Date of Filing : 17/06/2014
Order No. 21 dt. 29/11/2017
The case of the complainant in brief is that the complainant is a policy holder of o.p. no.1 on payment of premium being policy no.30143218201200 for the period from 22.11.12 to 21.11.13, plan opted for Family First Silver Plus 15 lakhs sum assured Rs.35 lakhs along with Mrs. Monika Gupta (wife), Nripesh Gupta (Son) and Yashvi Gupta (daughter). During the subsistence of the policy the daughter of the complainant felt acute pain in abdomen and immediately consulted with o.p. no.2 where o.p. no.2 after examination advised for URS with laparoscopy. The complainant’s daughter was admitted to Belle Vue Clinic on 14.9.13 where an operation was conducted by o.p. no.2 on 15.9.13 and after recovery the patient was discharged on 16.9.13. After the recovery of the patient the complainant submitted a medical bill for reimbursement to the tune of Rs.1,77,086/-, but o.p. insurance company disallowed the claim of the complainant on 26.11.13 on the ground of suppression of pre-existing disease. The complainant subsequently came to know that as per query from the treating doctor i.e. o.p. no.2 and on the basis of the said doctor who opined that the patient was suffering for 2 years and on suppression of material fact that the claim of the complainant was repudiated. In order to clarify the matter the complainant made treating doctor i.e. o.p. no.2 as a party to this case. on the basis of the said fact the complainant filed this case praying for direction upon the o.p. insurance company for reimbursement of the medical bill of Rs.1,77,086/- as well as compensation of Rs.1 lakh and litigation cost of Rs.50,000/-.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. In their w/v o.p. no.1 stated that the complainant made pre authorization request to o.p. no.1 for which o.p. no.1 wanted to have some documents which were not complied for which the pre authorization request was not accepted. Subsequently the complainant submitted the medical bill for reimbursement which was registered as reimbursement claim no.54500. The claim of the complainant was disallowed with the reason that the patient was suffering from UTI for 2 years and it was not disclosed at the time of inception of the policy and because of suppression of material information at the time of opening the policy, the claim of the complainant was not entertained. During the enquiry of the claim of the complainant the o.p. no.2 Dr. Ramana of Belle Vue Clinic stated that the complainant’s daughter Yashvi Gupta was having past medical illness of history of UTI for the last 2 years. But such pre existing UTI was conveniently suppressed by the complainant at the time of inception of the policy in 2012. Due to such non disclosure of pre existing disease of UTI from which the complainant’s daughter was suffering the claim of the complainant was disallowed by o.p. no.1 under clause 5 g 3 II of the terms and conditions of the policy. There was no deficiency or unfair trade practice on the part of o.p. no.1 and as such, o.p. no.1 prayed for dismissal of the case.
In their w/v o.p. no.2 stated that o.p. no.2 admitted that he issued a certificate on 16.9.13 to the effect that the patient Mrs. Yashvi Gupta was not aware that she has UTI problem and would need any surgical treatment for UTI. After examination o.p. no.2 on evaluation of the patient took the decision to have the examination of the patient to URS along with laparoscopy. It was further stated that in UTI cases in spite of having some kind of infection the patient may not be aware that she was suffering from an organic disease leading to recurrent UTI like a ureteric stone or a stricture. The patient may not have the knowledge of either ureteric problem or that she would in future need any surgical treatment for that disease. The o.p. no.2 denied that there was any collusion between o.p. no.1 and o.p. no.2 and thereby o.p. no.2 prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant was insured with o.p. no.1 at the relevant point of time?
- Whether the daughter of the complainant had the disease which she had suffered for the last 2 years?
- Whether there was any suppression of material fact at the time of obtaining the policy?
- Whether there was any deficiency in service 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 is a policy holder of o.p. no.1 on payment of premium being policy no.30143218201200 for the period from 22.11.12 to 21.11.13, plan opted for Family First Silver Plus 15 lakhs sum assured Rs.35 lakhs along with Mrs. Monika Gupta (wife), Nripesh Gupta (Son) and Yashvi Gupta (daughter). During the subsistence of the policy the daughter of the complainant felt acute pain in abdomen and immediately consulted with o.p. no.2 where o.p. no.2 after examination advised for URS with laparoscopy. The complainant’s daughter was admitted to Belle Vue Clinic on 14.9.13 where an operation was conducted by o.p. no.2 on 15.9.13 and after recovery the patient was discharged on 16.9.13. After the recovery of the patient the complainant submitted a medical bill for reimbursement to the tune of Rs.1,77,086/-, but o.p. insurance company disallowed the claim of the complainant on 26.11.13 on the ground of suppression of pre existing disease. The complainant subsequently came to know that as per query from the treating doctor i.e. o.p. no.2 and on the basis of the said doctor who opined that the patient was suffering for 2 years and on suppression of material fact that the claim of the complainant was repudiated. In order to clarify the matter the complainant made treating doctor i.e. o.p. no.2 as a party to this case. on the basis of the said fact the complainant filed this case praying for direction upon the o.p. insurance company for reimbursement of the medical bill of Rs.1,77,086/- as well as other reliefs.
