Date of Filing : 06/03/2020
Date of Judgement : 03/08/2023
Mrs. Sashi Kala Basu, Hon’ble President
This complaint is filed under section 12 of the Consumer Protection Act 1986 by the complainant Sri Rabindra Ray alleging unfair trade practice on the part of the Opposite Parties (referred as OPs hereinafter) namely (1) Manipal Cigna Health Insurance Company, (2) Efficient Insurance Broker Pvt. Ltd. and (3) Sri Sourav Ghosh Dastidar.
Case of the complainant in short is that complainant was a policy holder under National Insurance Co. Ltd. which was later ported to Manipal Cigna Health Insurance Company on being approached by OP 3 the relationship manager of OP 2. Complainant was holding the MEDICLAIM policy for 20 years under National Insurance company till 15/05/2018 and ported on solicitation of OP 3 on 19/4/2018 effective for the period from 17/5/2018 to 16/5/2019 by paying the premium of Rs.48,707/-. Complainant and his wife were joint holders of the policy being No. PROHLRO10688273 – 2019 under OP 1. At the time of porting the policy, comprehensive health check-up was made by the OP through their representative SAI CLINIC. The policy was renewed on 17/5/2019 which was effective till 16/5/2020. The premium was enhanced to Rs.58,013/-.
On 27/5/2019, wife of the complainant was admitted at Yashoda Hospital in Hyderabad and during the course of admission, complainant claimed cashless benefits, but the claim was repudiated on the ground that, as per the investigation, discrepancies were found in the duration of Hypertension and Diabetes Mellitus and so complainant was asked to file for reimbursement with all supporting documents. Thus, complainant paid the full amount of Rs.1,56,683/- on 30/5/2019 at the time of discharge from the Hospital. Thereafter, complainant claimed for reimbursement and submitted all the relevant documents through OP 3, but after making many correspondences OP repudiated the claim on 07/02/2020 without any cogent reason just by saying required indoor papers must be filed. The rejection of the reimbursement only shows unfair trade practice on the part of OP and thus present complaint is filed by the complainant praying for directing the OP 1, 2 & 3 to reimburse the claim amount of Rs.1,56,683/-, to pay compensation of Rs.2,00,000/- for harassment and mental agony, to pay Rs.1,00,000/- as litigation cost and Rs.1,00,000/- as punitive damage.
OP 1 & 2 have contested the case by filing the written version contending specifically that cashless benefits during the hospitalization of complainant’s wife namely Shampa Ray for banign neoplasm of unspecified adrenal gland was refused as TPA opined that as per investigation, discrepancies were found in the duration of Hypertension and Diabetes Mellitus. Since Diabetes Mellitus and Hypertension was not disclosed at the proposal stage, it was crucial to know the duration of the said condition to determine the admissibility of the claim. It is further contended that the reimbursement claim of Rs.1,56,683/- was repudiated in terms of clause VII.6 of the policy, as complainant failed to submit documents necessary for adjudicating the claim despite repeated requests sent to him. So, OP 1 & 2 have prayed for dismissal of the complaint.
OP 3 did not turn up on service of notice, so the case has been heard exparte against him.
During the course of trial, both parties filed their respective examination-in-chief on affidavit followed by filing of questionnaire and reply thereto and ultimately arguments of both sides have been heard.
Following points thus require to be determined :-
- Whether there has been unfair trade practice on the part of the OPs?
- Whether the complainant is entitled to the relief as prayed for?
Decision with reasons
Both the points being inter-related are taken up together for discussion in order to avoid repetition.
Complainant has filed the copy of insurance policy issued by OP 1 Insurance Company wherefrom it is evident that policy was for the period from 16/5/2018 to 15/5/2019 and the sum insured was Rs.3,50,000/-. There is also no dispute that the policy was subsequently renewed on 17/5/2019. It is evident from the said health insurance policy that the complainant and his wife were previously insured under national insurance company and the date of enrolment of the policy was 16/5/2014.
