IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 02nd day of March, 2022
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member,
Sri. K.M. Anto, Member
C C No. 240/2018 (filed on 09-11-2018)
Petitioner : Rachel Thomas,
W/o O.A. Joseph,
Onayathumkuzhy House,
Pampady P.O.,
Kottayam – 686502.
Vs.
Opposite party : The Divisional Manager,
Divisional Office,
LIC of India,
Jeevan Prakash,
PB No.609,
Kurian Uthupu Road,
Kottayam – 686 001. (Adv.D. Dominic and Adv. James K. Peter)
O R D E R
Smt. Bindhu R. Member
The complaint is filed under Section -12 of the Consumer Protection Act 1986.
The complainant purchased comprehensive health insurance named Jeevan Arogya 904 on 11.07.2015 from the opposite party. The petitioner had three consecutive hospitalisations in SH medical centre Kottayam, Pushpagiri Medical college hospital Thiruvalla and MGM Muthoot medical centre, Pathanamthitta during 02.05.2017 to 15.05.2017, 29.05.2017 to 07.06.2017 and on 14.06.2017 respectively for claim numbers 17003125,17004867,17005543 with the opposite party. On 23.09.2017, the opposite party sent an email informing the complainant that the three claims are recommended for admission subject to consent from PI for exclusion of Bronchial asthma. Later the opposite party informed the petitioner that as a result of an investigation conducted by the opposite party with the S.H.Medical centre Kottayam the claim of 17003125 was rejected as the report from the said hospital ascertain respiratory tract infection partially treated in 2009.But the said letter dated 24.06.17 only speaks about LRTI and not anything about bronchial asthma. Thus without any basis the opposite party compelled the complainant to give a consent letter for excluding not LRTI but bronchial asthma for the entire policy period. Under some misconception the complainant gave a consent letter to exclude bronchial asthma for the entire period of the policy. Violating the offer issued to the petitioner vide email dated 23.09.2017 the opposite party informed the complainant that claim no 17005543 was rejected citing L18 total hospitalisation period less than 28 hours without considering the fact that the complainant was eligible for the day care hospital benefit for 5 HCB and the procedure held was Bronchoalveolar Lavage”.
The opposite parties replied to the RTI application of the complainant that the letter dated 21.6.18 is the only available document with them which states that the complainant had only LRTI. So there was no mention of bronchial asthma anywhere. The complainant was admitted as inpatient in MGM Muthoot Medical Centre Pathanamthitta for Bronchoalveolar Lavage for which she was eligible for Rs.21,000/- as day care procedure benefit. Suppressing this fact, the opposite party compelled the complainant to give a consent letter for excluding bronchial asthma and denied the claim. Hence his complaint is filed for getting the claim amount and compensation.
The opposite party was noticed and they appeared before the Commission.
The policy is admitted by the opposite party in the version. The policy is a non unit linked health insurance policy with declared benefits of Hospital cash benefit, Major surgical benefit, Day care procedure benefit, Other surgical benefit surgeries which do not come under MSB and DCPB will be considered under OSB, subject to the terms and conditions of the policy. In the case of the complainant 3 consecutive hospitalisation claims were submitted in S.H. Medical Centre Kottayam, Pushpagiri Medical college Hospital, Thiruvalla and MGM Muthoot Medical Centre, Pathanamthitta during 02.05.2017 to 15.05.2017, 29.05.2017 to 07.06.2017 and on 14.06.2017.The duration of the 3rd hospitalisation was 6 hours and 51 minutes. The first hospitalisation was for lower respiratory tract infection. The second hospitalisation was for Pyrexia of unknown origin. The third hospitalisation was for bronchoscopy the duration of which was only 6 hours and 51 minutes. As per the certificate dated 16.06.2017 from S H Medical Centre, Kottayam, the patient was a known case of Bronchial asthma since 2010. Hence it is understood that the patient had history of Bronchial Asthma before taking the policy on 11.07.2015 that she was having preproposal illness which was not disclosed. So the claims could only be admitted upon receiving a consent letter from the complainant for excluding claims arising out of BronchialAasthma under this policy. Thus it was for a genuine reason based on the doctor’s report and according to the terms and conditions of the policy.
