Order14.
Date-11/05/2015.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that complainant is a bona fide mediclaim policy holder of the OP1 since 13-12-1996 having policy No.03110048/37/11/0566/96 and same has been renewed for several years and the policy was under the name and heading of Mediclaim Insurance Policy and Individual Health Insurance Policy – 2010.
Premium of the said policy on the year 2013 is Rs.24,803/- which was paid by the complainant on 07-03-2012 bearing policy No.031100/48/11/97/00005999, and having policy period from 09-03-2012 to 08-03-2013 and the said insurance coverage was for the complainant and for his wife Smt. Laxmi Gupta and sum insured for Rs.3 lakhs for each policy holder and complainant is a bona fide mediclaim policy holder of the OP1 since more than 18 years for himself and his family members. During the present policy period complainant became seriously ill and was examined by Dr. Abhijit Aich Bhowmik at B.M. Birla Research Centre, thereafter, complainant was admitted at B.M. Birla Heart Research Centre on 04-03-2013 under the care of Abhijit Aich Bhowmik where the doctor’s diagnosis for treatment as : “Accelerated Hypertension, Benign Hypertrophy of Prostate, Type II Diabetes Mellitus Microalbuminuria”. After thorough treatment patient was discharged on 10-03-2013.
After admission of the Hospital the complainant informed the OPs for such admission in hospital for regarding treatment hospitalization for consideration of the same as total expenditure of Rs.4,30,000/- and complainant sent a letter on 05-03-2013.
After discharge from the Hospital the complainant intimated the insurance company about such hospitalization during the period of admission in hospital and the complainant submitted claim in respect of reimbursement of medical expenditure on 04-03-2013 for an amount of Rs.4,30,000/- to the OPs1 and 2 for necessary action but in the meantime OP2 TPA sent a letter to the complainant vide letter dated 07-03-2013 with the following observation : “for this case we are unable to issue the Authorization Letter for the following reasons - “Looking at the inception date of policy (09-03-2009) and pre-existing nature of the disease ( IHD along with D.M. & HTN since 10 years we regret our inability to sanction the cashless authorization, as per Rule 4.1”.
Thereafter, OP Insurance Company vide letter dated 12-04-2013 repudiated the claim of the complainant with the following observations : “Any pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her first policy with the company”. Therefore, as per terms and condition of the policy the claim is non-admissible as per policy Exclusion Clause 4.1”. Complainant being informed the matter and aggrieved and dissatisfied with the repudiation letter of the OPs the complainant immediately sent one protest letter dated 29-05-2014 to the OP1 insurance company with a request to reconsider the claim but in spite of receipt of the said letter the insurance company did not take necessary measure to solve the problem.
Again complainant sent a letter on 08-06-2013 and 04-07-2013 to the OP1 and submitted some important documents for settlement of his claim but even after receipt of the same they did not take any step or settled the claim.
Finding no other alternative complainant appeared before this Forum for negligent and deficient manner of service and adopting arbitrary process for repudiating the claim without any ground though complainant is a mediclaim policy holder continuously for 18 years and the Clause 4.1 is not applicable in view of the fact 48 months had already covered from the date of inception of the policy in the year 1996 and further it is submitted that complainant has no knowledge about any such disease and for the first time such disease detected by the doctor on 20-02-2013 and the said Dr. Abhijit Aich Bhowmick issued the discharge certificate on 20-02-2013 wherein he erroneously wrote in the column of “history was known case of Hypertension, Type II Diabetes Mellitus – 10 years admitted with increased BP level” and in fact OP company observed wrongly the pre-existing disease and in fact, OP company repudiated the claim on such baseless ground and in fact, prior to such admission there was no such illness and also had no knowledge about the same at the time of policy i.e. in the year 2000 or for the period of last couple of year and therefore, the plea taken by the insurance company for repudiation of the legitimate claim are baseless and created for some illegal gain and in the above circumstances, complainant has prayed for disbursement of the entire medical treatment cost of Rs.4,30,300/- along with interest and compensation for harassment etc.
