DIST. CONSUMER DISPUTES REDRESSAL FORUM
NORTH 24 Pgs., BARASAT.
C. C. CASE NO. 270/2016
Date of Filing Date of Admission Date of Disposal
03.05.2016 11.05.2016 05.06.2018
Complainant:- 1. Sri Gomatham Raghavan Vijay Kumar,
S/o Sri G.R. Raghavan,
Aged about 51 years,
By faith Hindu,
By occupation Medical Practitioner,
Residing at F- 2,
Dwarika Complex, 20 Currie Road,
Dist- Howrah, 711104,
Presently residing at
1702, Tritiya, Upohar Luxary Complex,
2052 Chakgaria, Kolkata- 700094
=Vs.=
O.P/s:- 1. The Manager,
Max Bupa Health Insurance
Company Ltd.
Having its Corporate Office at
B- 1/ I- 2, Mohan Cooperative
Industrial Estate, Mathura Road,
New Delhi- 1100044
2. The General Manager,
Max Bupa Health Insurance Company Ltd.
Having its Registered Office at
Max House, 1, Dr. Jha Marg, Okhla,
New Delhi- 110020
3. The Manager,
Columbia Asia Hospital,
Salt Lake City, Kolkata,
(A Unit of Navketan Home Pvt. Ltd.)
Having its Hospital and Registered Office at
IB- 193, Sector- III, Salt Lake City,
Kolkata- 700091
P R E S E N T :- Sri Siddhartha Ganguli …………………….Member.
:- Smt. Silpi Majumder………………………….Member.
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Final Order & Judgment
An Application has been filed by the complainants U/S 12 of the Consumer Protection Act, 1986 alleging deficiency in service for non-payment of medical expenses in respect of a Mediclaim Insurance Policy of the complainant being Max Bupa Helth Insurance Policy No- 30297435201602 and prays for payment of 93,693/- to the complainant towards the medical expenses in respect of Operation, Medicines as well other consequential expenses, which the complainant has borne from his pocket for the treatment of his wife and further prays for compensation amounting to Rs. 3,00,000/- towards mental pain, agony, harassment etc and for costs which has been prayed as per the prayer of the complaint petition.
The fact of the case of the complainant is that the complainant purchased one medical insurance policy being Policy No- 30297435201602 under the Max Bupa Helth Insurance standing in the name of the complainant along with his wife namely Kakoli Vijay Kumar & Son namely Sagar Vijoy Kumar and one daughter namely Nikhita Vijay Kumar. It is stated by the complainant that the complainant initially had purchased one Insurance Policy from New India Assurance Company Ltd. in the year of 2004 and from time to time he renewed the said insurance policy till 01.03.2014 but subsequently the said policy was ported to the present OPs with the assurance that all the benefits from previous policy no claims would be honored and the same was continued uninterruptedly till the date of filing and the sum assured of the said policy is 35,50,000/- in which the individuals sum insured to the tune of Rs. 5,00,000/- only and floater sum insured is to the tune of Rs. 15,00,000/- only in case of family first with a loyalty benefit which is the subject to increase in sum assured against the yearly premium of Rs. 53,296/- including all charges. It is stated by the complainant that since initiation of the said policy no occasion had come to make any claim.
The said policy was renewed by the complainant on 01.03.2016 through an authorized agent of the Ops namely Secure Now Insurance Broker Private Ltd.- TPD, being agent code no.- BR01340003 for the period from 01.03.2016 to the mid night of 28.02.2017 against of which the OPs have duly issued the insurance certificate in favour of the complainant and deliver the same to the complainant.
It is stated by the complainant that the wife of the complainant felt an acute pain in the end of June 2014 as such the complainant and his wife both being the doctors initially treated the same with medicine but when the pain persists the complainant consulted with a surgeon colleague and was advised for USG report of the whole abdomen which revealed the presence of gall stone which was very much necessary to be take out by an operation.
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It is also stated due to some other reasons the wife of the complainant had under gone a USG in the year of 2013 which reported normal study.
