FINAL ORDER/JUDGMENT
SMT. SUKLA SENGUPTA, PRESIDENT
This is an application U/s 12 of CP Act, 1986. as amnedated up to date filed by the complainant submitting inter alia that she is a policy holder in respect of Apollo Munich Health Insurance Co. (presenting known as HDFC Ergo General Insurance Ltd. ) under the OP-1 vide policy No. 120100/22001/2019/A012951/PEO1460252, ID No. EA01209708 and after purchasing the health insurance policy, the complainant being a policy holder has regularly paid the insurance premium to the OP-1.
It is further stated that the complainant was admitted in C K Birla Hospital (BMB) due to her cardiac disease on 09.07.2019 and she was advised by t he consultant Dr for PTMC Surgery and she had undergone surgery on the same self date on 09.07.2019 and was discharged on 11.07.2019 there from. Hereafter, the complainant placed the claim on her medical expenditure along with a forwarding letter dated 10.07.2019 coupled with all medical document and reports to the OP-1 through concerned TPA from the said hospital for approval of cashless benefits by the OP-1 demanded additional documents regarding all records of balloon valvo plasty of 20 years ago along with other document vide letter dated 10.07.2019.
It is alleged by the complainant that hereafter without assigning any cogent reason the OP-1 rejected the cashless request of the complainant which compelled the complainant to bear a sum of Rs. 1,10,200/- as per final invoice prepared by the concerned hospital but being bona fide policy holder is entitled to get cashless benefit.
Subsequently, the complainant vide letter dated 11.07.2019 replied the OP-1 that no such document of 20 year back were in their custody but she submitted all the medical documents to the OP-1 through hospital and she further stated that at the time of executing the subject health insurance policy by the complainant, all the required document were submitted to the OP-1 and being satisfied with the same, the OP-1 issued the policy and at this stage the OP-1 arbitrarily rejected the cashless facility of the complainant and intimated the complainant through SMS and thereafter, the complainant served a legal notice to the OP-1 vide letter dated 23.07.2019 demanding the reimbursement of Rs. 1,10,200/- paid by the complainant for her medical treatment but no response was there.
It is also stated by the complainant that she paid insurance premium regularly through the OP-2 Canara Bank and she initiated the health insurance policy as a consumer of the OP-2 vide letter dated 29.07.2019 then the complainant requested the OP-2 to intervene in this matter but in vain.
Hence, the complainant has compelled to file this case with a prayer to give the direction to the OP-2 to get the medical expenses amounting to Rs. 1,10,200/- in favour of the complainant and also give direction to the OP-1 to pay compensation to the complainant of a sum of Rs. 20,000/- for harassment, mental pain and agony along with litigation cost of Rs. 20,000/-.
The OP insurance Co. has contested the claim application by filing WV denying all the material allegation leveled against him.
Admittedly, the complainant availed the “Group Insurance Health Plan” policy all the applicable terms and conditions of the OP and accepted by signing necessary enrolment form. Accordingly, the policy was issued in favour of the complainant.
It is further stated by the OP that in the subsistence of the policy, the complainant got admitted in CK Birla Hospital, Kolkata on 09.07.2019 and diagnosed with Percutaneous Trans Mitral Commissurotomies (PTMC) and further request form cashless facility to the tune of Rs. 1,10,200/- by filing a preauthorization form. Giving the course of investigation with an intention to settle the claim of cashless facility, it has come to the knowledge of the OP that in the past, the complainant received treatment towards Balloon Valvo Plasty which was not disclosed by the complainant at the time of obtaining policy so, there was suppression of material facts towards her ailment of Balloon Valvo Plasty. Then the OP sent several letters to the complainant raised quarries and also requested to proceed the relevant document regarding Balloon Valvo Plasty but the complainant never responded to that effect. Hence, the OP duly rejected the claim of the complainant for cashless treatment facility by its letter dated 11.07.2019. It is alleged by the OP that the complainant do have past history of critical MS on WARF.AF.S/P PTMC for the past 20 years.
Under such circumstances, it is the view of the OP that the complainant is not entitled to get the alleged medical expenses on cashless facility and the claim of the complainant has been rejected by the OP.
As per OP case, the complainant has no cause of action to file this case. Thus, the case is liable to be dismissed with cost.
In view of the fact and circumstances, the points of consideration are as follows:-
- Is the case maintainable in its present form?
- has the complainant any cause of action to file the case
- Is the complainant a consumer?
