MRS. FIROZA KHATOON, PRESIDENT
The brief facts of the case is that the complainant is a professor of orthopaedics and medical practitioner. In the year 2009 he got himself insured under Mediclaim policy with Oriental Insurance Company Limited having policy No.311500/48/2010/7602 and renewed the same uninterruptedly till 18.01.2020. Thereafter, the complainant shifted and ported his insurance plan to Max Bupa Health Insurance vide policy No. 31521037202100 having customer I.D. No. 2001052581 and date of commencement was 19.01.2020 as per portability guidelines till 18.01.2023. Max Bupa Health Insurance by its letter accepted intimated the complainant that his above referred Insurance had been ported. The complainant again shifted and ported his Insurance plan to CARE HEALTH INSURANCE COMPANY LIMITED commencing on and from 19.01.2023 and ending on 18.01.2024. According to the complainant, one Niladri Chakraborty filled up the proposal form and ensured that there shall be portability of the policy for the period 19.01.2023 to 18.01.2024. On being assured regarding the facility of portability, the complainant paid a sum of Rs.60,820/- (Rupees sixty thousand eight hundred twenty) only as premium to the opposite party. Thereafter, opposite party accepted proposal form and premium paid by the complainant and issued policy bond bearing No. 49789114 under the plan name ‘CARE’.
The complainant states that he had fallen ill on 01.04.2023 with ST elevation myocardial infarction and had to be admitted in North City Hospital & Neuro Institute Pvt. Ltd. and had to undergone surgical procedure for stenting to left vein for removing 30% plaque in atrium. He was treated as indoor patient in North City Hospital & Neuro Institute Pvt. Ltd. on and from 01.04.2023 to 07.04.2023. Thereafter, the complainant submitted his claim along with all documents with opposite party to the tune of Rs.2,60,113/- (Rupees two lakh sixty thousand one hundred and thirteen) only which he paid to North City Hospital & Neuro Institute Pvt. Ltd. for his treatment but the opposite party refused the claim on filmsy grounds and informed the complainant through a letter dated 30.07.2023. The complainant categorically stated that as the portability of the policy is accepted by the opposite party, it cannot refuse the claim of the complainant by taking shield of waiting period. According to the portability guidelines, the policy shall be deemed to be continuing since the year 2009 uninterruptedly as such the question of waiting period does not arise in this case. The complainant alleges that refusal on the part of the opposite party tantamount to deficiency in service, hence this case.
The opposite party filing written version denies and disputes the allegation made in the complaint. The opposite party states that the complainant was issued a health insurance policy namely ‘CARE’ with add on policy namely ‘Care Sheild’ bearing policy No.49789114 from 19.01.2023 to 18.01.2024 covering the complainant and his spouse for a sum insured up to Rs.5,00,000/- (Rupees five lakh) only each subject to the policy terms and conditions. It is admitted by opposite party that the said policy was ported to Max Bupa Health Insurance wherein the first date of enrolment was 19.01.2020. The said policy was renewed till 18.01.2025.
The opposite party supplied the relevant documents together with policy, terms and conditions, premium acknowledgement, key policy information and claim process together with policy to the complainant. The complainant did not raise any dispute during the 15 days free look period as prescribed in the terms and conditions of the policy. It is admitted by the opposite party that a re-imbursement claim was filed by the complainant owing to his treatment and hospitalization of North City Hospital & Neuro Institute Pvt. Ltd. from 01.04.2023 to 07.04.2023 as he was diagnosed with Non ST Elevation Myocardial Infarction – IVUS guided + stenting to left vein was done, PTCA stenting to LMCA with DES was done. The complainant submitted claim form along with discharge certificate. The opposite party rejected the claim of the complainant vide denial letter/non registration letter dated 30.07.2023 on the following grounds :-
4.I.(A).(I) 48 MONTHS WAITING PERIOD FOR TREATMENT OF PRE EXISTING DISEASE AND ITS COMPLICATIONS(CODE EXCL 01) – DIABETES.
4.I.(a).(i) 48 MONTHS WAITING PERIOD FOR TREATMENT OF PRE EXISTING DISEASE AND ITS COMPLICATIONS (CODE EXCL 01).
The opposite party categorically states that Non-ST-elevation myocardial infarction (NSTEMI) is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle.
It is alleged that the complainant at the time of filing proposal form had declared about his medical history of diabetes and its complication.
The opposite party submits that as per medical literature, Diabetes mellitus is an important cardiovascular risk factor of myocardial infarction. It is also stated that as per terms and conditions of the policy the waiting periods for Pre-existing Disease – Code – Excl 01 is mentioned in clause 4.1(iii)(a). As per the aforementioned clause expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer. Clause (c) states that if the insured person is continuously covered without and break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage. The opposite party has rightly repudiated the claim of the complainant and as such, there is no deficiency in service on the part of the opposite party. Therefore, the complaint case is liable to be rejected.
