By Sri. Mohamed Ismayil.C.V, Member
Complaint filed under 35 of Consumer Protection Act.
1. The complainant availed two insurance policy from the first opposite party. One is in the name of his father Balakrishan Variyath (Policy No.P.E.01793890, Ref. No.1347547) and another one is in the name of his mother Prassannakumari P.T. from the first opposite party named Apollo Munich Health Insurance and the second opposite party is the intermediary Canara Bank. Now the insurance company is known as HDFC ERGO General Insurance Ltd after the taking over. The complainant’s father admitted in Almas Hospital (comes under Al Madeena Institution of Medical Science Pvt. Ltd.) on 28/03/2020 due to pneumonia. Being a holder of insurance policy, the complainant approached the opposite party for availing facility of cash payment. But the application was rejected by the opposite party. Later the complainant submitted application for reimbursement. As per the direction of the first opposite party complainant submitted all necessary medical details before the Canara Bank, Vengara Branch on 19/05/2020. On the basis of the advice given by the insurance customer care, the assistant manager of Canara Bank handed over documents to the first opposite party . On 03-06-2020 the complainant got text message from the first opposite party confirming the reception of documents. After some days the complainant came to know that the claim was rejected. It was informed by the customer care service of the first opposite party that the father of complainant was treated for psychiatric ailment for around 45 years so cash less claim was rejected and there is no provision for reimbursement for treatment of psychiatry. Then the complainant informed the first opposite party that his father was under treatment for pneumonia not for psychiatric ailment. Subsequently a medical certificate showing the treatment for pneumonia was sent to the opposite party as per the request. This certificate categorically stated that the father of the complainant undergone treatment for pneumonia, Hypo alimentation not for psychiatric illness. This certificate was sent to the email ID of the first opposite party. But no reply was received. Complainant again contacted the customer care service centre of the opposite party. According to the customer care centre no documents were received so far. But when complainant explained about earlier text messages showing reception of documents and its date then they conceded as documents were received already by them. The complainant waited for ten days but no reply was received from the opposite party. When complainant attempted to contact through telephone, the opposite party declined to attend the same. The first opposite party is denying the reimbursement by depending frivolous excuses. The act of the opposite party is caused much mental agony and hardship to the complainant. The opposite party is obliged to reimburse the medical expenses as per the policy to the complainant. Hence this complaint.
2. The complaint is admitted. Issued notice to the opposite parties. The first opposite party appeared before this Commission through counsel and filed version. The second opposite party received notices but did not appear and set exparte .
3. In the version it is admitted by the first opposite party that Housing Development Finance Corporation Ltd has acquired Apollo Munich Health Insurance company Ltd. and it has been renamed as HDFC ERGO Health Insurance company Ltd. The first opposite party was represented by its authorised officer. According to the first opposite party, this complaint is an abuse of the process of law and approached with unclean hands . The complaint is not maintainable either in law or on facts. It is contented that there is no privity of contract between the complainant and the first opposite party and no locus standi to file this complaint. The proposer named Mr. Balakrishnan Variyath submitted duly filled and signed up enrolment from proposing the issuance of an group Assurance Health Plan which has been specifically customised for the customers of canara bank to Apollo Munich Health Insurance Co. Ltd. proposing to insurance his health with sum assured Rs.1,00,000/-. The complainant submitted the enrolment form on behalf of the insured after going through the terms and conditions of the policy . The details of the policy was also explained . It is contended that complainant had detailed knowledge of the term ands and conditions of the policy . So considering the declaration information and details provided including medical history of the insured by the complainant / proposer in the enrolment form to be true , correct and complete in all respect giving due evidence to the underwriting norms of the company a policy No.120100/12586/2017/A007873/PE00651117 was issued to the beneficiary/insured for a period commencing from 19-09-2017 till 18-09-2018. The policy was renewed on yearly basis till 17/10/2020.
4. According to the first opposite party, the proposer / beneficiary insured had suppressed material information which was vital in assessing the undertaking of risk by the first opposite party. The non disclosure of facts relating to pre – existing psychiatric illness of the insured is material fact that had direct bearing on the underwriting of risk by the first opposite party. It is contended by the first opposite party that contract of insurance is based on terms and conditions of the policy . So if any claim or information claim is in any manner dishonest or fraudulent or is supported by any dishonest or fraudulent, incorrect , incomplete , suppressed or not disclosed means or devices , then the policy shall be cancelled abnitio , benefits under the policy shall be forfeited and claim shall be repudiated . According to the first opposite party, if the proposer/beneficiary, insured would have furnished correct details of his pre – existing psychiatric condition, then the first opposite party would not have issued the policy to proposer/ beneficiary, insured.
