For the complainant - Mr. Barun Prasad, Advocate
For the OP Nos. 1 & 2 - Ms. Ananya Chatterjee, Advocate
FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application u/s 12 of the C.P. Act, 1986. The brief facts of the case is that the complainant is a joint mediclaim policy holder with his wife Smt. Rina Bedi who obtained group health insurance policy from the OP No. 1 & 2 from their Kolkata office bearing Policy No. 1200020960 where the sum assured was Rs.10,00,000/- valid for the period from 25.08.2017 to 24.08.2018. The said policy was provided by the Bank of Baroda being the OP No. 3 to their customers. During the said policy period the complainant met with an accident following fall on ground while roaming in Iskon, Mayapur and due to such fall fracture shaft of right femur with implant in situ occurred for which the complainant immediately consulted local doctor and thereafter consulted Dr. Rajkumar Chhajer at Kothari Medical Centre on 27.03.2018. Thereafter the complainant was advised to get admission for treatment at Kothari Medical Centre. The complainant got admitted on 27.03.2018 at Kothari Medical Centre for the treatment of fracture shaft of right femur with implant in situ and necessary operation was done on 30.03.2018 and thereafter got discharged on 11.04.2018, The complainant asked for cashless benefit from the insurance company which was allowed initially to the tune of Rs.41,800/- subject to submission of final bill and discharge summary vide letter dated 29.03.2018. But subsequently, the approval was denied. The complainant thereafter submitted the final claim of Rs.2,86,991/- on 11.04.2018. The insurance company vide letter dated 05.04.2018 at the time of denial of cashless benefit intimated the complainant that “as the patient is a K/C/O Right Shaft of Femur Fracture and Platting done 2 years back and the present hospitalization is related to that does as per the details submitted along with the pre-authorization suggest that patient has adverse medical condition due to which it is not possible to ascertain the liability at this juncture due to patient having H/O of right femur fracture along shaft and has been hospitalized for fracture at same place. Hence, cashless cannot be extended to this case and needs further verification.” On getting such observation the complainant approached the concerned doctor who treated the complainant and the said treating doctor vide his certificate dated 06.04.2018 opine that “the patient had a right shaft femur (upper 1/3) fracture 2 years ago and now patient is having a periprothetic fracture of right shaft of femur, which is absolutely of a different anatomical position in comparison to last time. Hence, the present hospitalization is not related to the past hospitalization.”
The complainant submitted this certificate along with his final claim to the insurance company on 11.04.2018. The insurance company vide their letter dated 03.05.2018 repudiated the claim of the complainant with the following reasons “as per the discharge summary the patient is K/C/O right shaft of femur fracture and platting done 2 years back and the present hospitalization is related to that, treatment related to the complication of pre-existing condition hence claim stands denial as per policy T & C”. The complainant thereafter submitted further claim of Rs.28,638/- for post hospitalization expenses on 21.06.2018 which also was rejected by the insurance company on the ground that as the main claim is rejected no question of consideration of post hospitalization claim. Being aggrieved with the decision of the insurance company the complainant has come up before the Forum for getting justice.
The opposite party 1 & 2 have contested the case by filing written version contending inter-alia that the complaint petition is harassing, baseless, vague, frivolous and devoid any merit and ought to be dismissed on this ground. The OP No. 3 i.e. Bank of Baroda had approached the OP No. 1 & 2 for availing group insurance policy for his customers. The complainant after going through the policy terms and conditions enrolled for seeking insurance for himself and his wife under the group insurance policy No. 00215100201500 issued to the master policy holder Bank of Baroda being the OP No.3 for the period from 25.08.2017 to 26.08.2018. OP No. 1 & 2 received a pre-authorization request for cashless facility from the OP No. 4 on or about 03.04.2018 in the matter of treatment of fracture of neck of femur of the complainant. On the basis of available documents the OP No. 1 & 2 initially approved Rs.41,800/- and expressly stated that the final approval can only be given upon the discharge summary and final bill being presented to them. Thereafter, a detail investigation was carried out to check the genuineness of the pre-authorization request of the complainant. It was revealed in the investigation that the complainant had K/C/O right shaft femur fracture and platting done 2 years back and due to adverse medical condition the liability cannot be ascertained. Thus, the pre-authorization request was rejected vide their letter dated 05.04.2018. Thereafter, the complainant filed the final bill amounting to Rs.2,86,991/- for his treatment which was however rejected by the OP No. 1 & 2 vide their letter dated 03.05.2018 with the reason as “K/C/O right shaft of femur fracture and platting done 2 years back” and the present ailment is related to the past hospitalization. It is important to note that the treatment for which the complainant had submitted claim reimbursement – was a pre-existing condition. It is not out of place to mention that the any pre-existing disease is covered after 24 months of the continuous coverage for the insured person with OP No. 1 & 2 in accordance to the clause titled waiting period in the policy terms and conditions. The claim was rightly rejected as the complainant at the time of taking policy failed to disclose his past medical history and this present ailment is related to the past surgery. Therefore, there has been no deficiency in service or unfair trade practice on the part of OP No. 1&2. It is further stated that the claim for reimbursement was rejected in accordance with the terms & conditions of the policy. It is stated that the complainant had a fracture shaft of the right femur 2 years prior to the present ailment and the benefits for any pre-existing medical condition is accepted only after 24 months of the policy. Ld. Advocate of the OP No. 1 & 2 has cited one case law in (2009) 4MLJ811 (SC)- Vikram Greentech (I) Ltd. vs. New India Assurance Co.Ltd. In the said judgement it has been mentioned that since upon issuance of insurance policy the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the insurance policy, its terms have to be strictly construed to determine the extent of liability of the insurer. The endeavor of the Court must always be to interpret the words in which the contract is expressed by the parties. The Court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties. The insured cannot claim anything more than what is covered by the insurance policy. Therefore, OP No. 1 & 2 have not committed any deficiency of service nor they have committed any act which can be termed as unfair trade practice.
