Order-25.

Date-30/06/2015.

Complainant Ashoke Samanta by filing this complaint submitted that complainant had an Insurance Policy with op for a long period on the basis of which complainant can claim mediclaim on the basis of the said Insurance Policy and complainant has been paying premium at the rate Rs. 4,710/- from 03.03.2013.

On 27.12.2013 due to severe illness, complainant was admitted to Ruby General Hospital and was taken to ICU for further treatment and complainant asked the op to pay his cashless benefit during his stay in the Ruby Hospital for treatment.But that was denied as the cashless service was not provided, but complainant should get the said claim after treatment is done and after submission of the claim with bill for reimbursement.

Further on completion of treatment and after discharged from hospital, complainant submitted all documents required for the reimbursement of his amount, but ops denied the same on the grounds that he had pre-existing disease i.e. High Blood Pressure for which the complainant’s claim was repudiated.After receipt of the said letter of the op, complainant sent a letter to the op on 22.05.2014 asking for suitable remedy.But op refused to take any step to resolve the issue and in fact the repudiation is completely illegal and for which it is no doubt a deficiency of service and for which complainant has prayed for directing the op to refund Rs. 38,085/- towards treatment cost against that claim.

Whereas TPA op no.1 by filing written statement submitted that no doubt Ashoke Samanta submitted complete treatment documents along with filled up claim form seeking reimbursement of expenses incurred for treatment for Rs. 35,085/- on 08.01.2014 and after process and verification of the documents, the claim was found inadmissible as per Clause 4.1 of the Mediclaim Policy.

Accordingly op recommended for repudiation and the original claim file was sent to the office Insurance Company on 21.03.2014 except this op did nothing.

On the other hand op no.2 Insurance Company by filing written statement submitted that the complainant patient has been suffering from known case of Ankylosing Spondylosis (HLA B27 positive) on medication for the past 3 years and complainant has Hypertension for last 5 years.Fact remains that Ashoke Samanta has his individual Mediclaim Insurance Policy vide Policy No. 313102/48/2013/3089 with sum insured of Rs. 1,00,000/- with CB nil- valid from 03.03.2013 to 02.03.2014 and no doubt complainant was admitted to Ruby General Hospital on 27.12.2013 diagnosed with Chest Pain and he applied for cashless settlement as the patient got discharged and did not avail of cashless facility and thereafter he submitted a complete treatment document along with filled up claim form seeing reimbursement of expenses incurred for Rs. 35,085/- on 08.01.2014 and the claim was processed and TPA found inadmissible as per Clause 4.1 of the Mediclaim Policy for which after due consideration that was repudiated.

Complainant was suffering from pre-existing disease or ailment for last 4 years prior to purchasing the said policy.But complainant at the time of purchasing the said policy, he did not disclose his illness etc. which is pre-existing in nature and for which this complainant’s claim was repudiated and in fact there was no deficiency on the part of the op no.2, but complainant suppressed his pre-existing disease for which the claim was repudiated.

                                               Decision with reasons

On careful consideration of the complaint, written version and also considering the argument as advanced by the Ld. Lawyers for the both the parties and particularly considering the rejection of prayer for reimbursement as made by the TPA, it is found that op Insurance Company and TPA disallowed the claim of the complainant on the ground that there was a history of suffering for the last 5 years from Hypertension and that is only cause for repudiating the claim.

But fact remains that complainant was admitted to Ruby General Hospital with history of Chest Pain with Sweating which was radiating from Left thigh to Left Shoulder and from the discharge certificate it is found that he was admitted to hospital on 27.12.2013 and was discharged on 30.12.2013 and after investigation, it was found that it was non-specific Chest Pain.But he was admitted for Chest pain and sweating etc.But at the time of diagnosis it was found that he was also suffering from Ankylosing Spondylosis (HLA B27 positive) for the last 3 years and he was under medication and there is past history of Hypertension for the last 5 years.