As per the consent obtained from the insured, claims arising out of Bronchial Asthma are excluded. As per rejection letter dated 12.07.2017 the rejections codes are Ho1—Pre existing illness irrespective of prior medical treatment or advice.
L18 – Total hospitalisation period is less than 28 hours. The decision of the ZMR was that the procedure done as per the discharge summary does not qualify under the Day care procedure benefit. It is clear from the discharge summary from Muthoot hospital that the insured underwent bronchoscopy for evaluation of consolidation with parendial and pleural effusion. No fluid collection and biopsy was done. The bill dated 14.06.17 clearly mentioning that the bronchoscopy charge as Rs. 3,000 /-. Bronchoscopy does not come under the listed 140 procedures for day care procedure benefits. The treating doctor’s certificate proves beyond doubt that the insured had Bronchial Asthma since 2010. Other than this, the TPA was not provided with any treatment details of Bronchial Asthma. So the claim was rejected. Moreover, the treating doctor’s letter dated 16.06.17 revealed that the complainant was having Bronchial Asthma even before the commencement of the policy so on the ground of non disclosure of pre-existing decease also the claim is liable to be rejected. As per the hospital records the complainant was treated for bronchoscopy which was not included in the policy coverage. Moreover, the total hospitalization period was for less than 28 hours and so it was rejected under the code L18.It was the duty of the policy holder to reveal pre-existing diseases if any at the time of taking the policy. Hence the party’s consent was obtained for exclusion of claims arising out of Bronchial Asthma. Since claim numbers 17003125 and 17004867 were not related to Bronchial Asthma, they were admitted for Rs. 58,800/- and Rs.37,800/- respectively after obtaining the consent letter. Though the condition of the policy was to reject the claim if any material fact is not disclosed at the time of taking the policy, the policy shall be null and void and all benefits shall cease., it is for the benefit of the insured, the opposite party collected the consent letter for exclusion of Asthma and settled claims which were not related to the Bronchial Asthma.
The complainant has produced Ext. A1 to A11 towards the evidence and the complainant himself was examined as PW1. The Opposite party adduced evidence through proof affidavit along with Ext. B1 to B8.
The complaint is filed for compensation for the loss caused due to the repudiation of the insurance policy by the opposite party stating the reason that the complainant was treated for bronchoscopy which does not come under the policy coverage either in day care procedure benefit or in hospital cash benefit.
On a detailed perusal of the pleadings and documents submitted by both the parties, we would like to frame the following points:
1. Whether the complainant has succeeded in establishing the deficiency
in service from the side of the opposite party.
2. If so what are the reliefs?
Point no 1 and 2
The complainant’s case is that she had undergone Bronchoalveolar Lavage which was included in the policy conditions but the opposite party had wilfully denied the claim.
The contention of the opposite party is that the complainant had submitted claim forms for three consecutive hospitalizations in S.H Medical centre Kottayam, Pushpagiri Medical college hospital, Thiruvalla and MGM Muthoot Medical Centre, Pathanamthitta during 02.05.2017 to 15.05.2017, 29.05 2017 to 07.06.2017 and on 14.06.2017 respectively. The duration of the 3rd hospitalization was only 6 hours and 51 minutes. The first hospitalisation for lower respiratory tract infection, the second one for pyrexia of unknown origin the claims of which were approved by the opposite party and they paid the amount in both the cases. As per Ext. B3 certificate of S.H.Medical centre, it is stated that the complainant was having Bronchial Asthma even in 2010 and was not in active treatment. So it was inferred that the complainant had defrauded the opposite party by not disclosing the decease at the time of filling the proposal form. As per the policy conditions, the opposite party is not bound to satisfy the claim 17005543 on the grounds that non disclosure of pre-existing decease, exclusion of bronchoscopy and the duration of less than 28 hours of hospitalisation as per the policy conditions.
