Date of filing: 23.11.2016 Date of disposal:12.04.2016
Complainant: Pulak Kumar Ray, S/o. Late Sasthi Charan Roy, resident of Nevedita Pally, Town,
P.O.-Sripally, P.S. & Dist.-Burdwan, Pin-713103.
-VERSUS-
Opposite Party: 1. Good health TPA Services Ltd., represented by its Director, having its Head
office at Plot No.49, Nagarjuna Hills, Hyderabada-500 082.
2. United India Insurance Company Ltd., Burdwan Division, represented by its
Divisional Manager, having its office at Rudco, Floor No.., G.T. Road, Palika
Bazar, Burdwan, Pin-713101.
3. Andhra Bank, Burdwan Branch, represented by its Brach Manager, having
its office at Parbirhata, P.G. Complex, 1st Floor, G.T. Road, P.O.-Sripally,
Dist.-Burdwan, Pin-713103.
Present: Hon’ble President: Smt.Jayanti Maitra(Ray).
Hon’ble Member : Dr. Tapan Kr. Tripathy.
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty
Appeared for the Opposite Party No.1 : None.
Appeared for the Opposite Party No.2 & 3: Ld. Advocate, Shyamal Kr. Ganguli.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.2,77,904/-, to pay Rs.30,000/- as compensation for mental pain, agony and harassment and to pay Rs.20,000/- as litigation cost to the complainant.
The complainants’ case in short is that he along with his wife incepted a Medi-claim Insurance Policy of Opposite Party no.2 and from O.P. No.3 for the year 2015-2016 being Policy No.0504002815P103075013 and the said policy was valid from 9.6.2015 to 8.6.2016. It is pertinent to mention here that in respect of the said policy the O.P. No.1 registered the name of the complainant and provided an ID bearing No.GHUIAB01307045.
During continuation of the policy the complainant suffered from illness. The complainant consulted with Dr.Debabrata Roy at Rabindra Tagore Hospital at Kolkata as per advice of the treating doctor and admitted in the said hospital on 28.9.2015. On 30.9.2015 coronary angiogram was done by the treating doctor and discharged the complainant on 2.10.2015. An amount of Rs.2,77,904/- has been incurred by the complainant for such treatment.
Before releasing from the hospital the complainant intimated the fact of treatment to the O.P. No.3 & 1. Thereafter O.P. No.1issued claim form through O.P. No.3. Complainant filled up the claim form submitted the same before the O.P. No.3. After submitting the claim form the complainant on several times requested the O.Ps. to disburse the claim amount. But the O.ps. have not paid any heed to the request of the complainant. The O.P. No.3 verbally intimated the complainant that O.P. No.1 & 2 would not pay any amount as the complainant was suffering from hypertension and other pre-existing disease before the date of inception of the policy. After knowing the fact the complainant sent a letter to the O.P. No.2 stating that he has no symptoms of hypertension before taking admission in the said hospitals and he was not suffering from any disease. It is pertinent to mention here that neither the O.P. No.1 nor O.P. No.2 have sent any letter of repudiation of the claim. More over the O.P. No.1 & 2 are dragging the matter since receiving of the claim form by such way keeping themselves mum regarding the settlement of insurance claim. Finding no other alternative the complainant filed this case before this forum for relief as prayed for.
O.P. No.2 contested this case by filing written version stating inter-alia that the complainant along with his wife and daughter incepted a mediclaim insurance policy under Andhra Bank, Arogyadaan Group Health Insurance Policy being No.0504002815P103075013 for the period from 9.6.2015 to 8.6.2016 from the O.P. No.3 for the purpose of covering risk for himself and his family members for getting the risk coverage under Arogyadaan Sum Insured (Family Floater) of Rs.1,00,000/- and paid Rs.1,763/- being premium excluding service tax of Rs.247/-, which was certified by the O.P. No.2, United India Insurance Co. Ltd. and the complainant registered the name with O.P. No.1, Good Health TPA Services Ltd. and they provided an ID bearing No.GHUIAB01307045. It was mentioned that the complainant hospitalized on 28.9.2015 and discharged on 2.10.2015 from R.N. Tagore International Institute of Cardiac Sciences at Kolkata where he was diagnosed for significant single vessel coronary artery disease.
As per certificate of R.N. Tagore Hospital and clinical discharge summary, the complainant Pulak Ray is a diabetic patient since 2000 and hypertensive since 2006 i.e. well before the inception of his above health policy(11.7.2014) which established pre-existing of the disease and hence as per policy clause No.5.25 ‘Pre-Existing Disease’, the claim was repudiated by the Good Health TPA Services Ltd. It is also mentioned here that his wife Mrs. Tulsi Ray has further declared in the cashless request form that her husband Mr. Roy was suffering from Diabetics since 2000 and hypertensive since 2006. O.P. stated that it is well established that charges of complainant are false and fabricated. The motive of the complainant is to gain money in unlawful manner.
