SMT. G. VASANTHAKUMARI, PRESIDENT.

This complaint is filed by the complainant claiming the refund of medical expenses to the tune of Rs.90101/- with interest and also compensation.

          Complainant’s case is as follows:   The complainant proposed for the “Family Health Optima Insurance Plan “ of the opp.party Insurance company by  paying a total premium of Rs.7191/-, that the proposal was accepted and the opp.parties issued policy No. p/181112/01/2008/000631 ,    that the period of Insurance was from 19.01 hours on 15..9..07  to mid night of 14..9..2008, that the complainant is entitled  for cash less treatment in hospital as per the terms of the policy, that at the time of subsccription the complainant had no pre-existing disease other than Diabetes Mellites  which was disclosed to the opp.party’s  representative and on which he was under medication and under control, that the medical check-up of the complainant, conducted at the empanelled hospital of the opp.parties also found that, that  the complainant had no pre-existing or  for that matter any existing disease and hence complainants proposal for the medical insurance was accepted by the opp.parties, that while so  the complainant suddenly developed severe neck pain, headache and vomiting and had to undergo hospitalization at the Holy Cross Hospital, Kottiyam on 7..3..2008 and was discharged on 11.3.2008, that the entire hospital bill of Rs.8950/- was met by the opp.parties under the above said policy, that thereafter the doctors referred the complainant to the  Ananthapuri Hospitals and Research Institutes, Thiruvananthapuram for surgery, that the complainant was admitted there on 17..3..2008 and was discharged on 29..3..2008, that he had to undergo Burr hole Evacuation  on 18..3..2008, that the complainant was treated for Subdural Haematoma, that the disease for which he was treated was not pre-existing, that the total expense incurred at the hospital for the said hospitalization was Rs.90101/- out of which Rs.30,390/- was incurred for Prostrate treatment and the entire amounts were paid by the complainant himself, that though the claim was put by the complainant with the opp.parties as early as  on 31..3..2008 the claim was not settled, that there is serious deficiency in service on the part of the opp.parties, that they have not repudiated the genuine claim of the complainant, that  the mere silence of about 19 months even after the submission of the claim is  itself a serious deficiency in service on the part of the opp.parties and hence the complaint

