By Sri. Mohamed Ismayil.C.V, Member
The grievances of the complainant is as follows:-
1. The complainant and his wife availed a medical insurance coverage policy fromthe opposite parties and issued Policy Certificate No. GHI-BF-18-IN3110990 to the complainant. The period of insurance coverage was started from 31/01/2019 to 30/01/2020 and its value was worth Rs. 2,00,000/-(Rupees Two lakh only). Later, due to physical discomfort the wife of the complainant consulted with a doctor and consequently on 19/03/2019, she was admitted to Metromed International Cardiac Centre, Kozhikode and undergone Angiogram and Angioplasty and later discharged on 21/03/2019. It is stated in the complaint that the application dated 20/03/2019 for cashless treatment was rejected by the opposite parties and advised to utilise reimbursement facility after scrutiny of documents. The complainant struggled to pay hospital bill and finally he managed to remit Rs. 1,72,500/- (Rupees One lakh seventy two thousand and five hundred only) to the hospital as expenses for treatment with much constraints. Subsequently, the complainant applied for reimbursement with all necessary original documents, but unfortunately the opposite parties did not reimburse the amount incurred for the treatment. It is contended by the complainant that the opposite parties are liable to reimburse the amount spent for treatment under the coverage of insurance policy. It is stated by the complainant that his wife did not undergone treatment for hyper tension and diabetes mellitus. According to the complainant, there was only a slightest variation of diabetes and blood pressure and did not undergone any kind of treatment for the same. The complainant further stated that he had revealed all facts before the agent of the opposite parties and accordingly it was stated by the agent of the opposite parties that there would be no legal impediment to the policy coverage as there was no treatment underwent. So it is contended by the complainant that the act of repudiation of the claim by the opposite parties is amounted to deficiency in service and exploitation of consumer. It is also stated in the complaint that the wife of the complainant had never taken medical treatment for heart connected disease. The complainant was availed insurance coverage to get financial assistance at the time of emergencies. But the opposite parties neglected the claim resulting mental agony and hardship to the complainant. So the complainant claimed Rs. 2,00,000/- (Rupees Two lakh only) as compensation for the deficiency in service committed by the opposite parties. The complainant also claimed Rs. 1,72,500/-(Rupees One lakh seventy two thousand and five hundred only) from the opposite parties as the amount incurred for the treatment of the wife of the complainant. The complainant further demanded Rs. 25,000/-from the opposite parties as the cost of the proceedings. The complainant claimed 12% interest to the above said amount from the opposite parties.
2. The complaint is admitted on file and issued notice to the opposite parties. The opposite parties entered appearance and filed version jointly.
3. The opposite parties are doing insurance business. In the version, the opposite parties denied all allegations. The opposite parties also challenged the maintainability of the complaint. The opposite parties admitted that the complainant had availed a Group Active Health Policy as stated in the complaint. But the opposite parties denied the statements of the complainant that he had disclosed about mild diabetes and blood pressure of his wife before the agent. The opposite parties also denied the alleged statement of Insurance agent that it would be endorsed in the policy as false and incorrect. According to the opposite parties, at the time of subscription of policy, the wife of the complainant was suffered from hypertension and diabetes. These facts are suppressed by the complainant and got enrolled insurance coverage. So it is contended by the opposite parties that inaccurate answer will entitle the insurer to repudiate the claim because there is a presumption that information sought in the proposal form is material for the purpose of entering into a contract of insurance. It is further contended that the complainant was under a solemn obligation to make a full and true disclosure of the information on the subject which is within his knowledge, but he failed to do so. The complainant was legally bound to disclose the facts pertaining to pre-existing medical conditions. So the complainant obtained policy by suppression and misrepresentation which has rendered the policy void ab initio. According to the opposite parties, the wife of the complainant was treated for block in the valve of heart, which is a heart disease. So it is stated by the opposite parties that diabetes greatly increases the risk of heart disease. Moreover diabetes coupled with hypertension increases the risk for cardiovascular disease. According to the opposite parties, the pre-existing disease waiting period for the policy of the complainant is 2 years. Since the treatment undertaken by the wife of the complainant fell within the pre-existing disease waiting period of 2 years, the claim of the complainant’s wife is not payable. So it contended by the opposite parties that the complainant is not entitled to any relief as sought in the complaint and prayed for dismissal of the same.