It is further stated that on 30.07.2014 the complainant applied for cashless facilities to the OPs as per the quotation of the concerned doctor as well as the pro-forma Op 3, but without any rhyme and reason or asking any clarification from the complainant or from the OP 3 or from concerned doctors the OPs by its letter dt. 30.07.2014 addressed to the OP 3 denied to clear the claim of the complainant based on two allegations which are enumerated below.
- USG report showing 1cm. calculus and possibility of pre-existing conditions can be ruled out.
- Non-disclosure of severe menorrhagia at the time of the inception of the policy.
It is stated by the complainant that the OPs admitted that they were not sure about the pre-existing of the gall stone as because they disclose the facts that there were possibilities of same but they also intentionally neglected and felt to be sure about the pre-existing condition of the gall stone of the wife of the complainant by seeking clarification from either the complainant or his wife or from the concerned doctors or from the pro-forma OP 3. Further they also intentionally and willfully with a malafide intension neglected and failed to check up the health of the insured person at the time of inception of the said policy whereas it was their solemn duty to check the health of the persons who applied to be insured under them as such the allegation of non-disclosure also could not stand against the complainant or his family members.
It is further stated by the complainant that the pain of the wife of the complainant was so severe and acute that the complainant had no option but to spent a lot of money for the operation to the tune of Rs. 59,821/- as well as for the medicine to the tune of Rs. 5,767/- and other consequential expenses to the tune of Rs. 29,369/- totaling Rs. 93,693/- which the complainant agreed to do and accordingly the wife of the complainant got admitted at the hospital of the OP 3 on 04.08.2014 under general surgeon Dr. Aniruddha Dasgupta and after operation of the gall stone she was discharged on 06.08.2014 and the hospital authority provided a bill of Rs. 93,693/- in total. The complainant had to pay the said amount from his own pocket while he and all his family members were under cover of insurance of the OPs with an individual sum assured of Rs. 5,00,000/- and floater sum insured of Rs. 15 lakhs in case of family first along with loyalty benefit which is the subject to increase the sum assured. The complainant has lodged the written complaint on 17.08.2014 before the OPs through email and disclosed the fact that the USG report of the whole abdomen of the wife of the complainant which was done in the month of
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June of 2013 for some other purpose showed normal and the further USG report done in the month of July 2014 showed that there was a gall stone which clearly proves that the said gall stone of the wife of the complainant was not a pre-existing one but the OPs never turned up or no reply was given by the Ops till the date of filing of the case.
The complainant finding no other alternative approached in the month of October and November 2014 tried to contact with the Ops over phone but in vain. The complainant in the month of January 2015 lodged a complaint at local police station of Salt lake against the OPs but the police personnel disclosed their inability to take any action in that regard unless there was an order from the Forum and therefore the complainant filed this case against the OPs alleging deficiency in service as well as gross negligence and unfair trade practice on the part of the OPs and filed this case for the reliefs as prayed hereunder.
Relief sought for:-
- An order directing the OP 1 and 2 immediately to pay the sum of Rs. 93,693/- only to the complainant, towards the total expense of operation, medicines as well as the other consequential expenses, which the complainant has borne from his pocket for the treatment of his wife and which is well within the jurisdiction of this legal claim as per the Suit Policy, with interest, without any further delay.
- An order for compensation amounting to Rs. 3,00,000/- towards mental pain and agony for harassment upon the complainant as well as his family members.
- For costs.
- For any other relief/ reliefs to which the complainant is entitled to in law and equity.
The complainant along with his complaint petition filed some documents which are as follows:-
- Denial of authorization from Max Bupa Health Insurance Company Ltd. dt. 30.07.2014
- Endorsement related to policy no- 30297435201400 dt. 12.11.2014
- Mediclaim policy card of the complainant and his family issued by New India Assurance Company Ltd. (8 numbers)
- Copy of reminder of renewal request from New India Assurance
Company Ltd., January 2006. - Documents relating to continuation of insurance policy.
