SMT. RAVI SUSHA : PRESIDENT
Complainant has filed this complaint U/S 35 of the Consumer Protection Act 2019 seeking to get an order directing opposite party to refund the treatment expenses of Rs.72,193/- with 12% interest along with Rs.50,000/- towards compensation for mental agony and sufferings to the complainant and cost of proceedings of this complaint.
Brief facts of the complaint are that the complainant has obtained an Arogya plus policy SBI General Insurance and it has coverage to his wife Smt.Sahida P.M and his daughter Raniyabi.P.M. Further the policy period was from 13/5/2022 to 12/5/2023 and sum insured is Rs.3,00,000/-. Further complainant made claims 4 times as Raniyabi T.M (dautghter/insured) was admitted and treated 4 time at KMC Hospital Mangalore within the policy period. So far the complainant has met the treatment expenses of an amount of Rs.72,193/- towards the 4 admission periods. Complainant submitted the 4 claims to the OP, but the OP is repudiated 4 claims. It is submitted that by virtue of the policy referred the OP is bound to indemnify the complainant towards the medical and treatment expenses of complainant’s daughter who is also covered under the policy, denial of the medical expenses is a sheer violation of the insurance agreement entered into between the complainant and OP. Complainant submitted that he is entitled to get the treatment expense from the OP and denial of policy benefit by the OP amounts to deficiency in service on the part of insurance company. Hence this complaint.
After receiving notice OP entered appearance through their panel counsel and filed written version. OP admitted the Arogya policy of the complainant. OP submitted that claims was lodged alleging hospitalization of the insured Raniyabi.P.M that the claim was denied upon scrutinizing the submitted claim documents, it had been observed that this-16 years old female was admitted on 27/8/2022 with Rheumatoid Arthritis. Since this is a first year policy (policy inception date 13/5/2022) and there is a one year waiting period for arthritis, the claim attracts exclusion clause No.3. Further submitted that 2 claims was denied as it was a continuation to the first claim and the same exclusion are attracted. Moreover, during the stay there was no active treatment whereas it was only evaluation. The claim was denied as the medical records read past history of gluteal abscess in 2021 ie, before the policy inception. Hence the claim shall fall within the meaning of Pre-existing disease defined in the policy. The exclusion under the policy is for pre-existing disease, whereby its treatment and its direct complication shall been excluded until 48 months/ 4 years from the inception of the policy. The claim was rightly denied by the OP by invoking the exclusion and it was duly communicated to the complainant. It is submitted that it is well settled position of law that the policy terms and conditions should be strictly construed. Therefore , the policy may be strictly construed. Therefore, the policy may be strictly construed and uphold the claim denial.
Complainant has filed his chief affidavit and documents. Examined as PW1. Marked Exts.A1 to A8. Ext.A1 is the policy details, Ext.A2 is the copy of lawyer notice, Ext.A3 is postal receipt. Ext.A4 is acknowledgment card. Exts.A5 to A8 are discharge summaries 4 in Nos. issued from KMC Hospital, Mangalore. On behalf of OP, the Consumer Litigation claims Manager of OP Insurance company filed his proof affidavit and was examined as DW1. Marked Exts.B1 to B11. Ext. B1 is the policy schedule, Ext.B2 is the certificate from the treating doctor,Ext.B3 is the copy of cashless claim form ,Ext.B4 is the copy of progress notes from KMC hospital Mangalore, Exts.B5 and Ext.B11 are copy of initial assessment form, Exts.B6, B7& B10 are the copy of cashless claim denial letter, Ext.B8 is a copy of letter issued by OP to KMC hospital, Ext.B9 is the copy of cashless claim form.
After that the learned counsel of both parties filed written argument notes.
We have considered the submissions of both parties and perused the records available before us.
