ORDER

21.06.2024

Sh. Sanjay Kumar, President

1. The factual matrix of the present case is that complainant had purchased a health policy continuously from the OP1 vide customer id no.000021599 and paid premium of Rs.21,782/- to OP1 and complainant was assured that OP1 shall reimburse the medical claim as and when complainant suffering from illness till the expiry of policy. It is stated that complainant previously on 20.09.2012 discharge on 01.10.2012 after the treatment of bypass surgery at Max Hospital OP2 and the bills were reimbursed by OP1.
2. It is stated that after six seven months on 26.4.2013 the complainant again felt ill and admitted to OP2 hospital for treatment of retention of urine off and on and discharged on 02.05.2013. It is further stated that at the time of admission OP2 directed complainant to deposit a sum of Rs.10,000/- as initial security amount and later on raised bill of Rs.1,33,363/- which was duly approved by OP1 on 26.04.2013. It is stated that at the time of issuance of medical documents it was inadvertently wrongly mentioned by the doctor of OP2 that “retention of urine off and on for six to seven years instead of six to seven months and later on the mistake was duly rectified by Dr. Amit Attam vide letter dated 02.05.2013.
3. It is stated that OP1 flately refused to reimburse the medical claim of the complainant and complainant had to pay Rs.95,736/- to OP2 against the bills of OP2. It is stated that complainant filed many complaints before IRDA having no.APP no/05/13/035481 dated 09.05.2013 but OP1 denied the claim. It is stated that OP1 committed an offence of deficiency or negligency of its services and complainant suffered a lot. Hence present complaint filed.
4. Complainant is seeking direction against OPs for releasing the amount claim of Rs.95,736/-, to pay compensation of Rs.1,00,000/- for mental agony and pain and Rs.25,000/- as litigation charges.
5. OP1 filed detailed WS and taken preliminary objections and submissions. It is stated that on 30.12.2010 OP1 issued Heart Beat Silver Insurance Policy bearing no.30018264201000 in the name of complainant. It is stated that the policy was issued with a four year waiting period on preexisting diseases Urolithiasis and Hyperplasia of Prostrate. It is further stated that any treatment or surgeries due to these diseases shall not be covered for the first four years for the date of commencement of the policy.
6. It is stated that as per clause 5 (f) of terms and conditions, the complainant had 15 days from the date of receipt of the policy documents to review terms and conditions of the policy if not agreed but the complainant did not object to the terms and conditions nor requested any clarification with regard to insurance policy from OP1. It is further stated that complainant underwent three surgeries relating to coronary artery disease on September 2011, February 2012 and September 2012 which was duly approved by OP1 because they were not relating to pre existing conditions of Urolithiasis and Hyperplasia of Prostrate. It is stated that on April 26 2013 OP1 received a pre authorization request from OP2 for complainants treatment of lower urinary tract symptoms and it was stated as emergency, therefore, pre authorization request was approved subject to submission of all documents alongwith discharge summary documents.
7. It is stated that OP1 did not want to inconvenience the complainant specially when an emergency has been stated by hospital. It is further stated that OP1 on receipt of discharge summary documents came to the knowledge that complainant had underwent treatment of Malignant Neoplasm of Prostrate which is related to pre existing conditions of Urolithiasis and Hyperplasia of Prostrate which has a four year waiting period from the date of commencement of the insurance policy. The pre authorization was declined vide letter as per clause 4 (a).
8. It is stated that all the allegations and averments made in the complaint are false, frivolous and vexatious, therefore, present complaint is liable to be dismissed. It is stated that present issue cannot be decided without seeking expert opinion and also requires evidence of the expert.  It is stated that OP1 has to lead evidence and examine witnesses and expert evidence, therefore, the present case is triable by civil court and not by this hon’ble forum. It is stated that present complaint is out of the purview of jurisdiction of this hon’ble forum.