On the other hand, OP by filing written statement submitted that as per policy condition and considering the discharge summary of the B.M. Birla Heart Research Centre the claim was repudiated as it is pre-existing disease as it was evident from the discharge summary and in fact, as per terms and conditions of the policy both the parties shall be guided and as per policy complainant is not entitled to get such disbursement and for which it was repudiated on just and proper ground and there was no negligent and deficiency on the part of the OP and for which the present complaint should be dismissed.
Decision with Reasons
On comparative study of the complaint, written version and also considering the letter dated 04-07-2013 sent by Hiralal Gupta, the complainant it is clear that complainant continued the policy up to 2008 but thereafter due to overlook in renewal a gap for few months took place and thereafter, a new policy was started so, it is clear that it was not a continuous policy since 1996. But renewal was denied up to 2008 and thereafter, there was a gap so, after 2008 subsequent policy is not treated as renewal since 1996. On the other hand, from the present policy it is clear this policy was for the period from 09-03-2012 to 08-03-2013 midnight but there is no such policy to show that the said policy which expired on 08-03-2013 was continued or renewed. But fact remains the complainant was admitted to hospital on 04-03-2013 and discharged on 10-03-2013. So, at best for the period from 04-03-2013 to 08-03-2013 complainant may claim medical policy for that period but not for the period from 09-03-2013 and 10-03-2013 because at that time there was no continuity of the said policy. Fact remains in respect of present policy it is found on the date of opening the present policy that is on 09-03-2012 complainant Hiralal Gupta was aged about 73 years but at the time of submitting that policy no such document was filed by the complainant to show that he had not been suffered from any diseases. Another factor is that from the discharge summary it is found that complainant was suffering from hypertension etc. from preceding 10 years and truth is that at the age of 73 years as per medical science the entire body system loses the normal capacity in respect of all organs and as per medical science the function of the organ decreases up to 50 percent, other in respect of bone capacity, liver, kidney, apatite system etc. including heart, lung. So, it can be said that at the time of opening the present policy invariably complainant did not disclose his health status or anything and no doubt this is not for the said application and in the discharge summary it is specifically mentioned diabetes mellitus 10 years, hypertension 10 years, and so, coronary angiogram was done on 06-03-2013 which shows double vessel disease and he was reviewed by Dr. P.S. Nandi and moreover, he had his psychological problem for which on 07-03-2013 consultant Psychiatry doctor was deputed for such problem, thereafter, stenting to LAD was done and thereafter, patient recovered uneventfully with no hematoma at puncture site and so, the patient was stable and was discharged with necessary advices.
Considering all the above materials it is clear that the present policy was not continuously renewed since 1996, break was there in the year 2009 and in the present policy it is specifically noted pre-existing diseases excluded with policy as per Exclusion Clause and present complainant is covered by policy under Senior Citizen Policy condition and it is individual health insurance policy since 2010 and if we consider the policy then it is clear that the present policy further started from 2010 and was continued up to 2013 that is only for 36 months, not for 48 months but the present disease were detected within 36 months from the date of his policy of the year 2010. Another factor is that the present policy expired on midnight of 08-03-2013 then complainant is not entitled to claim any mediclaim in respect of his treatment dated 09-03-2013 and 10-03-2013 but complainant has claimed Rs.4,30,000/- whereas as per policy sum insured is Rs.3 lakhs and bonus is Rs.30,000/-. Now, question is whether complainant is entitled to get any amount as mediclaim as per the present policy.
In this regard we are confirmed that claim of the complainant to the extent of Rs.4,30,300/- is not tenable because sum insured is Rs.3 lakhs, bonus is Rs.30,000/- then his claim may be filed within that limit that is Rs.3,30,000/- but it is proved that the present policy is not a continuous policy since 1996 but on the other hand it is proved that the present policy is continued for 3 years from 2010 and it expired on 08-03-2013. Thereafter, it was not renewed. So, in respect of the claim for his treatment from 04-03-2013 to 10-03-2013 cannot be entertained by the OP. At best complainant can claim disbursement of the treatment cost from 04-03-2012 to 08-03-2013 in this regard we have gathered that continuous policy for 4 years that is for 48 months is or was not in existence but it s continued from the year 2010.
