DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this the 28th day of November, 2024
Filed on: 14/01/2019
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member Smt.Sreevidhia.T.N Member
C.C. NO. 32/2019
COMPLAINANT
R. Pankajakshan Pillai, Kumpazha, Grace Garden, Thrikkakara P.O., Kochi 21.
Vs.
OPPOSITE PARTY
The Officer-in-charge, United India Insurance Company, Divisional Office III, Bhaskara Building, Mavelipuram, Kakkanad, Kochi 682030.
(Rep. by Adv. Umarani M.N., Kay Vee Gee Arcade, 2nd Floor, Punnackal, Elamakkara, Pin 682026)
F I N A L O R D E R
Sreevidhia T.N., Member:
- A brief statement of facts of this complaint is as stated below:
The complainant and his family were covered under the Group Mediclaim of the company, United India Insurance Company. The complainant had included the name of his daughter Parvathy Pillai on completion of 3 months, by paying adequate required premium on 03/04/1988 and had continued the policy upto 31/03/2020. The complainant had submitted a clam on 2018 for treatment of his daughter Parvathy Pillai at Amritha Institute of Medical Science for an amount of Rs.2,18,570/-. The company repudiated the claim vide letter No. 101300/TPA/023 dated 10/05/2018 stating exclusion clause 4.6. The complainant had also sent a letter to the opposite party on 20/05/2018 stating that no such exclusions in his policy and the repudiation of the policy is unjustified. The office of the opposite party has not replied to the representation made by the complainant dated 16/06/2018. The complainant states that the health condition of the person at the time of taking the policy only to be considered and not at the time of claim. As per Protection of Policy Holders Interest Regulations 2017 of Regulator IRDA the claim has to be settled or repudiated within 30 days from the date of receipt of documents and the complainant had submitted the documents on 22/02/2018 and it was not settled within 30 days. The complainant states that he is entitled for interest at the bank rate + 2% from the date of submission of documents. The complainant has approached the Commission seeking orders directing the opposite party to give the claim amount Rs.2,18,750/- to the complainant +interest at the bank rate + 2% from the date of submission of documents plus cost of proceedings Rs.5,000/- and an amount of Rs.10,000/- towards the mental agony suffered by the complainant.
2) NOTICE
The notice was issued to the opposite party from this Commission on 19/08/2019. Upon notice opposite party appeared and filed their version.
3) Version of Opposite party
The complaint is frivolous, misconceived and devoid of any merit and is not maintainable either in law or on facts and hence liable to be dismissed.
The complainant is aggrieved by the fact of repudiation of claim submitted by him on behalf of his daughter for treatment expenses for an amount of Rs.2,18,750/-. The complainant therefore filed this claim seeking Rs.2,18,750/- for reimbursement of the medical expenses as well as for compensation and costs along with interest from the opposite party.
It is admitted by the opposite party that the complainant and his family members were covered under the group mediclaim policy of the opposite party. The averment in paragraph 2 of the complaint that the daughter of the complainant had joined the mediclaim policy from the age of 3 months and is continuing under the same policy till date is denied by the opposite party. The complainant had removed the name of his daughter from the group medical insurance scheme when she had attained 22 years of age and he had taken another policy in the name of his daughter in the year 2010 vide policy No, 101300/48/10/97/00000006 with coverage from 01/04/2010 to 31/03/2011 and is renewed yearly accepting the specific terms and conditions there in till 31/03/2020. The policy is an individual health insurance policy and not a group policy. The terms of the individual health insurance policy varies from the staff group mediclaim policy and there is absolutely no similarity in the clause contained in both these policies. A claim was preferred by the complainant was the company relating to expense incurred in connection with treatment of his daughter at Amrutha Institute of Medical Science from 11/02/2018 to 15/02/2018. On verifying the hospital records it was found that the doctor had diagnosed the disease as morbid obesity and the same was stated in the discharge summary. The claim for morbid obesity treatment could not be entertained by the company due to the exclusion clause contained by the policy issued to the complainant at the relevant time and therefore the company repudiated the same.
Clause 4.6 of the policy reads ‘Convalescence, general debility, run down condition or rest cure, obesity treatment and its complications including morbid obesity, congenital external disease or defects and anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, intentional self-injury and use of intoxications drugs/alcohol.’ These are all excluded from the preview of the insurance coverage taken by the complainant at the relevant time. In view of the exclusion contained in the policy, the claim of the complainant was rejected.
The insurance policy in the name of the daughter of the complainant was not a continuous one since 1988, rather the name of the daughter was deleted from the group insurance and subsequently a fresh individual health policy in her individual name was taken by the complainant. Therefore the contention that the policy was a continuous one since 1988 is incorrect and hence refused.