9. On merit all the allegations are denied and contents of preliminary objections and submissions reiterated. It is stated that complainant is not  entitled to any relief claimed in the complaint.
10. Complainant filed rejoinder to the WS of OP1 and reiterated contents of complaint.
11. As per record no WS filed by OP2.  
12. Complainant filed evidence by way of affidavit and reiterated contents of complaint. Complainant relied on copy of said policy Ex.CW1/1, copy of approval letter Ex.CW1/2, copy of justification and disclosed letter Ex.CW1/3 and CW1/4, copies of paid bills and complaint Ex.CW1/5 (colly) and Ex.CW1/6.
13. OP1 filed evidence by way of affidavit of Anand R Choudhary Head Legal and reiterated contents  of WS.  OP relied on copy of first policy Ex.R1, copy of terms and conditions alongwith insurance policy documents Ex.R2,  copy of renewed policy of 24.12.2012 Ex.R3, coy of claims approved Ex.R4, copy of pre authorization request from Max Hospital Ex.R5 and copy of pre authorization decline letter Ex.R6.
14. Written arguments filed by complainant  and OP.
15. We have heard complainant in person and Sh. D.K Sinha proxy for Sh. Suman Tripathi counsel for OP and perused the record.
16. It is admitted case of the parties that complainant purchased a health policy from OP1  and paid premium of Rs.21,782/-. The insurance policy was valid for the period 29.12.2012 to 28.12.2013. It is admitted case of the parties that complainant admitted to hospital for treatment of bypass surgery on 20.09.2012 and discharged on 01.10.2012 and all the bills were reimbursed by OP1. It is further admitted case of the parties that on 26.04.2013 complainant again admitted to hospital for retention of urine off and on and discharged on 02.05.2013. The complainant remained under treatment of OP2 Dr. Amit Attam at Max Super Speciality Hospital Shalimar Bagh. The hospital raised bill  of Rs.1,33,363/- which was duly approved by OP1 on 26.04.2013.
17. As per complainant the OP1 refused to reimburse the claim of Rs.95,736/-. As per OP1 the complainant had undergone Laser Prostratectomy Surgery for retention of urine off and on and this treatment related to pre existing conditions of Urolithiasis and Hyperplasia of Prostrate which has a four year (4 year) waiting period from the date of commencement of policy. OP1 admitted that on 26.04.2013 a pre authorization request received from Max Super Speciality Hospital Shalimar Bagh for complainants treatment of lower urinary tract symptoms and it was approved being a emergency but subject to submission of all medical documents alongwith discharge summary. According to OP on receiving discharge summary document it came to the knowledge that complainant underwent treatment of Malignant Neoplasm of Prostrate which relates to pre existing conditions of Urolithiasis and Hyperplasia of Prostrate and pre authorization was declined as per clause 4 (a)  of terms and conditions of the policy.
18. We have gone through the terms and conditions of the health policy taken by complainant for the period 29.12.2012 to 28.12.2013. It is admitted that complainant undergone treatment at OP2 hospital on 26.04.2013 and discharged  on 01.05.2013. As per discharge summary the diagnosis is DM, HTL, CAD POST CABG, BENIGN PROSTRATIC HYPERPLASMIA. As per letter dated 30.12.2010 the complainant discloses pre existing illness Urolithiasis and Hyperplasia of Prostrate. The medical documents established on record that the complainant had undergone a treatment which was a preexisting illness. Therefore, OP invokes clause 4 (a) of the terms and conditions of the policy which has waiting period of 48 months. Admittedly, complainant has undergone treatment of pre existing disease within 48 months. We are of considered opinion that the OP1 insurance company is fair, justified and legally denied the reimbursement of the claim of the complainant.
19. On the basis of above observation and discussion present complaint is dismissed. No order as to cost. File be consigned to record room.
20. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  21.06.2024.

SANJAY KUMAR                                                           NIPUR CHANDNA    

       PRESIDENT                                                                      MEMBER