Order-18.
Date-07/04/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
The case of the complainant, in short, is that complainant obtained a health insurance policy of Apollo Munich Health Insurance Co. Ltd. (OP1) vide Policy No.150100/11119/6000064900 from OP1. OPs 2 and 3 are the other branches of OP1. OP4 is the claim settlement office (TPA). The complainant previously had Health Insurance coverage with United India Insurance Company Ltd., and subsequently ported under OP1 continuing the previous insurance policy for last 10 years. The complainant has not filed any claim there and has opted for portability to OP1. The complainant has no previous treatment record as he had been hospitalized for the first time in his life on 08-05-2013 and availed treatment at Woodland Multi-specialty Hospital Ltd. The complainant submitted entire treatment papers in original before OP1 for reimbursement a sum of Rs.1,40,717/- but the complainant received a letter dated 22-08-2013 from OP4 whereby he came to know that his claim had been closed due to non-receipt of deficient document requested by OP4. It is alleged that the plea taken by OP4 was absolutely baseless as the complainant submitted his claim, treatment papers on 17-07-2013. It is also alleged that he complainant pursued the claim vide letters dated 19-07-2013, 30-12-2013. OP1 also issued reminder to the complainant vide letter 22-10-2014 that the health insurance policy of the complainant was due for renewal on 09-12-2014 and approached to send premium cheque/DD in favour of the OP1 before the due date and the policy kit was also renewed for the period 10-12-2014 to 09-12-2015. The complainant expressed his grievance vide his letter dated 16-10-2015 to OP1 about closure of the claim and approached to reopen the said issue and to reimburse his claim but OP did not pay any heed to it. It is also alleged that previously the policy was Multiplier benefit of Rs.5 lakhs but later from Policy No.150100/11119/6000064900-02 onwards Multiplier Benefit was reduced to Rs.3 lakhs and complainant sought for clarification vide his letter dated 20-11-2015 to OP1 for deduction of insured amount. OP2 surprisingly all on a sudden remitted a notice dated 24-11-2015 for termination of Optima Restore Policy No.600064900-02 to the complainant alleging that he suppresed about his health condition, about his diabetes mellitus since 2010. It is alleged that after submitting the proposal form by the complainant OP Company continued the said and renewed the same and the complainant moreover declared that during continuation of policy for 10 years to previous insurer United India Insurance Company Ltd. he never faced any medical problem and he never claimed anything. OP Company also issued the policy without thorough check up of the complainant. The complainant has alleged deficiency of service and unfair trade practice against the OP. Complainant has prayed for reimbursement of his medical expenses as well as for renewal of the policy for the year 2016-2017 and other reliefs in terms of the prayer in the complaint.
OPs1,2 and 3 have contested the case in filing written version contending, inter alia, that the complaint is not maintainable in its present form and prayer and is harassing, vague, frivolous and devoid of any merit and is barred by limitation. It is stated that the complainant had taken a health insurance Optima Restore Policy bearing No.150100/11119/ 6000064900 from the answering OPs by porting from his existing policy. It is also stated one of the terms of the policy was that at the time of entering such policy the insured must disclose any previous ailment which he or she might have suffered and non-disclosure of such information would result repudiation of such insurance claim of the insured and termination of the policy. The complainant had taken admission in the Woodlands Medical Centre Ltd and the OP received a pre-authorization request from the said medical centre. OP also requested some additional documents from the medical centre and the medical centre sent a certificate dated 09-05-2013 stating “Diagnosis pancreatitis, h/oDM, HTN since 2010. No other papers available”. The cashless service was denied as such as the complainant has been suffering from diabetes mellitus since 2010 which had not been disclosed to the OPs at the time of filing the insurance policy. As per discharge summary the complainant was diagnosed for hypertension and diabetes mellitus too. Despite this complainant also failed to provide documents. Hence, the said claim was closed on 22-08-2013. On 26-10-2015, the complainant sent a letter for consideration of his claim along with few documents. Ultimately the claim was rejected for non-disclosure of diabetes mellitus since 2010 in the proposal form. Subsequently, the policy was also terminated in accordance with the policy terms. It is stated that the complainant has not been able to make out any case of unfair trade practice or deficiency of service against the OPs. These OPs have prayed for dismissal of the case.
Point for Decision
- Whether the OPs have been deficient in rendering services to the complainant?
- Whether the claim is barred by limitation?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We take up all the issues together for the sake of brevity and convenience of discussion.