4. The complainant and the opposite parties are filed affidavits as part of their evidence. The documents produced by the complainant are marked as Ext. A1 to A4 documents. Ext. A1 document is the original policy document No.GH1-BF-18-IN 3110990 issued by the opposite parties in favour of the complainant. Ext. A2 document is the copy of repudiation letter dated 20/03/2019 issued by the opposite parties to the complainant. Ext. A3 document is the copy of inpatient invoice summary dated 21/03/2019 issued in favour of the wife of the complainant by the hospital authority. Ext. A4 document is the copy of discharge summary dated 21/03/2019 issued from Metromed International Cardiac Centre Private Limited, Kozhikode. The opposite parties are also produced documents and marked as Ext. B1 to B3 documents. Ext. B1 document is the copy of true extract of the recording of the telecall for proposal of insurance policy. Ext. B2 document is the copy of the Group Active Health Policy issued to the complainant by the opposite party. Ext.B3 document is the copy of pre-authorization form produced by the wife of the complainant. The opposite parties are also filed notes of arguments.
5. Heard both sides. Perused documents, affidavits and notes of arguments. The points considered for adjudication are:
- Whether the opposite parties are committed deficiency in service towards the complainant?
- If yes, what will be the relief to be granted and cost of the proceedings?
6. Point No.(1) and (2):-
It is averred by the complainant that he along with his wife availed a Medical Insurance Policy coverage from the opposite parties valid from 31/01/2019 to 30/01/2020. The complainant produced insurance policy document and marked it as Ext. A1 document. The opposite parties also produced insurance documents and same is marked as Ext. B2 document. It is also averred by the complainant that the insurance amount is Rs. 2,00,000/-. The complainant stated that his wife was treated for heart disease and he claimed cashless treatment under the policy coverage availed by Ext. A1 document. But his claim was repudiated by the opposite parties and repudiation letter is produced and same is marked as Ext. A2 document. The complainant produced inpatient invoice summary issued from the hospital and marked it as Ext. A3 document. The complainant also produced discharge summary issued from hospital and same is marked as Ext. A4 document. Ext. A3 and Ext. A4 document shows that the wife of the complainant had undergone treatment for coronary artery disease as stated in the complaint. It is stated by the complainant that later he applied for reimbursement of the amount spent for hospital treatment. But the opposite parties did reimburse the expenses incurred for treatment so far.
7. On the contrary, the opposite parties justified the repudiation of claim and contended that the complainant is not entitled to claim the amount under insurance coverage. In the version and affidavit, the opposite parties categorically stated that the complainant had obtained insurance policy by suppressing material facts at the time of enrolment of policy. The opposite parties produced true extract of recording of the telecall for insurance proposal and same is marked as Ext. B1 document. It is contended by the opposite parties that the wife of the complainant was suffered from diabetes mellitus and hypertension. These facts did not disclose at the time of availing insurance coverage. Moreover, it is also contented that diabetes coupled with hypertension increases the risk for cardio vascular diseases. The opposite parties also produced copy of the pre-authorisation form for the wife of the complainant and marked it as Ext. A3 document.
