Order No. 17 Dated 27-03-2015.
The case of the complainant in short is that complainant was a policy holder in respect of Family Floater Health Insurance Policy being no.4034/FFH/W-408799/00/000 of ICICI Lombard General Insurance Co. Ltd. since 15.11.08. Complainant has purchased the aid policy for his wife Nivedita Sharma and his son Harshit Sharma, for sum insured of Rs.2 lakhs and paid premium of Rs.7369/- for a period of 2 years. The said policy was subsequently renewed by the complainant for further two years and by enhancing the sum insured amount to Rs.3 lakhs. Complainant has paid a sum of Rs.8137/- as premium for further two years. Complainant has continued and maintained the said policy since 15.11.08 without any break till expiry.
Complainant paid a sum of Rs.6469/- as premium to o.p. and thereafter o.p. issued a new Ported Health Insurance Policy no.30145231201200 under their Plan (Health Companion Silver) for sum insured of Rs.3 lakhs for 1 Adult & 1 Child i.e. complainant’s wife Nivedita Sharma and son Harshit Sharma. O.p. and the concerned agent / representative assured the complainant that “we are committed to providing you with world-class health insurance solutions, backed by the highest standards of service”.
Sometime in 1st week of January 2013, complainant’s wife Mrs. Nivedita Sharma felt some vision problem in her left eye and accordingly complainant accompanied by his wife have consulted with Dr. Nandini Ray on 16.1.13. After thorough check up, Dr. Nandini Ray advised some tests and cataract surgery of left eye.
As per advice of Dr. Nandini Ray, complainant decided to have cataract surgery of left eye of his wife at Woodlands Multispeciality Hospital Ltd. on 25.1.13 and accordingly complainant has applied for cashless facility for he said cataract surgery, to the o.p. against above health insurance policy through Woodlands Multispeciality Hospital Ltd., Kolkata but on 23.1.13 complainant was shocked and surprised when he came to know through a SMS sent by o.p. that they have denied cashless facility as applied for under their Ref. No.15701.
On 25.1.13 the hospital authorities also intimated the complainant about the denial of cashless Pre-Authorization Request by o.p. and handed over a copy of a Fax message / letter dt.23.1.13 received from o.p. denying the request of the complainant for cashless facility on the ground that “CASHLESS FACILITY CAN NOT BE PROCESSED AS PATIENT DISEASE / AILMENTS IS PRE-EXISTING. HENCE THIS CASHLESS REJECTED AS PER CLAUSE (4.A). KINDLY COLLECT AMOUNT FROM THE CUSTOMER”.
As per schedule on 25.1.13, complainant’s wife Mrs. Nivedita Sharma has been admitted in Woodlands Multispeciality Hospital Ltd. as IP/13/000740, for having cataract surgery of her left eye. Dr. Nandini Ray has conducted successful surgery of the complainant’s wife on 25.1.13 and discharged her on the very same day.
Complainant strongly objected the action of o.p. in respect of their denial of cashless facility illegally, vide his letter dt.25.1.13 (Registered on 28.1.13), on the grounds as stated therein and requested the o.p. to reimburse all the expenses incurred for the treatment of the complainant’s wife’s cataract surgery of left eye.
Despite receipt of the aforesaid letter of the complainant on 29.1.13 by o.p. they have failed and neglected the complainant’s request and willfully and with some malafide intention, avoided to reply the said letter.
Subsequently complainant submitted claim form duly filled, completed and signed along with all other relevant original documents for reimbursement of total medical expenses incurred of Rs.34,857.75, before the o.p. in person against proper receipt.
Complainant was once again shocked and surprised upon receipt of an e-mail dt.14.2.13 from o.p. in which complainant’s claim for Rs.34,857.75 was rejected by o.p. on the self same ground “Pre-existing disease” – as per documents received during cashless claim, patient is suffering from complains since 6 months which falls prior to policy inception so claims not payable as per exclusion no.4a (pre-existing disease) etc. Hence, the case was filed by the complainant with the prayers contained in the petition of complaint.
Decision with reasons:
Sole o.p. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Ld. lawyer of o.p. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.
We have gone through the pleadings of the parties, evidence and documents in particular. It is seen from the record that before issuance of insurance policy complainant was obliged to make full and frank discloser of his illness suffered by him in the proposal form. Complete discloser in proposal form enables o.p. to decide whether insurance policy should be issued to the complainant. It is pertinent to mention here that malafide intention did not disclose that his wife Mrs. Nivedita Sharma was suffering from cataract three months prior to inception of policy which is violation of clause 5 of the proposal form. It is further seen from the record that insurance policy would not have been issued to complainant if cataract suffered by his wife had been disclosed at the time of filling up the proposal form and since the crucial information was hidden from the o.p. the insurance policy was issued on the basis of proposal form filled in and signed by complainant. Therefore, we find no deficiency on the part of o.p. and complainant is not entitled to relief.
Hence, ordered,
That the case is dismissed on contest without cost against the o.p.
Supply certified copy of this order to the parties free of cost.