We have travelled over the documents i.e. Xerox copy of the proposal form of Apollo Munich Health Insurance, Xerox copy of letter dated July, 17,2013 to the Claim Manager in respect of documents as required upon the OP Company, Xerox copy of in-patient care plan of Woodlands Hospital, Xerox copies of doctor’s continuation sheets of Woodlands Hospital, Xerox copies of bills, Xerox copy of letter dated 22-08-2013 in respect of closing of claim of the complainant, Xerox copy of letter dated December 30, 2013 requesting to reopen the claim file, Xerox copy of the letter dated 22-10-2014 to the complainant requesting for renewal of the policy renewal date being 09-12-2014, Xerox copy of the renewal letter for the period 10-12-2014 to 09-12-2015, Xerox copy of premium payment, Xerox copy of the letter dated 16-10-2015 to the OP persuading the claim, Xerox copy of renewal of advice of OP for the next term from 10-12-2015 to 09-12-2016, Xerox copy of the letter dated 20-11-2015 of the complainant to the OP alleging the rejection of the insurance amount from Rs.5 lakhs to Rs.3 lakhs, Xerox copy of the termination letter of the Optima Restore Police of the complainant, Xerox copy of the letter of the complainant to the OP as against such decision of termination of the policy, Xerox copy of the rejection letter dated 08-12-2015 of OP to the complainant, Xerox copy of the letter dated 18-12-2015 as against such rejection, Xerox copy of another letter of the OP dated 21-12-2015 informing rejection of the claim, Xerox copy of the letter dated 30-12-2015 of the complainant to the OP requesting for renewal of the policy, Xerox copy of the rejection letter dated 08-01-2016 of the OP to the complainant, Xerox copy of letter dated 12-01-2016 to the complainant by the OP, assuring proper response by 20-10-2016, Xerox copy of further rejection letter dated 13-01-2016 to the complainant by the OP, x08-01-2016 of the OP to the complainant, Xerox copy of letter dated 12-01-2016 to the complainant by the OP, assuring proper response by 20-10-2016, Xerox copy of further rejection letter dated 13-01-2016 to the complainant by the OP, Xerox copy of the letter dated 21-01-2016 of the OP to the complainant informing decline of sum assured to Rs.3 lakhs and other documents on record.
It appears that the health insurance coverage of the complainant was with United India Insurance Company Ltd. since 2001. Complainant has continued the insurance policy with the previous insurer United India Insurance Company Ltd. for last 10 years and he opted for portability to Apollo Munch Health Insurance Co. Ltd. OP Company on December, 2012. So, it appears that the complainant has been continuing the policy since 2001 i.e. for a period for more than one decade. Complainant was hospitalized at Woodlands Multispecialty Hospitals Ltd. for the first time in his life on 08-05-2013 and submitted claim for reimbursement of the sum of Rs.1,40,717/- incurred by him for treatment. The OPs closed the claim on 22-08-2013 due to non-receipt of deficient documents. We, however, find that the complainant has sub mitted his entire treatment papers on 17-09-2013 and he had further deposited with first enquiry of OP4 on 19-07-2013 which was received and acknowledged by hand-seal by OP on 19-07-2013. The complainant further brought the fact to the notice of oP4 vide his letter dated 30-12-2013 which was duly received and acknowledged by the OP4 on 02-01-2014. We also find from the documents on record that OP1 vide his letter dated 22-10-2014 asked the complainant for renewal for the period of 10-12-2014 to 09-12-2015.
It is stated from the side of the OP that the insurance company received a pre-authorization request from Woodlands Hospital for the complainant and came to know from a certificate dated 09-05-2013 of the said hospital that the complainant has been suffering from diabetes since 2010 stating “Diagnosis pancreatitis, h/o DM, HTN since 2010, no other papers available”. Following the certificate as stated the cashless service was denied vide a letter dated 11-05-2013 in as much as it appeared that complainant has been suffering from diabetes mellitus since 2010. It is stated that the complainant did not disclose the pre-existing disease at the time of taking the policy i.e. 07-12-2012. It is also stated that the complainant failed to provide the same that he was suffering from Diabetes Mellitus since 2010. Hence, the said claim was closed on 22-08-2013.
We have discussed earlier that the complainant submitted his entire treatment papers on 17-09-2013 and he also met up first query of the OP4 on 19-07-2013 and the complainant further brought the fact to the notice of the OP4 vide his letter dated 30-12-2013 which was duly received and acknowledged by OP4 on 02-01-2014. So, it is not true that the complainant did not provide with additional documents as required by the OPs. Complainant has categorically stated that he has no previous treatment records as he has been hospitalized for the first time on 09-05-2013. We also get the reflection of the same in the certificate of Woodland Hospital dated 09-05-2013 that “no other papers available. It is apparent that the complainant has been running the policy since 2001. According to Section 45 of Insurance Act, 1948 policy shall not be called in question on the ground of miss-statement after expiry of 3 years from the date of the issuance of a policy or the date of commencement of risk or the date of revival of policy or the date of rider of the policy whichever is later from the date of the issuance of policy from the date of commencement of risk. So, we find that the policy can be called in question within three years on the ground that any statement or suppression of material fact to expectancy of life of the insured was incorrectly made in the proposal form or other documents on basis which policy was issued or revived. The policy of the complainant as we find is more than 12 years and we think that the complainant will get the advantage of portability. Moreover OP has not been able to file any document or paper regarding his previous treatment for diabetes mellitus or hypertension. So, the ground of misrepresentation or non-closure or his statement does not sustain.
