Tamil Nadu

South Chennai

CC/68/2022

Mrs. Pushpa Chauhan - Complainant(s)

Versus

M/s United India Insurance Company Co. Ltd., Represented by its Chairman cum Managing Director an - Opp.Party(s)

Yusuf S

12 Apr 2023

ORDER

Date of Complaint Filed : 28.01.2022

Date of Reservation      : 13.03.2023

Date of Order               : 12.04.2023

 

          DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT: TMT. B. JIJAA, M.L.,                                           : PRESIDENT

                    THIRU. T.R. SIVAKUMHAR, B.A., B.L.,           :  MEMBER  I 

                   THIRU. S. NANDAGOPALAN., B.Sc., MBA.,     : MEMBER II

               

CONSUMER COMPLAINT No.68/2022

WEDNESDAY,THE 12^th DAY OF APRIL 2023

 

Mrs. Pushpa Chauhan,

W/o Late Ramesh M Chauhan,

Represented by her Power Agent and son,

Mr. Kuldip Chauhan

S/o Ramesh M Chauhan,

 

Residing at:

 

No. 9/2, Pavapuri Apartments,

2^nd Floor Kariappa Street, Purasawalkam,

Chennai-600 007.                                                           …Complainant.

..Vs..

1.M/s United India Insurance Company Co. Ltd,

   Represented by its Chairman cum Managing Director

   Mr. Satyajit Tripathy

 

   Having Registered Office at

   24, Whites Road, Peters Colony,

   Royapettah, Chennai-600014

 

2.M/s United India Insurance Company Co. Ltd,

   Represented by Branch Manager

 

   Having Branch Office at 1 & 2, II  Floor,

   Fagun Chambers, 26A, Ethiraj Salai,

   Chennai- 600 008.                                                .. Opposite Parties.

 

                                                               

* * * * *

Counsel for the complainant      : M/s. Yusuf S Q

Counsel for Opposite parties      : M/s. C. Paranthaman

 

         On perusal of records and having heard the oral arguments of the Counsel for the Complainant and the Counsel for the Opposite Parties this Commission delivered the following:

ORDER

Pronounced by Member-I, Thiru. T.R. Sivakumhar, B.A., B.L.,

(i) The Complainant has filed this complaint as against the Opposite Parties under section 35 of the Consumer Protection Act, 2019 and prays to direct the opposite parties to pay remaining claim amount of Rs.3,23,499/- incurred as hospitalisation expenses on the Complainant and so covered under Insurance Policy bearing No.0131012820P101191111, valid from 13.05.2021 to 12.05.2021 and direct the Opposite Parties to pay a compensation of Rs.1,00,000/- jointly and severally for financial loss/interest, Mental agony suffered due to delay, negligence and deficient service.

