SMT. RAVI SUSHA : PRESIDENT
This complaint has been filed by the complainant U/S 35 of the Consumer Protection Act 2019 for getting an order directing opposite party to pay Rs.44,874.00 +Rs.2329/- the hospital expenses incurred to the complainant with interest and cost.
The facts of the case are as follows:- The complainant is a policy holder of OP. On 19/3/2023 the complainant was admitted to MIMS hospital Kannur due to coronary artery disease and myocardial infarction and underwent angio plasty and he was discharged from the hospital on 22/3/2023. The complainant is entitled to insurance benefits from the OP, however the OP has denied his claim, holding that the complainant was suffering from the disease condition for the past 15 years. The complainant submits that he was not treated for any disease condition such as coronary artery disease and myocardial infarction at any time prior to the admission in the aforementioned hospital. The complainant’s medical records and testimony of the treating physicians will demonstrate that he had never been diagnosed with coronary artery disease and myocardial infarction prior to his admission to MIMS hospital in Kannur. Therefore the OPs assertion that the complainant had a pre-existing medical condition is false and baseless h Hence this complaint.
On service of notice, OP appeared through its counsel filed its version denying the averments of the complainant contending that the complainant submitting the proposal form is the basis of insurance contract, in the proposal from the complainant has specifically declared that he was not suffering from any disease or ailment except diabetes. It is submitted that during the aforesaid policy period, the OP had received a request for cashless treatment from MIMS hospital Kannur stating that the complainant was admitted at the hospital on 19/3/2023 and was provisionally diagnosed with ACS, Severe LV dysfunction, Hypertension, Diabetes Mellitus, coronary artery disease. As per the treatment records, the complainant has history of old ASMI, since 15 years. Based on the available medical records it is clearly evident that the complainant had history of the above diseases for the past 15 years which is prior to the inception of policy and the same was not revealed in the proposal form at the time of inception of policy. It is submitted that under Exclusion clause No.IV(1)(a) of the policy, “Expenses related to the treatment of pre-existing disease(PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer”. Hence the OP had rejected the cashless facility and the same was informed to the complainant and the hospital authority on 22/3/2023. Thereafter the complainant has not submitted the original documents before the OP showing that he had incurred Rs.44,874/-for the reimbursement of the medical expenses. It is submitted that the OP had repudiated the claim based on the medical records and as per the terms and condition of the policy. Hence prayed for the dismissal of this complaint.
In order to substantiate the complainant’s averments, complainant filed chief affidavit and produced some documents. He was examined through advocate commissioner. Marked Exts.A1 to A5 and Ext.X1. On the side of OP, Deputy Manager- Legal of OP Insurance company has filed his chief affidavit. Examined as DW1,and marked Exts.B1 to B5 . After that the learned counsels of both parties made arguments.
The only question to be decided is as to whether complainant is entitled to get the policy benefit ie, medical re-imbursement?
We have duly considered the submissions of both learned counsel and have also gone through the pleadings of both parties and materials on record including medical records.
It is not in dispute that the complainant had taken a medi classic insurance policy on 30/8/2016 and the same has been renewed upto 29/8/2023 for a sum of Rs.3,00,000/-. It is also an admitted fact that in the proposal form, the complainant has specifically declared that he was not suffering from any disease except diabetes at the time of submitting the proposal form. It is a fact that the complainant was admitted to MIMS hospital at Kannur on 19/3/2023 due to coronary artery disease and myocardial infraction and underwent angio plasty and was discharged on 22/3/2023. According to complainant, he is entitled to get insurance benefits from the OP.
OP submitted that at the time of issuing the policy the complainant was supplied with the terms and conditions of the policy. Further submitted that as per the treatment records issued from the hospital, the complainant has history of old Anteroseptal myocardial infraction since 15 years, which is prior to the inception of policy and the same was not revealed in the proposal form at the time of inception of policy. It is submitted that under Exclusion clause No.IV(1)(a) of the policy, “Expenses related to the treatment of pre-existing disease and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer. Further the complainant has not submitted the original treatment bills before the OP. As per the above contention the OP had issued Ext.B5 letter dtd.22/3/2023 stating that ”As per the documents received by us, the patient has been suffering from this disease/condition for the past 15 years which is prior to inception of the first policy. Hence it is a pre-existing disease/condition. The insured has failed to disclose this in his proposal form at the time of inception of the first policy. As per the waiting period/exclusion No.Excl 01 of the policy, the claim for treatment of the disease/condition is not admissible until the expiry of 48 months from the date of admission 19/3/2023-after 1/10/2020”.
