Date of filing : 27/06/2014
Order No. 23 dt. 05/03/2018
The case of the complainants in brief is that the complainant no.2 initially obtained the policy from Apollo Munich Health Insurance Co. and subsequently he applied for portability of such policy from Apollo Munich Health Insurance Co. to Max Bhupa Health Insurance Co. Ltd. and the policy was issued bearing no.30179557201300 covering the risk for the period of 3.2.13 to 12.2.14. The complainant paid an annual premium of Rs.22,732/-. The said policy covered the medical treatment and other related expenditure for the complainant along with her husband and daughter and the sum insured to the tune of RS.30 lakhs. The complainant had the advantage of cashless benefit in terms of the said policy up to the amount of Rs.5 lakhs for her medical treatment. The complainant suffered pain on 25.2.13 and admitted to Belle Vue Clinic under Dr. Manoj Agarwal and Dr. Balaram Prasad. The complainant had to undergo a surgery on 28.2.13 and she was discharged on 2.3.13 and submitted a claim for an amount of Rs.1,18,503/- only through Belle Vue Clinic and Rs.72,287/- only for herself. The o.ps. finalized the claim and paid a sum of Rs.92,066/- directly to the hospital Rs.68,279/- to the complainant. During the continuance of the said policy the complainant felt ill in the month of April 2013 and she was admitted to Vision Care Hospital on 10.4.13 and discharged on 13.4.13. The complainant again felt pain on 25.4.13 and she consulted Dr. Balaram Prasad who after going through the papers referred the complainant to Dr. D. Nageshwar Reddy and the complainant contacted him who was attached with Asian Institute of Gastroenterology, Hyderabad. The complainant was treated there and she submitted a bill to o.ps. and claimed an amount of Rs.1 lakh, but she was provided with the amount of Rs.66,403/-. The complainant, therefore, requested the o.ps. for settlement of the claim, but o.ps. refused to entertain the prayer of the complainant. At the time of treatment at Asian Institute of Gastroenterology, Hyderabad, on seeing the medical papers it was opined recurrent acute pancreatitis for four months. The said reports do not prove in any manner that the said disease was a pre existing one. Since the repudiation was made by o.ps. the complainant filed this case praying for direction upon the o.ps. to make payment of Rs.66,403.25 as well as compensation and litigation cost.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant had obtained medical insurance policy from Apollo Munich Health Insurance Co. and thereafter the insured person opted a different company in place and stead of erstwhile company having the same insurance policy. After going through the information the complainant’s husband in the proposal form and portability form, the “Family First Gold 5 Lacs + 15 Lacs” insurance policy was issued in favour of the complainant along with her husband and daughter which was valid from 13.2.13 to 12.2.14. As per clause 6 of policy proposal form asked the questions relating to medical history of the proposer. Clause 5 of General Selection: Sec III of the proposal form cautions the proposer to make full and frank disclosures of all materials facts to the assumption of risk of the proposer and all persons proposed to be insured. It further stated that if the disclosure obligations are breached then this may render any policy issued void. However, no disclosures of any medical history were made. Hence, the policy was issued on the basis of the proposal form and filed by the complainant’s husband. After the policy was issued the claim of the complainant received in Feb. 2013 and the same was duly paid, then another claim was received in 2013 and the amount was paid as per policy terms and conditions. Thereafter the complainant filed a post hospitalization claim in May 2013 for reimbursement of expenses incurred for consultation, medicines and tests at Asian Institute of Gastroenterology, Hyderabad along with travelling expenses from Kolkata to Hyderabad flight of Rs.35,625/-. The claim o the complainant payable firstly travelling expenses for seeking treatment or consulting doctor in another city are not covered under the policy terms and conditions. Only the expenses incurred for medicines, consultations, tests are covered. The complainant has been filing claims since the very month in which the policy was ported and as a different city hospital was also involved in this instance. An investigation was carried out to verify the claim. The patient’s documents i.e. IPD of the complainant were collected from all three hospitals where the complainant had consulted or received treatment. The discharge summary of Belle Vue Clinic where the complainant was admitted during 25.2.13 to 2.3.13 for treatment of pain in abdomen and vaginal bleeding and infective colitis clear states that the complainant was pregnant and underwent an abortion i.e. D & E which stands for Dilatation and Evacuation of uterus. As the policy was ported in Feb. 2013 it becomes clear that the complainant did not disclose the fact of her pregnancy in the policy proposal form or any time thereafter before the policy was issued. On going through a consultation paper dt.13.5.13 it was found that the complainant had suffered from acute gastroenteritis in Jan. 2013 when there was increase in pancreatic enzyme and her pancreas was bulky, though the complainant suffered in the month of Jan. 2013 and the policy was ported in the month of Feb. 2013 the same fact was not disclosed. As per history of physical record of Vision Care Hospital where the complainant was admitted from 10.4.13 to 13.4.13 whereby it was clearly stated that the complainant is a known case of pancreatitis since Jan. 2013. However, the said fact was not disclosed in the policy proposal form. In view of such non disclosure of past medical history of pancreatitis, the insurance claim of the complainant has been validly repudiated and the same was communicated to the complainant vide letter dt.17.4.14. On the basis of such background of the case o.ps. stated that there was no deficiency in service on the part of o.ps. and the case filed by the complainant has got no merit and the same is to be dismissed.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.p. insurance company?