Based on directions from Insurance Regulatory and Development Authority of India (IRDAI) health insurance products undergo changes in the terms and conditions of the policies offered. These changes are promptly published in the website of the opposite party which are accessible to the general public/policy holders. For the past several years’ morbid obesity, general debility, run down condition, obesity treatment etc. are excluded from the ambits of insurance coverage and even the platinum policies offered by the company does not offer coverage for medical expense of this natured.
The policy taken by the complainant in the name of his daughter for the period from 01/04/2017 to 31/03/2018 specifically contains the exclusion clause. A deviation from certain clauses can’t be permitted at any cost. Feigning ignorance of policy conditions is only an attempt on the part of the complainant to wriggle out the exclusion clause and to make an attempt to avail the benefit of the policy knowing fully well that he is disentitled for the same. There is no deficiency in service or unfair trade practice from the part of opposite party.
4) Evidence
Evidence in this case consists of the proof affidavit filed by the complainant and the documentary evidence filed by the complainant which were marked as Exbt. A1 to A12. Exbt. A8 is marked subject to objection from opposite party’s counsel. No other evidence from the side of the complainant.
Opposite party filed 7 documents which were marked as Exbt. B1 to B7.
Both parties filed argument notes. Heard the parties.
The case of the complainant is that his daughter Parvathy Pillai joined the Mediclaim Insurance policy at the age of 91 days that is in 1988 and continuously renewed the policy with the same terms and conditions without any break upto 2020 and no fresh proposal is collected during renewal. The policy under which the claim is lodged is a continuous renewal of 101300/48/10/97/00000006 without any break on the same terms and conditions. The matter of change is conditions are to be compulsorily communicated to the insured without fail. As per the present terms and conditions, morbid obesity is covered and the opposite party had repudiated the claim of the complainant.
Exbt. A1: Copy of the S.S.L.C. Book of the complainant’s daughter Parvaty P. to prove the date of birth of the complainant. The date of birth of the complainant’s daughter is 03/12/1987.
Exbt. A2: Newspaper published in Mzathrubhumi daily on 08/05/2018 stating that ‘insurance is based on health at the time of inception of the policy’
Exbt. A3 series: Policy copies – 5 numbers
- Individual health insurance policy 2009 for the period from 01/04/2010 to 31/03/2011 with policy No. 101300/48/10/00000006
- Individual health insurance policy 2010 for the period from 01/04/2012 to 31/03/2013 with policy No. 101300/48/10/00000005
- Individual health insurance policy 2010 for the period from 01/04/2013 to 31/03/2014 with policy No. 101300/48/10/00000003
- Individual Policy Schedule with Policy No. 1013002817P100539821 for the period 01/04/2017 to 31/03/2018
- Individual health insurance policy schedule 1013002818P1000116215 for the period 01/04/2018 to 31/03/2019
Exbt. A4: Proposal Form
Exbt. A5: Renewal notice issued by the opposite party
Exbt. A6: Policy copy 101300/48/11/97/00000003 for the period 01/04/2011 to 31/03/2012
Exbt. A7: Report dated 01/12/2021 published in Mathrubhumi daily
Exbt. A8: The pamphlet issued by United India Insurance Company
Exbt. A9: Additional document request sent by Health India Insurance TPA Services (P) Ltd. to the complainant
Exbt. A10: A copy of the order of the State Consumer Disputes Redressal Commission, Punjab Chandigarh in Appeal No. 178 of 2015 dated 06/04/2016.
Exbt. A11: Discharge summary of the complainant’s daughter from Amrutha Institute of Medical Science and Research Centre, Kochi
Exbt. A12: Repudiation letter from the opposite party .
We have verified the facts of the case, version filed by the opposite party, documents and evidence filed by both the parties.
Opposite party’s documents:
Exbt. B1: A copy of the claim form submitted by the complainant
Exbt. B2: A copy of repudiation letter dated 10/05/2018
Exbt. B3: A copy of the grievance reply dated 18/06/2019 issued by the opposite party to the complainant
Exbt. B4: A copy of discharge summary from Amrutha Institute of Medical Science
Exbt. B5: A copy of inpatient details
Exbt. B6: A copy of the Health Insurance Policy Platinum UIN No. IRDA/NL-HTL/UTI/P-H/V1/228/13-14
Exbt. B6: United India Insurance Policy for the period from 01/04/2017 to 31/03/2018
The complainant is aggrieved by the fact of repudiation of claim submitted by him on the fact the fact of repudiation of the claim filed before the opposite party on behalf of his daughter for treatment expenses for an amount of Rs.2,18,750/-. The claim was preferred by the complainant with the opposite party relating to the treatment expenses incurred in connection with the treatment of his daughter at the Amritha Institute of Medical Science from 11/02/2018 to 15/02/2018. As per the discharge summary produced by the complainant, the doctor had diagnosed the disease as morbid obesity. The opposite party repudiated the claim stating that the claim for morbid obesity could not entertained by the company due to the exclusion clause 4.6 contained in the policy issued to the complainant at the relevant time and therefore repudiated the claim.