8. When analysing the evidence adduced by both sides, it can be seen that the opposite parties admitted the insurance coverage and claim was made was during the period of coverage. The complainant challenged Ext. A2 document issued by the opposite parties. On examination of Ext. A2 document, it can be seen that the reason for repudiation was non disclosure of hypertension and diabetes mellitus at the time of enrolment of insurance policy. But the Commission cannot agree with the argument of the opposite parties related to cause of repudiation of the claim. The opposite parties specifically contended that there was non-disclosure of facts. But Ext. B1 document clearly shows that the complainant disclosed details of physical condition at the time of enrolment and the opposite parties were availed sufficient opportunity to deny the insurance coverage at the early stage. Moreover, the Commission cannot rely a part of Ext. B1 document. It can be found that the complainant explicitly revealed that there was no hypertension and there was no medication. The complainant had revealed that there were no treatment for hypertension and diabetes and all facts were disclosed to the agent of the opposite parties. It can be also seen that the opposite parties are not produced any evidence to show the pre-existence of disease to the wife of the complainant. Moreover, when we going through Ext. B3 document it can be also found that diabetes was recently detected and hypertension is found for the last 2 years. But the opposite parties did not produce any supporting evidence. Any kind of opinion or remark without valid proof cannot be accepted by the Commission, especially in a situation, where the right of a party is under challenge. At the same time, it can be seen that the name of signed person is not mentioned in Ext.B3 document. So, we not rely upon Ext. B2 document blindly. As we know, hypertension and diabetes are life style diseases. So those diseases can be affected at any moment of life. The opposite parties cannot passively reject the claim of the complainant under Ext. A1 document. The Commission cannot find any kind of violation of terms and conditions as per Ext. A1 document as well as Ext. B2 documents by the complainant.
9. In the version of the opposite parties, it is stated that two years waiting period is mandatory as per terms and conditions of the policy. It is further stated by the opposite parties that since treatment undertaken by the wife of the complainant fell within the pre-existing disease waiting period of 2 years, the claim of the complainant’s wife is not payable. The Commission cannot consider the above contention of the opposite parties as there was no such statement in Ext. A2 document. Ext. A2 document was also suggestive of reimbursement of expenses incurred for the treatment. Moreover the opposite parties did not respond to the application for the reimbursement submitted by the complainant so far. So the Commission finds that there was deficiency in service on the part of the opposite parties. The evidence of the case revealed that the opposite parties are legally bound to make payment for cashless treatment of the wife of the complainant as per Ext. A1 document. The Commission also finds that the complainant had suffered mental agony and hardship due to the negligent act of the opposite parties. In this situation, the Commission allow the complaint in the following manner:-
- The opposite parties are directed to pay Rs. 1,72,500/- ( Rupees One lakh seventy two thousand and five hundred only) to the complainant as the expenses incurred for the treatment with 9% interest from the date of rejection of application for cashless treatment until the date of this order.
- The opposite parties are directed to pay Rs. 25,000/- (Rupees Twenty five thousand only) to the complainant as compensation for the act of deficiency in service resulting mental agony and hardship.
- The opposite parties are also directed to pay Rs. 10,000/- (Rupees Ten thousand only) to the complainant as the cost of the proceedings.
The opposite parties shall comply this order within 30 days from the date of receipt of copy of this order otherwise the entire amount shall carry 12% interest per annum, from the date of order till its realisation.
Dated this 17th day of May, 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 A4
Ext.A1 : Document is the original policy document No.GH1-BF-18-IN 3110990 issued
by the opposite parties in favour of the complainant.
Ext.A2 : Document is the copy of repudiation letter dated 20/03/2019 issued by the
opposite parties to the complainant.
Ext A3 : Document is the copy of inpatient invoice summary dated 21/03/2019
issued in favour of the wife of the complainant by the hospital authority.
Ext A4 : Document is the copy of discharge summary dated 21/03/2019 issued
from Metromed International Cardiac Centre Private Limited , Kozhikode.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Ext. B1 to B3
Ext.B1 : Document is the copy of true extract of the recording of the telecall for
proposal of insurance policy.
Ext.B2 : Document is the copy of the Group Active Health Policy issued to the
complainant by the opposite party.
Ext.B3 : Document is the copy of pre-authorization form produced by the wife of
the complainant.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