5. It is also stated in the version that the claim was repudiated not because the treatment for psychiatric illness was not covered, but because the insured had not submitted the details required by the first opposite party for processing the claim. As per the document the insured was having psychiatric illness at the time of taking policy and same was suppressed. Inspite of repeated requests, the complainant did not provides those treatment records and hence claim repudiated by letter dated 30/07/2020. The first opposite party denied the allegation that the first opposite party required the insured to submit a document declaring the treatment was not for mental illness. So it is contended by the first opposite party that the insured had not disclosed true , complete and all correct facts in relation to the policy and had acted in a dishonest and fraudulent manner in relation to the policy and hence the insured is not entitled to any amount under the policy . It is also submitted by the first opposite party that the complainant is not entitled to the treatment expenses of the proposer/ beneficiary insured or for interest . So the first opposite party prayed for dismissal of the complaint.
6. The complainant produced documents and marked as Ext. A1 to A9. Ext. A1 document is the copy of insurance policy availed from the opposite party in the name of father of the complainant. Ext. A2 document is the medical bills (2 in numbers) issued from Almas Hospital. Ext. A3 (series) document is the copy of discharge summary and copy of doctor’s prescription dated 08/04/2020 issued to the father of the complainant from Almas hospital. Ext. A4 document is the copy of medical certificate dated 27/07/2020 issued from Almas hospital to the father of the complainant. Ext. A5 document is the copy of text message sent by the first opposite party to the complainant showing reception of medical records. Ext. A6 document is the copy of text message stating rejection of the claim sent by the first opposite party to the complainant. Ext. A7 document is the copy of the death certificate of father of the complainant issued by department of gramapanchyath. Ext. A8 document is the copy of the family membership certificate issued by village officer , Kannamangalam to the complainant. Ext. A9 document is the original consent letter issued by legal heirs of the deceased Balakrishnan infavour of the complainant to conduct the case before the Commission. The first opposite party produced documents and marked as Ext. B1 to B8. Ext. B1 document is the true copy of the enrolment form issued to Balakrishnan Variyath. Ext. B2 document is the true copy of certificate insurance policy of Balakrishnan Variyath. Ext.B3 (series) document is the true copy of additional information request form dated 28/03/2020 sent to the hospital by the first opposite party . Ext. B4 document is the true copy of letter of denial of cashless service dated 30-03-2020 written to the hospital by the first opposite party . Ext. B5 document is the true copy of first reminder letter dated 25/06/2020 sent to Balakrishnan Variyath. Ext. B6 document is the true copy of final reminder letter dated 29/05/2020 sent to Mr. Balakrishnan Variyath. Ext. B7 document is the true copy of rejection letter dated 30/07/2020 sent to Mr. Balakrishnan Variyath by the first opposite party. Ext. B8 is the copy of the letter sent by the complainant to the first opposite party .
7. Heard both parties in detail, perused affidavits and documents. The following points arised for the consideration of the Commission.
- Whether there is deficiency of service on the part of the opposite parties.
- Relief and cost .
8. Point No.1 and 2
The case of the complainant is that he availed an health insurance policy in favour of his father named Mr. Balakrishan Variyath from the first opposite party . The insured was admitted in Al mas hospital due to pneumonia on 28/03/2020 and then approached the first opposite party for availing cashless payment facility under the cover of the insurance policy . But the same was denied by Ext. B4 document which reveals that there is incorrect health declaration of psychiatric illness since 45 years which may have an impact on policy . Evidence adduced by the complainant shows that the complainant subsequently applied for reimbursement along with supporting documents but again rejected by the first opposite party on the ground of no provision to reimbursement for the treatment of psychiatry. The confirmation regarding rejection of reimbursed is received by the complainant as per Ext. A6 document . Ext. B7 document also revealed the same fact.
9. As per the evidence of the complainant his father admitted in the hospital for the treatment of pneumonia not for psychiatric illness. This fact revealed by Ext. A2 medical bill was well as Ext. A4 medical certificate . It is true that the name of disease psychiatric illness was seen in Ext. B3 series document pertaining to discharge summary . It can be considered as an inadvertent mistake on the part of the hospital authority. This confusion was clarified by Ext.A4 document issued by the treated doctor. So analysing the available evidence it can be seen that the father of the complainant undergone treatment for pneumonia not for psychiatric illness. As per documents produced by both sides it can be seen that the insuered Balakrishnan Variyath was leading a normal life as he was a retired Deputy Tahsildar.