- Is there any deficiency in service on the part of the OPs?
- Is the complainant entitled to get relief as prayed for?
- To what other relief or reliefs is the complainants entitled to get?
Decision with reasons
All the points of consideration are taken up together for convenience of discussion and to avoid unnecessary repetition.
On careful perusal and consideration of the materials on record, it appears that the case is well maintainable in the eye of law and the complainant has sufficient cause of action to file this case.
Now let us see whether the complainant is a consumer within the ambit of CP Act, 1986. It is admitted fact that the complainant has obtained the “Group Assurance Health Plan” Policy from the OP on payment of required premium and got the policy certificate vide Policy No 120100/2201/2019/A012951/PE011460252 ID No. EA01209708. It is a health insurance policy and the complainant used to pay the insurance premium to the OP-1 amounting to Rs. 4,813/- regularly. So, it is needless to mention here that the complainant obtained the policy for getting cashless facility and she is a consumer under the premises of CP act, 1986 and the OP Insurance Co. is a service provider.
It is alleged by the complainant that during continuation of the subject policy she admitted at CK Birla Hospital (BMT) for her cardiac disease on 09.07.2019 and was advised by the consultant dr. for PTMC surgery. The complainant had under gone the surgery on the same self dated was discharged from the hospital on 11.07.2019. Thereafter, she claimed the cashless facility from the OP Insurance Co. through the hospital with a forwarding letter dated 10.07.2019 for approval cashless benefit but the OP-1 Insurance Co. demanded additional documents regarding all records of Balloon Valvo Plasty of 20 year vide letter dated 10.07.2019 and subsequently without any cogent reason they repudiated the claim of the complainant. As a result the complainant compelled to bear the entire medical expense of Rs. 1,10,200/- only as per the final invoice prepared by the said hospital. Hence, the OP Insurance Co. in its WV, written argument and oral submission alleged that the complainant was under gone Balloon Valvo Plasty long back and she was suffering and she had past critical MS on WARF.AF.S/P PTMC for past 20 years. She has suppressed the material facts of her past disease for that reason the OP-1 rejected her prayer of cashless facility of Rs. 1,10,200/- but it is settled position of law that the duty of Insurance Co. has to examine the concerned policy holder by its own panel of Dr and also examined the Dr who treated the policy holder for the alleged ailment. but admittedly the OP-1 Insurance Co. did not taken any such step so, mere opinion from the hospital record, it is not sufficient to hold, that the policy holder was suffering from such ailment at the time of filing proposal form and without any cogent evidence the OP-1 cannot denied the claim of the complainant. In the instant case the OP Insurance Co. did not place any such document and material on record that the complainant had preexisting ailment. Hence, the onus is lying upon the OP Insurance Co. to prove that the complainant has suppressed the material fact in respect of her preexisting disease. but the OP Insurance co. failed to discharge its duty to prove the allegation raised by him in that case the complainant must get benefit of doubt and as the OP without proving allegation repudiated the claim of the complainant which she is entitled to get as per policy term and condition and such conduct of the OP Insurance Co. is amounts to deficiency in service and negligence which caused harassment, mental pain and agony to the complainant.
In view of discussion made above, this forum is of view that the OP Insurance Co. without having any cogent reason arbiterally repudiated the clam of the complainant in respect of cashless facility and compelled her to pay entire medical expense of a sum of Rs. 1,10,200/- only which put the complainant in mental pain and agony as well as financial crises. So, it can safely be held by this forum that the complainant could be able to prove the case beyond all doubts and is entitled to get relief as rayed for. On the contrary, the OP Insurance Co. is liable to pay compensation to the complainant for deficiency in service harassment, mental pain and agony.
In sum the case succeeds.
All the points of consideration are considered and decided accordingly.
The case is properly stamped.
Hence,
Ordered
That the case be and the same is decreed on contest against the OP insurance Co. (HDFC Ergo General Insurance Ltd.) with cost of Rs. 5,000/-.
The OP-1 is directed to pay the medical expenses to the complainant amounting to Rs. 1,10,200/- within 45 days from the date of this order.
The OP -1 is further directed to pay compensation to the complainant of Rs. 10,000/- to the complainant along with litigation cost of Rs 7,000/- within 45 days from this date of order id the complainant will be at liberty to execute the decree as per law.
Copy of the judgment be uploaded forthwith on the website of the commission for perusal.