Ld. lawyer for the o.p. no.1 argued that the complainant made pre authorization request to o.p. no.1 for which o.p. no.1 wanted to have some documents which were not complied for which the pre authorization request was not accepted. Subsequently the complainant submitted the medical bill for reimbursement which was registered as reimbursement claim no.54500. The claim of the complainant was disallowed with the reason that the patient was suffering from UTI for 2 years and it was not disclosed at the time of inception of the policy and because of suppression of material information at the time of opening the policy, the claim of the complainant was not entertained. During the enquiry of the claim of the complainant the o.p. no.2 Dr. Ramana of Belle Vue Clinic stated that the complainant’s daughter Yashvi Gupta was having past medical illness of history of UTI for the last 2 years. But such pre existing UTI was conveniently suppressed by the complainant at the time of inception of the policy in 2012. Due to such non disclosure of pre existing disease of UTI from which the complainant’s daughter was suffering the claim of the complainant was disallowed by o.p. no.1 under clause 5 g 3 II of the terms and conditions of the policy. There was no deficiency or unfair trade practice on the part of o.p. no.1 and as such, o.p. no.1 prayed for dismissal of the case.
Ld. lawyer for the o.p. no.2 argued that o.p. no.2 admitted that he issued a certificate on 16.9.13 to the effect that the patient Mrs. Yashvi Gupta was not aware that she has UTI problem and would need any surgical treatment for UTI. After examination o.p. no.2 on evaluation of the patient took the decision to have the examination of the patient to URS along with laparoscopy. It was further stated that in UTI cases in spite of having some kind of infection the patient may not be aware that she was suffering from an organic disease leading to recurrent UTI like a ureteric stone or a stricture. The patient may not have the knowledge of either ureteric problem or that she would in future need any surgical treatment for that disease. The o.p. no.2 denied that there was any collusion between o.p. no.1 and o.p. no.2 and thereby o.p. no.2 prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that that the complainant was insured with o.p. no.1 along with his family members including the patient being the daughter who underwent treatment under o.p. no.2. The o.p. no.1 has claimed that at the time of obtaining the policy the complainant suppressed the material fact of suffering of such illness prior to obtaining the policy and on that score the claim of the complainant was repudiated. In order to clarify the matter the complainant has made the treating doctor as party to this case who in his w/v as well as in the evidence admitted that the suffering made by the complainant’s daughter had no knowledge about UTI problem which came to know after investigation and during treatment. The o.p. no.2 in the w/v categorically stated that the patient was unaware about UTI problem even if there was any UTI cases in spite of having some kind of infection the patient may not be aware that she was suffering from an organic disease leading to recurrent UTI like ureteric stone or stricture. The impact of such disease was somewhat like people suffering from cold, cough and fever which may in future turn out to have been due to TB or a heart valve problem – but the complainant might not at all be aware of having such disease till it is diagnosed and established. Here in this case, it is found that the complainant’s daughter though had some problems, but those were not detected to be the UTI problem which came to light after investigation made as per the direction of o.p. no.2. It is an established fact that during the subsistence of the policy the daughter of the complainant had to undergo the treatment after detection of the UTI problem and the expenses incurred by the complainant was paid by him to the hospital as well as paid the necessary charges to the doctor, therefore we hold that the repudiation made by o.p. insurance company that there was suppression of pre-existing disease cannot be accepted. Therefore we hold that there was deficiency in service and unfair trade practice on the part of o.p. no.1 and as such, the complainant is entitled to get the relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.408/2014 is allowed on contest with cost against the o.p. no.1 and dismissed on contest without cost against the o.p. no.2. The o.p. no.1 is directed to pay a sum of Rs.1,77,086/- (Rupees one lakh seventy seven thousand eighty six) only to the complainant along with compensation of Rs.20,000/- (Rupees twenty thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
