IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 30th day of October, 2024
Present: Sri. Manulal V.S. President
Smt.Bindhu.R, Member
Sri. K.M. Anto, Member
C C No. 93/2024 (Filed on 11/03/2024)
Complainant :
Pattathil Sivaramapanicker
Mohanakumar
S/o N.G.Sivaramapanicker
Kavyasree
Manarcad.P.Ο
Kottayam - 686 019
(By Adv. Stevewaugh Stephen)
Vs.
Opposite Parties :
1) Managing Director
Care Health Insurance Ltd
3rd Floor,
Door No 55/886 D1& D2,
Vellathottam white tower
S.A Road,
Panampilly Nagar,
Kochi - 682 03
2) Pradeep kutty
Branch Manager
Care Health Insurance Ltd 3rd Floor,
Vellathottam White Tower
Door No 55/886 D1& D2, S.A Road,
Panampilly Nagar,
Kochi-682 036
(By Adv. Aji Joseph)
ORDER
Sri. Manulal V.S, President
This complaint is filed under Section 35 of the Consumer Protection Act 2019.
Crux of the complaint is as follows:
The complainant, who is a retired Civil Engineer, has availed a medical insurance policy with the first opposite party with a coverage period from 27-07- 2023 to 26-07-2024.
The second opposite party spoke over the phone with the complainant about their various policy insurance and had represented to the complainant that they offered superior services compared with their competitors and had convinced the complainant to get insured with the first opposite party for the "Care Health' policy which is a Health Insurance policy which would provide insurance coverage even for those who had already undergone cardiovascular ailments.
On 30/08/2023, the complainant had a sudden fall due to which he suffered from severe back pain and was having trouble walking, for which he was admitted at the Mannalil Ayurveda Hospital from 31/08/2023 to 09/09/2023. He further procured a bill amount of Rs. 26,764/-. As he was insured by the health insurance of the first opposite party, the complainant filed for reimbursement of the said medical bill with the first opposite party. However, the complainant's claim was repudiated on 28-10-2023 on the grounds that his back pain was a pre-existing disease that he was suffering prior to the policy and that there exists a waiting period of 24 months in cases of pre-existing diseases. It is further apparent from the discharge summary of the hospital wherein it is stated that the complainant was normal until he met with an accident due to which he suffered from severe lower back pain; hence, it was not an ailment or disease existing before the policy was availed.
The opposite parties did not provide any satisfactory explanation regarding the claim's repudiation despite the complainant's repeated attempts and their disregard and lack of re-examination into the matter, and further arbitrary repudiation would amount to deficiency of service.
Hence, the complainant filed this complaint praying for an order to direct the opposite parties to refund the bill amount of Rs. 26,764/- along with an interest and to pay Rs. 25,000/- as compensation for the mental agony, pain, and suffering caused, along with Rs. 10,000/-as litigation cost.
Upon notice from this commission, opposite parties appeared before this Commission and filed a joint version contending as follows:
The insurance is a contract of utmost good faith, and the contract of insurance is based on the Doctrine of Uberrima Fides. Even if any due diligence is done by the insurance company, it does not change the basic element of an insurance contract.
The opposite party issued a health insurance policy, namely "Care Heart," with add on policy, namely "Care Shield," bearing Policy No. 69057310 from 27-07-2023 till 26-07-2024 covering the complainant for a sum insured up to Rs. 5,00,000/- subject to policy terms and conditions. The insured was supplied with relevant documents with Policy, Terms & Conditions, Premium Acknowledgement, Key Policy Information, and claim process together with policy, and no dispute regarding the policy was raised during the 15 days free look period as prescribed in the terms and conditions. A link is also shared on the page No. I of the policy certificate to access the terms and conditions of the policy complainant also had the option to return the policy within the FREELOOK PERIOD, i.e., 15 days from receipt of the policy documents.
Believing the information and details provided by the Proposer, including the medical history, to be true and correct in all respects and giving due credence to the underwriting norms of replying to the opposite party, a policy was issued. A copy of the schedule bearing relevant details of the policy along with the policy bond with terms and conditions was duly sent and delivered to the proposer. Further, no assurance was given to the complainant beyond the terms and conditions of the policy.
A reimbursement claim bearing claim no. 93554291 was filed for the hospitalization of the complainant at Mannalil Ayurveda Hospital, Ettumanoor, Kottayam, from 31-08-2023 till 09-09-2023, as he was diagnosed with Kateegraham.
The back pain is considered as Kateegraham in Ayurveda. Katee is one of the Vata sthaanas and pain/stiffness is caused by Vata, hence Kateegraha can be considered as Vatavyadhi. It is a condition where the lower back region is afflicted with Vitiated Vata and presents with symptoms such as pain and stiffness. Katigraha, mentioned in Ayurveda, can be correlated with Lumbar spondylosis due to the similarity of clinical manifestations.
In the discharge summary, it was mentioned that the patient met with an accident, and due to a sudden fall, he started getting pain and swelling over his lower back. Accordingly, the opposite party raised a query dated 16-10-2023, and the complainant was asked to provide all past treatment records of road traffic accident and the first consultation paper immediately after an incident of the road traffic accident.
It is pertinent to mention that the complainant refused to supply documents relating to the history of the accident. Therefore, the opposite party sent a non- registration of claim letter dated 28-10-2023, stating that the claim has been rejected not-registered on the grounds of 4.1.A.I pre-existing diseases waiting period of 24 months (code excl.01) - low back pain prior to policy and 4.I.a.i pre-existing diseases waiting period of 24 months. In light of the above, the complaint is not at all maintainable since the complainant violated the policy's terms and conditions, and there is no deficiency in services on the part of the opposite party: hence, the present complaint is liable to be dismissed.