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6. Relating to good health insurance policy issued by New India Assurance Company Ltd. (7 pages)
7. Insurance card of the complainant and his family members issued by OPs.
8. Insurance certificate being policy no- 30297435201400 for the period 01.03.2014 to 28.02.2015
9.Copy of premium receipt dt. 01.03.2015 of Rs. 49,409/-
10.Copy of insurance certificate being policy no- 30297435201602 for the period 01.03.2016 to 28.02.2017
11.Copy of prescription of Dr. Aniruddha Dasgupta, dt. 04.07.2014, 18.07.2014
12.Copy of prescription of Sudeshna Mukherjee dt. 18.07.2014
13.Copy of report of USG dt. 10.06.2013
14.Copy of report of USG dt. 01.07.2014
15.Copy of report of USG dt. 01.07.2014
16.Copy of discharge summery
17. Copy of letter regarding denial of claim.
18.Copy of bill amounting to Rs. 93,693/-
19.Payment receipts.
20.Letter by the complainant.
The OPs appeared before this Forum and contested the case by filing W/V separately.
The OP 1 & 2 denied all the averments made in the complaint petition and further stated in their W/V inter alia that the complaint is not maintainable in its present form or at all and it has been filed with oblique motive in order to extract money from the Opposite Party without any legitimate basis thereof and the reliefs as claimed in the said complaint are misconceived and ought not to be granted by this Learned Commission and the complaint is harassive, baseless, vague, frivolous and devoid of any merit and ought to be dismissed on such grounds.
It is further stated by the OP 1 & 2 that sometime in the year 2014, the complainant approached Max Bupa Health Insurance Company for a Medical Insurance Policy. He informed that he has a medical insurance policy with New India Assurance Company Limited which he wanted to port to Max Bupa Health
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Insurance Company. After much deliberation, the complainant was issued the Family First Gold 5 lacs+ 15 lacs Policy bearing no.- 30297435201400 as per his requirement. The total sum insured at the inception of the policy was Rs. 35,00,000/-. The policy was renewed for a period of one year from 1st March, 2015 to 29th February, 2016 and again from 1st March, 2016 to 28th February, 2017. The total sum insured was increased to Rs. 35,50,000/- at the time of renewal of the policy in the year 2016.
A pre-authorized request was received by Max Bupa Health from the complainant on 30th July, 2014 for the treatment of the complainant’s wife for Gall Stones. From the documents submitted by the complainant and on investigation, it was noted that there were possibility of pre-existing conditions of the disease since the USG report of the complainant of July, 2014 showed 1cm calculus and the complainant had also undergone a USG in June, 2013. Therefore the logical conclusion was that the possibility of pre-existing conditions could not be ruled out at the time. Over and above that the complainant had also suffered from severe menorrhagia, which the complainant had failed to disclose at the time of taking the policy. All such facts have been admitted by the complainant had failed to disclose at the time of taking the policy. All such facts have been admitted by the complainant in his compliant and are not matters of dispute. Pre-authorized request is granted only in circumstances when the insurance company is satisfied of the genuineness of the claim of the complainant and all documents and/or details required for authorization of the same are made available to the insurance company. In absence of the same, the insurance company in entitled to ask for further information or documents and is also entitled to reject the request for cashless benefit and request the complainant to file a claim for reimbursement.
In view of the above possibility of pre-existence of the complainant-s disease and non-disclosure of facts, the pre-authorization request was denied vide a letter dated 30hth July, 2014.
The reasons mentioned in the denial of authorization letter re reproduced below for reference
1. Cashless cannot be provided due to information about the
chronicity of the illness in view of USG report showing 1cm
calculus and possibility of pre-existing conditions can be ruled
out, hence liability cannot be establish at this juncture in view of
the received document and need further verification, hence
cashless is denied.
2. Non disclosure of severe monorrhagia at time of policy
inception.