On pleading of the parties the following necessary points have come up for determination:-
- Whether the OP No. 1 & 2 have any deficiency in service.
- Whether the OP No. 1 & 2 have adopted any unfair trade practice.
- Whether the complainant is entitled for any relief as prayed for in the complaint petition.
Decision with Reasons
Point No. 1 to 3:-
All the points are taken up together for the sake of convenience and brevity in discussion.
Both parties have tendered their evidence on affidavit. They have filed replies to the questionnaire set forth by their adversaries. They have also filed their respective BNAs.
We have travelled over all the documents placed on record.
Facts remain the complainant took admission at Kothari Medical Centre on 27.03.2018 for the treatment of Fracture Shaft of Right Femur with implant in Situ and operation was done on 30.03.2018 within the valid insurance coverage period effective from 25.08.2017 to 24.08.2018. The complainant got discharged on 11.04.2018 and filed his claim of Rs.2,86,991/- on 11.04.2018 to the OP No. 1 & 2 whichgot rejected by the insurance company vide their letter dated 03.05.2018. It is also worthy to mention that the cashless benefit of Rs.41,800/- though initially approved by the OP No. 1 & 2 was also denied vide letter dated 05.04.2018. In the final repudiation letter dated 03.05.2018 the claim was denied for the reason “as per the discharge summary the patient is K/C/O right shaft of femur fracture and platting done 2 years back and the present hospitalization is related to that, treatment related to the complication of pre-existing condition hence claims stands denial as per policy T & C.”
Now, on going through the discharge summary, it is observed that the final diagnosis was FRACTURE SHAFT OF RIGHT FEMUR WITH IMPLANT IN SITU. In the said discharge summary there was a mention of history of past illness. In the said details it is mentioned that SURGICAL HISTORY OF FRACTURE SHAFT OF RIGHT FEMUR – 2 YEARS AGO, TREATED WITH PLATTING (DOCUMENTS NOT AVAILABLE). From the said discharge summary and reply of the complainant against the questionnaire of the OP No. 1 & 2, under question no.6 it is established that the complainant was hospitalized and underwent surgery due to fracture of shaft of right femur 2 years ago. On this aspect the complainantfurnished a certificate dated 06.4.2018 from the treating Doctor of Kothari Medical Centre concluding that the present hospitalization is not related to the past hospitalization .There from also it is proved that the complainant was hospitalized for treatment of Femur Fracture two years ago confirming the existence of pre existing disease. The plea taken by the OPNos.1 & 2 that the complainant has concealed the said material fact of existence of pre existing disease is not supported by any relevant document. As such putting blame on the complainant on this issue is very much unjustified. They did not find any scope to inform the same anywhere before.
Now, let us discuss the terms and condition of the Group Health Insurance Policy where the master policy holder is Bank of Baroda and primary insured /Beneficiary is Mr. Vivekanda Bedi. The terms and condition of the said policy is general and binding upon on both the insurer and the insured including the beneficiaries. In case of pre-existing diseases there is a waiting period. Under Clause A of the said waiting period the specific wordings are “BENEFITS WILL NOT BE AVAILABLE FOR PRE-EXISTING DISEASES UNTILL 24 MONTHS OF CONTINUOUS COVERAGE HAVE ELAPSED (48 MONTHS FOR GROUP CRITICAL ILLNESS COVER) FROM THE DATE OF COMMENCEMENT OF COVERAGE FOR THE INSURED PERSONS.”
Now let us examine the policy period and the date of hospitalization of the complainant in the said hospital. The policy was taken on 25.08.2017 and the date of hospitalization was 27.03.2018. As such, the complainant was hospitalized when the age of the policy was only 7 months 2 days. As such the waiting period clause is very much applicable in the subject case and accordingly the complainant is not entitled to the Insurance Benefit for the said treatment as per the terms and conditions of the policy. The Ld. Advocate for the OP Nos. 1 & 2 however has cited so many case laws in support of their contention.
Under the above circumstances, we are of the considered view that the complainant has failed to establish his case in the given situation.
In the result the complaint fails.
Ordered
That the complaint case be and the same is dismissed on contest against the OP Nos. 1 & 2 and ex parte against OP Nos. 3 & 4 without any costs.