But fact remains as per provision of Law and Insurance Regulations after 65 years no mediclaim policy shall be issued to any persons without medical check up but in the present case the policy was issued to the complainant who was about 73 years at the time of opening the policy on 09-03-2012 and as per IRDA and Insurance Regulation if any person above 63 years opens any mediclaim policy he must have to submit medical certificate about his health with papers but that was not submitted but senior citizen policy was accepted. It is undisputed fact that discharge certificate supports that complainant has suffered from diabetes and hypertension for 10 years but that was not disclosed at the time of opening the policy though he was 73 years. So, invariably it is the primary duty of the insured to prove that at the age of 73 years he was a general bodied man having no deficiency. Medical science does not accept such theorization. On the contrary medical science supports that after the age of 65 years the general function of the body decreases in respect of all system and practically complainant is or was a sexogenarian at the relevant time. Fact remains OPs have applied the terms and condition of the policy after relying upon the discharge certificate and invariably there was a continuous period of hypertension, diabetes etc. so, he suffers from heart ailment and that is normal at the age of 73-74 ages. Now, question is why the insurance company accepted the proposal for purchasing mediclaim policy by the complainant at the age of 73 years without any medical test. As per Insurance Policy Regulations after 65 years no mediclaim policy shall be opened by any insurance company without thorough medical test of person who have purchased the mediclaim policy but that has not been done by the OP then it is no doubt a fault on the part of the OP. Invariably OP at the age of 73 on payment of premium of Rs.24,803/- purchased the policy invariably with the purpose that during the valid period of the policy ne and his wife may get such mediclaim disbursement if any treatment is required at their old age and no doubt OP accepted it and issued senior citizen policy at their age about 73 and 63 respectively but without proper examination of the health condition of the complainant and his wife and then invariably it is the liability of the OP to give explanation for what reason such a policy was opened when it was known to the OP that insured are Senior Citizen and invariably old age complications shall be there for which some amount must be released in favour of the complainant when fact remains that he already spent about 4 lakhs but we are aware of the fact that insurance policy range is Rs.3 lakh and bonus Rs.30,000/- so, after considering the entire policy condition including the total clauses it is clear that out of the total amount of insurance, complainant may get 50 percent of the treatment cost that is further entitled to 25 percent of the doctor’s fees and 1 percent of the bed charge as per clause as per policy condition.
When the insurance is a social legislation then invariably adopting any technicalities the claim of a senior citizen cannot be curtailed when the policy heading is a senior citizen policy then it is within the knowledge of the OP that they have their some disabilities and diseases at the age of 63 or 73 years because in the present case insured persons were of age 63 and 73 at the time of taking the policy but as per regulation their health condition was not checked by the OPs then it is the liability of the OP too some extent to pay some of the treatment cost because this policy is for the senior citizen and all over the world the senior citizen get special preference when insurance company knows that they must have their pre-existing diseases when blood pressure and sugar are common for most of the people at this age, so, at this age OP cannot fully repudiate the claim of the complainant only on the ground of pre-existing condition as defined in the policy until 48 months of continuous coverage of such insured. So, considering that fact and materials and also the treatment sheets etc. we have gathered that complainant already spent more than Rs.4,25,000/- at this age for his treatment that is for medical treatment, investigation charge and for catheleb and after applying the percentage out of the total treatment as available as per policy and also after calculation of the bills complainant may be awarded a sum of Rs.1,75,000/- and OP must have to settle the claim by paying Rs.1,75,000/- to the complainant treating the claim as finally settled and order of repudiation is found not legal. Accordingly, the complaint succeeds in part.
Hence,
Ordered
That the case be and the same is allowed on contest in part with a cost of Rs.2,000/- against the OPs.
OP1 is hereby directed to pay a sum of Rs.1,75,000/- to the complainant as finally settled amount of the mediclaim policy treating the repudiation as illegal and same must be paid to the complainant within one month from the date of this order along with litigation cost failing which for non-compliance of the Forum’s order penal interest at the rateRs.200/- per day shall be assessed till full satisfaction of the decree. Even if it is found that OPs are reluctant to pay the dues in that case penal action shall be started against them under provision of Section 27 of the C.P. Act.