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The relevant clauses of the terms and conditions of the policy which outline the claim procedure in case pre-authorization request has not been obtained or approved, are reproduced below for reference
Clause 5(m)(a)(iv)
If pre-authorization is not obtained then the Cashless Facility will not be available and the claims procedure shall be as per (b) (ii) below
Clause 5(m)(b)(i)
In all Hospitalizations which have not been pre-authorized. We must be notified in writing within 48 hours of admission to the Hospital or before discharge from the Hospital, whichever is earlier. The notification of claim should be ideally provided by the policyholder/insured person. In the event policyholder and insured person is unwell, then the notification of claim should be provided by any immediate adult member of the family.
The following information is mandated in the notification
1. Policy number.
2. Name of Policyholder
3. Name of Insured person in respect of whom the claim has
been notified.
4. Name of Hospital with address and contact number.
5. Diagnosis
6. Treatment undergone(medical/Surgical management with
name of Surgical Procedure undergone, if applicable) and
approximate amount being claimed for.
Clause 5 (m) (b) (ii)
For any illness or accident or medical condition that requires
Hospitalization the Insured Person shall deliver to Us the necessary documents listed below, at his own expense within 30 days of the Insured Person-s discharge from Hospital(when the claim is only in respect of post-hospitalization, within 30 days of the completion of the post-hospitalization).
1. Claim from duly completed and signed by the claimant.
2. Cancelled Cheque
3. Self attested copy of valid age proof (Passport/Driving License/PAN Card/Class X certificate/ Birth Certificate)
4. Self attested copy of identity proof (Passport/Driving License/PAN Card/Voters identity card)
5. Original Discharge summary
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6. Original final bill from hospital with detailed break-up and paid receipt.
7. Original bills of medicines purchased, or of any other investigation done at an outside hospital with reports and requisite prescriptions.
8. Invoice of major accessories in case billed and utilized during treatment (if not included in the final hospital bill)
9. for medicolegal cases (MLC/FIR copy attested by the concerned hospital/police station (if applicable)
10. Original self-narration of incident in absence of MLC/FIR
11. Original first consultation paper (in case disease is first time
diagnosed)
12. Original Laboratory Investigation reports.
13. Original X-Ray/MRI/Ultrasound films and other Radiological investigations
14. Indoor case paper/OT notes (if required)
It is submitted that till date the Complainant has not submitted any claim form for reimbursement of medical expenses, to Opposite Party, as mandated by the abovementioned terms and conditions of the health insurance policy. It is further submitted that if the complainant would have filed claim for reimbursement of the medical expenses then Opposite Party would have processed the claim and would have taken appropriate decision regarding the same as per the terms and conditions of the health insurance policy. It is stated that the complainant has renewed the policy twice since 2014 and the same is still subsisting. It is also pertinent to mention that for a separate claim, pre-authorization Request (Pre Auth ID- 104952) of the complainant has been allowed vide the Max Bupa-s Letter of Authorization dated 2nd June, 2016, a copy whereof is annexed with the W/V.
It is further submitted that the IRDA (Health Insurance) Regulations, 2013 have established the regulatory framework for the Health insurance. It is pertinent to mention that the Regulation 9 (a) of the IRDA (Health Insurance) Regulations, 2013 deals with cashless facility and the same is reproduced as follows:
Subject to the terms of a policy, insurers shall extend to all policy holders a cashless facility for treatment at specified establishments or the reimbursement of the costs of medical and health treatments or services availed at any medical establishment.
It is clear from the above mentioned regulation that cashless facility in a health insurance policy is subject to the terms and conditions of the policy.
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It is submitted that there is no specific provision in the IRDA Regulations which makes it mandatory for insurers to give authorization for cashless facility in all cases. This observation has also been made by IRDA in its order 23.02.2015 in the Complaint no- 01-15-005920 (Shri Manu Sharma Vs Max Bupa Health Insurance Co. Ltd.)
OP No 3 appeared in the case and filed W/V separately.