That the cashless claim was submitted by Smt. Tulsi Ray, the wife of the complainant for Rs.50,000/- which was refused for the above REASONS by the TPA and subsequent the complainant submitted the entire claim for reimbursement which was also denied by the TPA as per policy exclusion under clause-6 and 6.1. It is also mentioned that the TPA i.e. O.P. No.1 received preauthorization request from R.N. Tagore International Institute of Cardiac Science, Kolkata on behalf of the insured Mr. Roy with presenting complaints of single vessel coronary artery disease, HTN, DM as per clarification letter dated 27.9.2015 from R.N. Tagore International Institute of Cardiac Sciences, Kolkata, the patient herein complainant is Diabetic since 2000 had complaints of HTN since 2006. The inception of policy is from 11.7.2014 and as the present hospitalization was for condition/ailment pre-existing to the policy inception date i.e. 11.7.2014, cashless authorization was denied with remarks ‘Cashless cannot be extended in this case, as per submitted documents, proposed plan of treatment for said ailment comes under pre-existing conditions- not covered under the policy. Pre-existing diseases are not covered and will be covered after three consecutive continuation claim free policy years.
Subsequently, the TPA, O.P. No.1 also received reimbursement claim on 16.2.2016. On scrutiny it was also denied as the patient was diabetic patient since 2000 had complaints of HTN since 2006. Therefore, the patient is a known case of diabetes mellitus and hypertension since 2006. Hence, as the hospitalization is for condition which is a complication of diabetics and hypertension which is pre-existing prior to the policy inception ate i.e. 11.7.2014, so the claim is not payable as per clauses 5.25 and 6 & 6.1 of terms and conditions of the policy. Hence, the case and prayed for dismissal of the instant case.
The O.P. No.3 contested this case by filing written version stating inter-alia that the complainant Pulak Kumar Ray was enjoying one Group health policy for the first time incepted on and from 11.7.2014 and renewed every year. As per self contempt note for CCN145440 (Mrs. Tulsi Ray) under a policy No.05040028145P10103075013 valid from 9.6.2015 to 8.6.2016 for the purpose of covering risk for himself and family members and premium was Rs.1763/- excluding service tax of Rs.247/- towards Andhra Bank Arogyadasn Medical Insurance. For which Good Health TPA Service Ltd. (O.P. No.1) provided an ID bearing No.GHUIAB01307045.
The details of terms and conditions have been clearly stated along with the name TPA MS Good Health TPA Service Ltd. having their office at Hydrabad as per clause No.1 & 2. it was agreed by all the parties that any claim becoming admissible under the scheme, the company will pay through TPA to the hospital/nursing home or to insured persons and the amount of such expenses would fall under different heads which are reasonable and necessarily incurred. Thus, it is clearly stated TPA’s recommendation is necessary for disbursement of any treatment expenses.
That as per advice of Dr. Debabrata Roy of RN Tagore Hospital at Kolkata the complainant got admitted on 28.9.2015 and discharged on 02.10.2015 where he was diagnosed for significant single vessel coronary artery disease, HTN, DM. It is seen from the clinical discharge summary of RN Tagore Hospital that complainant Pulak Ray is diabetic since 2000 and hypertensive since 2006 i.e. well before the inception of the health policy (11.7.2014) which established pre-existing of disease and hence as per policy clause5.25 ‘pre-existing disease’ the claim was repudiated by Good Health TPA Service Ltd. It can be stated here the wife of the complainant Mrs. Tulsi Ray have further declared in her cash less request from that her husband Mr. Pulak Kumar Ray was suffering from diabetic since 2000 and hypertensive since 2006 under her signature.
That the cashless claim was submitted by Smt. Tulsi Ray, the wife of the complainant for Rs.50,000/- which was refused for the above purpose by the TPA and subsequent the complainant submitted the entire claim for reimbursement which was also denied by the TPA as per policy exclusion under clause-6 and 6.1. It is also mentioned that the TPA i.e. O.P. No.1 received preauthorization request from R.N. Tagore International Institute of Cardiac Science, Kolkata on behalf of the insured Mr. Roy with presenting complaints of single vessel coronary artery disease, HTN, DM as per provided clarification letter dated 27.9.2015 from R.N. Tagore International Institute of Cardiac Sciences, Kolkata, the patient herein complainant is Diabetic since 2000 had complaints of HTN since 2006 and as per policy condition cash less authorization was denied with a remark of ‘cash less extended in this case’ since as per submitted documents, proposed plan of treatment of the ailment comes under pre-existing conditions not covered under the policy and therefore claim was denied.
O.P. No.1 received reimbursement claim on 16.2.2016 and after scrutiny denied the claim since the patient is known case of diabetic mellitus and hypertension which is pre-existing disease prior to the policy inception date i.e. 11.7.2014. So, claim was not payable as per clause No.5.2, 6 and 6.1 of the terms and conditions of the policy. The complainant submitted allegation against O.P. No.2 that this O.P. did not bother to intimate anything to the complainant regarding settlement of claim till date of filing the complainant” and alleged deficiency in service by O.P. No.1 & 2. It can be stated from above fact that above charges are ill motive and earn money in un-lawful manner. Clause 5.25 ‘Pre-existing Disease’ which reads as follows;
‘Pre-existing diseased in any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and /or were diagnosed, and/or received medical advice/treatment, within 36 months prior to the first policy issued by the insured’.