10. It is submitted by the first opposite party that the complainant did not adduced copies of documents of all investigation reports, treatment and follow up records related to psychiatric illness from last five years and Ext. B5 and Ext.B6 documents are produced before the Commission to substatntiate the claim of the first opposite party . But on the contrary the complainant stated that he produced all necessary medical records for the reimbursement through the office of second opposite party . This claim of the complainant is substantiate by the production of Ext. A5 document before the Commission. At the same time it has come out in evidence that the first opposite party sent Ext. B3 requests to the hospital authority for getting documents of treatment for psychiatric illness. If the father of the complainant had undergone treatment for psychiatric illness, surely the hospital authority could have produce those medical records before the first opposite party . More over it can be seen from Ext. A6 document produced by the complainant that the first opposite party was very well aware of the case of psychiatric illness at very inception of the policy. So the pleading by the first opposite party that the proposer / beneficiary insured had suppressed material information regarding psychiatric illness cannot beloved by the this Commission . So it can be concluded that the complainant did not suppressed material information to assess the undertaking of risk by the first opposite party . Moreover in the paragraphs No.6 to 17 of the version , it is submitted that the claim of the complainant was repudiated on the ground of non disclosure of treatment for psychiatric illness of the insured. But at the time in paragraph 19 it is stated that the claim of the complainant was repudiated not because of the treatment of psychiatric illness was covered , but because the insured had not submitted the details required by the first opposite party for processing the claim. The evidence adduced by the complainant shows that he had continuously tried to get reimbursement of the medical bills but turned down by the first opposite party . So the act of the first opposite party can be considered as deficiency in service.. As per Ext. A7 documents Mr. Balakrishnan variyath died on 12/04/2020. After the demise of Mr. Balakrishnan Variyath the remaining legal heirs authorised the complainant to file a complaint before this Commission and the authorization letter was marked as Ext. A9. Ext. A8 document is the legal heir certificate showing the names of the legal heirs of the deceased Balakrishnan. All these documents were not disputed by the first opposite party. Thus after scrutinising the entire available evidence adduced by the both parties this Commission finds that the complainant is eligible for reimbursement and allows the complaint as follows:-
- The first opposite party is directed to pay Rs.75000/- to the complainant as the amount of reimbursement of medical expenses incurred to the treatment of insured Balakrishanan Variyath.
- The first opposite party is directed to pay Rs.25,000/- as compensation for mental agony and hardship suffered due to the act of first opposite party .
- The first opposite party also directed to pay Rs.10,000/- as the cost of the proceedings to the complainant. There was no evidence against the second opposite party and so no relief is allowed. The first opposite party shall comply this order within one month from the date of this order, failing which the entire amount shall carry interest at the rate of 9% per annum from the date of this order till realisation .
Dated this day of , 2022.
Mohandasan K. , President
PreethiSivaraman 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.A1 to A9
Ext.A1: copy of insurance policy availed from the opposite party in the name of father of the complainant.
Ext.A2: Medical bills (2 in numbers) issued from Almas Hospital.
Ext A3: (series) copy of discharge summary and copy of doctor’s prescription dated
08/04/2020 to the father of the complainant from Almas hospital,
Ext A4: Copy of medical certificate dated 27/07/2020 issued from Almas hospital to
the father of the complainant,
Ext A5: Copy of text message sent by the first opposite party to the complainant
showing reception of medical records,
Ext.A6: Copy of first message stating rejection of the claim sent by the first opposite
party to the complainant.
Ext.A7: Copy of the death certificate father of the complainant issued by
department of gramapanchyath,
Ext.A8: Copy of the family membership certificate issued by village officer ,
Kannamangalam to the complainant,
Ext. A9 Original consent letter issued by legal heirs of the deceased Balakrishnan in
favour of the complainant to conduct case before the Commission.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B8
Ext.B1: Document is the customer form issued to Balakrishnan Variyath.
Ext.B2: Document is the true copy of certificate of insurance of policy of
Balakrishnan Variyath.
Ext.B3: True copy of additional information request form dated 28/03/2020 sent to
the hospital by the first opposite party .
Ext.B4: True copy of letter of denied of cashless service dated 30-03-2020 written to
the hospital by the first opposite party .
Ext.B5: True copy of first reminder letter dated 25/06/2020 sent to Balakrishnan
Variyath.
Ext.B6: True copy of final reminder letter dated 29/05/2020 sent to Mr. Balakrishnan
Variyath.
Ext.B7: Document is the true copy of rejection letter dated 30/07/2020 sent to Mr.
Balakrishnan Variyath by the first opposite party.
Ext.B8: Copy of the letter sent by the complainant to the first opposite party .
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
VPH