I.  The averments of Complaint in brief are as follows:-

1.      The Complainant submitted that she is a senior citizen and in order to lead a risk free life in future, she along with her husband Late Ramesh in the year 2011 upon complying with the requisite of filling in a proposal form, had availed a Floater Health Insurance policy so issued by the 1^st Opposite Party through its branch office, the 2^nd Opposite party, with high anticipation and aspirations. The said insurance policy was renewed every year without a break, wherein the 1^st Opposite Party during one such renewal in the year 2014 had upgraded the insurance policy with sum insured of Rs.3,00,000/- under "Family Medicare Policy 2014", and the said policy was renewed time and again with the 1^st and 2^nd Opposite Party.  In the year 2020, the Complainant further intended to enhance the sum insured, and hence refilled the proposal form and upon receiving the same the 1^st Opposite Party had underwritten the above said insurance policy under "Family Medicare Policy 2014" by enhancing the sum insured from Rs.3,00,000/- to Rs.6,00,000/- vide Policy No: 0131012820P101191111 dated 13.05.2020. It was during the course of enhancement period, the Complainant was informed by the 2^nd  opposite party that there was an initial waiting period of 30 days for all illness on enhanced limit and a waiting period of 60 days for any Pre-Existing Ailments contracted during the renewed insurance period. However the said clause was not of relevance to the complainant as she was not diagnosed with any pre-existing ailments at the time of availing policy. On 08.07.2020 she had visited Narayana Hospital (An ISO certified Hospital), Purasawalkam with complaints of chest pain and incidental issues and after preliminary investigation and on advice of medical experts she was admitted to the said Hospital for keeping her under their observation. She was discharged from the said Hospital with Prescribed medication the very next day ie 09.07.2020, but her discomfort did not subside. Hence she was rehospitalized with Apollo Hospital, Chennai on 10.07.2020 under cashless scheme so offered by the 1^st Opposite Party and upon initial analysis she was diagnosed with a complete heart blockage and therefore the medical professionals of Apollo Hospital had performed a Coronary Angiogram on 10.07.2020. Post coronary Angiogram she was informed of the severe distal Left anterior descending Artery and thereafter obtaining consent from her, the medical professionals of Apollo Hospital in order to eradicate the medical issue had performed Percutaneous Transluminal Coronary Angioplasty upon her. Post operation she was placed under observation, and while being placed under observation few other procedures were performed in Intensive Care Unit on 12.07.2021. She had started developing post operational complications and her complications were managed with IV diuretics and after considerable administration and observation the complainant's condition had improved and on due satisfaction of her recovery she was subsequently discharged on 16.07.2021 from Apollo Hospital. Upon her discharge, she was shocked to see that she was tagged as Diabetic for the reasons best known to the associates of Apollo Hospital. Her discharge from Apollo Hospital on 16.07.2021, was not smooth and her son was made to run from pillar to post by the opposite parties to invoke her rights under the Insurance policy issued by the 1^st opposite Party defeating her interest in the insurance policy and also thrusting mental strain and agony upon the complainant and her family. During the time of the hospitalization with the Apollo Hospital, the 1^st Opposite party's assigned TPA "Vipul Medcorp Insurance TPA Pvt Ltd" had provided pre-authorization on cashless treatment, and had only sanctioned a sum of Rs. 2,40,037/-, citing eligibility on GIPSA PPN package rates. Thereby without any other choice the complainant at the time of Discharge had paid the remaining sum of Rs.3,23,999/- to Apollo Hospital. And thereupon her power agent and Son had submitted a reimbursement claim on 18.08.2020 with the 1^st Opposite party's assigned TPA "Vipul Medcorp Insurance TPA Pvt Ltd" for a sum of Rs. 3,23,999/- and upon such request a sum of Rs. 500/- was effected as settlement on claim. Upon further enquiry about short settlement/reimbursement as to insurance cover of Rs. 6,00,000/- provided in the insurance policy, the 1^st Opposite party's assigned TPA "Vipul Medcorp Insurance TPA Pvt Ltd" had simply advised her to reach out to the regional office for resolving further claims. Upon the advise of the TPA, her insurance Agent had sent an email to the 2^nd Opposite Party on 12.12.2020, as there was no response from the both the Opposite Parties as mentioned above. On failing to receive any response from the 2^nd Opposite Party her Power Agent and Son had sent a Letter of complaint to the Office of The Insurance Ombudsman, State of Tamil Nadu and Puducherry dated 20.03.2021. On receipt of such letter The Insurance Ombudsman, State of Tamil Nadu and Puducherry had registered a complaint under Rule No. 13(1) (b) of the insurance Ombudsman Rules, 2017 vide complaint No. CHN-H-051-2122-0012. The above quasi-Judicial body in their proceedings has dismissed the petition of the complainant on flimsy grounds without providing proper reasoning. Further completely relying on the findings and observation of the discharge summary issued by a third Party which had incorrectly tagged her as diabetic and the same being produced by the 2^nd opposite party as evidence to declare her as a Person with Pre Existing Disease (PED) and to such effect Clause 5.14 of the policy was interpreted irrationally from policy wordings thereby rejecting her claim, which has resulted in financial loss. She was put through all of the harassment only for the rejection of his lawful claim by the 1^st and 2^nd Opposite Party on basis of a faulty diagnosis report issued by a third party tagging her as a diabetic, which has further resulted in huge financial loss to her. Hence she relying upon the lab test report done by Unique Diagnostic Centre dated 08.07.2020, Discharge Summary dated 09.07.2020 issued by Narayana Hospital, Chennai, lab test report done by Nuclear dated 12.08.2021, lab test report done by Best Diagnostic Center dated 17.08.2021 and lab test report done by Aarthi Scans dated 03.09.2021 had sent a notice under Consumer act dated 29.11.2021 requesting the Apollo Hospital to rectify the error in tagging the complainant as diabetic and further requesting the 1^st and 2^nd Opposite party to take up responsibility for the deficient act of wrongly repudiating the claim and thereby deposit the remaining claim amount, as their decision merely stands on a third party document ie the hospital discharge summary and not upon the Declaration and Proposal filled by her, which binds the insurer and the insured in an insurance contract.  Hence the Opposite Party herein has failed to adhere to term sheet of "Family Medicare Policy" 2014. The order of the ombudsman and the decision of the 1^st and 2^nd party have come on irrational interpretation of the policy on the said term and condition and dependency on the erred discharge summary of a third party. The Opposite Parties jointly are deficient in their services in accordance to the provisions of the Consumer Protection Act, 2019,under Section 2(11), 2(11)(i). Hence the complaint.