As regards the statements made in paragraph nos. 1 to 13 (1)(2)(3) of the complaint petition, it is submitted by the pro-forma OP No- 3 that this OP is not in any way connected with the alleged matter and the same is totally by and between the complainant and the OP No- 1 and 2 and this OP submits that as the complainant has no allegation in respect of the treatment rendered by this OP, the complainant has no case at all as against this OP and so this OP is not in a position either to deny or to admit the statements made in the petition of compliant under reply and this OP further submits that considering the facts and circumstances as stated in the petition of complaint, this OP was/is neither negligent nor deficient in rendering service towards the complainant and very rightly no relief has been prayed by the complainant against this OP and so this OP has nothing to pray before the Ld. Forum but to pray for dismissal of the case as against this OP with cost and as this OP is simply unnecessarily party to the proceeding and/or as this OP has been impleaded as party to this proceeding without any cogent and convincing ground and this OP is entitled to get cost as per provisions as laid down in the Consumer Protection Act and this OP deserves to get the same.
Complainant adduced evidence by way of filing written examination in chief. O.P No: 1 & 2 also filed evidence by way of filing written affidavit in chief and also filed some Xerox documents as above.
The O.P No: 3 also adduced evidence by way of filing written affidavit in chief.
Complainant filed B.N.A
From the complaint petition, W/V of the O.Ps, evidence adduced by the Parties and other materials on record the following points have been framed-
- Is the complainant a consumer of the O.Ps?
- Are the O.Ps deficient in providing service to the complainant?
- Is the complainant entitled to get any relief as prayed for?
Decision with Reasons
All the points have been taken together for the sake of brevity and for avoidance of repetition of facts.
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From the evidence of the complainant it is evident that the complainant purchased one medical insurance policy being Policy No- 30297435201602 under the Max Bupa Helth Insurance standing in the name of the complainant along with his wife namely Kakoli Vijay Kumar & Son namely Sagar Vijoy Kumar and one daughter namely Nikhita Vijay Kumar. It is stated by the complainant in his evidence that the complainant initially had purchased one Insurance Policy from New India Assurance Company Ltd. in the year of 2004 and from time to time he renewed the said insurance policy till 01.03.2014 but subsequently the said policy was ported to the present OPs with the assurance that all the benefits from previous policy no claims would be honored and the same was continued uninterruptedly till the date of filing and the sum assured of the said policy is 35,50,000/- in which the individuals sum insured to the tune of Rs. 5,00,000/- only and floater sum insured is to the tune of Rs. 15,00,000/- only in case of family first with a loyalty benefit which is the subject to increase in sum assured against the yearly premium of Rs. 53,296/- including all charges. The said policy was renewed by the complainant on 01.03.2016 through an authorized agent of the Ops namely Secure Now Insurance Broker Private Ltd.- TPD, being agent code no.- BR01340003 for the period from 01.03.2016 to the mid night of 28.02.2017 against of which the OPs have duly issued the insurance certificate in favour of the complainant and deliver the same to the complainant.
Therefore the complainant is a consumer of the O.Ps as per the definition given U/S 2(1)(d) of the C.P.Act,1986.
Now in order to ascertain whether the O.Ps were deficient or not we have to look into the evidence and other materials on record.
It is further evident from the evidence of the complainant that the wife of the complainant felt an acute pain in the end of June 2014 as such the complainant and his wife both being the doctors initially treated the same with medicine but when the pain persists the complainant consulted with a surgeon colleague and was advised for USG report of the whole abdomen which revealed the presence of gall stone which was very much necessary to be take out by an operation.
It is also found from the evidence that due to some other reasons the wife of the complainant had undergone a USG in the year of 2013 which reported normal study.
It is also found from the evidence that on 30.07.2014 the complainant applied for cashless facilities to the OPs as per the quotation of the concerned doctor as well as the pro-forma Op 3, but they denied to clear the claim of the complainant based on two allegations:-1) USG report showing 1cm. calculus and possibility of pre-existing conditions and 2) Non-disclosure of severe menorrhagia at the time of the inception of the policy.
