By Sri. MOHANDASAN.K, PRESIDENT
Complaint in short is as follows
1. The complainant is the policy holder of the opposite parties. The policy number is 2828100770411900002, which stands valid for the period from 09/04/2020 to 08/04/2020.
2. The complainant had felt chest pain and he was taken to his doctor at MICC hospital private Limited, Calicut on 23/11/2020. On examination it was diagnosed that the complainant was suffering from cardiac disease and hence he was subjected to CAG on the same day and discharged on 25/11/2020. The complainant spent an amount of Rs.1, 46,294/- towards inpatient treatment in addition to an amount of Rs.25,000/- as related expenses including that of bystanders, transportation, nourishment etc.
3. The complainant claimed benefit of his insurance policy from the hospital and he got information from the hospital that his cash less claim request has been denied by the opposite parties on 25/11/2020 as there is possibility of the complainant’s ailment being a pre-existing disease cannot be ruled out.
4. The complainant submit that he is the holder of insurance policy from opposite parties from 26/04/2016 itself and his first policy number was 2828100112476200. The complainant renewed his policy periodically and that too complying all the policy conditions. The complainant got renewed his policy finally on 09/04/2020. Moreover he submitted that he was never ever suffering any ailments either in consistent with opposite parties policy conditions or otherwise, when he obtained policy for the first time i.e in 2016. Complainant’s health condition continued satisfactory to the opposite parties on the date of renewal of complainants existing policy also. The submission of complainant is that the opposite parties have no right to deny complainant’s claim and the rejection of cashless claim request from his hospital is but baseless and illegal. The act of the opposite parties amounts deficiency in service. The complainant suffered much agony due to the illegal rejection of his claim. Due to the rejection of the claim of cashless one, the complainant was compelled to borrow the amount necessary to meet his treatment expenses. The complainant claims a compensation of Rs.50,000/- on account of mental agony suffered by the complainant. The complainant issued lawyer notice to the opposite parties on 21/12/2020 stating all the details and demanding reimbursement of RS.2,26,294/- towards the medical as well as related expenses caused to him and also towards compensation. Though the opposite parties received the lawyer notice, they neither reimbursed the amount nor replied in any manner. Hence the complainant filed this complaint seeking direction to opposite parties to pay Rs.1, 46,294/- towards inpatient treatment expenses and Rs.25,000/- towards the expenses met for bystanders, transportation, extra nourishment and Rs.50, 000/- towards compensation.
5. On admission of the complaint notice was issued to the opposite parties and the opposite parties entered appearance and filed version denying the entire averments and allegations in the complaint. According to opposite party the complaint is not maintainable, totally vexatious, misconceived, based on misrepresentation of facts and so not maintainable against the opposite parties and there by liable to be dismissed.
6. The second opposite party admit that policy No.282/100770411900002 had been issued by them to the complainant which is valid from 09/04/2020 to 08/04/2021. This policy will show that first policy inception was only on 09/04/2020 and not prior to that as averred in the complaint.
7. The opposite parties submitted that as per section E: waiting periods and exclusions clause I (a) expenses related to the treatment of a preexisting disease and its direct complainants shall be excluded until the expiry 48 months of continues coverage after the date of inception of the first policy with insurer. As per clause (c) if the insured person is continuously covered without any break. Then waiting period for the same would be reduced to the extent of prior coverage. The entitlement of the benefit of the same, the preexisting disease need to be disclosed at the time of inception of the policy. The opposite parties submitted that as per policy schedule the complainant has not disclosed any pre-existing disease.
8. Within 7 months and 15 days of the issue of this policy, the complainant approached with claim for cashless treatment having got himself admitted in hospital on 23/11/2020. Since there existed a strong possibility that the decease / condition could be pre-existing, the opposite party wrote to the admitted hospital on 24/10/2020 enquiring exact duration of diabetics and dyslipidemia. The hospital wrote back on 25/11/2020 that the complainant had been affected with diabetics for 8 months and also opined that the cause of present illness could be due to diabetics. On the basis of this communication, the opposite party wrote to the hospital on 25/11/2020 that authorization for cashless facility was being denied but that reimbursement of medical expenses incurred would be considered on merit after perusing all documents.
9. It is submitted that the complainant has not so far prepared any reimbursement claim and when it is submitted that the claim will be considered on merit by the opposite party subject to the policy terms and conditions.
10. The opposite party submitted that as per section F of the policy, cashless facility is not given as a matter of right but has been authorized by the insurer after perusing the documents that are required to be submitted. The insurer has reserved the right to reject cashless facility in the policy itself. Hence the opposite parties submitted that they acted with due diligent and there has been absolutely no deficiency in service on the side of opposite parties.
