Order-36.
Date-05/09/2016.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case, in short, is that he purchased an insurance policy from OP2 through OP1 under the policy no.90275984201300 with coverage from 29-11-2013 up to 28-11-2014 and the sum assured was Rs.35 lakhs and the gross premium amount was Rs.33,749/-. The complainant, thereafter, removed the policy and the policy continued from 29-11-2014 to 28-11-2014 and the complainant paid premium of Rs.46,002/- to OP2 through OP1. The complainant due to the problem of incomplete voiding of urine went to Mumbai to consult with Dr. Phiroze F. Soonawala, MS, FRCS, MCH, DNBE(Urol) one of the eminent Urologists in the country on 14-11-2014. Dr. Soonawala advised the complainant to admit at Breach Candy Hospital, Mumbai. The complainant admittedly got him admitted there and underwent surgery on 17-11-2014 at the said hospital under Dr. P. Soonawala and was released from the hospital on 20-11-2014. The complainant paid bill amounting to Rs.2,76,460/-. The complainant, thereafter, being cured filed claim before OP Insurance. OP2 disallowed the claim vide letter dated 07-01-2014 arbitrarily without any valid ground. The ground of repudiation of claim was “pre-existing disease for a period of one year or more as per clause 4(a)”. The complainant has the case that actually the disease of the complainant started within the period of policy after first time payment on or before 29-11-2013 in favour of the OPs. The disease started in the month of August, 2014 well within the period of coverage of the insurance of the OP2. The complainant alleges deficiency in service on behalf of the OPs. Hence, this case.
OPs have contested the case in filing written version contending, inter alia, that the complainant has no cause of action against the OPs and the instant complaint is harassive, frivolous and devoid of any merit. One of the terms of the policies in the insurance policy was that the insurance company shall not be liable to pay for pre-existing diseases until 48 months from the date of inception. Under Clause 4(a) of the policy “benefits will not be available for pre-existing diseases until 48 months of continuous coverage have elapsed since the inception of the first policy with us”. It is also stated that post reviewing the claim and the documents submitted by the complainant it was found that the complainant had complaints of persistent obstructed voids for the past one year which he failed and neglected to disclose while taking the policy. It is stated that the claim was rejected on non-disclosure of medical details under the above mentioned policy wording. It is alleged that at the time of entering into the insurance policy the complainant did not reveal or disclose his past medical history. It is also stated that the investigation report conducted by the OP also confirmed that the complainant had been suffering from the disease for a period of more than one year. It is denied that the complainant is entitled to get the relief as prayed for.
Point for Decision
- Whether the OPs are guilty of deficiency of service?
- Whether the OPs have repudiated the claim of the complainant rightfully?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
The crux of the controversy is whether the complainant had pre-existing disease? Equally, whether he suppressed the disease at the time of taking the policy in question?
We have travelled over the documents on record namely, policy proposal form, insurance certificate, terms and conditions of the policy, Heartbeat-product benefit table, Medical papers of Breach Candy Hospital including discharge summary, medical bills of the said hospital, investigation report of the OP Company etc. etc.
It appears that the complainant had a mediclaim policy from MAX BUPA Health Insurance Company under Family First Gold Policy being No.30275984201300 for a period of one year from 29-11-2013 to 28-11-2014 which was renewed till 28-11-2015. The said policy was renewed and policy no.30275984201401 was issued to the complainant which was valid from 29-11-2014 to 28-11-2015. That policy was once again renewed and policy No.30275984201502 was issued to the complainant which was valid from 29-11-2015 to 28-11-2016.
From the medical papers we find that the complainant went to Mumbai to consult Dr. Soonawala, an eminent Urologist on 14-11-2014 due to problem of incomplete voiding of urine and he was admitted in Beach Candy Hospital in Mumbai on 16-11-2014. It also appears that USG – KUB of the patient was done on 23-08-2014 and the patient was diagnosed of a disease called “sensation of incomplete voiding of urine from the bladder after urination” by Dr. Soonawala. We find that USG was done on 23-08-2014 and accordingly, we cannot prefix the date of onset problem much earlier than 23-08-2014. It can safely be presumed that the problem of void of urine of the bladder started immediate before the USG and the USG was done and the USG report helped to detection of the disease. Eventually, the patient was admitted with sensation of incomplete void of urine at Breach Candy Hospital at Mumbai on 16-11-2014, surgery was performed on 17-11-2014. From the discharge certificate we also find that the patient came with complaints of sensation of incomplete voiding of urine from the bladder after urination since a few months and the patient complained of increased frequency of urination and nocturia since last few months. The certificate of Dr. Soonawala also shows that the patient complained of obstructed voiding diagnosed in August, 2014 and he had symptoms like frequency, nocturia and poor flow since August, 2014 and there were no symptoms prior to this and he was admitted at Breach Candy Hospital on 16-11-2014, underwent surgery on 17-11-2014 and was discharged on 20-11-2014. So, from the certificate of doctor, discharge summary of the Breach Candy Hospital and USG on 23-08-2014 it is clear that the disease started in the month of August, 2014, well within the period of coverage of insurance. We think that OPs have repudiated the claim arbitrarily. The enquiry report filed from the side of the OPs inspires no confidence in our mind as it is contradicted by medical papers and the certificate issued by Dr. Soonawala. Non-imbursement of the hospital bill in our opinion tantamounts to deficiency of service. The complainant we think is entitled to reimbursement of Medical Bill of Rs.2,76,460/-.
In result, the case succeeds.
Hence,
Ordered
That the instant case be and the same is allowed on contest against the OPs with cost of Rs.10,000/-.
OPs are jointly and severally directed to pay an amount of Rs.2,76,460/- as reimbursement of medical bill to the complainant within one month from the date of this order.
OPs are also directed to pay an amount of Rs.25,000/- as compensation for causing mental pain and harassment to the complainant 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. Act and in that event OPs will be liable to pay penal damage at the rate ofRs.5,000/- per month to be paid to this Forum.