The next question is whether the claim of the complainant is barred by limitation? It is argued from the side of the OP that the complaint is filed after two years of the cause of action. It is stated that the complainant filed a claim in 2013 and the claim was closed on 22-08-2013. The complainant has filed the present complaint on 05-09-2016 and as such, the complaint is filed after two years of the cause of action and accordingly is barred by limitation. We have perused the documents on record. We find that the complainant sent a letter to the OP on 30-12-2013 regarding the closure of the claim and for reopening the file. The OP Company vide letter dated 08-12-2015 turned down such request and however, repudiated it. Again OP vide letter dated 24-11-2015 terminated the policy, the OP further repudiated the claim vide rejection letter dated 08-01-2016, even we find that the OP company vide letter dated 02-01-2016, 13-01-2016, 21-01-2016 harped on the same string in rejecting the claim of the complainant. So, we find that the cause of action is a continuing one. Moreover, we find that the OP1 vide letter dated 22-10-2014 requested the complainant for renewal on 09-12-2014 and approached to send premium cheque/DD in favour of OP1 on or before the due date and accordingly the policy was further renewed for the period 10-12-2014 to 09-12-2015 and duly informed the complainant vide letter dated 12-12-2014. OP1 also vide letter dated 24-10-2015 informed the complainant that Health Insurance Policy of the complainant was for further renewal on 09-12-2015 and also gave an offer of 7.5 percent discount to renew for two years and approached to send the premium cheque or demand draft in favour of OP1. So, we find that the cause of action arose first on 17-07-2013 i.e. the date on which the complainant approached to OP4 for reimbursement of Rs.1,40,717/- and subsequently on 30-10-2013, 16-10-2015, 20-11-2015, 03-12-2015, 08-01-2016 and 09-02-2016. The cause of action we think is a continuous cause of action and the case is not barred by limitation as such.
It appears that the complainant has been continuing with the above policy (health insurance) since December, 2012, last renewal has been done for the period 10-12-2014 to 09-12-2015. We also find that the previous health insurance coverage was with United India Insurance Ltd. and complainant availed portability also. We find that the genuine hospitalization claim was not even attended to by the TPA – Family Health Plan Ltd. closing the mediclaim without giving any consideration to the papers submitted. We also find that renewals were invited from the complainant by the OP and renewal premium for consecutive two years i.e. December, 2013 and December, 2014 were paid and were accepted by the OP Company. Further renewal request letter dated 24-10-2015 has also been received by the complainant from the OP. We also find that there is also a time limit even for pre-existing disease which normally travels not more than 3 years. We think that the claim is closed unilaterally and arbitrarily without any genuine cause by the OP. We also think the premium cheque for renewal premium from 09-12-2015 is required to be accepted to keep the continuity of the policy coverage. We also find that the OP received his claim papers in 2013 and had been in the knowledge of the facts of the ailments of the complainant. Since then, the OP did not repudiate the claim (only closed) and invited renewals and accepted two more premiums - one in December, 2013 and other in 2014 and also invited renewals for 2015, exact date of renewal on 09-12-2015 and suddenly OP closed his claim. We think that OP should accept the premium for the 4th year i.e. for 2015-16 and make the policy ongoing in usual manner from the year 2016-17. Accordingly we think that insurance company is to renew the mediclaim policy of the complainant. The order of the OP company refusing to renew the mediclaim policy of the complainant is unfair and arbitrary. The act of the OP insurance was arbitrary in refusing to renew the policy and its termination. We think that the policy is required to be renewed w.e.f. the date when it fell due for its renewal. [Supreme Court of India in Biman Krishna Bose vs. United India Insurance Company Ltd., and Ors on 2nd August, 2001 in Case No. Appeal (Civil) 2296 of 20000 relied upon).
These issues are thus decided accordingly.
In result, the case merits success.
Hence,
Ordered
That the instant case be and the same is allowed on contest against OPs 1,2 and 3 and ex parte against OP4.
OPs are jointly and severally directed to reimburse Rs.1,40,717/- to the complainant apart from litigation cost of Rs.10,000/- within 40 (forty) days from the date of this order.
OPs are also directed to jointly and severally to accept the premium for the 4th Year i.e. 2015-2016 and to make the policy of the complainant continuing in usual manner from the year 2016-17 on receiving premium from the complainant within the stipulated period.
OPs are also directed to pay an amount of Rs.20,000/- to the complainant for causing harassment, mental pain and agony within the said stipulated period.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P..