That O.P. No.2 United India Insurance Company Ltd., in its letter dated 4.4.2016 send a letter to the wife of the complainant Mrs. Tulsi Ray with registered post therein the O.P. No.2 acknowledge the claim lodged with TPA and after scrutiny of the claim the doctor of TPA have recommended the claim for repudiation as per Andhra Bank Arogyadaan Policy terms and conditions. Hence, this case and prayed for dismissal of the instant case.
DECISION WITH REASONS
To prove the case the complainant has filed his affidavit of examination in chief where he stated all the facts as per his complaint petition. Thereafter, O.P. No.2 & 3 submit that they will not adduce any evidence separately but prayed for adoption of their written version supported by affidavit as their evidence. The prayer of the O.P. No.2 & 3 are allowed. Be it mentioned that O.P. No.1 did not contest this case and the case is running exparte against the O.P. No.1. Both parties submitted their elaborate argument in support of their respective cases. After hearing argument and going through the evidence, written version of O.P. No.2 & 3 and documents filed we find that as per advice of the Dr. Debabrata Roy of RN Tagore Hospital at Kolkata the complainant got admitted on 28.9.2015 and was discharged on 02.10.2015. He was diagnosed for significant single vessel coronary artery disease, HTN, DM. It is seen from the clinical discharge summary of RN Tagore Hospital that complainant Pulak Ray is diabetic since 2000 and hypertensive since 2006 i.e. well before the inception of the health policy (11.7.2014) which established pre-existing of disease and hence as per policy clause5.25 ‘pre-existing disease’ the claim was repudiated by Good Health TPA Service Ltd. It can be stated here that the wife of the complainant Mrs. Tulsi Ray have further declared in her Cashless Request From that her husband Mr. Pulak Kumar Ray was suffering from diabetic since 2000 and hypertensive since 2006 under her signature.
The details of terms and conditions have been clearly stated along with the named TPA MS Good Health TPA Service Ltd. having their office at Hydrabad as per clause No.1 & 2. It was agreed by all the parties that any claim becoming admissible under the scheme, the company will pay through TPA to the hospital/nursing home or to insured persons and the amount of such expenses would fall under different heads which are reasonable and necessarily incurred. Thus, it is clearly stated TPA’s recommendation is necessary for disbursement of any treatment expenses.
That the cashless claim was submitted by Smt. Tulsi Ray, the wife of the complainant for Rs.50,000/- which was refused for the above purpose by the TPA and subsequent the complainant submitted the entire claim for reimbursement which was also denied by the TPA as per policy exclusion under clause-6 and 6.1. It is also mentioned that the TPA i.e. O.P. No.1 received preauthorization request from R.N. Tagore International Institute of Cardiac Science, Kolkata on behalf of the insured Mr. Roy with presenting complaints of single vessel coronary artery disease, HTN, DM as per provided clarification letter dated 27.9.2015 from R.N. Tagore International Institute of Cardiac Sciences, Kolkata. The patient herein complainant is Diabetic since 2000 had complaints of HTN since 2006 and as per policy condition cash less authorization was denied with a remark of ‘cash less extended in this case’ since as per submitted documents, proposed plan of treatment of the ailment comes under pre-existing conditions not covered under the policy and therefore claim was denied.
Therefore, this Forum holds that cashless cannot be extended in this case as per submitted documents and proposed plan of treatment for said ailment necessarily come under pre-existing condition not covered under the policy and pre-existing disease are not covered. Pre-existing conditions will be covered after three consecutive continuation claim free policy years. Therefore, O.Ps. have rightly repudiated the claim of the complainant. the TPA, O.P. No.1 also received reimbursement claim on 16.2.2016. On scrutiny it was denied as the patient was diabetic patient since 2000 had complaints of HTN since 2006. The patient is a known case of diabetes mellitus and hypertension since 2006. Hence, as the hospitalization is for condition which is a complication of diabetics and hypertension which is pre-existing prior to the policy inception ate i.e. 11.7.2014, so the claim is not payable as per clauses 5.25 and 6 & 6.1 of terms and conditions of the policy. In the above circumstances the complainant has not been able to prove his case. Thus, the complaint case fails. Hence, it is
Ordered
that the case be and the same is dismissed on contest against the O.P. No.2 & 3 and exparte against the O.P. No.1 without any cost.
Let the copies of this order be supplied to the parties free of cost.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
Jayanti Maitra (Ray)
President
D.C.D.R.F., Burdwan
(Dr. Tapan Kr. Tripathy)
Member
D.C.D.R.F., Burdwan