The undisputed facts are that the complainant has obtained an Arogya plus policy SBI General Insurance and it has coverage to his wife Smt.Sahida P.M and his daughter Raniyabi.P.M. Further the policy period was from 13/5/2022 to 12/5/2023 and sum insured is Rs.3,00,000/-. Further complainant made claims 4 times as Raniyabi T.M(dautghter/insured) was admitted and treated 4 time at KMC Hospital Mangalore within the policy period. It is a facts that 4 claims were repudiated by OP. Complainant alleged that he is entitled to get the treatment expense from the OP and denial of policy benefit by the OP amounts to deficiency in service on the part of insurance company.
OP contended that the 1st claim was repudiated as per Exclusion clause V 2.(a) of the policy. The policy schedule is marked as Ext.B1. Clause V 2(a) ,V Exclusion clause 2(a) states that “Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 90 Days/12 months of continuous coverage after the date of inception of the first policy with us.”
It is seen that list of specific disease for 12 months (ie 1 year) include Non- infective Arthritis .
Case of complainant is that his daughter was admitted to KMC hospital at the first time was from 27/8/2022 to 9/9/2022 (marked as Ext.A5). The illness was diagnosed as Crohn’s disease, not rheumatoid arthritis. Hence complainant is entitled to get the 1st claim.
On the other hand OP submitted that “ upon scrutinizing the submitted claim documents, it had been observed that this-16 years old female was admitted on 27/8/2022 with Rheumatoid Arthritis. Since this is a first year policy (policy inception date 13/5/2022) and there is a one year waiting period for arthritis, the claim attracts exclusion clause No.3. Hence the claim is repudiated”.
On perusal of Ext.A5 submitted by the complainant reveals that final diagnosis recorded as “Crohn’s disease”.(a chronic inflammatory bowel disease that affects the lining of the digestive tract”). Further present illness:- 16 yrs old , 4th in order of birth came with complaints of dizziness of one month duration. Past History: patient is a known case of steven Johnson syndrome diagnosed at 3 years of age when she was admitted to ICU and received supportive care and steroids.
From the discharge summary (Ext.A7) it can be seen that K/C/o crohn’s disease diagnosed in September 2022 ie, after taking policy dtd.13/5/2022. Further Steven Johnson syndrome was diagnosed at 3 years of age. Medical literature said that Stevens’ Johnson syndrome is a serious, rare skin condition that can be treated and cured but it can take weeks or months to recover.
It is a fact that the said disease diagnosed at 3 years of age. The present admission for treatment was for crohn’s disease. OP contended that the treatment given was for rheumatic arthritis. But in the course of treatment reveals that though ortho opinion was juvenile rheumatoid arthritis ,RF factor Rheumatoid factor sent were negative. Which means no complaint of rheumatoid arthritis.
On overall analysis of Ext.A5 we can see that the patient was admitted for crohn’s disease which was diagnosed in September 2022. Since it is evident that the said disease diagnosed after taking policy in dispute and no symptom of Rheumatoid arthritis, the insured is entitled to get treatment expense incurred from him for Ext.A5 treatment. As per Exts.B2&B3 though there was complaint of joint pain since 20 days prior to 29/8/2022, not diagnosed Juvenile Rheumatic Arthritis only suspicion. So repudiation made by OP as per Ext.B6 is not justifiable.
Next discharge summary Ext.A6 treatment period was from 13/9/2022 to 28/9/2022 . 2nd claim was made by the complainant for getting treatment expense incurred for the treatment with relates to Ext.A6 discharge summary.
The claim application submitted was repudiated by OP(Ext.B7) due to the reason that” As per the treatment sheet diagnosed? Crohns disease. Patient has h/o Steve-Johnson disease since 3 years of age and treatment on going. So looking the short duration of policy and chronic nature of disease, pre-existing cannot be rule out. Hence, cashless is not accorded.”
On perusal ofExt.A6, Final diagnosis:- “ Crohn’s disease” and it was diagnosed in September2022. In Ext.A6 also we can realized that patient was not treated for Steven Johnson syndrome. C/o joint pain and fever since 1 day from the admission date 13/9/2022.