II. Written version of opposite parties in brief is as follows:

2.     The opposite Parties submitted that the allegations contained in the complaint are not correct. The complaint is not maintainable and liable to be dismissed. They admit the complainant took insurance policy Family Medicare Policy 2014 with the First Opposite party vide Policy No. 0131012820P101191111 Period From 12.12 Hrs on 13.5.2020 To Midnight on 12.05.2021. The complainant renewed the insurance policy in year 2014 with sum insured for Rs.3,00,000/-. insurance policy Family Medicare Policy 2014 and by enhancing the amount from Rs.3,00,000/- to 6,00,000/- on 13.05.2020. At the time of upgrading the coverage enhanced amount there was condition in the policy which is filed by complainant that condition under 4 Exclusions, the company shall not liable to make any payment under this policy in respect of any expenses whatsoever incurred by and insured person in connection with or respect of: 1. Any pre-existing condition(s) as defined in the policy until 48 months of continuous coverage of such insured person elapsed, since inception of his/her first policy as mentioned in the schedule attached to the policy. Any disease other that those stated in clause 4.3, contracted by the insured person during the first 30 days from the commencement date of the policy. Further condition 4.2 shall not however, apply in case of the Insured person having been covered for a continuous period 12 months without any break. As per condition No. 5.14 enhancement of sum insured the insured may seek enhancement of sum insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the company. However notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the sum insured under the policy in force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof. Any such request for enhancement must be accompanied by declaration that the insured or any other insured person in respect of whom such enhancement is sought is not aware of any symptoms or other indication that may give rise to a claim under the Policy. The company may require such insured person/s to undergo a Medical examination to enable to company to take a decision on accepting the request for enhancement in the sum insured.   According to the complainant that she took treatment at Apollo Hospital on 12.07.2020 as in patient up to 16.07.2020. And he was undergone for operated and Apollo Hospital Percutaneous Transluminal Coronary angioplasty upon her. Further the Apollo Hospital discharge summary dated 16.12.2020 mentioned as "TYPE 2 DIABITES MELLITUS”, further under the head of history of present illness mentioned as History of Diabetes mellitus yes < 6 Months. As per the Apollo Hospital the complainant was diabetes in last 6 months hence as per the terms of the policy claim is rejected and as per the terms of policy the complainant to pay the hospital expenses. As the complainant got diabetic at the time of enhancing the coverage limit from Rs.3,00,000/- to Rs.6,00,000/- hence as per the terms of policy conditions issued to the complainant they repudiated the Hospital expenses. She approached this forum not with the clean hands and the calculation of the damages assessed by the complainant are high and not reasonable one. After the repudiation of the claim of the compliant, she approached the Ombudsman and the learned Ombudsman by the proceeding dated 10.08.2021 held that the insurance company rejected the complainant is correct by it is Award No 10/CHN/A/HA/0118/2021-2022. There is no deficiency in service on their part and the complainant is not entitled to any redressal as stated in the complaint. The claim for mental agony and hardship is baseless and exaggerated. Hence prayed to dismiss the complaint.

III.      The complainant has filed his proof affidavit, in support of his claim in the complaint and has filed documents which are marked as Ex.A-1 to A-13. The opposite parties had submitted their proof affidavit. No document was marked on their side.

IV.    Points for Consideration:-

 

1. Whether there is deficiency in service on the part of the Opposite Parties?

2. Whether the Complainant is entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

Point No. 1 :-

 

3.     It is an undisputed fact that the Complainant had availed Mediclaim Policy, namely Floater Health Insurance Policy from the 1^st and 2^nd Opposite Party in the year 2011 and the said policy was renewed without any break and during 2014 the said policy was upgraded as Family Medicare Policy 2014 with sum assured of Rs.3,00,000/-. It is also not in dispute that the sum assured under the said policy was enhanced from Rs.3,00,000/- to Rs.6,00,000/- on 13.05.2020.

