Order-17.
Date-03/11/2016.
This is an application u/s.12 of the C.P. Act, 1986.
Case of the complainant, in short, is that OP is a registered company discharging its function in the field of insurance covering different type of risks including medical etc. The complainant obtained a hospitalization with domiciliary hospitalization benefit policy, (family mediclaim policy) from the OP covering the risk for himself and his family. The complainant obtained the policy bearing no.AA002825273 from the OP. The policy commenced on 28-09-2011 and sum insured was of Rs.1 lakh with the National Insurance Company Ltd. and every year mfrom time to time without any break he renewed the policy. Subsequently, the said policy was ported to OP on 28-09-2015. The complainant was admitted on 05-01-2016 in United Nursing Home, Serampore and was discharged on 10-11-2016. He was admitted there for post anal fissure by Dr. R. Parui and treatment was given to the complainant for fissurectomy, sphineterotomy and mucoplasty. After discharge the complainant submitted his medical bills on 18-01-2016 amounting to Rs.41,409/- and Rs.5,314/-. The complainant also submitted all the reports and necessary medical documents but unnecessarily OP asked further documents for claim on 09-03-2016 and 17-03-2016. Lastly, OP illegally rejected the claim of the complainant stating that post anal fissure is excluded from the health insurance policy. Hence, this case.
OP has contested the case by filing written version contending, inter alia, that the case is not maintainable in its present form and in law. It is stated that the complainant in the year 2015 approached the OP for an insurance policy and submitted application form bearing No.1102902971 dated 18-09-2015 for issuance of a, Easy Health Insurance Policy for himself as well as his family. The complainant had signed and submitted the proposal form after going through the terms and condition of the policy as he himself is an educated person and had full knowledge of terms and condition of the policy. On 18-01-2016, OP sent a claim for reimbursement of hospitalization expenses for operation of the complainant for fissurectomy, sphineterotomy and mucoplasty. The company reviewed all the documents. The complainant was diagnosed as a case of post anal fissure before commencement of the policy with the OP. OP issued a notice of Exclusion dated 01-03-2016 stating that the material facts were not disclosed to the company at the time of application for health insurance coverage. The complainant was suffering as a known case of anal fissure since 11-08-2015. It was further confirmed in the notice that for continuation of the policy, a revised term is required to be applied as per the underwriting norms “Permanent Exclusion for fissure for Mr. Kajal Biswas, to be applied through endorsement, effective ab initio”. So, it is stated that the specific exclusion clause would be applied and the complainant has suppressed the said material fact and such non-disclosure was deliberate. It is also stated that the complainant duly acknowledged the notice of Exclusion from the OP. It is stated that fissure was specifically excluded from the coverage of the policy and revised policy was also issued to the complainant on 22-03-2016 w.e.f. 28-09-2015, OP submits that the instant complaint is gross abuse of process of law and is liable to be dismissed as such.
Point for Decision
- Whether the OP has rightfully repudiated the insurance claim of the complainant?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have gone through the documents on record, i.e. Photostat copy of portability form, copy of subject insurance policy, copy of proposal form, copy of discharge certificate, copy of reminder letters by the OP and other documents on record. It appears that the complainant obtained the subject policy bearing no. AA002825273 from the OP. Virtually the said policy was commenced on 28-09-2011 with a sum insured of Rs.1 lakh with the National Insurance Co. Ltd. and the policy was also continued by the OP from year to year without any break. Subsequently, the said policy was ported to the OP’s company and the complainant also submitted his portability form on 03-09-2015. OP issued a policy details as well as the policy certificate on 28-09-2015 in favour of the complainant. the complainant was admitted in United Nursing Home, Serampore, Hooghly on 05-01-2017 and was discharged on 10-01-2016. From the discharge certificate, it appears that the complainant was admitted for surgery for post anal fissure by Dr. R. Parui and the treatment received by the complainant was for fissurectomy, sphineterotomy and mucoplasty. The complainant after discharge from the Nursing Home submitted his medical expensed bill on 18-01-2016 including bills for ECG investigation report etc. amounting to Rs.41,409/- and Rs.5,314/-. OP asked for documents for claim on 09-03-2016 and 17-03-2016 and on scrutiny of the documents repudiated the claim of the complainant. We find that the complainant submitted his claim on 18-01-2016 for surgery of post anal fissure on 11-03-2015. We find that OP sent a letter under the caption notice for ‘exclusion’ stating that fissure has been permanently excluded from general clause of the complainant. From the prescription of Dr. R. Parui we find that the complainant was suffering from pain in the anal passage, i.e. post anal fissure for one year since prior to 11-08-2015. But the policy as we find commenced on 28-09-2011 and the policy was subsequently ported to the OP’s company. We think that OP had no scope to ignore the guideline of IRDA portability which is mentioned in Section 14(1) of the IRDA Act, 1999. The rights of the insured cannot be taken off by the OP vide Exclusion Notice dated 11-03-2016. OP cannot bypass the portability norm of IRDA. We find that the notice of Exclusion Clause was given to the complainant after the claim submitted by the complainant to the OP. The complainant submitted the claim on 18-01-2016 to the office of the OP and after passing three months, the OP issued the Exclusion notice dated 11-03-2016. Moreover, OP has not sent any revised policy certificate to the complainant. We find that post anal fissure was not excluded from the policy of the complainant when the said policy was commenced on 28-09-2011 and the complainant paid the premium of his policy year to year. Subsequently, the said policy was ported to the OP Company and the complainant submitted his portability form on 03-09-2015 and OP issued the policy certificate on 28-09-2015. We think that OP had no scope to ignore the guidelines, norms of IRDA regarding portability. According to portability policy all the insurers issuing health insurance policy shall allow for credit gained by the insured for preexisting conditions in terms of waiting period when he/she switches from one insurer to another or from one plan to another, provided the previous policy has been maintained without break. We think that OP has not been justified to discard the claim of the complainant on the plea of the Exclusion Clause for fissure. Moreover, no insurer can make rule or guideline for his own interest for a particular consumer and ignore the interest of a particular consumer. We think that OP has illegally repudiated the medical claim of the complainant. We think that the complainant is entitled to get the relief as prayed for.
In result, the case succeeds.
Hence,
Ordered
That the instant complaint be and the same is allowed on contest against the OPs.
OP is directed to pay an amount of Rs.46,728/- along with interest at the rate of10 percent p.a. from the date of passing this order within one month henceforth.
OP is also directed to pay an amount of Rs.10,000/- as litigation cost and Rs.15,000/- as compensation for causing harassment, mental agony and pain to the complainant within the stipulated period of time.
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. Act and in that case OP shall be liable to pay penal damage at the rate ofRs.5,000/- per month to be paid to this Forum till full and final satisfaction of the decree.