So repudiation of treatment date 13/9/2022 availed in Ext.A6 as per Ext.B7 with a finding that treatment for Steven Johnson disease in going on is also unjustifiable. No medical records submitted by OP or no medical practitioner was examined to establish that the patient Miss.Raniyabi P.M is continuing treatment for Steven Johnson disease since 3 years of age. So complainant is entitled to get claim amount as per Ext.A6 with a finding that there is no suppression of pre-existing disease in the proposal form submitted on 13/5/2022.
Ext.A7 discharge summary issued from KMC Hospital pertains to the treatment availed by the patient for a period from 18/10/2022 to 19/10/2022.
The claim filed by the complainant for re-imbursement of the treatment expense incurred to him.
On perusal of Ext.A7, final diagnosis as gluteal abscess with Klebsiella species growth. Complaints- Discharge from fistula since 1 week.
Ext.A7 also reveal that the disease diagnosed was not a pre-existing one. So there is no suppression of material part from the side of complainant.
Ext.A8 is the treatment for a period from 25/10/2022 to 3/11/2022. Final diagnosis was crohn’s disease. Diagnosed in September 2022. Not a pre-existing disease. So eligible to get reimbursement of treatment expense to Ext.A8 treatment.
Here though OP raised a contention that the patient has a complaint of Rheumatic arthritis at the 1st treatment Ext.A5, the RF factor was negative. So we cannot rely the contention of OP about rheumatic arthritis. Further OP raised another contention that the treatment of Steven Johnson syndrome was continuing on the patient since 3 years of age. But there is no medical records submitted by OP to establish the said contention. Though in Exts.A5 to A8, mentioned about Steven Johnsons syndrome diagnosed at 3 years of age, no supportive evidence submitted for the continues treatment till 16 years. Medical literature tells that Steven Johnson’s syndrome is a curable disease under treatment. In such a situation OP should have proved with medical evidence through treatment record and by examining the treating doctors.
So from the available evidence, we are of the view that Insurance company was not able to prove the allegation of suppression of material facts pertaining to the health of the patient and apply exclusion clause V(s) in the instant case. In Ext.A9, we can reveal that the OP has given bill amount of Rs.89,658/- towards the treatment expenses of Miss.Raniyabi P.M, patient in this case for the treatment availed for the period from 2/8/2023 to 3/8/2023 for the complaint cutaneous abscess without raising suppression of pre-existing disease.
So from the overall evidence and circumstances complainant is entitled to get treatment expenses of Exts.A5 to A8. Denial of 4 claim application by the insurer company is deficiency in service and unfair practice. Hence our view is that the complainant is entitled to get policy benefits from the OP Insurance company.
In the result complaint is allowed . Opposite party is directed to refund treatment expenses of Rs.72,193/- to the complainant( in 4 claims). Opposite party is also directed to pay Rs.25,000/- towards compensation for the mental agony and financial loss happened to the complainant together with Rs.10,000/- towards cost of the proceedings of this case. Opposite party shall comply this order within one month from the date of receipt of the certified copy of this order. Failing which , the awarded amount Rs.72,193+25,000/- carries interest @9% per annum from the date of order till realization. Complainant is at liberty to execute the order as per the provision in Consumer Protection Act 2019.
Exts:
A1- Policy details
A2-copy of lawyer notice
A3-Postal receipt
A4-Acknowledgment card
A5 to A8 -Copy of discharge summary(treatment records), KMC hospital Mangaluru
B1-Policy with terms and conditions
B2-Certificate from the treating doctor
B3 -Copy of cashless claim form
B4-Copy of progress notes from KMC hospital Mangalore
B5 and B11-Copy of initial assessment form
B6, B7& B10-Copy of cashless claim denial letter
B8-Copy of letter
B9- copy of cashless claim form
PW1-P.Muhammed Rafi-complainant
DW1-Leo John V.A- OP.
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
