Order-14.
Date-28/06/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short is that OP-1 is Insurance Company, OP-2 is its Branch Office and OP-3 is the Broaker of OP-1.
The Complainant purchased a Medical Claim Policy being No.30385058201400 from OP-1, valid from 29.12.2014 to 28.12.2015, sum insured 30 lacs, plan opted – Family First Silver Rs.5 lacs + Rs.15 lacs and Complainant has paid premium of Rs.28,811/-. The names of the persons insured were, Complainant himself, her son, namely Amit Sharma, her daughter Swati Sharma. The Complainant also purchased a Health Insurance of the OP previously vide Policy No.30286474201300 for the period from 31.12.2013 for the next one year. The Complainant is quite hale and hearty and did not suffer from any disease. But, unfortunately on or about 18.05.2015 the Complainant experienced sudden chest pain for which he consulted a local Physician, who prescribed certain medicines. As per prescription, the Blood pressure appears to be normal in range i.e.160/90.It is stated that the Complainant never took any medicine for Blood pressure earlier. Again towards the morning of 20.05.2015 the Complainant again experienced the chest pain and the consulted the Cardiologist. But the chest pain did not subside.The Complainant thereafter went to emergency counter of B.M. Birla Heart Research Centre and was admitted there for observation as an Indoor patient. On 21.05.2015 the Complainant as per advise of the Doctor underwent tests like Angiography and it was diagonosed that there has been two blockage in the Artery and he was advised for Angioplasty. The Complainant submitted Cashless pre authorization letter. It is stated that in application for Cashless Insurance pre authorization letter, it is written wrongly and incorrectly ‘hypertension for last one year’. The pre authorization was denied on the ground of non closure of hypertension. It is stated that in the certificate dated 01.06.2015 issued by Dr. Anjan Siotia of the said Hospital, it is written that there has been no previous history of Cardiac illness and that he is having high BP for the last one month back.. But the Personal Assistant of Dr. Siotia inadvertently and wrongly had written hypertension for last one year in the ap[placation for Cashless Insurance and preauthorization. Dr. Anjan Siotia however, made the necessary correction. The Complainant has stated that he has incurred the medical expenses to the tune of Rs.5,20,456/- being the claim amount. He stated that the Complainant submitted the claim amount in the Claim Form being an amount for Rs.5,20,456/-, but the OPs without making any enquiry arbitrarily and whimsically repudiated the claim of reimbursement on the ground of deliberately suppression of material fact like Hypertension at the time of taking health policy. It is denied that the Complainant is suffering from hypertension for the last 05 years. It is stated that the complainant never suffered from any such disease like Hypertension and never used the medicine like Amlodipine. The Complainant has alleged deficiency of service and unfair trade practice against the OPs. Hence this case.
The Complainant has prayed for a decree in terms of prayers in the petition of complaint.
OPs 1 and 2 have contested the case in filing w.v. contending inter alia that the case is not maintainable in law or in fact. It is stated that OP-1 nd 2 are individual employees of Max Bupa Health Insurance Company and cannot be sued in their individual capacity for the action of the Company. It is stated that there has been no deficiency of service committed by OP1 and 2. It is stated that in 2014 the Complainant had proposed to obtain a policy from Max Life Insurance Company bearing no. 30385058201400 from 29.12.2014 to 28.12.2015. The Family First Silver Rs.05 lacs + Rs.15 lacs Insurance Policy was issued in favour of the Complainant along with family. One of the terms of the Policy specified in the Insurance Policy was that at the time of entering into such policy the insured must disclose all previous ailment which he or she might suffer or has suffered. It is alleged that the Complainant did not reveal and / or disclose the past medical history of hypertension at the time of entering into the Insurance Poilicy. It is also alleged that complainant filed pre authorization request over sudden on set of chest pain of Complainant. The pre authorization request was investigated and it was noted that the Complainant had prior history of hypertension. The OP with such request sought for more additional information vide letter dated 21.05.2015. From the documents submitted, it was revealed that Complainant had a past medical history of hypertension since six years and the Complainant was taking Amlodipine for the last one year. In the case history form dated 20.05.2015 of Nursing Home, it is stated – hypertension under the heading, ”past history”, during investigation multiple overwriting was also observed on the case history sheet. The pre authorization was also denied on the basis of past history, and for such non disclosure. It is stated that the Complainant obtained a cerftificate subsequently after denial of the authorization and it was afterthought. The Complainant also filed a claim with the OP. The Insurance Claim of the Complainant has been validly denied for non disclosure of past medical history. It is stated that there has been no deficiency of service on the part of the OP and the case is filed to extract money which is not due and payable by the OP. It is also stated that the Insurance works on the principle of utmost good faith which in this case was blatantly violated by the Complainant by misleading the OP to issue the policy. It is stated that the proposal form is not merely a document to be signed and submitted for formality and it is the basis of the contract of Insurance. It is submitted that Complainant has been filed with mala fide intention to extract money from the OP. The OPs have prayed for dismissal of the case.
Point for Decision
- Whether OPs are deficient in rendering service to the Complainant?
- Whether the OPs have repudiated the claim of the Complainant validly?
