Order No. 15 dt. 08/06/2017
The case of the complainant in brief is that the complainant is a subscriber of the health insurance of o.p., the policy included the complainant along with his family members viz. wife and daughter, the policy was opened in the year 2012 and the complainant paid the premium of Rs.17,604/-. The policy was valid during the period from 17.2.12 to 26.2.13. The complainant thereafter renewed the policy for the year 2013-14. In the month of May 2013 the complainant felt chest pain and consulted Dr. Pankaj Singh who gave him some tests for investigation and thereafter the complainant consulted Dr. Mrinalendu Das of R. N. Tagore Hospital and treated was conducted on 17.2.14 and it was suggested that the complainant will have to undergo for surgery. The complainant thereafter took the advice of another Dr. Kunal Sarkar of Medica Super Speciality Hospital who also advised for surgery. The complainant was finally operated by Dr. Devi Shetty and he was discharged on 23.3.14. The complainant incurred expenditure of Rs.4,52,000/-. After recovery the complainant claimed for reimbursement of the said amount and o.p. insurance company repudiated the claim stating that internal congenital condition as per documents patient suffering from congenital bicuspid aortic valve so the claim was not entertained. On the basis of the said fact the complainant filed this case praying for direction upon the o.p. for reimbursement of the medical bill of the complainant to the tune of Rs.4,52,000/- along with interest of Rs.9,04,000/- and compensation of Rs.2,50,000/- and litigation cost of Rs.25,000/-.
The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that in the policy documents itself there was exclusion clause “Permanent Exclusion:- wherein insurance mentioned that we will not be liable under any circumstances for any claim in connection or with regard to any of the following permanent exclusion and any such permanent exclusions as may be specified in the schedule of insurance certificate.
(VI) Congenital conditions
Treatment for any “Congenital Anomaly”.
The complainant suffered from bicuspid aortic valve which is crystal clear from the medical documents filed by the complainant. The said defect is a congenital heart defect which is present from birth. The defect is always present from birth because it involves malformations of valve s and formations of valves only take place at the development stage of the foetus in its mother’s womb. As per permanent exclusion clause the complainant was not provided with the claim made by him. There was no deficiency in service on the part of o.p. insurance company and accordingly o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the heart ailment for which he was treated in the hospital?
- Whether the complainant had the policy with o.p.?
- Whether the policy of the complainant was valid at the time treatment?
- Whether the repudiation made by o.p. was justified?
- Whether there was any deficiency in service on the part of o.p.?
- 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 had the policy with his family members under the o.p. The complainant from time to time paid the premium. In the month of May 2013 the complainant felt chest pain and he contacted the doctors who asked the complainant to undergo some medical tests. After perusal of the medical papers the doctors opined that the complainant should undergo heart surgery for getting relief of his sufferings. The complainant visited two different hospitals, ultimately he was treated at R.N. Tagore Hospital and he was treated by Dr. Devi Shetty. The complainant was admitted in the said hospital on 4.3.14 and discharged on 17.3.14 after operation. The complainant had to incur the expenses for such treatment to the tune of Rs.4,52,000/-. After recovery the complainant submitted bill to o.p. but o.p. repudiated the claim of the complainant with the observation that the complainant was suffering from congenital bicuspid aortic valve and the said disease is a congenital disease and as per permanent clause (4) of the terms and conditions of the policy o.p. repudiated the claim of the complainant. The repudiation made by o.p. was illegal and without any justifiable cause since the repudiation was made for which the complainant had to file this case praying for relief including the expenditure incurred by the complainant to the tune of Rs.4,52,000/-.
Ld. lawyer for the o.ps. emphasized that it is no doubt that the complainant had the policy with o.p. and the policy was valid at the relevant point of time and the complainant paid the premium during the period the complainant was treated at the said hospital. After recovery from the said surgery the complainant submitted bills to the tune of Rs.4,52,000/-. The o.p. at the time of scrutinizing the bill found the doctors’ made opinion that the complainant was suffering from congenital bicuspid aortic valve. The said disease is a congenital disease and the suppression of the said fact and moreover, as per the permanent exclusion clause (VI) of the terms and conditions of the policy the repudiation was made. There was no deficiency in serviced on the part of o.p. Ld. lawyer for o.p. in support of his contention filed some documents including the documents to clarify what is bicuspid aortic valve. From the said documents it appears that the said defect is most commonly a congenital condition of the aortic valve reaflets fuse during development resulting in a valve i.e. bicuspid instead of normal tricuspid configuration. As per the permanent exclusion clause the complainant was not provided with the medical reimbursement and there was no deficiency in service. Having regard to the said fact o.p. emphasized that it is a fit case to dismiss the claim of the complainant.
Considering the submissions of the respective parties it is an admitted fact that the complainant along with his family members had the policy with o.p. at the relevant point of time. The o.p. has also admitted that the policy was valid at the time of undergoing surgery by of the complainant. The complainant in order to substantiate his claim filed some documents including medical papers. It is also an admitted fact from the medical papers that the complainant had the serious nature of heart ailment and he was treated by renowned doctors of Kolkata, ultimately he was treated by renowned cardiologist Dr. Devi Shetty and the surgery was made for repairing of the defect at R.N. Tagore Hospital. It is also found from the materials on record that after recovery of the said surgery he submitted medical bills to o.p. claiming for reimbursement of the medical bills. The o.p. after receiving the documents filed by the complainant found that the complainant was treated for congenital bicuspid aortic valve and o.p. at the time of argument specifically mentioned “as per the terms and conditions of the policy clause (4) the permanent exclusion was mentioned whereby it was stated that insurance company will not be liable for any circumstances, for any claim in connection or with regard to any of the following permanent exclusions and any such permanent exclusion as may be specified in the schedule of the insurance certificate:
(VI ) Congenital conditions
Treatment of any Congenital Anomaly”.
On perusal of the form for obtaining the policy it appears that the complainant did not disclose that he had the congenital heart disease. The documents filed by the insurance company as well as authority produced by the insurance company clearly stated that the disease suffered by the complainant was congenital in nature. If the complainant would have disclosed the said disease to the insurance complainant at the time of obtaining policy the insurance company would not have issued the policy in favour of the complainant. In this respect we can rely on a decision as reported in 2016(4) CPR 471 (NC) wherein it was held that insurer was justified in repudiating claim on account of false statement made by the assured in proposal form. In the proposal form there were several questions put to the complainant whereby he answered all the questions in negative excepting the question whereby it was put to the complainant what has been your usual state of health. The complainant answered ‘good’. Therefore the complainant suppressed the material fact and he did not disclose the congenital defect in his heart. Apart from the said fact, the documents filed by o.p. established the fact that the complainant suffered from heart ailment which was congenital in nature and as per clause (IV) of the policy document o.p. rightly repudiated the claim of the complainant on the basis of the exclusion clause. Therefore we hold that there was no deficiency in service or any unfair trade practice adopted by o.p. for which the complainant will be entitled to get any relief. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.532/2014 is dismissed on contest without cost against the o.p.
Supply certified copy of this order to the parties free of cost.
