Order NO.  16  dt.  28/03/2017

        The case of the complainant in brief is that the complainant applied for a medical insurance policy before o.p. and a policy was issued by o.p. being policy no.30146570201200. in terms of the policy it was provided a cashless hospitalization  and treatment policy and a full cover and or payment for all medical requirements including surgery and Diagnostic Procedure and other medical expenses. The policy was duly renewed from time to time on payment of due premium. When the policy was in force complainant was admitted in Belle Vue Clinic on 30.09.2013 and was discharged from the said hospital on 03.10.2013 The Belle Vue Clinic  for and on behalf of the complainant sent a cashless request to the o.p. via SMS being claim no.55754 and for  granting cashless of hospitalization as per terms and conditions of the insurance policy.Due to failure or refusal on the part of the o.p.  complainant had to pay Rs.69,224/- as medical expenses. For further treatment, the complainant was again admitted in Fortis Hospital, Anandpur on 03.10.2013 and the complainant was discharged from the said hospital on 13.10.2013. Again the said hospital sent a cashless request to o.p. via SMS being claim no.59949 But the cashless request was pending on the ground that the case needs to be scrutinized. Complainant was discharged form Fortis Hospital on payment of bills in cash amounting to Rs.2,98,172/-. O.p. in reply to the  above requests vide email dated 13.1.2013 informed the complainant that the claim was under verification and o.p. required 15 more days to confirm its decision. On 18.11.2013 complainant asked about the status of claims of the complainant. The o.p once again vide email dated 24.11.2013 informed the complaint that the amount of the said claim are generated under process. On 03.01.2014 o.p. informed that the claims of the complainant were disallowed on the ground that the complainant had a Hypertension since last 5 years. Upon receiving the said mail complainant immediately contacted with the Regional Manager of o.p. to furnish the document in support of their contention but the o.p. refused to do so. The o.p. asked for the hardcopy of the treating Doctor’s certificate stating that the complainant does not have any history of hypertension. In reply Complainant sent the Doctor’s certificate trough speed post on 20.01.2014. On 31.01.2014 o.p. sent an email informing the complainant that the claims of the complainant would be resolved within 8 days. Again complainant enquired about status of the claim vide email dated 15.02.2014. On 28.02.2014 o.p. declined reimbursement of the complainant’s claim on the purported ground of nondisclosure of alleged hypertension since last 5 years.  Hence the application praying for reimbursement of Rs.3,67,436/- along with compensation of Rs.2,00,000/- and litigation cost of Rs.10,000/-.

            O.p. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them inter alia stated that

            O.p. appeared before this Forum and filed their written version. In their w/v o.p. denied all material allegation inter alia stated that upon proper investigation of the documents furnished by inpatient department of Belle Vue Clinic o.p. observed that the complainant had past history of hypertension since last 5 years. As per discharge summary the patient was admitted for retrosternal chest paid and upper abdominal discomfort and had diagnosed as coronary artery disease with triple vessel Coronary Artery Disease.Then the complainant transferred to Fortis Hospital on 03.10.2013 with complaint of chest discomfort with sense unconscious with upper abdominal pain. Such affairs clearly suggest existence of hypertension in the past but complainant suppressed the fact  at the time of policy inception in November,2012. Since the patient had past history of hypertension since last 5 years, the claim of the complainant was disallowed by o.p. as per terms and conditions of the insurance policy. Doctor’s certificate was  furnished by complainant but that certificate must be sworn on evident before the Judicial Magistrate, First Class. Therefore the complaint petition is totally devoid of merits and is liable to be dismissed in limini with cost.

            Decision with reason

       We have gone through the pleadings of the parties and materials on record. It is admitted fact that the complainant was under medical insurance policy issued by o.p. The policy no. was 30146570201200. It is also admitted fact when the policy was in force the complainant was admitted in Belle Vue Clinic on 30.09.2013 and was discharged from the said hospital on 03.10.2013. The complainant was again admitted in Fortis Hospital, Anandpur on 03.10.2013 for further treatment and on 13.10.2013 complainant was discharged from Fortis Hospital, Anandpur. From both the hospitals the cashless request was sent to o.p. via SMS being claim nos.55754 and 59949. But the cashless request was pending when the complainant was discharged from said Belle Vue Clinic. The cashless request arising from claim no.59949 was also pending on the ground that the case needs to be scrutinized. At the time of discharge from both the hospital  & complainant had to pay the hospitalization bills. When the complainant was treated in the Belle Vue Clinic o.p. informed the complainant that the claim was pending  since the case needs to be studied. When the complainant was treated in Fortis Hospital, Anandpur, again cashless request was pending on the ground that the case needs to be scrutinized. On 13.11.2013 o.p. informed the complainant that the claim was under verification and they required 15 more days to confirm its decision. On 24.11.2013 o.p. again informed the complainant that the amount of the claims of the complainant are generated and under process. On 03.01.2014 the claims of the complainant was disallowed on the ground that the complainant had a hypertension since last 5 years.