In the version OP has submitted that under exclusion clause No.IV(1)(a) of the policy states that “Expenses related to the treatment of pre-existing disease(PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer”.
From the facts of this case, it is revealed that the date of inception of the 1st policy was in 2016(Ext.B1). Then coverage of 48 months expired on 2020. Within this period there is no evidence that the complainant had taken treatment from any hospital for ASMI or its complication. So according to us, OP cannot raise such a contention for excluding the policy benefit of the complainant.
More over complainant has denied the contention of the OP that he had a history of 15 years of the disease of ACS.
OP has submitted Ext.B4 medical records of the complainant from the MIMS hospital,Kannur, complainant has submitted discharge summary(Ext.A3). Inboth the documents it is seen that the complainant had “Old ASMI” . In Ext.B4, the treating doctor reported that “ old ASMI-15years”.
Since complainant denied the said endorsement, OP should have examined the treating doctor of the complainant, from MIMS Hospital and established the said recording in the medical records. Moreover, OP had not submitted any piece of evidence to clarify that the complainant availed treatment for ASMI prior to 19/3/2023. Also OP failed to submit any medical record to show that on which date ASMI was diagnosed on the complainant by a competent medical practitioner.
It is an undisputed matter that the complainant had admitted in the proposal form that he had diabetes mellitus.
Hence from the available medical records, OP failed to establish the contention that the complainant had taken treatment prior to 19/3/2023. So the endorsement in Ext.B4 that ASMI-15 years alone is not sufficient for repudiating the complainant’s legitimate claim.
The Hon’ble High court of Kerala in a judgment in Star Health and Allied Insurance Company Ltd vs. V.P.Santhosh Menon 2020(1)KLJ 71 “ Redressal of Public Grievances Rules ,1998-Rules 14(2)- Rejection of medical insurance claim for the reason that insure contracted disease within 30 days of commencement of policy- A disease can be said to be contracted for the purpose of insurance claim, only when after diagnosis it is clinically found that the patient is suffering from the disease. The symptoms related to the disease may be in existence for long periods prior to the diagnosis and the symptoms may be within the knowledge of the patient. For the purpose of an insurance claim, a disease can be said to be contracted only when it is diagnosed by a competent physicians and confirmed”
So we cannot come to a conclusion that there is suppression of pre-existing disease made by the complainant in the proposal form.
On considering the entire facts and circumstances of this case and also from the view of Hon’ble High Court of Kerala, we are of the view that there is deficiency in service and unfair trade practice on the part of OP. Hence the complainant is entitled to get relief. Exts.B4&B5 show that the complainant had spend Rs.44,874+Rs.2329/- in the hospital Aster Mims,Kannur for the disputed treatment.
In the result, complaint is allowed in part. Opposite party is directed to pay Rs. Rs.44,874+Rs.2329/- with interest @4% per annum from the date of complaint ie 15/5/2023 till the date of realization of the amount with Rs.5000/- towards cost of the proceedings of this complaint. Opposite party shall comply the order within one month from the date of receipt of certified copy of this order. Failing which the awarded amount Rs.44,874+Rs.2329/- except the cost portion, will carry interest@9% per annum from the date of complaint till realization. Complainant is at liberty to file EA against opposite party, as per the provision of
Consumer Protection Act 2019.
Exts:
A1- Insurance Policy
A2-Rejection letter
A3- Discharge summary
A4- Payment receipts and bill
A5- Medical bills (2 in No)
X1-Medical records
B1- proposal form
B2-Policy schedule
B3- request for cashless treatment
B4- copy of treatment records
B5- copy of rejection of cashless facility
PW1- Valsamma- Complainant
DW1- Balu.M- OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