4.     The disputed fact is the rejection of claim of the Complainant on the ground that she was diabetic during the proceeding Policy which was suppressed during enhancement of sum assured from Rs.3,00,000/- to Rs.6,00,000/-. The Complainant contended that she had sustained chest pain and was admitted in Narayana Hospital  on 08.07.2020 and was discharged on 09.07.2020. As her pain did not subside, she was admitted in Apollo Hospital on 10.07.2020, where she was diagnosed with heart blockage and had performed a Coronary Angiogram, post Angiogram she was informed of severe distal left anterior descending Artery and to eradicate the same had performed Percutaneous Transluminal Coronary Angioplasty and after cure she was discharged on 16.07.2020 (year has been mentioned wrongly as 16.07.2021 in the Complaint). The Final bill of the Hospital was Rs.5,63,072.98p and the Opposite parties Third party Administrator, namely, Vipul Medcorp Insurance TPA Pvt Ltd had settled cashless amount of Rs.2,40,037/- to Apollo Hospital and the balance sum of Rs.3,23,036/- along with a pharmacy bill amounting to Rs.963/-, totaling to Rs.3,23,999/- was not settled by the said Third Party Administrator, in spite of insurance coverage to a sum of Rs.6,00,000/-. Thereafter when a claim was made on 18.08.2020 for the balance amount of Rs.3,23,999/- the said TPA had settled only Rs.500/- on 23.10.2020 as against the amount claimed and advised to contact the Regional Office of the Opposite parties, subsequently an email dated 12.12.2020 was sent to the Opposite Parties to consider the claim for balance amount of Rs.3,23,499/-, left with no response, which constrained her to approach the Insurance Ombudsman by way of a complaint, which was dismissed on 30.08.2021 and only through the award passed by the Insurance Ombudsman she come to know the stand taken by the Opposite Parties in rejecting her claim relying upon Clause 5.14 of Policy terms and conditions based on the discharge summary of Apollo Hospital which says that she is diabetic less than 6 months, which is during the period of preceding policy, in spite of having given a declaration and accepted towards enhancement of sum assured to Rs.6,00,000/-.

5.     The contentions of the Opposite Parties are that admitting the Policy availed and the enhancement of sum assured to Rs.6,00,000/-, whereas relying upon Condition No.4.1 and 4.2,  wherein there was a waiting period of 48 months for pre-existing disease since the date of inception of the first policy and any disease mentioned in Clause 4.3 contracted by insured person during the first 30 days from the commencement date of the policy and  Condition 4.2 shall not apply in case of Insured person having been covered for a continuous period of 12 months without any break. Further relied upon condition No.5.14 which says that “Enhancement of sum assured the insured may seek enhancement of sum insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the company. However notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the sum insured under the policy in force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof. Any such request for enhancement must be accompanied by declaration that the insured or any other insured person in respect of whom such enhancement is sought is not aware of any symptoms or other indication that may give rise to claim under the Policy. The Company may require such Insured person/s to undergo a Medical examination to enable the company to take a decision on accepting the request for enhancement in the sum insured. 50% of the cost of the medical examination will be reimbursed to the insured person on acceptance of the request for enhancement of sum insured”. In the discharge summary dated 16.12.2020 (month was wrongly mentioned instead of 16.07.2020) for the treatment taken by the Complainant it was mentioned as “Type 2 Diabetes Mellitus” less than 6 months, as the Complainant was diabetic at the time of enhancing the coverage limit from Rs.3,00,000/- to Rs.6,00,000/- the claim was rejected as per the terms and conditions of the policy. Hence the Complainant had approached with unclean hands and the calculation of damages assessed by the Complainant were high and not reasonable one. The claim made before the Insurance Company which held that the rejection made by the Opposite Parties was correct. There was no deficiency in service on their part.