11. The insurance policy is a contract of utmost good faith and the terms and conditions are binding on the both parties and the terms and conditions are to be interpreted strictly. The opposite parties allege the complaint is a gross abuse of social welfare legislation like the Consumer Protection Act and it is liable to be dismissed with cost to the opposite parties. The opposite parties specifically denied all the averments in the complainant and it is submitted that the complainant is put to strict proof of the same. It is submitted that there is no deficiency in service or unfair trade practice and so the commission be pleased to dismiss the complaint imposing exemplary and punitive cost to the complainants.
12. The complainant and opposite parities filed affidavit and documents. The documents on the side of complainant marked as Ex. A1 to A10. Ext. A1 is copy of insurance policy No.2828100770411900002 dated 15/07/2020 valid from 09/04/2020 to 08/04/2021. Ext. A2 is copy of letter issued by the opposite party to the complainant dated 09/04/2020. Ext. A3 is insurance identification card valid from 26/04/2016. Ext. A4 is discharge summary, 2 pages issued from MICC hospital, Kozhikode dated 23/11/2020. Ext. A5 is IP receipt voucher for Rs.1, 46,294/- dated 25/11/2020. Ext. A6 is impatient invoice summary issued from MICC hospital Kozhikode dated 25/11/2020. Ext. A7 is copy of denial of a cashless claim facility issued by opposite party to MICC hospital Kozhikode. Ext. A8 is copy of notice issued by the complainant to the opposite party dated 21/12/2020. Ext. A9 is acknowledgement card for receipt of lawyer notice by second opposite party dated 28/12/2020. Ext. A10 is print out of computer-generated consignment track report of postal department showing receipt of lawyer notice by first opposite party dated 28/12/2020. Documents of the opposite parties marked as Ext. B1 to B4. Ext. B1 is copy of letter issued by the opposite party to the complainant along with terms and conditions. Ext.B2 is copy of query sent to the hospital by the opposite party dated 24/11/2020. Ext. B3 is copy of reply from treating hospital dated 25/11/2020. Ext. B4 is copy of letter sent to hospital by the opposite party denying authorization for cashless facility.
13. Heard the complainant and opposite parties, perused affidavit and documents. The following points arise for consideration:-
Whether there is insurance coverage for the complainant?
Whether there is deficiency in service and unfair trade practice on the part of the opposite parties?
Relief and cost?
14. Pont No.1 & 2
The case of the complainant is that he insured with the opposite parties vide policy No.2828100770411900002, which stands valid period from 09/04/2020 to 08/04/2021. The opposite party admitted the existence of insurance policy in favor of the complainant vide the said policy. But the opposite party contended in the version that this policy will show that first policy inception was only on 09/04/2020 and not prior to that as averred in the complaint. At the same time in the affidavit of the opposite party it is admitted that the insured had taken a health suraksha plus policy viz policy No.2828100112476200 for the period from 26/04/2016 to 25/04/2017. It is further submitted that later after a gap he took another health suraksha policy viz policy No.2828100256626700 for the period 11/12/2017 to 10/12/2018 and thereafter a long gap he took another policy i.e, policy No.282810077041190 for the period from 09/04/2020 to 08/04/2021. Hence the submission of the opposite party is that the present policy can only be treated as a fresh policy and the conditions regarding preexisting illness are applicable for this policy.
15. Now it can be seen that the complainant produced Ext. A3 along with complaint but while filing the version by the opposite party denied the existence of a prior policy issued by the opposite party to the complainant during the year 2016 itself. Off course, as per the averment in the affidavit it can be seen that there is break in continuity of the policy. That doesn’t mean the complainant had not incepted the policy of the opposite party in the year 2016 and so the issue now is limited to the fact whether preexisting illness is applicable for this policy or not and whether the complainant was having non disclosed preexisting decease as contended by the opposite party.