          The opp.parties filed version admitting the issuance of the policy and contenting that, as per the terms of the policy, the insured is entitled for reimbursement of medical expenses incurred as an inpatient, that however when treatment is taken from  listed hospitals for the diseases covered by the policy, cashless facility is extended by the opp.party in claims where the  liability of the company is established beyond doubt, that at the time of subscribing  to the policy the complainant had admitted that he had  pre-existing disease by answering “Yes” to the question on Medical History in the proposal form, but he had not furnished the details of any illness/treatment despite a specific question to provide  for such details of pre-existing diseases , that during the subsistence of the policy the complainant had undergone treatment at  Holycross hospital, Kottiyam  from 7..3..2008 to 11..3..2008 for his ailment of severe headache, that in the pre-authorization  request form  dated  7..3..2008, the hospital had reported  the B] Presenting symptoms with duration as “Severe head ache – 3 days , No history of trauma”, C] Medical history as “Diabetes – 5 months, Hypertension – 3 months” and E] Positive findings of investigation done at “CT scan – Bilateral Fronto tempero parietal Chronic subdural haematoma”, that none of the above diseases were found to be pre-existing as the policy has commenced on 15..9..2007, that the claim of Rs.8724/- submitted   by the hospital in this connection was fully honoured by the opp.parties in good faith as per the claim enhancement letter dated 11.3..2008, that on 17..3..2008  when  the entire medical  records were submitted by the Holycross Hospital, requesting the opp.party to pay the claim as per the authorization given, the opp.party received the discharge summary for the first time, that in the discharge summary under the subheading “Clinical features”  it has been found recorded that “CT showing C/c  SDH, was on treatment for the same” and so it became evident that the pre-existing illness admitted by the complainant in his proposal was Chronic case of SDH, that as this illness was pre-existing and the complainant was on treatment, the opp.party was not liable to pay the claim under the policy as per  exclusion clause No.1, which excludes all pre- existing illness, that however as per the authorization for Rs.8724/- was already given to the hospital and any refusal to pay the authorized amount would cause embarrassment to the hospital, that was paid to the hospital on 4..4..2009 after a series of discussions, that subsequently it was learnt that the complainant was referred to the Ananthapury Hospital  and Research Institute, Thiruvananthapuram for further treatment of Chronic SDH, that it is further learnt that during his treatment at the Ananthapury Hospital, he had undergone surgery called Burr hole Evacuation for treatment of Chronic Subdural Heamatoma, that while so he also developed difficulty in passing urine which was later diagnosed as Prostate  Hyper Trophy and undergone prostate  surgery also that based on a  fresh  claim intimation, the claim was studied based on the pre- authorization request dated 17..3..2008 from Ananthapuri Hospital and the earlier claim documents for the same illness for which treatment was availed from Holycross Hospital ,Kottiyam, that this request was found to be erroneous in many aspects like 1) age of the patient was recorded wrongly as 71 years , 2) Medical history on Hypertension was answered as “No” , 3- history of past  illness relevant to present illness was  answered as “Nil”, 4)  No reference has been found about the past diagnosis and treatment at Holycross Hospital, Kottiyam and hence the facts on this  pre-authorization request were given lesser importance and reply was  faxed  to  Ananthapuri Hospital Thiruvananthapurm stating that the opp.party was unable to provide cashless facility  as the claim was for the treatment of a pre-existing illness / condition, that in pursuant to the discharge from the hospital the complainant submitted total bill for Rs.90101/- including Rs.30390/- towards treatment of prostate alone, that admittedly the surgery for prostate Hypertrophy   was done  within one year  of the insurance cover, which is not liable to be reimbursed as it is specifically excluded from the purview of the policy, that the other medical expenditure  is for  “Bilaterial  Chronic Subdural Haematoma” for which  the complainant has undergone treatment at Ananthapuri Hospital, that the treatment certificate from Ananthapuri Hospial  is silent about the past illness and treatment earlier  at Holycross Hospital , that  in the medical certificate forming part of the claim form   ,  it has been certified that  [5] date of first consultation  [prior to hospitalization] is “17..3..2008”, [7] Past history of the patient [if any] with the duration of illness does not mention anything on the SDH, [8] Whether the present ailment is a complication of pre-existing disease is answered as “No”, that moreover, in the claim form,  for the question - date of injury sustained or disease/illness first detected, the insured has answered as “ 17..3..2008, “that he is well aware  of his past treatment and this clearly showed that the patient had suppressed all his previous treatment from the present treating doctor at Ananthapuri Hopital, that the claim was found to be arising out of treatment for a pre-existing illness and it can be seen that it is within  the exclusion period of 48 months and the claim  was rightly repudiated by the insurer in terms of the insurance policy and there is no deficiency in service or unfair trade practice on the part of the opp.parties and as such the complaint is only to be dismissed with compensatory cost to the opp.party.

Points that would arise for consideration are:

1.     Whether the treatments undergone by the complainant will come within the ambit of exclusion clause in the policy?

2.     Whether there is any deficiency of service on the part of the opp.party?

3.     Reliefs and costs?

For the complainant PW.1 was examined and marked Exts. P1 to P17

For the opp.party DW.1 was examined and marked Exts. D1 to D12.

