SMT. RAVI SUSHA: PRESIDENT
Complainant filed this complaint U/s 35 of Consumer Protection Act 2019, seeking to get an order directing opposite party to pay Rs.27,028/- together with Rs.1 lakh towards compensation and Rs.10,000/- towards cost of the proceedings of this case.
Complainant had obtained a policy SBI General Insurance for a sum of Rs.3,00,000/- for a period form 17/10/2021 to 16/10/2022. Following a sudden stomach pain. Complainant consulted doctor at MIMS Hospital on 16/12/2021, who prescribed him Medicine for 10 days. As there was no improvement, on 24/12/2021, he consulted the Doctor again and got admitted in the hospital and was discharged on 29/12/2021. At the discharged time, he was given an impatient bill of Rs.27,028/-. He submitted the said bill to the OP insurance company but they denied his claim. Hence this complaint.
OP filed version stated that the complainant had taken an Arogya Plus, health insurance policy from OP for the period from 17/10/2021 to 16/10/2022 subject to policy terms and conditions. A claim was lodged in the above policy alleging hospitalization of insured member Mr. Devadasan T at Aster Mims hospital for the period 28/12/2021 to 29/12/2021. As it could be noted, the hospitalization is within 3 months of the 1st policy inception. From the preliminary medical documents made available by the hospital for the purpose of cashless claim, it could be noted that the patient was admitted with complaints of Acute colitis, gastritis, IBS (Irritable Bowel Syndrome) with DM (Diabetes mellitus) and was managed medically. The patient has presented with complaints of left sided lower abdominal pain, and altered bowel habits since 1 month and also a history of surgery for haemorrhoids. Considering the nature of ailment and the line of treatment, in order to determine the claim admissibility required certain documents/clarification. In pursuance the Third Party Administrator on behalf of OP requested documents/ clarification. However, nothing was forthcoming, without submitting documents, it is practically impossible for the OP to decide the claim admissibility under the policy. The complainant was under medication which was not declared while availing the policy. More importantly, the discharge summary also reveals that he had undergone surgery for hermorrhoids earlier. However, such material facts as to the health was not declared while awaiting the policy. The submission records may warrant invoking ‘non-disclosure’ and policy cancellation with premium forfeiture as per the policy terms and conditions. The learned Ombudsman had considered the above points at length and held that (Ref. para 4 of Ombudsman award) “It is not unreasonable for an insurer to seek to know the medical history in the context of these circumstance to enable them to take a decision on their liability under the policy. He also conceded the RI’s submission that the Doctor’s certificate submitted by the complainant does not clarify the matter adequately.” The complainant did not respond to the above referred query and remained indifferent throughout the claim process. Since nothing was forthcoming, the claim was closed. The case of the complainant is a suspected case of “Pre-existing disease” Under the policy which is exclusion for a defined period of time. Without submitting the above documents the claim admissibility under the policy cannot be determined. Hence there is no deficiency in service or unfair trade practice as defined under the claim process. Therefore, it is humbly prayed to dismiss the complaint with cost.
Complainant filed his chief affidavit and documents. Examined as Pw1 marked Ext.A1 to A5. Cross-examined by OP. On behalf of OP, Consumer litigation claims, Manager of OP Company filed his proof affidavit and documents. He was examined as Dw1 and marked Ext.B1 to B6. Dw1 was cross-examined for complainant. After that the complainant and learned counsel of OP made oral submissions.
The learned counsel for OP submitted that since insurance is a contract entered into in utmost good faith between the two parties, the insure by not giving correct information sought in the insurance claim form, the claim was justifiably repudiated.
Complainant on the other hand submitted that he did not suppress any material fact regarding his health because he had approached the doctor due to temporary sudden stomach pain and had recovered from the same.
The question for consideration is whether the repudiation by the Insurance Corporation on the aforesaid ground was justified.
Medical record, Discharge summary of Aster Mims Hospital has been placed on record (Ext.A2) which goes to show that the insured Mr. Devadas T was admitted in this hospital on 28/12/2021 for Acute colitis, Antral Gastritis, constipation predominant.
In History portion it is recorded as the complainant presented with complaints of left sided lower abdominal pain and altered bowel habits since 1 month. Further he had on and off constipation earlier and also had mass PIR and was diagnosed to have morrhoids earlier and undergone surgery.
According to OP, complainant had suppressed such material facts in the proposal form while taking the policy in question. While cross-examining Pw1, the learned counsel of OP, put a question to the complainant. Page (2) ഇതിന് മുൻപ് എപ്പോഴാണ് operation നടത്തിയത്? 6 വർഷം മുൻപ്. In Ext.A2 Discharge summary and in Ext. B4 certificate issued by the treating doctor did not mention on which date the previous surgery was done. In ext.B4 there is a statement by the Insured that previous surgery was 8 years back. Here though Op raised such a contention, they failed to submit any medical records to establish about the date of previous surgery conducted on the patient (Complainant). No record of subsequent period has been placed on record, which indicates that he insured had not taken treatment within earlier surgery and the disputed treatment. As no record of treatment has been produced, we can presume that he patient had not taken any treatment after the previous surgery till the present ailment. In Ext.B4 it is certified by the treated doctor that previous discharge summary was not available. During cross-examination complainant also deposed that previous Medical records are not available with him.
As per the available information from the complainant, the insured had been diagnosed have morrhoids and under gone surgery, six years prior to 28/12/2021. Herein the policy was obtained in the year 2021. Long period had passed after the 1st surgery. It is a settled position that withholding of such information will not deprive the complainant form receiving the payment of insured amount.
Here both side produced judgment of Insurance ombudsman in which Insurance Ombudsman dismissed the complainant’s petition, as he had not submitted previous Medical records sought by Insurance Company.
On perusal of available documents, Ext.B4 shows that the doctor recorded that the previous discharge summary was not available. During deposition Pw1 has stated that as a previous Medical records are not available with him, he could not submit before Insurance company.
Complainant also submits that ധP had not given the policy terms and condition to him along with policy certificate. OP failed to submit documents to rebut said contention of complainant. This is also deficiency in service on the part of OP.
For the forgoing reasons, we find that the complainant is entitled to get reimbursement of the medical expenses Rs.27,028/- incurred to him at Mims Hospital for the treatment availed by him during the period from 24/12/2021 to 29/12/2021.
In the result complaint is allowed in part. Opposite party is directed to pay Rs.27,028/- to the complainant. Opposite party is further directed to pay Rs.10,000/- towards compensation for the mental agony suffered by the complainant due to the deficiency of service of opposite party and Rs.5,000/- towards cost of the proceedings of this complaint. Opposite party shall comply the order within one month from the date of receipt of the certified copy of this order. Failing which Rs.27,028+10,000 carries interest @ 9% per annum from the date of compliant till realization. Complainant is at liberty to execute the order as per the provision of Consumer Protection Act 2019.
Exts.
A1- Policy
A2- Discharge summary
A3- Hospital bill (Mims)
A4- Order in Insurance ombudsman
A5- Reply send by OP dated 17/04/2023
B1- Policy with condition
B2- Cash less form
B3- Cash less claim denial letter dated 29/12/2021
B4- Document required letter
B5- Certificate issued by Doctor dated 25/07/2022
B6- Order passed by Hon’ble ombudsman(Ext.A3)
Pw1- Devadasan T - Complainant
Dw1-Leo John V A- witness of OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
