Order-15.
Date-12/09/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainants’ case in short is that OP is an insurance company and is involved in rendering Private health Care. Complainants obtained a health insurance policy being Policy No.30185082201300 from OP before taking the insurance policy the complainants underwent medical tests and reports were also submitted along with dully filled in application form provided by the agent of the OP in February 14, 2013. The sum assured was Rs.2 lakhs and the period of the policy was for one year from the date of issuance of the insurance certificate. During the coverage period complainant no.2 in the month of January, 2014 was suffering from diminishing eye vision in her left eye. Subsequently, the complainant no.2 went to BBI foundation, Kolkata on January 24, 2014 for medical consultancy. She was advised a surgery. Complainant no.2 subsequently, was admitted in the said hospital and surgery procedure was also conducted by the doctors of the said hospital on 10-02-2014 and as per suggestion of the doctors of the said hospital the complainant no.2 was kept under observation till February 11, 2014 and subsequently, she was discharged. The complainant no.2, thereafter, approached the OP for medical reimbursement but the OP refused to settle the claim of the complainants. The OP also asked the complainants to provide the past medical history of her diminution in vision in her left eye. Complainants were at a distressed situation because of the unusual delay on the part of the OP to settle their claim. The OPs have allegedly deficiency and negligence as well as unfair trade practice against the OPs. The complainant has prayed for a direction upon the OPs to pay the entire amount of claim along with other reliefs in terms of prayers in the petition of complaint.
OP has contested the case in filing written version contending, inter alia, that the case is not maintainable either in fact or in law. It is stated that the complainants have filed the case with ill motive in order to extract money from the OP without any legitimate basis. It is stated that there has been no deficiency in service or indulgence into unfair trade practice by the OPs which can entail any relief as claimed in the petition of complaint. It is stated that the complainants had availed a health insurance policy from Max Bupa Health Insurance Ltd. under the policy named “Heartbeat Silver 02 lacs 2 Adults” for a span of one year from 22-02-2013 to 21-02-2014 and thereafter, it was lapsed on 21-02-2014 due to non-renewal of policy from the end of the insured. It is stated that the complainants agreed acknowledge and accepted the terms and condition which were provided in the said policy. On 2nd February, 2014 the complainants received a claim from the complainants for reimbursement of Rs.26,065/- on account of diagnosis of Neuclear Sclerosis and Posterior Subcapsular Cataract in the left eye and the operative procedure is Phacoemulsification of complainant no.2. The OP asked the complainants to submit certain documents vide letter dated 13-01-2016 but the complainants failed to furnish the necessary documents in spite of several reminders to the complainant. OP, therefore, had no option but to close for reimbursement on account of non-submission of mandatory documents by the complainants. It is also alleged that the complainant no.2 was suffering from hypertension which was not disclosed initially. It is also stated that complainant no.2 underwent operation for cataract and there was no urgency of operation. The surgery is suggested only after a few years of constant diminishing of vision. It is denied that complainants provided all the medical details correctly while taking the said policy. It is alleged that complainant suppressed the fact that she was suffering from hypertension and this amounts to non-disclosure of past medical history. It is also stated that the complainant no.2 was suffering from diminishing eye sight from sometime even after issuing the said policy and still the same at the time of taking the policy. It is stated that the allegations of the complainants are false, fake, frivolous and the case is liable to be dismissed with cost.
Point for Decision
- Whether the OP has been deficient in rendering service to the complainants?
- Whether the complainants are entitled to get the relief as prayed for?
Decision with Reasons
We take up both the points together for the sake of brevity and convenience of discussion. Let us take a glance towards the documents filed by the complainants, i.e. Xerox copy of proposal form duly filled in, Xerox copy of insurance certificate, Xerox copy of medical records, Xerox copy of discharge certificate, Xerox copy of letter to complainant no.2 dated 13-01-2016 claiming documents. OP has also filed some documents i.e. Xerox copy of welcome letter of the policy dated 23-02-2013, Xerox copy of insurance certificate, Xerox copy of customer information issued through the Xerox copy of proposal form, Xerox copy of reimbursement claim check list, Xerox copy of letter regarding missing information dated 13-01-2016 regarding reimbursement of medical expenses and other documents on record.
It appears that complainant no.1 availed a health insurance policy from Max Bupa Health Insurance Co. Ltd., under the policy named “Heartbeat Silver 02 lacs 2 Adults” being policy No. 30185082201300 for a span of one year from 23-02-2013 to 21-02-2014. The complainant No.2 suffered from diminishing eye vision and was admitted into BBI Foundation. Date of admission was 10-02-2014 and she was discharged on 11-02-2014. She suffered from Neuclear Sclerosis and Posterior Subcapsular Cataract in the left eye and underwent Phacoemulsification + IOL (F) under TA done by Dr. Lav Kochgaway as per discharge summary. From the prescription of BBI Foundation it also appears that the complainant no.2 suffered from left eye decrease vision for one week. So, it cannot be said that complainant no.2 suppressed any material fact at the time of obtaining the policy. It is stated from the side of the OP that complainant no.2 suffered from hypertension. We are afraid hypertension in the instant case has no connection with diminishing eye vision. Moreover, hypertension does not necessarily give rise to complication in all cases and accordingly it cannot be said that hypertension goes within the purview of preexisting disease. It cannot be said that every person suffering from hypertension is suffering from heart disease or would develop blockage in artery We cannot say that the complainant suppressed the past medical history before inception of the policy. Moreover, the pre-policy medical tests were performed and on the basis of medical details provided in the proposal form the policy was issued. So, OP cannot take the plea that complainant no.2 failed to reveal her medical history since pre-policy medical tests were done before issuance of the policy. Moreover, from the treatment sheet filed by the complainants it appears that complainant no.2 suffered from diminishing eye vision for one week. Considering all facts and circumstances and having regard to the documents on record we think that OP has withheld the claim of the complainants without any valid reason or genuine ground. We think that complainants are entitled to get the reimbursement of the medical expenses of OPs amounting to Rs.26,065/-.
Consequently, the case merits success.
Hence,
Ordered
That the instant case be that the same is allowed on contest against the OP.
OP is directed to pay an amount of Rs.26,065/- towards medical reimbursement, to the complainants within one month from the date of this order apart from litigation cost of Rs.10,000/-.
Failure to comply with the order will entitle the complainants to put the order into execution under appropriate provision in C.P. Act.
