This is a complaint U/s 12 of the Consumer Protection Act, 1986 with the prayer for an order directing the O.P./ Insurer to pay Rs.1,02,396/- for medical reimbursement of the son of the complainant and a compensation of Rs.50,000/- and litigation cost of Rs.5,000/- and for any other reliefs.
The complaint case in short is that the complainant is the resident of Shakti Nagar Colony, Islampur and purchased a policy covering total four (04) members of his family, being policy No.456814155 valid from 21.11.2012 to 21.11.2013 under LIC’s ‘Jeevan Arogya’ scheme. During subsistence of the policy son of the policy holder fell seriously ill. He was treated by the doctor at Bangalore in Narayana Hrudayalaya Hospital, where he undergone surgery of VSD on 25.03.2013. The son was discharged on 06.04.2013. The complainant incurred expenditure of Rs.1,02,396/- for medical treatment of the said son namely Rudranil. Thereafter, he submitted claim with the O.P. for medical reimbursement for the aforesaid treatment, but till date O.P. did not settle the claim in spite of several request. On 28.05.2013 he received letter from Medicare TPA Service rejecting the claim of the complainant. Complainant then contacted with the Divisional Manager of LICI on 16.08.2013. O.P. served a letter that they are relooking the matter, but on 03.10.2013 they repudiate the claim in writing. Therefore the complainant filed this case stating the fact that his cause of action arose from 03.10.2013 and come up with the above mentioned prayer before this Forum.
O.P. No.1 and 2 filed written version to contest the case. O.P. admits the health insurance policy of the complainant, commenced from 21.11.2012 with insured member of the family of complainant, complainant himself, his wife and two children. O.P. also admitted that the son of the complainant was treated at hospital at Bangalore from 20.03.2013 to 06.04.2013. O.P. claimed that the son undergone open heart surgery for VSD closure and the ailment was ‘congenital’ disorder in nature. That complainant did not disclose the pre-existing disease of the son at the time of taking policy. O.P. referred the documents of treatment by the hospital authority dated 09.04.2013. That terms & conditions of the policy does not fall under the purview of the said disease as it is ‘congenital anomalies’, treatment of correction of birth defects. That the ailment occurred prior to the taking of the policy and was not disclosed by the insured. That hospitalization undertaken as a preventive or recuperative measure and the claim was rightly repudiated for that reason in writing dated 03.10.2013 through TPA Medicare Service following examination and opinion by the panel doctors.
To establish the case of the complainant has relied upon affidavit-in-chief sworn in by him as P.W.-1 and relied upon some documents. O.P. also filed documents and adduced evidence.
DECISIONS WITH REASONS
Giving due consideration to the contents of the complaint petition, documentary evidence on record, hearing, arguments advanced by the lawyers of both sides, the Ld Forum has come to the findings as follows: -
Admittedly the complainant purchased the policy. The son of the complainant as insured member of the family was admittedly undergone treatment at the hospital at Bangalore. Therefore the complainant submitted claim papers for medical reimbursement as it is within the policy coverage. The O.P./ Insurance company repudiated the claim on the ground of Exclusion clause No.7 of the said ‘Jeevan Arogya’ policy and Sub-Clause - VIII that treatment for correction of birth defects or congenital anomalies, no benefits are available under this policy on account of hospitalization or surgery directly or indirectly caused by, based on, arising out of or attributable to.
O.P./ Insurance company cited the decision of Hon’ble National Commission as reported in 2014 CJ 407 (NC) and argues the Ld. Lawyer for the O.P. that the policy holder was suppressing the pre-existing disease that the son was with ailments with a known case of congenital disorder and complications had arisen from a pre-existence disease and will be considered part of pre-existing condition. But there is no evidence in support of this argument. In our case there is no such pre existent disease of the son and at the time of obtaining policy no such fact was declared by the policy holder. Therefore this decision of Hon’ble National Commission will not be in any help to the O.P./ insurance company.
On the other hand Ld. Lawyer for complainant in this regard cited decision as reported in 2010 (2) CPR 509 that Exclusion clause in the policy which had not been explained to insured at the time of issuance of policy, it could not be used by insurer against insured. The exclusion clause not be binding on Insured and there was violation of Regulation 3 of IRDA. No evidence was placed by the company showing compliance of Regulation 3. He cited the reference of Hon’ble National Commission as reported in 2009 (3) CPR 252 (NC) that there is nothing on record to suggest that the Company had explained all exclusion clauses to the Insured. Therefore exclusion clauses are required to be ignored as the company did not adhere to the mandatory requirement before issuance of insured cover.
In our case no evidence was placed by O.P./ Insurance company showing compliance of such explanation of exclusion clause to the complainant. Moreover, there was no material on record to show that insured was suffering from ailments prior to purchase of policy. There is no evidence that complainant had knowledge of existence of any such disease of son. Ld. Lawyer for complainant cited 2010 (4) CPR 57 (NC) in this regard. Hon’ble National Commission held that onus of constituting panel of medical practitioner was with the O.P./ insurance company to prove the fact of pre-existence of disease of the son of the complainant or that the insured had prior knowledge of such disease. Company only filed a document of Medicare TPA Services Private Limited that opines that the ‘diagnosis VSD’ is a congenital ailment. No evidence is adduced in this regard by O.P. On the other hand complainant has been able to prove that his son had no history of heart ailment, breathing problems etc. before he was admitted in the Hospital.
We have gone through the complaint petition, written version, medical documents filed by the complainant, policy papers including terms & conditions of the policy and the decisions cited by both the parties that the petitioner admitted his son in a hospital at Bangalore, when his son fell ill during subsistence of the policy. The son was treated and was discharged from the hospital and expenses incurred of Rs.1,02,396/- by the complainant for Open Heart Surgery for VSD Closure. O.P. repudiated the claim that it is a ‘Congenital’ anomalies and fall in the Exclusion clause of the policy. Since the exclusion clause of the policy had not been explained to insured, while issuing policy so it would not be binding upon the insured and it could not be used by the O.P. against the insured. Moreover, there is no evidence of knowledge of complainant about existence of such disease and O.P. fail to prove this fact by credible evidence oral and documentary, therefore, O.P. cannot repudiate the claim. As a result the complainant has been able to prove his case that he is entitled to medical reimbursement of the son for the purpose of the treatment of his son. The documents filed by the petitioner in this regard goes to show that he incurred a total expenditure of Rs.1,02,396/-. All the medical papers, bills, prescriptions in original are filed by the complainant showing treatment of Narayana Hridayalaya Hospital. Perused all those documents and we have also heard arguments of both sides. The policy papers are also filed and the copy of the claim Form is also filed. The expenses incurred during the subsistence of the policy coverage. Therefore petitioner is entitled to receive the claim.
Fees paid is correct.
Hence, it is
ORDERED,
That the case being No.CC - 53/2015 is allowed on contest but in part against O.P./ Life Insurance Company Limited.
O.Ps. are directed to pay Rs.1,02,396/- towards medical reimbursement for the medical treatment of the son of the complainant and further directed to pay Rs.2,000/- as litigation cost to the complainant within one month from this date, failing which the awarded amount will carry interest @ 9% p.a. till full realization; failing which the complainant will be at liberty to realize his claim in accordance with law.
Copies of this order be supplied to the parties free of cost.