                Thereafter   the complainant  immediately contacted with the Branch Manager of the o.p. and requested the o.p. to furnish the documents in support of their contention. O.p. did not provide any document to the complainant. Moreover they asked for hardcopy of the treating Doctor’s certificale from which it can be revealed that complainant does not   have any history of hypertension. Accordingly complainant sent the doctor’s certificate through Speed Post on 20.01.2014.Ccomplainant annexed the photocopy of the document with the complaint petition. The treating doctor clearly declared that the complainant never suffered from any hypertension. When the complainant supplied the same o.p. sent an email dated 31.01.2014 informing the complainant that his claim would be resolved  within 8 days. Thereafter on 15.02.2014 complainant enquired about the status of his claims and on 28.02.2014 o.p. declined the reimbursement on the ground of nondisclosure of hypertension since last 5 years.

                In the w/v o.p. argued that complainant did not furnish the doctor’s certificate by swearing on evident by treating doctor. But o.p. asked for the treating doctor’s certificate complainant sent the treating doctor’s certificate on 20.01.2014. Thereafter o.p. informed the complainant through email dated 31.01.2014 that the claims of the complainant  would be resolved within 8 days. But they did not inform anything  within 8 days. When the complainant enquired about the status of his  claim vide his email dated 15.02.2014 o.p. informed vide their email dated 28.02.2014 that the claims of the complainant was disallowed on the ground of  nondisclosure of hypertension since 5 years at the time of policy inception. The complainant was admitted in Belle Vue Clinic on 30.09.2013 and thereafter when the claim was sent  they informed the complainant that the claim was  pending and needs to be studied. Thereafter o.p. asked for treating doctor certificate. When the complainant sent the treating doctor certificate then o.p. took the plea that complainant had a preexisting disease i.e. hypertension. O.p. received the Belle Vue Clinic certificate much earlier and they would have rejected  the claim at the time of discharge from Belle Vue Clinbic but o.p. continuously informed the complainant  the claims were under process. After receiving the treating doctor certificate they took the plea of preexisting disease suffered by the complainant. O.p. never asked for the treating doctors’ certificate sworn on evident. If the o.p. asked the document sworn on evident complainant must have supplied the same. Therefore the plea taken by o.p.  In their w/v that the documents was not sworn on evident is not at all acceptable. In support of his argument, complainant filed the photocopies of both the treating doctors’ certificates i.e certificate dated 17.01.2014 issued by Dr Tapan Sarkar, Belle Vue Clinic and certificate dated 07.01.2014 issued by Dr K M Mandana of Fortis Hospital (Annjex F, running pages 23 & 24 with the complaint petition.

                We know that the cashless benefit given by the Insurance Company is not mandatory if scrutiny is needed.  In that case the cashless facility are denied with an advise for submitting claim form for reimbursement after discharge. Here in the instant case4 o.p. never denied the cashless claim and did not give any advise to submit the claim form for reimbursement after discharge from the hospitals. Rather, they informed the complainant that the claims were pending. After more than 4 months they repudiated the claim on the ground of nondisclosure of hypertension. O.p. received the treatment documents of the complainant much earlier and they repudiated the cflaim on 28.02.2014 on the basis of the Belle Vue Clinic documents. It is astonishing that in the month of January o.p. asked for treating doctor’s certificate. After receiving the treating doctors’ certificate which clearly stated that complainant never suffered from any hypertension, they repudiated the claim on the ground of preexisting disease which is not at all acceptable.

                 In view of the above we find deficiency in service and unfair trade practice on the part of the o.p. and as such the complainant is entitled to get relief .

                As a result complaint petition succeeds.

                Hence ordered

                That the case no.233/2014 is allowed on contest with cost.

                O.P. is directed to pay Rs.3,67,396/- towards hospital expenses  to the complainant. O.P is also directed to pay Rs.20,000/- to the complainant as compensation along with litigation  cost of Rs.5,000/- .

                OP is directed to pay the aforesaid amount  within 30 days from the date of communication of this order, i.d. an interest @ 10% 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.