At the time of clinical test at the said hospital it was found that Blood Pressure was 140/90 mmhg, Pulse Rate was 74.So, at the time of admission, it is found that his Blood Pressure was normal, may be complainant suffered from Hypertension prior to admission and in fact on the date of admission, there was no Blood Pressure.

Fact remains that Blood Pressure sometimes increases due to several reasons.But if it is controllable by medication, then it cannot be treated as a pre-existing disease.

Another factor is that after treatment doctor found no specific reason for Chest Pain either for High Blood Pressure or for any other pain for any Cardiovascular or other type of vascular disease and in fact after treatment the doctor came to a conclusion that there was nothing significant history about the patient and only some tablets were given conservatively and was discharged.

Considering the above fact, it is clear that in the present days minor increase of Blood Pressure or Sugar cannot be treated as pre-existing disease, if those are controllable by medication and worldwide such sort of Blood Pressure or Sugar are taken into account by different well known world famous doctor that if those are controllable by medication, then it cannot be treated as pre-existing disease.Because a patient may suffer from fever one after another occasion and after medication if it is found that he is cured, then such sort of fever cannot be treated as pre-existing disease.

In this present case op has failed to prove that complainant’s Hypertension is uncontrollable and there are certain degree of Hypertension which are uncontrollable and even after medication, same are called pre-existing disease because such sort of Hypertension is very serious in nature for which at any time a patient may die.But in the present case there is no such opinion of doctor that he suffered from Hypertension (critical in nature) and it may cause different type of damages in the body system.

So, considering that fact we are confirmed that even after the date of admission, Blood Pressure of the complainant was normal i.e. 140/90 mmhg.So, the approach of the op that he was suffering from pre-existing Hypertension which is completely baseless and having no foundation and for the above reasons, we find that the repudiation of the claim of the complainant by the TPA and the Insurance Company is without any foundation and such sort of finding is very casual, not with any judgement of the doctor as per observation of the world famous doctor, specialist in respect of Hypertension and Sugar,

In the result, we are confirmed that the repudiation as made by the op is baseless, without any foundation and there is no history of any pre-existing disease of the complainant and discharge certificate also does not support that.Accordingly complainant is entitled the entire mediclaim.But considering the entire materials including the in patient bill, it is found that complainant is not entitled to certain amount because as per policy condition, complainant is entitled to 1percentof the bed charge per day.Then for the 3 days, complainant is entitled to only Rs. 3,000/-.Whereas bed charge was assessed to the extent of Rs. 7,200/-.But complainant is entitled to Rs. 3,000/-.Similarly complainant is entitled to get ward service of Rs. 6,615/- and so complainant claimed as per bill.But complainant has claimed Rs. 35,085/-.

But after considering the entire policy and conditions, complainant is only entitled to Rs. 24,000/- in view of the above findings.Accordingly op Insurance Company is hereby directed to pay a sum of Rs. 24,000/- as final settlement of the claim at once along with litigation cost of Rs. 1,000/- to the complainant.

Accordingly, this complaint succeeds.

Hence, it is

                                                    ORDERED

That the complaint be and the same is allowed on contest with cost of Rs. 1,000/- against the op no.2 the Insurance Company and same is also allowed against op no.1 but without any cost.

Op no.2 is hereby directed to pay a sum of Rs. 24,000/- to the complainant as final disbursement of the Mediclaim as filed by the complainant treating the claim of the complainant is finally disposed and it shall be paid to the complainant within one month from the date of this order along with litigation cost of Rs. 1,000/- and if op no.2 fails to comply the order, in that case, penal interest at the rate Rs. 200/- per day shall be assessed till full satisfaction of the decree and if it is collected, it shall be deposited to this Forum.

Even if it is found that op no.2 is unwilling to comply the order, in that case, op no.2 shall be prosecuted u/s 25/27 of C.P. Act 1986 for which he shall have to impose further penalty and fine.