- Whether the Complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have perused the documents on record i.e. photocopy of Max Bupa Health Insurance Pollicy kit along with policy documents, photocopy of customer information sheet, photocopies of premium receipts, photocopy of heart beat health insurance policy proposal form, photocopy of key feature document, photocopy of claim form, photocopy of insurance certificate, photocopy of prescription of Dr. Probodh Ranjan dated 18.05.2015, photocopy of prescription of Apollo Clinic dated 20.05.2015 of Dr,. Janaki Raman, photocopy of ECG report, photocopy of discharge summery of B.M.Birla Heart Research Centre, photocopy of certificate of Dr. Anjan
Siota dtd. 01.10.2015, photocopy of certificate of Dr. Anjan Siotia dated 22.05.2015, photocopy of OPD registration of the Complainant, photocopy of Case history form of B.M.Birla Heart Resarch Centre and the other documents on record.
It appears that the Family First Silver Rs.5.0 lacs + 15 lacs Insurance Policy was issued in favour of the Complainant along with his family. We also find that the Complainant also obtained Insurance Certificarte earlier and the pervious period was from31.12.2013 to 30.12.2014. The Complainant purchased the present mediclaim policy which has coveratge from 29.12.2014 to 28.12.2015.It is stated by the Complainant that he got himself admitted following sudden chest pain in the Emergency department of B.M.Birla Heart Research Centre, Kolkata-700 027 under the Cardiologisst Dr. Anjan Siotia. The OPs have repudiated the pre authorization as well as the claim of the Complainant on the ground that at the time of entering into the policy, the Complainant did not disclose that he was suffering from Hypertension. It is stated by the OPs that the Complainant did not reveal or disclose the past medical history of Hypertension. It is stated that the Complainant had a past medical history of Hypertension. It is stated that case history form dated 20.05.2015 reveals that Complainant had past medical history of hypertension.
From the case history form we find that the patient was admitted there following sudden on set of chest pain radiating towards left arm. It is argued from the side of the Complainant that the repudiation on the ground of non closure of hypertention and pre authorization dated 22.05.2015 is wrong, illegal and arbitrary. It is also stated by the PW-2 Ms. Swati Sharma that the case history form bears only her signature and other coloumns aere filled by the said Hospital authority. Dr. Probodh Ranjan and Dr. Anjan Siotia which is not in her hand writing. She has also staterd that she never said to any Hospital authority or the PA of Dr. Anjan Siotia that her father has been suffering from disease of hypertension with the last one year and such entry has been made wrongly and intentionally by the Hospital authority and P.A. of Dr. Anjan Siotia. It is also stated by her that the Complainant never suffered from hypertension and never took any medicine.
Be that as it may, the question is, can Hypertension be said to be a pre-existing disease for repudiation of any mediclaim? First of all, it is pertinent to mention that the OPs have not been able to produce any document to show that the Complainant was suffering from hypertension any Heart Disease prior to taking up of the policy. There is no proof that Complainant was suffering from any Heart Disease. Even, if we take it for granted for argument sake that the Complainant was suffering from Hypertension, it cannot be said that every person suffering from Hypertension is suffering from Heart Disease or would develop blockages in artery. Moreover, the Complainant was admitted to the Hospital with sudden chest pain and after diagonosis in the hospital by Dr. Anjan Siotia revealed that the Complainant had blockage in in the Heart. It is often seen in most of the cases that the person suffering from hypertension may not show any symptom. If one suffering from hypertension, it is not necessary that he is suffering from Heart Disease. Hypertension is a common ailment and it can be controlled by medicine and it is not necessary that persons suffering from hypertension would always suffer Heart attack/blockage. Treatment for hypertension or heart problem cannot be termed as ‘ claim in respect of pre-existing disease’. Dr. Anjan Siotia issued two certificates stating that the Complainant was having hypertension from the past one month back and is not taking drug/medicine for such hypertension. The case history form as we know is generally and commonly written by some one of the Hospital Staff and further it does not appear to be in the hand writing of the Complainant’s daughter Ms. Swati Sharma which she claims. The signature of Ms Swati Sharma differs from the hand writing appearing in the body of such case history form. Ms Swati Sharma has stated in her evidence that the PA of Dr. Anjan Siotia took her signature in the form, requested for eligibility treatment and the form bears her signature but the forms are not filled in by her. We find that no questionnaire was made on this point either by the OPs 1 and 2 or OP-3. We also find that OPs subsequently renewed the policy for the period from 29.12.2016 to 28.12.2017. We have also seen the renewal of the policy enclosed with the affidavit on Evidence of the Complainant. We find that OPs did not cancel the subject policy even when they denied the pre authorization and also repudiated the claim. We find that the Insurance Company allowed the renewal of the Insurance Policy still thereafter. It is astonishing that OPs have repudiated the claim and at the same time renewed the policy. We think renewal of the policy operates as waiver and estopel as against repudiation.
We think that the repudiation is not valid and illegal. The OPs-Insurance Company has demonstrated a gesture of deficiency of service in repudiating the claim of theComplainant.
[Perused the decision reported in 2016 CPJ 613 NC, (2017) CPJ 438 NC as cited from the side of the Complainant.]
It appears that the Complainant has incurred medical expenses to the tune of Rs.5,20,456/-. OPs be directed to release the claim accordingly.
Consequently, the case merits success
Hence,
Ordered
That the instant case be and t he same is allowed on contest against the OP 1 and 2 and ex parte against OP-3.
OP 1 and 2 aere directed to pay an amount of Rs.5,20,456/- to the Complainant towards medical expense apart from litigation cost of Rs.10,000/- within one month from the date of this order
Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision of C.P. Act.