- Whether during the subsistence of the policy the complainant underwent treatment?
- Whether the complainant suppressed the material fact of her pre existing disease?
- Whether for non disclosure of disease by the complainant gave right to the o.ps. to cancel the policy?
- Whether there was any deficiency in service or unfair trade practice on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant no.2 initially obtained the policy from Apollo Munich Health Insurance Co. and subsequently he applied for portability of such policy from Apollo Munich Health Insurance Co. to Max Bhupa Health Insurance Co. Ltd. and the policy was issued bearing no.30179557201300 covering the risk for the period of 3.2.13 to 12.2.14. The complainant paid an annual premium of Rs.22,732/-. The said policy covered the medical treatment and other related expenditure for the complainant along with her husband and daughter and the sum insured to the tune of RS.30 lakhs. The complainant had the advantage of cashless benefit in terms of the said policy up to the amount of Rs.5 lakhs for her medical treatment. The complainant suffered pain on 25.2.13 and admitted to Belle Vue Clinic under Dr. Manoj Agarwal and Dr. Balaram Prasad. The complainant had to undergo a surgery on 28.2.13 and she was discharged on 2.3.13 and submitted a claim for an amount of Rs.1,18,503/- only through Belle Vue Clinic and Rs.72,287/- only for herself. The o.ps. finalized the claim and paid a sum of Rs.92,066/- directly to the hospital Rs.68,279/- to the complainant. During the continuance of the said policy the complainant felt ill in the month of April 2013 and she was admitted to Vision Care Hospital on 10.4.13 and discharged on 13.4.13. The complainant again felt pain on 25.4.13 and she consulted Dr. Balaram Prasad who after going through the papers referred the complainant to Dr. D. Nageshwar Reddy and the complainant contacted him who was attached with Asian Institute of Gastroenterology, Hyderabad. The complainant was treated there and she submitted a bill to o.ps. and claimed an amount of Rs.1 lakh, but she was provided with the amount of Rs.66,403/-. The complainant, therefore, requested the o.ps. for settlement of the claim, but o.ps. refused to entertain the prayer of the complainant. At the time of treatment at Asian Institute of Gastroenterology, Hyderabad, on seeing the medical papers it was opined recurrent acute pancreatitis for four months. The said reports do not prove in any manner that the said disease was a pre existing one. Since the repudiation was made by o.ps. the complainant filed this case praying for direction upon the o.ps. to make payment of Rs.66,403.25 as well as other reliefs.
