DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 26th day of May 2015
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 23/09/2014
(C.C.No.145/2014)
Roy George.P
S/o.P.A.George,
Pulikkaparambil House,
Mudukurishi,
Thachampara,
Palakkad – 678 593 - Complainant
(By Adv.Viju K Raphel)
Vs
Branch Manager
United India Insurance Company Ltd.,
Personal Life Insurance Office,
Surya Complex,
Mission HSS JN,
Palakkad – 678014 - Opposite party
(By Adv.T.P.George)
O R D E R
By Smt.Shiny.P.R. President.
Brief facts of the complaint.
The complainant has joined the Health Insurance Policy having No.101201/48/12/97/00002430 with opposite party for himself, his wife Susan George, his son Athul Abraham George and his daughter Anupa Susan George on 8/2/2007.Since then the complainant was renewing the Health Insurance Policy of the complainant and his family members yearly. On 8-2-2013 complainant had renewed the policy by paying a total premium of Rs.7512/-. According to the complainant as per the terms of the policy complainant himself and his wife Smt.Susan George was insured for an amount of Rs.1,50,000/ each for hospitalization expenses and for an amount of Rs.27,250/- each from domiciliary hospitalization benefit till 7/2/2014.
While so the complainant’s wife was diagnosed with renal stones in an Ultra Sound Scan and was taken to Christian Medical College, Vellore, Tamilnadu and was admitted in the hospital as inpatient on 16-7-2013 and discharged on 22-7-2013. Even before getting admitted in the Christain Medical College hospital complainant have enquired with the opposite party and they had assured all support and benefits. Then the complainant requested for cashless benefit from the opposite party. But they denied the cashless benefit and advised him to claim the re-imbursement of the hospital expenses after treatment. As per the advice given by the opposite party complainant had paid the hospital expenses of his wife.
Complainant submitted that after the clinical and laboratory examinations, wife of the complainant was diagnosed with the diseases of Fibromyalgia, Systemic Hypotension, Vascular Headache, Allergic Rhinitis, Bronchial Asthma, Impaired Fasting Glucose, Hypovitaminosis D, Dyslipidemia, Recurrent Renal Stones, Urinary Incontinence, Fibroid Uterus-Multiple, Subclinical Hypothyroidism, Deviated Nasal Septum to right and was recommended the medications of 1800K Calories diabetic diet, fixonate nasal spray twice daily, avoidance of allergens as advised, Tab romilast 10mg once daily till review, Duonose MDI 140/50mg once daily till review, Asthalin 125mcg twice daily till review, Tab.Losartan A 40/5mg once daily, Tab.Thyronorm 25mcg once daily empty stomach in the morning, Tab.Stator 10mg once daily after dinner, Tab.Sibelium 5 mg once daily after dinner, Tab.Cetrizine s mg once daily at bed time, Calcirol granules 60,000 units once a week for 6 weeks followed by 60,000 units once a month for 6 months followed by 60,000 units once in 3 months till review, Tab.Sandocal 500 mg once daily till review, Tab.Betahistine 8 mg one tablet whenever required and to review in endocrinology OPD after one year.
Complainant further submitted that after the discharge from the hospital on 23/7/2013 the complainant approached opposite party for reimbursement of medical expenses incurred with all original bills and necessary documents. On the request of opposite party a cancelled cheque was also produced to facilitate the NEFT transfer of the claim amount. Since there was no information from opposite party, after submission of documents on 5/10/2013 a reminder was sent to opposite party. On 30/10/2013 complainant received a letter from opposite party, repudiating the claim under exclusion clause of 4.11 of the policy. Complainant had spent an amount of Rs.72,897.60 at Christian Medical college Vellore for treatment of his wife. Complainant submitted that opposite party has repudiated the claim stating flimsy grounds and the indifferent attitude of sanctioning the cashless facility as well as reimbursement of the treatment expenses of his wife caused great mental agony, pain and financial loss to the complainant. Complainant also submitted that the act of opposite party is a clear deficiency in service and unfair trade practice. Hence the complainant prays for an order directing opposite party to pay policy claim amount of Rs.72,847.62/- alongwith 12% interest from the date of the claim till realization by the opposite party, pay Rs.50,000/- as compensation for mental agony and pain suffered by the complainant and pay cost of the proceedings.
Complaint was admitted and issued notice to opposite party. Opposite party entered appearance and filed their version contending the following:
Opposite party admitted the policy. As per policy terms and conditions, exclusions and definitions contained in the policy, company undertakes that during the policy period the insured person contacts any disease or suffers from any illness or sustains any bodily injury through accident and if such diseases or injury requires such insured person, upon the advice of a doctor to incur hospitalization expenses for medical / surgical treatment at any nursing home/ hospital as an inpatient, the company will pay through TPA to the hospital on the insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person.
Opposite party submitted that Sub clauses of 4.11 exclude certain treatment expenses like diagnosis x-ray, or laboratory examinations or other diagnosis studies not consistent with incidental to the diagnosis and treatment of positive existence of any ailment, sickness or injury, for which confinement is required at a hospital. Expenses on vitamins, tonic etc., are also excluded. Only those diseases, ailments and injuries or related conditions, for which insured person had signs or symptoms were diagnosed and received medical treatment. In this case hospitalization was for the diagnostic x-ray, or laboratory examinations not consistent with treatment of positive existence of any ailment or disease as per the discharge summery. All expenses incurred were for diagnostic, X-ray or laboratory examinations not consistent with treatment of positive existence of any ailment or disease which are excluded as per Exclusion Clause 4.11 of the policy terms and conditions.
