be dismissed.
The complainant filed proof affidavit along with Ext.A1 to A11 and deposing as Pw1. The opposite parties also filed proof affidavit along with Ext.B1 and B2.
On a detailed evaluation of the pleadings and evidence or record, the points to be resolved are
- Whether there is any deficiency in service on the part of the opposite parties?
- If so, whether the complainant is entitled for any reliefs?
Point No.1
The case of the complainant is that though he had a valid insurance policy, at the time of his hospitalization for myocardial infarction, the opposite parties rejected his claim on such grounds which was not intimated prior to the inception of the policy. The opposite parties justifies the repudiation of the claim that the claim was excluded under the policy conditions as it originated within 24 months period which is excluded as per annexure II.
Ext.A3 is the discharge summary issued by St.Mary’s Hospital, Thodupuzha on 13-01-2020 in which the complainant is diagnosed with “Coronary Artery Disease – ACS –ST – Elevation Anterior Wall Myocardial Infarction, Triple Vessel Disease, S/p-Primary PTCA with DES to LAD on 13-01-20, Mild LV Dysfunction.Hypokalemia”. In A3 report it is noted that systemic hypertension, family history of coronary artery disease and smoking are noted as the risk factors. Ext.A10 is the discharge summary issued by the Bharath Hospital while discharging the complainant on the 2nd time. In which the history of the patient is recorded as he is a non-case of CAD with recent AWMI and primary PCI to LAD etc.
The opposite parties in their version and affidavit has contended that the policy of the complainant was rejected as he was previously detected hypertension and was undergoing treatment for hypertension. This attracted the exclusion clause of pre-existing disease and as per Ext.A9 and B2 rejection letter it has been observed that 2 year waiting period for hypertension and its complication and hence claim cannot be approved.
Ext.A1 is the original policy and B1 is the copy in which clause 41 is pre-existing disease waiting period in which it is stated as “We will not make any payment for any claim in respect of any Insured Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to any Pre-Existing Diseases or any complication mentioned in Annexure II arising from the same, until 24 months from the Start Date of the first Policy with Us”. As per clause 41 the exclusion is for the diseases under annexure II. On a detailed perusal of annexure II, 2 year waiting period it is seen that treatment for hypertension is not included in it. The main contention of the opposite parties is that the complainant was a known case of hypertension and the same was excluded as per the policy conditions under the 24 months waiting period. But this contention is disproved with Ext.A1 and B1. Nowhere in Ext.A3 and A10, which are the discharge summaries of St.Mary’s Hospital and Bharat Hospital respectively, also nothing has been recorded to show that the complainant was having hypertension for several years and he had been undergoing any treatment for hypertension. Again in Ext.A6 dated 21-05-2020 and Ext.A8 dtd.06-03-2020 issued by Dr. Mathew Abraham, HOD cardiology of St.Mary’s Hospital it is clearly stated that the complainant did not have a past history of systemic hypertension and it was detected only at the time of admission and it can be inferred that the hypertension of the complainant was almost normal at the time of admission. Both these letters were submitted as per requirement of the opposite parties.
Now, when the contentions of the opposite parties are considered the 1st contention is that the complainant had a pre-existing disease of hypertension which was not disclosed by him at the time of filling the proposal form. As per the policy conditions all undisclosed pre-existing diseases are excluded from the coverage of the policy. Here the opposite parties has not produced any relevant documents to prove that the complainant had been suffering from and undergoing treatment for systemic hypertension even before the enrolment to the policy. Moreover, this contention is disproved by Exts.A3, A6, A8 and A10.
As per the settled position also if the insured suffers a sudden sickness that is not expressly excluded under the policy, the insurer is to indemnify the expenses incurred (Manmohan Nanda Vs. United India Insurance Co. Ltd,) 2021 (6) KLT online 1052 (SC)
In Raj Vilas Dongare Vs. B.M.Bhartiya Jeevan Bima Nigam & anotherConsumer Protection Act, 1986-Sections 2(1)(g), 14(1)(d),21(b)- Hon’ble National Consumer Disputes Redressal Commission stated that “Insurance Company has not produced any evidence or filed any document to show that deceased was suffering from any heart ailments or was treated for the same before date of proposal - Concealment of hypertension has not been taken as suppression of any material information sufficient to repudiate claim-Repudiation not justified."
Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi in the case Life Insurance Corporation of India Vs. Sudha Jain 2007(2) CLT 423 has drawn conclusions in para 9 of the order and the relevant clause is 9(iii), which is reproduced as under:-
"9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured is in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease."
In Bajaj Allianz General Insurance ... vs Manjit Singh Chawla on 19 July, 2017, The Honourable State commission,Chandigarh observed as:
“20. It is also relevant to mention here that Section 19 of the General Insurance Business Nationalization Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre- existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non- arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.”
Not only that though the opposite party cites clause 42-2year waiting period which states “a waiting period of 24 months from the start date shall apply to the treatment, whether medical / surgical and of the illness / conditions and their complications mention in annexure II”
In annexure II of Ext.B1 diseases under 8 different categories are listed as “ waiting period of 24 months from the start date shall apply to the treatment, whether medical or surgical and of the illness/conditions and their complications mentioned below”. But all along the categories we could not find cystemic hypertension in the list or myocardial infarction. So the opposite parties have failed to prove that the claim of the complainant comes under the exclusion of the policy conditions.
Thus we find that the opposite parties have rejected the claim of the complainant without any basis but only to deceive the complainant by putting forward lame reasons. Hence Point No.1 is found in favour of the complainant.
Point No.II
As per Ext.A1 the sum insured is Rs.2,00,000/-and the complainant has been paying the premium without any default. Hence he is entitled to get the entire hospital expenses. Hence the complaint is allowed and the opposite parties are directed to
- Pay Rs.1,50,000/- along with 9% from the date of 01-04-2020 till realization
- Pay Rs.15,000/- as compensation to the complainant
- Pay Rs.2,000/- as litigation cost.
Order shall be complied within a period of 30 days from the date of receipt of Order.If not complied as directed, the compensation amount shall carry 6% from the date of Order till realization
Pronounced in the Open Commission on this the 17th day of March, 2022
Smt. Bindhu R, Member Sd/-
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Witness from the side of complainant
Pw1 – Dinesh Kumar
Exhibits marked from the side of complainant
A1 – Policy document issued by opposite party
A2- Copy of active care claim form – Part B issued by opposite party
A3 – Copy of discharge summary issued by St.Mary’s Hospital
A4- Copy of ambulance service bill dtd.16-01-20
A4 series – copy of medical bills (24 nos.)
A5- Copy of letter dtd.28-02-2020 issued by opposite party
A6- Copy of letter dtd.21-05-2020 issued by Dr. Mathew Abrham, St.Mary’s
Hospital to opposite party
A7 –Copy of e-mail dtd.04-03-20
A8-Copy of letter dtd.06-03-2020 issued by Dr. Mathew Abrham, St.Mary’s
Hospital to opposite party
A9 – Copy of claim rejection letter issued by opposite party
A10- Discharge summary from Bharath Hospital
A11- Discharge bill dtd.03-04-20 from Bharath Hospital
Exhibits marked from the side of opposite party
B1 – Copy of the Group Activ Health – Certificate of Insurance issued by
opposite party
B2 – Copy of letter dtd.21-03-2020 issued by opposite party
By Order
Assistant Registrar