Though the complainant alleges that the opposite party did not approve her third claim for Broncheoalveolar Lavage, she has not produced any document to support that claim. In Ext. A7 discharge summary issued by MGM Muthoot medical centre stating that “Patient was admitted for bronchoscopy, she underwent bronchoscopy for evaluation of consolidation with parendial and pleural effusion. To R/o PTB matoux test report awaited, advised medicines and review on 16.06.17.”
Ext. B7 is the hospital bill in which Rs.3,000/- is charged for Bronchoscopy. Ext.B3 is the letter issued by Dr.Bobby Kunnel, Consultant physician ,S.H.Medical centre, Kottayam stating that the complainant was a known case of Bronchial Asthma since 2010-Not on active treatment.
Though in Ext. B3 letter the doctor certifies that the complainant was not admitted for Bronchial Aasthma on 02.05.2017, it is evident that the complainant was under knowledge of her Bronchial Asthma at the time of proposing the policy but she had not disclosed it. Hence the exclusion clause of non disclosure of previous decease would be invoked.
Further on going through the evidence on record, we find that the admission of the complainant was for bronchoscopy which was not covered under the policy.
Another ground for rejection of the policy is that the admission of the complainant in the hospital as per Ext.B5 in the said claim does not come under the 2(I) (a)
Hence we find that as per the contract between the complainant and the opposite party the claim of the complainant comes under the exclusion clauses and we do not intend to reconstruct the terms of the contract.
In Star Health and Allied Insurance VS Smt.Renu Abhi (2017) State Consumer Disputes Redressal Commission, Shimla Honble apex commission held that:
“11. Submission of learned Advocate appearing on behalf of respondent/complainant that order passed by learned District Forum is strictly as per law and strictly as per proved fact is decided accordingly. State Commission is of the opinion that liability of insurance company is limited as per terms and conditions mentioned in the insurance policy. State Commission is of the opinion that complainant cannot be allowed to approbate and reprobate the terms and conditions of insurance policy at the same time. See AIR 1993 SC 352 R.N. Gosain Versus Yashpal Dhir. In view of the above stated facts point No.1 is decided accordingly.”
Hence in view of the findings in the above points the complaint is dismissed.
Dictated to the Confidential Assistant, transcribed and typed by her, corrected by me and pronounced in the Open Commission on this the 02nd day of March, 2022.
Smt. Bindhu R. Member Sd/-
Sri. Manulal V.S. President Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1- Power of Attorney dated 11.08.2017
A2- A true copy of the RTI application issued by the complainant
A2(a) – A true copy of the reply 14.09.2018 issued by the opposite party
A3 – A true copy of the rejection letter dated 24.06.2017
A4- A true copy of the appeal dated 29.06.2017
A5- Mail issued by the opposite party to the complainant on 23.09.2017
A6- A true copy of the consent letter
A7- Tue copy of the discharge summary issued by MGM Muthoot Medical Centre, Pathanamthitta.
A8- A true copy of the treatment form
A8(a)- copy of the culture report on BRONCHOSCOPIC WASH dated 16.06.2017
A8(b)- Biochemistry on Koh preparation and Microbiology report on Fuid from Gram stain dated 15.06.2017
A8(c)- A true copy of the additional tests on Bronchoscopes wash dated 14.06.2017
A8(d)- Culture and sensitivity manual fungus report on bronchoscope wash dated 14.06.17.
A8(e)- AFB culture report or bronchial wash dated 16.06.2017
A8(f)- A true copy of the interim report using culture medium dated 26.06.2017.
A9- Brochure of the Jeevan Arogya 904.
A10- Receipt and result dated 15.06.2017 issued by RNTCP, Pathanamthitta.
A11- A true copy by the policy document issued by LIC
Exhibits marked from the side of opposite party
B1- Claim form and documents to be submitted
B2- Discharge summary issued by MGM Muthoot Medical Centre
B3- Letter dated 16.06.2017
B4- Consent letter dated 23.09.2017
B5- The brochure containing conditions and provilages of LIC’S
Jeeven Arogya Policy
B6- Letter dated 31.12.2018
B7- Bill issued by the MGM Muthoot Medical Centre
B8- Reply letter dated 14.09.2018.
By Order
Assistant Registrar