The opposite party admits in their version that the complainant and his family were covered under the group mediclaim policy. The opposite party denied that the averment in paragraph 2 of the complaint that the daughter of the complainant had joined the mediclaim policy from the age of 3 months and is continuing under the same policy. The opposite party states that the complainant had removed the name of his daughter from the group medical insurance scheme when she attained 22 years of age and had taken another policy in the name of his daughter in the year 2010 vide policy No.101300/48/10/97/00000006 with coverage from 01/04/2010 to 31/03/2011 and is renewed accepting the specifications and conditions, therein till 31/03/2020. This is an individual health insurance policy and not a group policy. The terms of the group insurance policy varies from the staff group mediclaim policy and absolutely there is no similarity in the clauses contained in both the parties. Opposite party also stated in the argument note that from the year of 2012-13, clause 4.6 morbid obesity treatment exclusion is included in the policy terms and conditions. The opposite party also states in their argument note that the complainant’s daughter surgery is not to treat illness and is not a disease or an injury and it may be part of weight loss program or cosmetic surgery.
As per the discharge summary the complainant’s daughter was admitted in the hospital on 11/02/2018 and was discharged on 15/02/2018. The doctor has diagnosed the disease as morbid obesity (BMI 40.8) and a gastro intestinal surgery was done on 12/02/2018. The complainant was having a weight of 118 kg at that time. There is no mention in the discharge summary that the complainant’s daughter had underwent a cosmetic surgery as a part of weight loss programme. The complainant has produced 5 policy copies (1) 01/04/2018 to 31/03/2018 (2) 01/04/2018 to 31/03/2019 (3) 01/04/2020 to 31/03/2021 (4) 01/04/2012 to 31/03/2013 (4) 01/04/2013 to 31/03/2014. The complainant had submitted his claim based on the policy No. 1013002817P100539821 for the period from 01/04/2017 to 31/03/2018. In all the policies issued from 2010 to 2020 the opposite party had printed in the 2nd page of the policy subject to the 1st inception exclusion date 03/04/1988. The policy has been continuously renewed without any break upto 31/03/2020 and the policy was renewed based on the renewal notice issued by the opposite party to maintain continuously. As per Exbt. A6 produced by the complainant (for the period from 01/04/2011 to 31/03/2012) the wording of 4.6 reads:
Convalescence, general debility run down conditions or rest cure, congenital external disease or defects or abnormalities sterility, venereal disease, intentional self-injury and use of intoxication drugs/alcohol. The policy No. 101300/48/11/97/00000003 with coverage 01/04/2011 to 31/03/2012 does not have the wording obesity treatment and its complications including morbid obesity. There was no objection from the opposite party to mark this documents (Exbt. A6). The complainant states that the insurance company can’t unilaterally change the terms without the concurrence of the insurer.
The judgment of the Hon’ble Supreme Court in case of Jacob Punnen/Mariam Punnen Vs. United India Insurance Company Ltd. in Civil appeal No. 6778 of 2013, it has been clearly established that the insurer can’t change the terms without concurrence of the insured.
The opposite party produced Exbt. B7 policy in which as per 4.6 is morbid obesity is excluded in the exclusion clause. The insurance policy does not contain the exclusion wording ‘obesity treatment and its complications include morbid obesity’ under 4.6 either in the group policy or in the transferred policy. Opposite party argued that from the year 2012-2013 clause 4.6 morbid obesity treatment exclusion clause included in the policy terms and condition. But opposite party has not produced any copy of the policy which was taken by the complainant from the year of 2012-13. Only Exbt. B7 policy is produced by the opposite party.