Points for decision
- Is the complainant a consumer in terms of the Consumer Protection Act, 2019 ?
- Is the case barred by limitation ?
- Has the complainant any cause of action to file the complaint case ?
- To what relief or reliefs the complainant is entitled to ?
Decision with reasons
In order to proof the case the complainant submitted affidavit in chief and reply on affidavit to the questionnaire of the opposite party. The documents submitted by the complainant in evidence are as follows :-
Document 1: The insurance policy numbers and its period from 19.01.2019 to 18.01.2020 issued by the Oriental Insurance Company Limited (yearly renewal).
Document 2: Issued by Max Bupa Health Insurance showing accepting port of the insurance of Oriental Insurance Company Limited in the name of the complainant.
Document 3: Policy document of Care Health Insurance.
Document 3/1: Proposal form.
Document 3/2: Premium receipt.
Document 4: Bill of North City Hospital & Neuro Institute Pvt. Ltd.
It is pertinent to mention here that the written version as well as affidavit in chief and reply on affidavit to the questionnaire of the complainant signed by one Prabhjyot Singh, purported to be Manager of opposite party and he claimed to be authorised person to swear affidavit. Though in affidavit in chief he stated in paragraph no.1 “I am filling the authorisation letter issued by the competent authority of the company” but no such authorisation letter has been submitted either at the time of entering appearance and filing written version or at the time of submitting evidence in the case. The letter dated 30.07.2023 filed by opposite party is marked Document – A.
Point No.1
This point is taken up first for consideration and discussion.
Admittedly the complainant has availed service of opposite party by way of obtaining a Health Insurance Policy ‘Care’ on payment of premium amount of Rs.60,820/- (Rupees sixty thousand eight hundred twenty) only for the period from19.01.2023 to 18.01.2024.
Therefore, the complainant is a consumer in terms of section 2(7) of the Consumer Protection Act, 2019.
Thus point no.1 decided in favour of the complainant.
Point Nos. 2, 3 and 4
For the sake of brevity and convenience, all the above three points are taken up together for consideration and discussion.
On perusal of the pleadings and evidence on record we find the following facts have not been traversed by the opposite party.
- The complainant was issued a health Insurance policy namely ‘care’ with add on policy namely “Care Shield” bearing policy No.49789114 from 19.01.2023 till 18.01.2024 covering the complainant and his wife for a sum of Rs.5,00,000/- (Rupees five lakhs) each only. (Document - 3, 3/1 & 3/2).
- The above referred policy was ported from Max Bupa Health Insurance Company.
- The complainant got himself insured under Mediclaim policy with Oriental Insurance Company on 19.01.2009 and renewed the same every year uninterruptedly till 18.01.2020. (Document – 1).
- The complainant got his policy shifted from Oriental Insurance Company to Max Bupa Health Insurance Company on and from 19.01.2020 as per portability guideline and continued the same till 18.01.2023. (Document – 2).
- The complainant was treated as in-door patient at North City Hospital & Neuro Institute Pvt. Ltd. on and from 01.04.2023 to 07.04.2023. He had undergone stenting to left vein as he had Non ST elevation myocardial infarction.
- The period of treatment in North City Hospital & Neuro Institute Pvt. Ltd. was within the validity period of the health policy ‘Care’.
- The complainant submitted his claim for sum of Rs.2,60,113/- (Rupees two lakh sixty thousand one hundred and thirteen) only for reimbursement. (Document-4).
- The opposite party refused to register the claim vide its letter dated 30.07.2023 on the following grounds :-
- 4.I.(A).(I) 48 MONTHS WAITING PERIOD FOR TREATMENT OF PRE EXISTING DISEASE AND ITS COMPLICATIONS (CODE EXCL 01) – DIABETES.
- 4.I.(a).(i) 48 months WAITING PERIOD FOR TREATMENT OF PRE EXISTING DISEASE AND ITS COMPLICATIONS (Code Excl 01).
In course of argument Ld. Advocate for the opposite party submitted that Non ST elevation myocardial infarction (NSTEMI) is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen rich blood to the heart muscle. Such disease develops due to diabetes mellitus. At the time of submission of proposal form the complainant disclosed of his medical history of diabetes. Diabetes is an important cardio vascular risk factor of myocardial infarction. The expenses related to the treatment of a Pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer. According to the Ld. Advocate for the opposite party the complainant is not entitled to get any reimbursement of his medical expenses and the case is liable to be rejected.