As per the details of discharge summary, wife of the complainant has no serious health problems. She was advised to have tablets including vitamins tablets, exercises, physiotherapy, and avoidance of allergens and also advised to have preventive tablets. Complainant’s wife was also advised to continue Bharathanatyam, painting and singing as like before her marriage days.
The opposite party further submitted that medical bills for 72,847/- submitted by the complainant were spent only for diagnosis and laboratory examinations and not consistent with treatment of a positive existence of any ailment or disease as per the discharge summary and no hospitalization was required for any of the ailments or sickness. Hence the claim was repudiated. Cashless hospitalization was denied because the admission was primarily for investigation / evaluation and the liability under the policy at that time was not determinable from the details available and hence the cashless hospitalization was denied.
The opposite party also submitted the complainant has suppressed material facts regarding the health of his wife. As per the discharge summary from the CMC Vellore she was suffering from hypertension, headache for more than 10 years, she has psychological problems also for which she has already taken treatment. All these details were purposefully suppressed and obtained the insurance policy. Insurance policy is a contract of good faith. In this case the policy holder has withheld correct information and made deliberate incorrect statements making the document null and void and therefore the opposite party has repudiated the claim and accordingly the opposite party is not liable for any payment under the above policy.
There is no deficiency in service on the part of opposite party. Hence complaint is liable to be dismissed.
Both parties filed their respective chief affidavit. Ext.A1 to A9 were marked from the side of complainant and Ext.B1 to B6 were marked from the side of opposite party.
Issues are to be considered
- Whether there is any deficiency in service on the part of opposite party?
- If so, what is the relief?
Issues 1 & 2
Both parties heard. We have perused the documents on record. Opposite party admitted the policy. Complainant submitted in the complaint that his wife was detected with renal stones in an Ultra Sound Scan and was taken to Christian Medical College, Vellore. But the complainant did not produce Ultra Sound scan report which was previously taken to show that she had diagnosed with renal stone before getting admission to the CMC Vellore. Nothing is produced to show that she has taken treatment for the diseases mentioned in Ext A2 discharge summery before or after the treatment of CMC Vellore. From the verification of Ext.A2, it reveals that the wife of complainant was admitted for detailed investigation of her health conditions for further treatment. She consulted specialist doctors for this purpose. All the listed diseases were treated by oral medicines in the Christian Medical College, Vellore. No serious ailments are shown in the listed diseases in Ext.A2 which required hospitalization. No evidence was adduced to show that they have taken further treatment for listed diseases. From these circumstances, we are of the opinion that the wife of complainant was admitted in hospital only for conducting medical checkup of her physical condition. For this purpose they had taken x-ray, laboratory examinations and ultra sound scan and consulted specialist doctors. All these expenses are excluded under clause 4.11 of the Ext.A1 & B1 policy. Hon’ble National Commission held in National Insurance Co.Ltd Vs Aparna kahar that Insurance claim can only be allowed within terms and conditions of policy (2014 NCJ 850(NC). Ind Swift Ltd Vs New India Assurance Co.Ltd Hon’ble National Commission held that it is to be construed strictly as per policy terms and conditions which are binding contract between parties and nothing can be added or subtracted by giving different meaning to words mentioned therein (2012 CPJ IV NC148). Hence, we found no illegality in repudiating the reimbursement of medical expenses.
The contention of opposite party of suppression of material facts about pre-existing diseases cannot be taken into consideration. Ext.A1 policy clause 4.1 reveals that any pre-existing disease as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception is the policy holder with company is only excluded. The complainant had taken policy since 07/02/2007. Hence all diseases or illness are covered even if it was pre-existing since 48 months has elapsed after the inception of the policy.
In the above circumstances, we are of the view that there is no deficiency in service from the part of opposite party. Hence complaint dismissed.
Pronounced in the open court on this the 26th day of May 2015.
Sd/-
Shiny.P.R.
President
Sd/-
Suma.K.P.
Member
Appendix
Exhibits marked on the side of complainant
Ext.A1 – Original Insurance Policy issued by opposite party
Ext.A2 – Copy of discharge summary issued by Christain Medical College,
Vellore dt.22/7/13.
Ext.A3 – Copy of letter addressed to Christain Medical College, Vellore
regarding repudiation cashless facility.
Ext.A4 – Copy of claim raised by complainant’s wife dated 23/7/13
Ext.A5 – Copy of letter dated 23/7/13 issued to opposite part by the
complainant’s wife
Ext.A6 – Copy of letter dated 5/10/13 issued to opposite party by
complainant’s wife
Ext.A7 – Copy of letter dated 10/10/13 issued by opposite party to the
complainant
Ext.A8 – Copy of letter dtd.30/10/13 issued by opposite party repudiating the
claim
Ext.A9 – Copy of inpatient discharge bill issued by Christain Medical College,
Vellore in the name of complainant’s wife dated 22/7/13
Exhibits marked on the side of opposite party
Ext.B1 – Copy of Insurance policy in the name of Roy George P
Ext.B2 – Discharge Summary
Ext.B3 – Copy of Inpatient bill dated 22/07/2013
Ext.B4 – Copy of letter issued by TPA dated 16/7/2013 denial of cashless
facility
Ext.B5 – Copy of repudiation letter issued by TPA dated 17/9/2013
Ext.B6 - Copy of claim repudiation letter issued by United India Insurance Co.
dated 30/10/2013.
Cost
No cost allowed.