We have thoroughly perused the documents. On the date surgery of the complainant’s daughter (12/02/2018) the complainant was having a valid insurance policy. Complainant’s daughter Parvathy Pillai was covered under the policy. The sum insured was Rs.2,00,000/-. The complainant has preferred a claim under claim No. 41-UIC-0004816635-0 for considering the policy No. 1013002817P100539821 (01/04/2017 to 31/03/2018) in which the inception date of the first policy was shown as 03/04/1988. The complainant has renewed the policy without any break upto 31/03/2020. The complainant states that in none of the policies issued by the opposite party, the word obesity treatment and its complication including morbid obesity is seen in the exclusion 4.6. To prove this complainant has produced policy No. 101300/48/11/97/0000003 for the period from 01/04/2011 to 31/03/2012 which does not have the wording obesity treatment and its complications including morbid obesity (Exbt. A6). The opposite party repudiated the claim of the complainant citing the reason of 4.6 exclusion clause in the policy for the period from 01/04/2017 to 31/03/2018. From these evidences, it is proved that opposite party had changed the policy conditions without the knowledge of the insurer. Hence deficiency in service is proved from the side of opposite party. The opposite party had repudiated the claim of the complainant without sufficient reasons. Issue No. (1) and (2) found in favour of the complainant. The complainant is eligible to get Rs.2,00,000/- as treatment expenses. Eventhough the treatment expenses was Rs.2,18,570/-, the sum assured as per the policy was Rs.2,00,000/-. Deficiency in service is proved from the side of opposite party and the following orders are hereby passed.
- The opposite party shall pay an amount of Rs.2,00,000/- (Rupees two lakh only) towards the treatment expenses of the complainant’s daughter
- The opposite party shall pay an amount of Rs.10,000/- (Rupees ten thousand only) as compensation towards deficiency in service.
- The opposite party shall pay an amount of Rs.5,000/- (Rupees five thousand only) as cost of proceedings to the complainant.
The above order shall be comply with by the opposite party within 30 days from the date of receipt of this order. Failing which the amount ordered will attract 9% interest from the date of order till realization.
Pronounced in the Open Commission on this the 28th day of November, 2024.
Sd/-
Sreevidhia.T.N, Member
Sd/-
D.B.Binu, President
V.Ramachandran, Member
Forwarded/By Order
Assistant Registrar
Appendix
Complainant’s Evidence
Exbt. A1: Copy of the S.S.L.C. Book of the complainant’s daughter Parvaty P. to prove the date of birth of the complainant. The date of birth of the complainant’s daughter is 03/12/1987.
Exbt. A2: Newspaper published in Mzathrubhumi daily on 08/05/2018 stating that ‘insurance is based on health at the time of inception of the policy’
Exbt. A3 series: Policy copies – 5 numbers
- Individual health insurance policy 2009 for the period from 01/04/2010 to 31/03/2011 with policy No. 101300/48/10/00000006
- Individual health insurance policy 2010 for the period from 01/04/2012 to 31/03/2013 with policy No. 101300/48/10/00000005
- Individual health insurance policy 2010 for the period from 01/04/2013 to 31/03/2014 with policy No. 101300/48/10/00000003
- Individual Policy Schedule with Policy No. 1013002817P100539821 for the period 01/04/2017 to 31/03/2018
- Individual health insurance policy schedule 1013002818P1000116215 for the period 01/04/2018 to 31/03/2019
Exbt. A4: Proposal Form
Exbt. A5: Renewal notice issued by the opposite party
Exbt. A6: Policy copy 101300/48/11/97/00000003 for the period 01/04/2011 to 31/03/2012
Exbt. A7: Report dated 01/12/2021 published in Mathrubhumi daily
Exbt. A8: The pamphlet issued by United India Insurance Company
Exbt. A9: Additional document request sent by Health India Insurance TPA Services (P) Ltd. to the complainant
Exbt. A10: A copy of the order of the State Consumer Disputes Redressal Commission, Punjab Chandigarh in Appeal No. 178 of 2015 dated 06/04/2016.
Exbt. A11: Discharge summary of the complainant’s daughter from Amrutha Institute of Medical Science and Research Centre, Kochi
Exbt. A12: Repudiation letter from the opposite party .
Opposite party’s Exhibits
Exbt. B1: A copy of the claim form submitted by the complainant
Exbt. B2: A copy of repudiation letter dated 10/05/2018
Exbt. B3: A copy of the grievance reply dated 18/06/2019 issued by the opposite party to the complainant
Exbt. B4: A copy of discharge summary from Amrutha Institute of Medical Science
Exbt. B5: A copy of inpatient details
Exbt. B6: A copy of the Health Insurance Policy Platinum UIN No. IRDA/NL-HTL/UTI/P-H/V1/228/13-14
Exbt. B6: United India Insurance Policy for the period from 01/04/2017 to 31/03/2018
Despatch date:
By hand: By post
kp/
CC No. 32/2019
Order Date: 28/11/2024
