For Complainant : Sri Arun Kumar Panda, Advocate & associates.
For Op No.1 : Sri Sisir Kumar Mishra, Advocate.
For OP No.2 : None.
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1. The brief history of the case of the complainant is that he being influenced by the agent and broker of Ops opted for Health Family Floater-2015 Medical Insurance Policy and on deposit of Rs.8500/- towards policy premium, the Ops issued Policy No.345402/48/2018/285. Accordingly the complainant has deposited 4 annual premiums from the year, 2014 to 2017 and the policy covered a sum assured of Rs.2.00 lacs each year covering 4 persons i.e. petitioner, his spouse, son and daughter. It is submitted that the petitioner had undergone treatment for Carcinoma of lower gum at Panda Cancer Hospital, Cuttack from dt.03.03.2014 to 16.03.2014 and also undergone surgery for CA Tongue (LT) Lateral Border with Neck Nod at HGC Panda Cancer Hospital from 01.12.2017 to 09.12.2017 and surgery Neck Node (LT) 24.02.2018 to 03.03.2018 and took Radiation and Camo Therapy from 17.03.2018 to 23.04.2018 and Pet Scan 06.07.2018 incurring huge expenditure. It is submitted that the complainant filed claim application dt.21.12.2017 for Rs.1, 21,819/- before the Ops but the Ops rejected the claim on 24.01.2018 on the ground that this disease is pre-existing as the complainant had undergone treatment for the said disease on 03.03.2014 to 16.03.2014 before inception of this policy. The complainant submitted that occurrence of new cancer of tongue does not come under pre-existing disease but the Ops repudiated the claim arbitrarily. Thus alleging deficiency in service he filed this case praying this Commission to direct the Ops to pay Rs.4, 96,793/- towards medical expenses with interest @ 12% p.a. and to pay Rs.2, 20,000/- towards compensation and cost to the complainant.
2. The OP No.1 filed counter denying the allegations of the complainant but admitted about the medical insurance policy issued in favour of the complainant. It is contended that the complainant had undergone treatment for Carcinoma of Lower Gum at HCG Panda Cancer Hospital, Cuttack from 03.03.2014 to 14.03.2014 and had taken first Policy bearing No.428 from 09.07.2015 to 08.07.2015 and hence prior to commencement of the policy bearing No.428, the complainant had undergone treatment. It is further contended that the complainant was under treatment for the same disease from 01.12.2017 to 09.12.2017 and the treatment for the period 17.03.2018 to 23.03.2018 and on 06.07.2018 were also after repudiation of the claim. The OP further contended that pre existing disease shall be covered only after the policy has been continuously in force for 48 months and thus they repudiate the claim. Thus denying any fault on its part, the OP.1 prayed to dismiss the case of the complainant.
3. The OP No.2 in spite of valid notice neither filed counter nor participated in this case in any manner. The complainant has filed certain documents, written argument along with affidavit in support of his case. The OP.1 also filed certain documents, citations and affidavit in support of his case. We have heard from the complainant as well as A/R for the OP.1 at length perused the materials available on record.
4. In this case it is an admitted fact that the OP.1 on receipt of proposal and premium has granted Happy Family Floater-2015 policy for medical insurance in favour of the complainant vide Policy No.345402/48/2015/428 with date of commencement 09.07.2014 to 08.07.2015 covering 4 persons i.e. the complainant, his spouse, son and daughter. It is also an admitted fact that the policy was renewed 4 consecutive years up to 11.07.2017 to 10.07.2018 and policy covers a sum assured of Rs.2.00 lacs for each year.
5. The case of the complainant is that he has undergone treatment for Carcinoma of Lower Gum at Panda Cancer Hospital, Cuttack from 03.03.2014 to 16.03.2014 and has undergone surgery for CA Tongue (LT) Lateral Border with Neck Node in the same hospital from 01.12.2017 to 19.12.2017 and for surgery neck Node (LT) from 24.02.2018 to 03.03.2018 and Radiation Camo Therapy from 17.03.2018 to 23.04.2018 and Pet Scan on 06.07.2018 and thus incurred a huge amount for treatment. It is a further case of the complainant that he filed claim application dt.21.12.2017 before the Ops for Rs.1, 21,819/- for the treatment period 01.12.2017 to 09.12.2017 but the Ops rejected the claim on 24.01.2018 on the ground that the ailment is pre existing which is prior to commencement of the policy and not satisfied the terms and conditions of the policy and the policy does not cover any pre existing ailment.
6. The OP.1 in its counter stated that the complainant took the first policy bearing No.428 from 09.07.2014 to 08.07.2015 whereas he has undergone treatment of cancer prior to commencement of the said policy. The OP.1 relied Clause 4.1 of terms and conditions of contract of policy which reads “All pre existing disease (whether treated/untreated, declared or not declared in the proposal form which are excluded up to 48 months of the policy being in force. Pre existing disease shall be covered only after the policy has been continuously in force for 48 months”. This is an exclusion clause. On perusal of above clause, the words in the exclusion clause ONLY AFTER are vital and can be considered while deciding the present dispute.
7. The complainant at para-6 of his complaint petition stated “That on the very date of the commencement of the Medical Insurance Policy on its application the petitioner has categorically and specifically mentioned about pre existing disease. For that the complainant has undergone operation of “CARCINOMA” Lower Gum dt.03.03.2014 to 16.03.2014. Whereas the complainant in his memo of argument stated that the doctor found new cancer tongue and the OP did not lay any evidence that “Cancer Tongue” disease and lower Gum Cancer disease is also same disease and thus it is not a pre existing disease. The complainant has not furnished any document in this case for his treatment period 03.03.2014 to 16.03.2014 though admitted in the complaint petition. It is seen that the complainant has not renewed his policy after 10.07.2018.
8. From the above facts it is crystal clear that the complainant was suffering Carcinoma Lower Gum before the date of commencement of the policy and this is an admitted fact. Hence it is concluded that the complainant was suffering cancer before inception of first policy and thus it is a pre existing disease case for which clause 4.1 of the terms and conditions of the policy is applicable. This exclusion shall also apply to any complications arising from pre existing disease and thus the complications will be considered as part of the pre existing health condition or disease. It is also seen that the claim of Rs.1, 21,819/- by the complainant before the Ops is for the period 01.12.2017 to 19.12.2017 and during that period 48 months excluded period was not over. As per terms of the policy, the pre existing disease shall be covered only after the policy has been continuously in force for 48 months subject to other conditions of the policy.
9. The complainant as well as the OP.1 has filed citations in support of their cases. In the citation relied by the complainant, the Hon’ble High Court of Madurai Bench hold that hypertension and diabetics suffered by the petitioner in that case does not co-relate to the Coronary Artery Disease and hence CAD is not a pre existing disease at the time of issuance policy. The present case in hand is quite different than that of the relied and will not be helpful to the complainant. Therefore, repudiation of claim by the Ops is with proper application of mind. We find no deficiency in service on the part of the Ops. In the above circumstances, the case of the complainant needs dismissal.
10. In the result, we dismiss the case of the complainant. There shall be no order as to costs.
(to dict.)