THE POINTS

 The specific case of the complainant is that the complainant has purchased a Medi claim policy , valid from 15..9..2007 to1 4..9..2008, that at the time of subscription of the policy he had no pre- existing disease, and while  so the complainant had undergone treatment at Holy cross Hospital for his neck pain, head ache and vomiting from 7..3..2008 to 11..3..2008, that the hospital bill of Rs.8,950/- was reimbursed by the opp.party, that thereafter complainant was referred to Ananthapuri Hospital Thiruvananthapurm,  where he has  undergone treatment from 17..3..2008 to 29..3..2008, that on 18..3..2008 he had undergone burr   hole evacuation surgery, that he was treated for subdural haematoma and developed difficulty in passing urine,  and hence he has undergone prostrate surgery also, that the hospital issued a total bill of Rs.90,101/- out of which Rs.30,390/- was incurred for prostrate treatment, that  even though the complainant submitted claim, it was not honoured and hence the complaint.  The complaint filed on 18..8..2009, claim repudiated on 21..10..2009 after the filing of the complaint stating that pre- existing disease is not payable  as per exclusion No.1  and that Benign Prostate Hypertropy is excluded from scope of Policy under Exclusion NO.4  In this case the complainant was examined as PW.1.  The first and foremost question to be considered in this case is as to whether the complainant was suffering from  the pre-existing illness of Sub Dural Hematoma as alleged by the  opp.parties.  Ext.P2  policy was  for the period from 19.01 hours on  15..9..2007 to Midnight of 14..9..2008.  The complainant was initially admitted  at the Holy Cross Hospital on 7..3..2008  and was discharged on 11..3..2008.  Admittedly opp.party honoured the medical expenses incurred in Holycross Hospital, Kottiyam  Here  it is pertinent to note that the above claim was settled after perusing all  the medical records.  The doctors at the Holycross Hospital, Kottiyam  referred the complainant to Ananthapuri Hospital for surgery . The reference was for the continuation of the same treatment.  The patient was admitted in Ananthapuri hospital on 17..3..2008 and was discharged on 29..3..2008.   There he has undergone  Burr Hole Evacuation  surgery . It is a disease condition of “Bilateral Chronic Subdural Haematoma” .  There  he was  treated for Subdural Haematoma.  According to the complainant he was never treated for any such disease earlier to the taking of the policy.  Thus the illness for which he was treated was not pre- existing .  But according to the opp.party Discharge card  from Holycross Hospital, Kottiyam under the head clinical features it is shown “CT showing C/C  SDH.  It means nothing but that the complainant was a patient of chronic case of SDH and he was under treatment for the same .  But this fact was suppressed by the complainant in the proposal form.  It is true that in proposal form Ext. D2   in Column No.8 page No.2 it is asked  “ Has the proposer suffered from any disease or illness irrespective or whether hospitalized or not or sustained accident?  If yes Give details” The complainant  answered “Yes”  but did not give any details.  He had also answered “Yes” to the last column “Had any medical treatment, mental or physical impairment” .  But the details of such  disease  and treatment  is not stated.  So according to the learned of counsel  appearing for the opp.party  complainant suppressed  details in the proposal form.  But without giving details of such disease and treatment why the opp.party accepted proposal form stands unexplained.  So on going through Ext. D2 proposal form alone we cannot say that the complainant suppressed material facts regarding the alleged disease.   Further it is argued by the learned counsel appearing for the opp.party that in Ex.D8 certificate dated  31..3..2008 issued from the  Ananthapuri Hospital  it is  certified that” Mr. John Mathai 61/M [MRD No.44066] was admitted with Sub Dural Haematoma [L] Tempero Parietal Region with mass effect.   Chronic Sub Dural Haematoma is used when the hemorrhage is older than 3 weeks,   So the present is a recent one..”  But it is surprising to note that the word “Chronic” is deleted by the Ananthapuri Hospital. Ext.P6 is true copy of Ext. D8 and in Ext.P6 chronic  finds  a place.  In Ext. D8  after deleting chronic the seal of the hospital is seen affixed.  In that it is also explained that  Chronic  subdural heamatoma is used when  hemorrhage is older than 3 weeks.   So the  present is a recent one.  The word chronic why deleted in Ext. D8 not known to the complainant.   So also in Ext.P6 photocopy copy of Ext. D8 chronic is there.  So that argument is of no help to the opp.party.  Further  it is argued by  the learned counsel appearing for the opp.party that  the complainant  admitted that  he sustained head injury due to a fall from height. It is true that in box he has stated that “construction \S-¶-t¸m-gm-bn-cp¶p  construction \S-¯nb building  sâ apI-fn \n¶pw Xmtg¡v hoW-Xm-bn-cp¶p ? tF-Wn-bn \n¶pw Xmtgm«v Cd-§n-b-t¸mÄXm-tg¡v hoW-Xm-Wv.  5 ASn bpsS apI-fn \n¶mWv hoW-Xp  Imen\p am{Xw ]cn-¡v]-än.  ImepIp-¯n-hoWp. left  Imen-\pv  fracture D­m-bn-cp-¶p. Upasana bn NnIn-Õn-¨p.  Further  down he would swear before the forum tha”t A]-I-Ss¯ XpSÀ¶p \n§Ä Xe CSn-¨mWv  hoW-sX-¶pw AXns\ XpSÀ¶v Xe-bpsS DÄ`m-K¯v càw I«-]n-Sn-¨n-cp¶p F¶pw Bb-Xn\v treatment      Â Bbn-cp-¶p-F-¶pw Dff hnh-cw  proposal form  mention sN¿p-Itbm    Insurance company .sb Adn-bn-¡p-Itbm sNbvXn-cpt¶m ? A§s\ Hcp kw`whw D­m-bn-«n-Ã.  Xe-bnse Akp-J-¯nsâ BZy symptoms F¶pXpS§n?  operation \pvv Hcm-gvN-ap³]v   So the above arguments also is of no help to the opp.party .  Policy was issued on 15..9..2007 whereas the burr hole evacuation surgery  was done on 18..3..2008. Since the chronic  subdural heamatoma  was not pre- existing the repudiation of the claim is against the policy conditions. The claim is to be honoured by the opp.party