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Further it is stated by the complainant that the O.Ps failed to check up the health of the insured person at the time of inception of the said policy whereas it was their solemn duty to check the health of the persons who applied to be insured under them and as such the allegation of non-disclosure also could not stand against the complainant or his family members.
It is further seen from the evidence of the complainant that the pain of the wife of the complainant was so severe and acute that the complainant had no option but to spent a lot of money for the operation to the tune of Rs. 59,821/- as well as for the medicine to the tune of Rs. 5,767/- and other consequential expenses to the tune of Rs. 29,369/- totaling Rs. 93,693/- which the complainant agreed to do and accordingly the wife of the complainant got admitted at the hospital of the OP 3 on 04.08.2014 under general surgeon Dr. Aniruddha Dasgupta and after operation of the gall stone she was discharged on 06.08.2014 and the hospital authority provided a bill of Rs. 93,693/- in total. The complainant had to pay the said amount from his own pocket while he and all his family members were under cover of insurance of the O.Ps. The complainant has lodged the written complaint on 17.08.2014 before the OPs through email and disclosed the fact that the USG report of the whole abdomen of the wife of the complainant which was done in the month of June of 2013 for some other purpose showed normal and the further USG report done in the month of July 2014 showed that there was a gall stone which clearly proves that the said gall stone of the wife of the complainant was not a pre-existing one but the OPs never turned up or no reply was given by the Ops till the date of filing of the case.
It is seen from the documents submitted by the parties that the wife of the complainant got admitted in hospital of O.P No 3 on 04.08.2014 for such operation and she was released on 06.08.2014. Further it is seen from the insurance certificate issued by the O.Ps that insurance policy was in force at the time of operation.
It is further seen from the medical prescription of Sr. Aniruddha Dasgupta dated 04.07.2014 that he wrote in his prescription C/O Upper abdominal pain 2 weeks ago improved with medication- Calculus cholecystitis. It is seen from the USG report of the wife of the complainant, namely Dr. Kakoli Kumar done on 10.06.2013 that the Gall Bladder was studied normal. It is written in the said report that Gall Bladder- It is normally distended. There is no intraluminal calculus or mass lesion. Gall bladder wall thickness is normal. No pericholecystic fluid collection seen. Impresion- Normal study.
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Further it is seen from the USG report of the wife of the complainant, namely Dr. Kakoli Kumar, done on 01.07.2014 that Gall Bladder- It is normally distended. Calculii are present in the lumen, measuring upto 1 cm. Gall Bladder wall thickness is normal. No pericholecystic fluid collection seen. Impression- Gall Stones.
From both the reports of the USG and the prescription of the treating doctor it is clear to us that the patient namely Kakoli Kumar had no Gall Stone at the time of taking policy and the Gall stone was not pre-existing.
Further it is seen from the medical prescription of Dr. Sudeshna Mukherjee, dated 18.07.2014 that the patient Dr. Kakoli V Kumar had Severe Menorrhagia- short cycles x 6 months.
From the USG report of the patient Dr. Kakoli Kumar dated 01.07.2014 it is seen that the Uterus- Measures- 6.6x6.1 cm. It is retroverted with normal size and position. The posterior myometrium is heterogenous. A 2.3 x 1.3 cm posterior intramural fibroid is present. The endometrial thickness is 9 mm. The uterine cavity is empty. The cervix is normal. Impression Posterior intramural fibroid.
From the dictionary meaning of Menorrhagia it is found that it is a menstrual period with excessively heavy flow and falls under the larger category of abnormal uterine bleeding (AUB)- Excessive uterine bleeding occurring at the expected intervals of the menstrual periods. The bleeding from the uterus starts on schedule but is heavier than usual and may last longer than usual. It may be a sign of an underlying disorder, such as hormone imbalance, endometriosis, uterine fibroids or rarely cancer of the uterus. It may cause significant anemia.
It is further seen from the medical prescription of Dr. Sudeshna Mukherjee dated 18.07.2014 that the patient namely Dr. Kakoli V Kumar had been suffering from Menorrhagia since last 6 months.