Ld. lawyer for the o.ps. argued that the complainant had obtained medical insurance policy from Apollo Munich Health Insurance Co. and thereafter the insured person opted a different company in place and stead of erstwhile company having the same insurance policy. After going through the information the complainant’s husband in the proposal form and portability form, the “Family First Gold 5 Lacs + 15 Lacs” insurance policy was issued in favour of the complainant along with her husband and daughter which was valid from 13.2.13 to 12.2.14. As per clause 6 of policy proposal form asked the questions relating to medical history of the proposer. Clause 5 of General Selection: Sec III of the proposal form cautions the proposer to make full and frank disclosures of all materials facts to the assumption of risk of the proposer and all persons proposed to be insured. It further stated that if the disclosure obligations are breached then this may render any policy issued void. However, no disclosures of any medical history were made. Hence, the policy was issued on the basis of the proposal form and filled by the complainant’s husband. After the policy was issued the claim of the complainant received in Feb. 2013 and the same was duly paid, then another claim was received in 2013 and the amount was paid as per policy terms and conditions. Thereafter the complainant filed a post hospitalization claim in May 2013 for reimbursement of expenses incurred for consultation, medicines and tests at Asian Institute of Gastroenterology, Hyderabad along with travelling expenses from Kolkata to Hyderabad flight of Rs.35,625/-. The claim o the complainant payable firstly travelling expenses for seeking treatment or consulting doctor in another city are not covered under the policy terms and conditions. Only the expenses incurred for medicines, consultations, tests are covered. The complainant has been filing claims since the very month in which the policy was ported and as a different city hospital was also involved in this instance. An investigation was carried out to verify the claim. The patient’s documents i.e. IPD of the complainant were collected from all three hospitals where the complainant had consulted or received treatment. The discharge summary of Belle Vue Clinic where the complainant was admitted during 25.2.13 to 2.3.13 for treatment of pain in abdomen and vaginal bleeding and infective colitis clearly states that the complainant was pregnant and underwent an abortion i.e. D & E which stands for Dilatation and Evacuation of uterus. As the policy was ported in Feb. 2013 it becomes clear that the complainant did not disclose the fact of her pregnancy in the policy proposal form or any time thereafter before the policy was issued. On going through a consultation paper dt.13.5.13 it was found that the complainant had suffered from acute gastroenteritis in Jan. 2013 when there was increase in pancreatic enzyme and her pancreas was bulky, though the complainant suffered in the month of Jan. 2013 and the policy was ported in the month of Feb. 2013 the same fact was not disclosed. As per history of physical record of Vision Care Hospital where the complainant was admitted from 10.4.13 to 13.4.13 whereby it was clearly stated that the complainant is a known case of pancreatitis since Jan. 2013. However, the said fact was not disclosed in the policy proposal form. In view of such non disclosure of past medical history of pancreatitis, the insurance claim of the complainant has been validly repudiated and the same was communicated to the complainant vide letter dt.17.4.14. On the basis of such background of the case o.ps. stated that there was no deficiency in service on the part of o.ps. and the case filed by the complainant has got no merit and the same is to be dismissed.
Considering the submissions of the respective parties it is an admitted fact that the complainant had the policy with Apollo Munich Health Insurance Co. earlier, subsequently it was ported with Max Bhupa Health Insurance Co. Ltd. and the policy was issued to the complainant. Immediately after commencing of the said policy the complainant took admission in the hospital and after her release from the hospital the bill was submitted which was paid by o.ps. The complainant again made claim in the month of April 2013 for her hospitalization during 10.4.13 to 13.4.13 and the claim of the complainant was paid as per terms and conditions of the policy. Thereafter the complainant filed the claim for reimbursement of expenses not only for his medical treatment, but also for the travelling expenses from Kolkata to Hyderabad. In the policy bond itself it was not mentioned that the policy holder will be entitled to get the travelling expenses. Apart from the said fact o.ps. during the treatment received by the complainant at different hospitals made query in respect of the medical papers of the complainant it was found that the complainant for the first time admitted to Belle Vue Clinic for the purpose of undergoing abortion and she made the claim immediately after opening of the policy i.e. in the month of Feb. 2013. The complainant again went to Kothari Medical Centre for treatment on 13.5.13 wherein she reported that she was suffering from gastroenteritis and had suffered from the said disease since the month of Jan. 2013, but it was not disclosed in the proposal form which she filled in the month of Feb. 2013. The o.ps. thereafter made query regarding the treatment received by the complainant during the period from 10.4.13 to 13.4.13 and she underwent for treatment of pain in abdomen and pancreatitis and in the medical papers it was clearly stated that she was suffering from said pancreatitis disease since Jan. 2013. The said fact was not disclosed by the complainant in the proposal form. It appears from the materials on record that all the previous claims of the complainant had been paid under the bona fide impression that the complainant has honestly filled the proposal form. However, the last claim of the complainant for post hospitalization expenses was denied as per clause 4 of the policy terms and conditions which says that pre existing disease shall not be covered until 48 months of continuous coverage have elapsed and also for non disclosure of material fact as per clause 5(g)(3)(ii) of the policy terms and conditions. On the basis of such fact and for non disclosure of past medical history of pancreatitis the insurance claim of the complainant has been validly terminated. In view of such facts and circumstances of the case, we hold that the evidence adduced by o.ps. supports the contention of o.ps. and on perusal of those documents we find that there was clear suppression of the material fact of pre existing disease and insurance company rightly held that there was violation of the terms and conditions of the policy resulting in cancellation of the policy itself. In view of such evidence on record we do not find any deficiency in service or unfair trade practice on the part of o.p. insurance company and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.440/2014 is dismissed on contest without cost against the o.ps.