Admittedly, complainant’s wife was admitted on 27/5/2019 in Hyderabad at Yashoda Super Speciality Hospital and complainant had claimed for cashless treatment, but the same was refused by OP stating that on investigation by TPA, discrepancies were found in duration of Hypertension and Diabetes Mellitus. The claim of the complainant for reimbursement of Rs. 1,56,683/- after the discharge of his wife was also repudiated stating the reason that complainant failed to submit day to day treatment papers (Indoor patient bed head ticket).
It may be pertinent to point out that in this case apparently there was portability of the MEDICALIM Policy under National Insurance Company to OP 1 Health Insurance Company at the solicitation of OP 3 without losing the existing benefits. It is nowhere specific case of the OPs that there was any suppression of pre-existing disease. However, according to OPs, cashless treatment was refused because discrepancies were found in the duration of Hypertension and Diabetes Mellitus. But in this regard, it may be mentioned that the proposal form was submitted by the complainant and all the required information was furnished. It is also the specific claim of the complainant that at the time of porting of the policy, comprehensive health check up of the complainant and his wife was done by the representative of OP namely SAI CLINIC. OP 1 & 2 have filed the said Medical Examination Report wherefrom it appears that the doctor on examination of Shampa Roy did not find any such disease including Hypertension and Diabetes Mellitus. Consequent to such medical examination, OP Insurance Company being appraised about the medical condition of the complainant and his wife, issued the policy stating specifically in the policy against column “Pre-existing Disease/illness condition – Nil”. So once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing a medical existing condition.
It is already discussed above that the complainant and his wife were insured under National Insurance Company and were holding MEDICLAIM Policy upto 15/05/2018. However, according to complainant, they were holding the said MEDICLAIM Policy upto 20 years, but in the policy issued by the OP Company the date of first enrolment has been stated as 16/05/2014. There is no material before this commission that there was suppression of any pre-existing disease/ailment by the complainant and his wife at the time of enrolment of the said MEDICLAIM Policy. So the contention of the OP 1 & 2 that cashless treatment was denied because discrepancies were found in the duration of Hypertention and Diabetes Mellitus, is devoid of any merits and thus cannot be accepted. Consequent to the same, contention of the OP 1 & 2 that the reimbursement claim was repudiated as complainant failed to submit day to day treatment sheet (Indoor patient bed head ticket) also loses its significance and thus the same is also not accepted. However, it may be pertinent to point out that it appears from the documents filed in this case that the complainant did comply the terms of the policy and submitted the documents as specified in clause VII.5 of the policy. But OP 1 & 2 appears to be asking some additional documents which was with the hospital. Even though OP 1 & 2 have stated that company tried to procure the indoor case papers from the Hospital, but hospital refused to share the same and informed that the same can be provided only upon request of the patient. But no document in support of such claim has been filed by the OP 1 & 2. It may further be mentioned that even submission of Indoor bed head ticket could not change the complexion of the matter in view of the discussions as highlighted above that there is no material before this commission that there was suppression of any pre-existing disease. So, the repudiation of the claim by OP amounts to deficiency in service and unfair trade practice on the part of OPs.
It will not be out of place to mention here that when it comes to taking premium, OP insurance company takes no time to enhance it. In this case also premium was enhanced to Rs.58,013/- from Rs.48,707/-. But when it comes to indemnify the insured regarding the expenses incurred by him towards his medical treatment, insurance Co. starts searching for Lacuna and reason to repudiate the claim. The very objective of seeking a health insurance policy would be frustrated if indemnification in respect of a sudden illness is not done by the Insurance Company. So, in view of the discussions as highlighted above, complainant is entitled to the claim amount of Rs.1,56,683/- along with compensation (in the form of interest)
Hence,
Ordered
CC/108/2020 is allowed on contest against OP 1 & 2 and exparte against OP 3. Opposite Parties are directed to pay jointly and severally Rs.1,56,683/- to the complainant along with interest on the said sum @7% per annum from 30/05/2019 to till this date, within 45 days from the date of passing of this order. OPs are further directed to pay litigation cost of Rs.12,000/- within the aforesaid period of 45 days. In default of payment, the entire sum shall carry interest @ 7% till realization.