6.     In view of the above discussions and on perusal of records, the Complainant is aged about 77 years and as per Ex.A-1 Individual Family Medicare Policy dated 13.05.2020 Insured in the name of Ramesh M Chauhan, husband of the Complainant and the interest of the Complainant had also been insured in the said policy for a sum of Rs.6,00,000/- for a period covering from 13.05.2020 to 12.05.2021. From Ex.A-4, Cashless Authorization Letter dated 16.07.2020 it is evident that the Opposite Parties Third Party Administrator, namely, Vipul MedCorp Insurance TPA Pvt Ltd, wherein a sum of Rs.2,40,037/- was approved as per Eligibility and the said sum was settled to Apollo Hospital for the treatment taken by the Complainant under the policy. From Page Nos.16 and 17 of Ex.A-4 the Complainant had paid a sum of Rs.80,000/- on 10.07.2020 and Rs.2,43,036/- on 16.07.2020 to Apollo Hospital and the said sum of Rs.3,23,036/- along with pharmacy bill for a sum of Rs.963/-, totalling to a sum of Rs.3,23,999/- was claimed by the Complainant as found in Ex.A-5 Claim Form dated 15.08.2020. From Ex.A-6 Mail dated 12.12.2020 sent on behalf of the Complainant/Insured to the Opposite Parties, wherein it was mentioned that as against the Hospital bill of Rs.5,63,072.98p a sum of Rs.2,40,037/- was settled through cashless facility to Apollo Hospital and as against the claim made for the balance sum of Rs.3,23,999/- only a sum of Rs.500/- was settled on 23.10.2020 and had requested to reconsider the claim made. It is clear from Ex.A-7 Complaint dated 20.03.2021 lodged before Insurance Ombudsman, that as there was no response to Ex.A-6 the Complainant was constrained to approach the Insurance Ombudsman. From Ex.A-8 Award dated 02.09.2021 passed by the Insurance Ombudsman, the complaint filed by the Complainant was found to be dismissed relying upon Condition No.5.14 of the terms and conditions of the subject policy. From Page Nos.37, 38 and 39 of Ex.A-9 the Lab Test Reports of the Complainant taken on 12.08.2021, 17.08.2021 and 08.07.2020, respectively, whereby the Blood Sugar levels of the Complainant taken prior to admission made for treatment in Apollo Hospital and thereafter, reveals that the sugar levels of the Complainant was normal and as per the values she was not a diabetic patient. From Ex.A-3 Discharge Summary of Apollo Hospital the Complainant was observed with a history of Diabetes Mellitus as YES < 6 months, ie., less than 6 months or within 6 months. It is to be noted that the contentions of the Complainant that she was not a diabetic at the time of enhancement of the sum insured from Rs.3,00,000/- to Rs.6,00,000/- which was accepted on the declaration submitted by her following the terms and conditions of the Policy mentioned in 5.14, and it was mentioned in Condition No.5.14 that Enhancement of sum assured the insured may seek enhancement of sum insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the company. However notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the sum insured under the policy in force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof. Any such request for enhancement must be accompanied by declaration that the insured or any other insured person in respect of whom such enhancement is sought is not aware of any symptoms or other indication that may give rise to claim under the Policy. The Company may require such Insured person/s to undergo a Medical examination to enable the company to take a decision on accepting the request for enhancement in the sum insured. 50% of the cost of the medical examination will be reimbursed to the insured person on acceptance of the request for enhancement of sum insured”.  It would be clear that taking advantage of Ex.A-3 the rejection of claim of Rs.3,23,999/- made  by the Opposite Parties interpreting Condition No.5.14 as the Complainant had pre-existing disease of Diabetes, which was during preceding policy period and she was entitled only for the sum insured of Rs.3,00,000/- as per the earlier policy period and not entitled for enhanced amount of Rs.6,00,000/-, and the same was observed and appreciated by the insurance Ombudsman apart from the submissions made by the Opposite Parties that the Complainant had not approached them and only her agent had approached, are baseless and against the records produced. 

7.     The Complainant had relied upon a Judgment of Hon’ble National Consumer Disputes Redressal Commission passed on 15.01.2008 in Revision Petition No.3335 of 2007 in National Insurance Company Vs. Raj Narain, wherein referring the earlier judgment passed in Revision Petition No.1696 of 2005, Praven Damani Vs- Oriental Insurance Co Ltd reported in IV (2006) CPJ 189 (NC) “ the District Forum also relied on Clause 4.1 of the Policy which states that it is not material whether the insured had knowledge of the disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables “the Insurance Company to disown the liability. If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4. 1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the medi-claim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain, etc. prior to 11^th  August, 2000. Since, there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the complainant that he was thoroughly checked up by the Doctors who were nominated by the Insurance Company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing, disease. In view of the above discussion and from the records available before us, in our opinion, the complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed.