16. The complainant herein got admitted in the hospital on 23/11/2020 and diagnosed suffering from cardiac disease. The complainant was submitted to CAG on the same day and discharged on 25/11/2020. The complainant claimed for his cashless benefit from the opposite party through the hospital. But the opposite party denied the claim as there is a possibility of the complainant’s ailments being a preexisting disease which cannot be ruled out. There after discharge from the hospital the complainant caused notice to the opposite party. But despite receipt of notice there was no response from the side of opposite parties. So from the perusal of documents what can be inferred is that the opposite party simply denied the insurance claim of complainant stating chance of preexisting disease. The opposite party produced Ext. B3 the letter issued from the hospital regarding the ailment of the complainant. The Ext B3 read as follows: “This is regarding Mr. Abdul Jaleel, the exact duration of diabetes since 8 months and dyslipidemia since 6 months. The cause of present ailment not sure – may be diabetes and dyslipidemia Do the need full”. So Ext. B3 is not certain about the cause of present ailment. But the opposite party opined in the affidavit that the cause of present illness could be due to diabetics, which is factually incorrect. The question of none disclosure of ailment arises when the same is brought to the notice of the insured. In the absence of knowledge, nobody can disclose existence of any sort of ailment. Moreover the name of the policy itself is health suraksha policy and so it is proper on the side of opposite parties to subject the insured for medical examination prior to the issuance of health policy. Mere contention that the insurance policy is a contract of utmost good faith and the terms and conditions are binding on both parties are not sufficient to decline the insurance benefit to an insured. In this complaint the opposite party could not establish that the complainant was suffering from preexisting disease and the complainant will fully suppressed the fact from the opposite party. It is also relevant to note the alleged pre-existing decease is nothing but life style decease like diabetes mellitus and cholesterol. The Delhi State Consumer Disputes Redressal Commission 1V (2022)CPJ 26(Del.) held in the case S.S JASPAL V/S NATIONAL INSURANCS COMPANY that the common life style disease like diabetes and hyper tension, cannot be treated as preexisting disease, therefor, cannot be a ground of repudiation of the claim by insurance companies. So, the denial of the insurance to the complainant from the side of opposite party without sufficient cause amounts unfair trade practice and deficiency in service. Though the right to reject cashless facility is rest with the insurance company it should be exercised with due care and caution. In this complaint, the complainant was taken to the hospital and he was undergone CAG on the same day itself and met with huge medical expenses. The complainant was under the belief that he is covered by health insurance policy, naturally he will be in a relax condition. But the opposite party, appears exercised the power of discretion arbitrarily which caused much inconvenience, hardship and financial loss to the complainant, we find the first and second point accordingly.
17. Point No.3
The complainant submitted that he spent Rs.1, 46,294/- for the treatment expenses and also 25,000/- rupees towards incidental expenses including bystanders, transportation, nourishment etc. The complainant produced Ext. A5 to show the expenses met in the hospital. Ext. A4, A6 shows the treatment history of the complainant. The complainant failed to produce documents to show expenses of Rs.25, 000/- as claimed in the complaint. The complainant claims compensation of Rs.50, 000/- on account of deficiency in service, inconvenience and hardship caused to the complainant. We find the claim of compensation is reasonable one. The complainant also entitled cost of the proceedings which we estimate Rs.10, 000/-.
In the light of above facts and circumstances, we allow this complaint as follows: -
The opposite parties are directed to pay Rs.1, 46,294/- (Rupees one lakh forty six thousand two hundred and ninety four only) to the complainant towards the treatment expenses met by the complainant.
The opposite parties are directed to pay Rs.50,000/- (Rupees fifty thousand only) as compensation on account of deficiency in service and unfair trade practice and thereby caused inconvenience, hardship and mental agony to the complainant.
The opposite parties are directed to pay Rs.10,000/- (Rupees Ten thousand only) as cost of the proceedings to the complainant.
The opposite parties shall comply this order within one month from the date of receipt of copy of this order, failing which the opposite parties are liable to pay interest at the rate of 9% per annum from the date of filing this complaint till date of payment.
Dated this 2nd day of April, 2023.
Mohandasan . K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1to A10
Ext.A1: Copy of insurance policy No.2828100770411900002 dated 15/07/2020 valid
from 09/04/2020 to 08/04/2021.
Ext.A2: Copy of letter issued by the opposite party to the complainant dated
09/04/2020.
Ext A3: Insurance identification card valid from 26/04/2016.
Ext A4: Discharge summary, 2 pages issued from MICC hospital, Kozhikode dated
23/11/2020.
Ext A5: IP receipt voucher for Rs.1, 46,294/- dated 25/11/2020.
Ext.A6: Impatient invoice summary issued from MICC hospital Kozhikode dated
25/11/2020.
Ext.A7: Copy of denial of a cashless claim facility issued by opposite party to MICC
hospital Kozhikode.
Ext.A8: Copy of notice issued by the complainant to the opposite party dated
21/12/2020.
Ext.A9: Acknowledgement card for receipt of lawyer notice by second opposite party
dated 28/12/2020.
Ext.A10: Print out of computer-generated consignment track report of postal
department showing receipt of lawyer notice by first opposite party dated
28/12/2020.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B4
Ext.B1: Copy of letter issued by the opposite party to the complainant along with terms
and conditions.
Ext.B2: Copy of query sent to the hospital by the opposite party dated 24/11/2020.
Ext.B3: Copy of reply from treating hospital dated 25/11/2020.
Ext.B4: Copy of letter sent to hospital by the opposite party denying authorization for cashless facility.
Mohandasan . K, President
Preethi Sivaraman.C, Member
Mohamed Ismayil.C.V, Member
VPH