In reply Ld. Advocate for the complainant argued that the health policy has the effect of portability since 2009 till 2025 uninterruptedly. So, the opposite party cannot take the plea of waiting period of 48 months for Pre-existing Disease.
It is admitted fact that since 19.01.2009 the complainant had Mediclaim policy with Oriental Insurance Company Limited uninterruptedly till 18.01.2020. Thereafter he shifted on availing portability facility to Max Bupa Health Insurance from 19.01.2020 to 18.01.2023. Again he shifted on availing portability facility to Care Health Insurance Company Limited. There is no interruption in continuation of the Health Insurance policy of the complainant since 19.01.2009 till date and on every shifting of policy to one Insurance Company to other was done through portability policy. So, the plea taken by opposite party in its letter dated 30.07.2023 has no leg to stand upon. (Document-A).
Admittedly, the complainant was treated within the validity period of the policy. The amount claimed by the complainant is also within the limit of insured amount.
The letter dated 30.07.2023 of opposite party reveals that the claim of the complainant was not registered due to want of waiting period of 48 months for treatment of pre-existing disease and its complications.
The Health Insurance Policy ‘Care’ (Document-3) clearly revels that the complainant disclosed his Pre-existing disease and port benefit was allowed for diabetes.
In course of cross-examination, the opposite party/witness has not specifically denied that Diabetes Mellitus or its complications are not the sole cause of Myocardial Infarction.
In this case we find the opposite party did not make any endeavour to proof that Non ST Elevation Myocardial Infarction was the direct effect of diabetes. The opposite party has submitted some medical literature from which it cannot be concluded that Diabetes Mellitus is the only cause of Myocardial Infarction. There is no evidence on the part of the opposite party that the illness of the complainant was direct result of the pre-existing disease i.e. Diabetes.
Having considered the discussion made above we are of the opinion that the opposite party could not prove by any cogent or convincing evidence that the illness of the complainant was the direct result of pre-existing disease i.e. diabetes. On the other hand, we find that the opposite party categorically admitted that the policy of portability of health insurance of the complainant was granted by all the Insurance Company since 2009 to 2025. Therefore, the question of waiting period for 48 months shall not arise in this case. It is admitted fact that the health Insurance policy in question was through portability and remained uninterrupted since 2009 till 2025.
Therefore the date of first inception of the health insurance policy of complainant shall be 19.01.2009. So, the waiting period of 48 months pre-existing disease as mentioned in the letter dated 30.07.2023 of the opposite party no.1 (Document-A) had expired long-long ago.
Hon’ble Apex Court in Manmohan Nanda –Vs- United Insurance (2022) 4 SCC 582 observed that insurance contracts are special contracts based on general principles of full disclosure in as much as a person seeking insurance is bound to disclose all material facts relating to the risk involved. Law demands a higher standard of good faith in matters of insurance contracts which is expressed in the legal maxim ‘uberrimaefidei’.
This principle has been enumerated in clause 3(ii) of the Insurance Regulatory and Development Authority (Protection of Policy Holder’s Interests, Regulation 2002) Act, dated 16.10.2002 which is also commonly known as IRDA Regulation, 2002.
Even Insurance Regulatory and Development Authority vide a letter having Ref. No. IRDA/HLTH/MISC/CIR/216/09/2011 dated 20.09.2011 stated “The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation”.
Rejection of bonafide claims of genuine consumers shall invite adverse effect of loosing faith of the common people upon Insurance Companies.
Considering the above, we have no hesitation to hold that the opposite party has rejected the claim of re-imbursement of medical expenses of the complainant, a bonafide consumer deliberately and without any basis compelling him to file the case.
It is apparent on the face of the record that the opposite party is liable for deficiency in service for causing harassment to the complainant without any just, valid and proper reason.
We find that the case is not barred by limitation.
Therefore, all the three points are decided in favour of the complainant.
Thus the case succeeds.
Hence, it is
O R D E R E D
that the complaint case be and the same is allowed on contest with cost.
The opposite party is directed to pay the amount of medical expenses to the tune of Rs.2,60,113/- (Rupees two lakh sixty thousand one hundred and thirteen) only to the complainant within 60 (sixty) days from the date hereof, in default to pay simple interest @ 9% p.a. from the date of refusal of the claim i.e. 30.07.2023 till the date of payment.
The opposite party is directed to pay a sum of Rs.1,50,000/- (Rupees one lakh fifty thousand) only as compensation to the complainant for harassment within 60 (sixty) days from the date hereof, in default to pay simple interest @ 9% p.a. till the date of payment.
The opposite party shall pay a sum of Rs.20,000/- (Rupees twenty thousand) only as litigation cost to the complainant within 60 (sixty) days from the date hereof.
Dictated and corrected
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President