It is admitted position that the complainant had a medical insurance policy with New India Assurance Company Ltd which was ported to Family First Gold 5 lacs Plus 15 Lacs policy of Max Bupa Health Insurance Co. Ltd. And a separate proposal form has been filled up by the complainant.
It is settled principle of law that Insurance Company cannot avoid consequences of insurance contract by simply showing inaccuracy or falsity of the statement made by a policy holder. Burden is cast on the insurer to show that statement on a fact had been suppressed which was material for the policy holder to disclose.
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It is further to be proved by the Insurer that statement was fraudulently made by the policy holder with the knowledge of falsity of that statement or that the suppression was of material fact which had not been disclosed. Unless insurance company is able to show that insurance claim falls within some exclusion or exception provided in terms and conditions, insurance company cannot evade its liability under insurance claim.
Further it is seen from the evidence of both sides that the policy in question is a ported one and it has been uninterruptedly continued since inception. Therefore non disclosure of severe menorrhagia of the wife of the complainant, which she was suffering since last 6 months from the date of the prescription i.e 18.07.2014, does not arise at all as the policy in question is a continuing policy or ported one.
The gall stone of the wife of the complainant was also not pre-existing as reflected from the above USG reports.
Further, Section 45 of the Insurance Act, 1938 provides that Policy not to be called in question on ground of mis-statement after two years- No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was in accurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose.
Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.
Again from the policy documents filed by the O.Ps we find that there is a clause- 5 under the head standard terms and conditions and under that clause there is a sub-clause-g, namely portability Benefit and it is stated in 5(g) i.(i) that If the proposed insured person was insured continuously and without a break under another Indian retail health insurance policy with any other Indian General
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Insurance Company or stand alone Health Insurance Company it is understood and agreed that
- If you wish to exercise the Portability benefit, we should have received Your application and the completed Portability Form with complete documentation at least 45 days before the expiry of Your present period of insurance,
- This benefit is available only at the time of renewal of the existing health insurance policy.
- Portability benefit is available only up to the existing cover. If the proposed sum insured is higher than the sum insured under the expiring policy, waiting periods would be applied on the amount of proposed increase in sum insured only in accordance with the existing guidelines of the Insurance Regularity and Development Authority.
- Waiting period credits would be extended to Pre-existing diseases and time bound exclusions/waiting periods in accordance with the existing guidelines of the Insurance Regulatory and Development Authority.
- The portability Benefit shall be applied by us within 15 days of receiving Your Completed application and Portability Form subject to the following-
- You shall give us all additional documentation and/or information we request
- You pay us the applicable premium in full:
- We may subject to our medical underwriting, restrict the terms upon which we may offer cover, the decision as to which shall be in our sole and absolute discretion:
- There is no obligation on us to insure all insured persons or to insure all insured persons on the proposed terms, even if you have given us all documentation:
- We have received necessary details of medical history and claim history from the previous insurance company for the insured person’s previous health insurance policy through the IRDA’s web portal.
- No additional loading or charges shall be applied by us exclusively for porting the policy.
The O.Ps did not raise or make any dispute regarding portability of the policy or any condition of that but raised only two disputes which according to us are not valid grounds.
But the O.Ps raised one point that the complainant has not make any claim petition as per proper format after denial of cash less facility and if the complainant would have filed the claim before the O.Ps they could consider the same and further stated that the instant case is premature one.
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Considering evidences of the parties and having gone through the materials on record we are of the considered view that the instant case is a pre-mature one and the complainant had to file the claim petition before the O.Ps prior to filing of the case and if the O.Ps denied to settle the claim or repudiated the claim of the complainant then the complainant may file a case against the O.Ps before the appropriate Forum of Law having proper Jurisdiction both pecuniary and territorial. The case is not maintainable at this stage being prematured.
Hence
It is ordered that the Consumer Complaint being No: C.C- 270 of 2016 is dismissed on contest.
Let free copies be given to the parties concerned as per the provisions of the C.P.R, 2005.
Member Member
Typed and Corrected by me.
Member
