Sri Utpal Kumar Bhattacharya, Member

            With the instant Complaint, the complainant prayed for redressal of his  grievances caused due to repudiation of his allegedly genuine claims for reimbursement of medical expenses incurred for treatment of his ailing wife duly covered under the mediclaim policy of the OPs.

            Briefly stated, the facts relevant to the instant complaint were that the complainant and his wife were insured under Health Insurance Scheme sponsored by Apollo DKV Health Insurance since the year, 2010. Subsequently, being allured by the exaggerated presentation about the prospect of the policy by the Agent of the OP Insurance Company, the complainant preferred to adopt the opportunity of portability and obtained “Family First Gold 5 Lakh +15 Lakh Plan” being run by the OPs.

            The OPs issued the Policy no. 30177413201300 dated 24/03/2013 in favour of the complainant and his wife having validity till February 21, 2014 on payment of an annual premium of 63,923/-.The new policy was having individual coverage of Rs. 10,00,000/-@ Rs.5,00,000/-each and a floatal coverage as well of Rs.15,00,000/-.

            In the month of September, 2013, the wife of the complainant caught cough and cold and had to undergo CT scan of her thorax as per advice of her family physician. The report of the C T scan detected her lung having cancer.

            The complainant shifted his wife immediately to Mumbai where the treating physician, after conducting several tests, advised surgery to be undertaken upon patient. The complainant’s prayer soliciting letter of authorization for undergoing the advised surgery was turned down by the OP. Since, surgery was an immediate need to save his wife’s life, the complainant had to borrow money from his friends and relatives. The patient, after the surgery being undertaken upon her on 20/09/2013 had to stay at the treating hospital till02/10/2013. On the same day, after the patient being discharged, the complainant wrote a protest letter to the OPs ventilating therein his grievance against illegal and arbitrary denial of the letter of authorization. The Complainant, thereafter, submitted his claim along with all the hospital bills and other requisite documents on 10/10/2013 for an amount of Rs. 14,18,948/-relating to his aforesaid treatment.

            The patient developed some post operative complications and had to be admitted to the same hospital once again on 07/10/2013 when the complainant had to spend a further amount of Rs. 12,18,272/-in connection with some important tests and treatment. The second claim of the like amount was submitted before the OP insurance company on 12/11/2013 in the same manner as observed during filing of the first claim.

            Neither of the said two claims was sanctioned by the OP insurance company in spite of persuasions and communications including legal notices.

            The OP insurance company ultimately repudiated both the claims on the ground of suppression of pre existing disease of hypothyroidism.

            The complainant, being aggrieved with the above mentioned repudiations, resorted to this commission filing the instant complaint.

            Heard both sides appearing through their respective Ld.Advocates.

            The Ld. Advocate appearing for the complainant emphasized on the deficiency in rendering services by the OP insurance company by repudiating his genuine claim for reimbursement. The Ld. Advocate claimed that there was no suppression of facts on the part of the patient as the information sheet supplied by the OP had no indication requiring the patient to provide with any intimation as to the pre-existence of hypothyroidism. Further, the Annexure-C at running page 50 did not leave any indication as to the exact duration of hypothyroidism reportedly pre existed in the patient.

            As continued, the claim was related only to the treatment and surgery related to lung cancer. Therefore the pre existence of hypothyroidism does not and cannot have any bearing with the instant claims. The Op insurance company, as contended, had tried to establish an absurd linkage between hypothyroidism medication and lung cancer which being farfetched and hypothetical one without any confirmatory evidence, lacked due qualification for acceptance.

            The Ld. Advocate appearing on behalf of the OP insurance company, in defence of his client, submitted that there were grounds of suspicion about the complainant’s adopting malafide practice since the claims were submitted immediately after the previous policy being ported to the instant policy having floater coverage and thereby having the scope of claiming higher amount of compensation.

            Referring to running page 50, being the Annexure-C, the Ld. Advocate contended that the said document was having specific reference about pre-existent hypothyroidism with the patient. It was also pointed out that hypothyroidism was having proximate link between the causes of carcinoma lung and the supplements and/or medicines taken by patients suffering from hypothyroidism.