The complainant filed proof affidavit in lieu of chief examination and marked exhibits Al to A5 from the side of the complainant. Prabhajyot Singh, who is the authorized signatory of the first opposite party, filed a Proof Affidavit in lieu of chief examination and marked exhibits B-1 to B6 from the side of the opposite parties.
We would like to consider the following points on the evaluation of the complaint, version and evidence on record.
- Whether the complaint had succeeded to prove any deficiency in service on
the part of the opposite party.
- If so, what are the reliefs and cost
Point No. One and Two Together
There is no dispute on the fact that the complainant has availed a medical insurance policy from the first opposite party vide policy number 69057310, for a sum insured of Rs. 5,00,000/-. On going through the Exhibit Al policy certificate, we can see that the policy was valid from 27-07-2023 to 26-07-2024. According to the complainant, on 30/08/2023, he had a sudden fall, due to which he suffered from severe back pain and was having trouble walking, for which he was admitted at the Mannalil Ayurveda Hospital. It is proved by Exhibit A4 (a), which is the discharge summary issued from the Mannalil Hospital, that the complainant was treated there as an inpatient from 31-08-2023 to 09-09-2023. As per Exhibit A4 (a) discharge summary, the complainant was presented at the hospital with complaints of pain and swelling over the lower back region for one week and was diagnosed with 'KateeGraham. The complainant had spent Rs.26,764 for his treatment at the hospital vide Exhibit A4. Though the complainant lodged a claim to reimburse the treatment expenses with the opposite parties, they rejected the claim via the Exhibit A5 letter.
The opposite party resisted the complaint, contending that the ailment for which the complainant had undergone the treatment was for a pre-existing disease. It is further contended by the opposite parties that though they requested the complainant to submit all past treatment records of road accidents and the first consultation paper immediately after the incident of the road traffic accident, he refused to submit the documents relating to the history of the accident. However, a close Perusal of Exhibit B-2 claim form submitted by the complainant reveals that he had not stated that he had suffered pain and swelling over the lower back region due to the accident.
On going through Exhibit B3, which is the discharge summary issued by Dr. Rakhee, who is the treating doctor, we can see that in history, it is stated the complainant was normal one week before, and he met with an accident, and due to sudden fall, he started to get pain and swelling over lower back. Therefore, it can be presumed that the complainant was well before 31-8-2023. He had a sudden fall, due to which he suffered some severe pain and swelling over his lower back.
The opposite parties, in the version as well as in the proof affidavit, submitted that due to the nonproduction records of the road traffic accident, they have sent a non registration of claim letter stating that the claim had been rejected/not registered on the grounds of pre-existing diseases waiting period of 24 months under clause 4.I.i a of the terms and conditions of the policy. However, in exhibit B5, Non-registration of claim' letter, opposite parties have stated that they have received the documents filed by the complainant and are unable to register the claim, as per the policy terms and conditions.
In Reliance Life Insurance Co. Ltd, and Anr. vs. Tarun Kumar Sudhir Halder, 2019 3 CPR (NC) 20, the Hon'ble National Commission has held that the onus to prove the pre-existing disease lies on the insurance company - Diabetes is a lifestyle disease and is so common in India that the whole insurance claim cannot be rejected on this ground.
Here, in the case on hand, the opposite parties have not adduced any evidence to prove that the complainant has suffered the ailment for which he had undergone the treatment at the time of proposing the policy. Therefore, the opposite parties have committed deficiency in service by rejecting the genuine claim of the complainant, and the complaint is to be allowed. In the result, we allow this complaint and pass the following order:
We hereby direct opposite parties:-
- To pay an amount of Rs. 26,764/- (Rupees Twenty six thousand seven hundred and sixty four only) to the complainant with interest @ 9% from 28-10-2023. ie., rejection of claim till the date of realization.
- We hereby direct the opposite parties to pay Rs. 10,000/- (Rupees ten thousand only) to the complainant as compensation for the deficiency in service on their part.
- We hereby direct the first opposite party to pay Rs. 2500/- (Two thousand and five hundred only) as the cost of this litigation.
The opposite parties are directed to pay the amounts to the complainant within 30 days from the date of receipt of a copy of this order, failing the compensation amount shall carry an interest @ 9% p.a. from the date of this order till its realization.
Pending Application(s), if any, are automatically disposed of as being rendered infructuous.
Pronounced in the Open Commission on this the 30th day of October, 2024
Sri. Manulal V.S. President Sd/-
Smt.Bindhu.R, Member Sd/-
Sri. K.M. Anto, Member Sd/-
APPENDIX :
Exhibits from the side of the Complainant :
Al - Copy of Policy Certificate dtd. 27/07/2023
A2 - Copy of the premium payment acknowledgement dtd. 31/07/2023
A3 - Copy of the Health Insurance Card
A4 - IP Bill No 133 issued by Mannalil Ayurveda Hospital
A4 (a) - Discharge Summary
A5 - Copy of Non-registration of claim dtd. 28/10/2023
Exhibits from the side of Opposite parties :
B1 - Copy of Policy Certificate
B2 - Copy of the claim form
B3 - Copy of the Discharge summary
B4 - Copy of query letter and query reply
B5 - Copy of Non-Registration of claim letter dtd. 28/10/2023
B6 - Copy of policy terms and condition
By Order,
Assistant Registrar