          Regarding the other surgery done to the complainant, that is prostate, it is very well evident that this surgery was done at the  Ananthapuri hospital in connection with the urinary retention occurred  at Ananthapuri Hospital.   As per the exclusion clause No.4, in Ext. P4 Insurance cover for specified treatment including “Prostate Hypertorophy” are not payable within one year . Here policy was subscribed on 15..9..2007 and the surgery was done at Ananthapuri Hospital from 17..3..2008 to 29..3..2008, which is very well within one year and hence this medical expense is  not payable.

          In this case it is  further pointed out by the learned counsel appearing for the complainant that  the claim of the complainant was raised as early as on31..3..2008 and opp.parties assured that the claim will be settled at the earliest but kept on dragging the matter and rejected the claim only after filing of the complaint.  It is true that the complaint was  filed on18..8..2009 and the claim was rejected on 26..12..2009.  It  amounts to deficiency in service.

          In the result, the complaint is partly allowed, directing the opp.parties to pay Rs.59,711/- in full and final settlement of the claim, Rs.5,000/- as compensation and Rs.1,000/- towards cost of the proceedings.   The order is to be  complied with within one month, in default ,  the claim amount Rs.59,711/- will carry interest at the rate of 12% from 18..8..2009, the date of complaint. 

          Dated this the 22^nd day of May 2012

                                                I N D E X

List of witnesses for the complainant

PW.1. – John Mathai

List of documents for the complainant

P1. – Policy holder’s Identity card

P2. – Policy schedule

P3. – Receipt for Rs.7.191/-

P4., - Insurance policy condition

P5. – Letter dated 23..9..2008

P6. – dated31..3..2008

P7. –Claim form for Medical Insurance

P8. – Medical certificate issued from Ananthapuri

P9. – Inpatient settlement receipt issued fromAnanthapuri Hospital

P10. – Discharge bill

P11. – Detailed discharge bill from Ananthapuri Hospital

P12. –Treatment certificate

P13. – Lab report

P14. – Certificate dated 14..1..2009

P15. – Treatment certificate of Ananthapuri Hospital

P16. – Bill of Holycross Hospital

P17. – Discharge summary of Holycross Hospital

List of witness for the opp.party

DW.1. – Dileepkumar.P.S.

List of documents for the opp.parties

D1. – Copy of Health Insurance Policy

D2. – Copy of proposal form

D3. – Terms and conditions

D4. – Discharge summary of Holycross Hospital

D5. – Pre-authorization request Form

D6. – Treatment certificate of Ananthapuri Hospital

D7. – Original claim form for Medical Insurance

D8. – Original Medical certificate

D9. – Claim Rejection Letter

D10. – Re    uisition slip dated 12..9..2007

D11. – Postal receipt

D12. – Acknowledgement card.