            As continued, the suspected non-disclosure of pre-existing disease led the OP insurance company to take the right decision of repudiating the claims.

            Perused the papers available with the record. Also considered the submissions of both sides. It was an admitted fact that the instant policy was ported from the erstwhile policy being maintained with another insurance company and the instant policy was in force when the patient was undergoing surgery with allied treatment.

            It was also a fact that the policy accommodated a floater coverage of 15 lakh in addition to individual coverage  of 5 lakh each in accordance with the provisions envisaged under para 2 of sub-clause 2-15 of the terms and conditions of the policy.

            There was no dispute as to the denial of issuing letter of authorization for initiating treatment by the insurance company for reasons best known to them but, it was fact as well that there was assurance from the OPs for reimbursement of claim depending upon its permissibility and accordingly, the complainant was asked to file claim after completion of treatment.

            The repudiation of both the claims indicated that the claims with supporting papers reached the hands of the OP insurance company in time as submitted by the complainant.

            Perused the Annexure-C at running page 50 where pre-existing hypothyroidism was recorded under head “Significant Past History”.

            The claims seemed to have been repudiated on the ground of non-disclosure of the material facts of the patient’s having pre-existing hypothyroidism, benefits of any claim of which, as alleged, would not be available until 48 months of continuous coverage have elapsed since the inception of the first policy with the OP company as per provision laid down under clause 4 a of the terms of the policy.

            The policy was ported from earlier insurance company after completion of two years. We did not have any evidence of any claim being reimbursed by the said company in course of continuation of the previous policy. The pre-existence of hypothyroidism is not confirmed in absence of any indication as to the existence of any disease during the previous policy period and also in absence of any reason to rule out the fact that the disease may well have invaded the patient silently within the policy period and beyond the knowledge of the patient herself.

            Moreover, the instant claims relate to the treatment of lung cancer which had no indication about any pre-existence. It is extremely unlikely that one should keep a serious disease like lung cancer suppressed without any manifestation of symptoms or without any treatment for months together with the intention of having higher coverage of claim. It seems that a mere coincidence of filing claims in the same year of adopting the policy of floater coverage after availing the portability opportunity, was not taken by the Appellant insurance company in proper spirit.

            Since the policy involved a higher coverage, the OP insurance company should have been more careful to get it confirmed through medical examination about the diseases pre-existing with the patient. This is now a critical juncture when the OP insurance company has no way left other than compensating the claim as per prayer in accordance with the policy guidelines as they do not have any confirmatory document substantiating the pre-existing lung cancer. It seemed that the OP insurance company, with the same impression, had sent the e-mail dated 07/12/2017 and 08/12/2017 to the complainant in their efforts to get the claim amicably settled.

            The OP insurance Company, in his submission, had taken a further plea that the Patients suffering from hypothyroidism are prone to lung cancer as there is direct and proximate link between the causes of “carcinoma lung” and the supplements and/or medicines taken by patients suffering from hypothyroidism.

            The remote linkage that the OP insurance company had tried to establish between hypothyroidism and lung cancer is more a hypothetical one than anything nearer to reality. Moreover, the OP insurance company failed to produce any convincing documentary evidence before the Bench to substantiate that the supplements or medicines taken by the patients of hypothyroidism are the proximate causes for lung carcinoma.

            With the above observation, we find merit in the complaint to be favourably considered. We, however, are not inclined to accept the total claim as the patient’s entitlement was not more than the sum total of individual and floatal coverage, that is, Rs.5,00,000+Rs.15,00,000=20,00,000/- only.

            Hence,

Ordered

 that the complaint be and the same is allowed in part on contest with cost of Rs. 10,000/-to be paid by the OP insurance company to the complainant.

            OP insurance company is further directed to pay to the complainant a reimbursement to the maximum of Rs. 20,00,000 /-subject to admissibility of every individual expenditure incurred in different heads by the complainant for the treatment of his spouse.

            The OP insurance company is also directed to pay to the complainant a compensation of Rs.1,00,000/-.

            The entire amount has to be paid to the complainant within 45 days from the date of the instant order, failing which, simple interest @ 9% only will accrue to the payable  amount to be reimbursed and compensation amount as aforesaid from the date of default till the amount is fully realized.