 (9) RATIO of this case is applicable to a great extent to this case on hand. Accordingly, we do not see any reasons to interfere with the concurrent decisions of the lower Fora. Therefore the Revision Petition is dismissed”.

8.     And the Complainant also relied on the Judgment passed on 10.07.2009 by the Hon’ble Supreme Court in Civil Appeal No.2776 of 2002 in Satwant Kaur Sandhu Vs- New India Assurance Company Ltd, it was observed that “ Para 12. “There is no dispute that Section 45 of the Insurance Act, 1938 (for short "the Act"), which places restrictions on the right of the insurer to call in question a life insurance policy on the ground of mis-statement after a particular period, has no application on facts at hand, inasmuch as the said provision applies only in a case of life insurance policy. The present case relates to a mediclaim policy, which is entirely different from a life insurance policy. A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses His opinion of the materiality of that knowledge is of no moment”. But it was observed that the non-disclosure in the proposal form made by the Appellant/Insured was with clear suppression of material facts and the case was remanded to National Commission for fresh adjudication on merits. The facts and circumstances of the above citations varies with that of the instant case.

9.     In the given facts and circumstances of the case, it is clear that the rejection of claim made by the Opposite Parties on the claim of Complainant for the balance sum of Rs.3,23,999/- towards Hospital Bills paid by the Complainant, as per Ex.A-5 Claim Form dated 15.08.2020, was found to be made as per Condition No.5.14 of the terms and conditions of the Policy as clearly mentioned in the Written Version and as per the contentions of the Opposite Parties. Hence it is necessary to reproduce Condition No.5.14 of the Policy, “Enhancement of sum assured the insured may seek enhancement of sum insured in writing at or before payment of premium for renewal, which may be granted at the discretion of the company. However notwithstanding enhancement, for claims arising in respect of ailment, disease or injury contracted or suffered during a preceding policy period, liability of the company shall be only to the extent of the sum insured under the policy in force at the time when it was contracted or suffered during the currency of such renewed policy or any subsequent renewal thereof. Any such request for enhancement must be accompanied by declaration that the insured or any other insured person in respect of whom such enhancement is sought is not aware of any symptoms or other indication that may give rise to claim under the Policy. The Company may require such Insured person/s to undergo a Medical examination to enable the company to take a decision on accepting the request for enhancement in the sum insured. 50% of the cost of the medical examination will be reimbursed to the insured person on acceptance of the request for enhancement of sum insured”. It would clear from the above condition that only if the Complainant found to be with pre-existing disease she would be entitled for the sum insured under the earlier policy and further only on the declaration made by the Complainant as required by the Opposite Parties the sum insured was enhanced from Rs.3,00,000/- to Rs.6,00,000/- and the contentions of the Opposite Parties that the Complainant was found to be “Type 2 Diabetes Mellitus” less than 6 months, from the discharge summary dated 16.12.2020 (month was wrongly mentioned instead of 16.07.2020) for the treatment taken by the Complainant and as the Complainant was with knowledge of she being diabetic at the time of enhancing the coverage limit from Rs.3,00,000/- to Rs.6,00,000/- and hence the claim was rejected as per the terms and conditions of the policy, is not legally sustainable, as the Opposite Parties in the said Condition No.5.14 had spelled out about declaration to be submitted by the Complainant, which was found to be submitted as the Policy sum insured was found to be enhanced to Rs.6,00,000/- from 13.05.2020 and further if at all the Opposite Parties would not have satisfied with the declaration submitted by the Complainant they would have subjected the Complainant to undergo medical examination before enhancing the sum insured. Hence it would be clear that the Complainant had satisfied the requirements of the Opposite Parties and having approved and accepted the enhancement of the sum insured to Rs.6,00,000/- the rejection of the claim of the Complainant made by the Opposite Parties amounts to deficiency of service on the part of the Opposite Parties. Therefore, this Commission is of the considered view that the Opposite Parties had committed deficiency of service and caused mental agony to the Complainant. Accordingly Point No.1 is answered.

Point Nos 2 &3:-

10.    As discussed and decided point No.1 against Opposite Parties 1 and 2, the opposite parties  1 & 2 are are jointly and severally liable to pay a sum of Rs.3,23,499/- towards Hospitalisation expenses covered under Insurance Policy No.0131012820P101191111, valid  from 13.05.2020 to dated 12.05.2021 and to pay a sum of Rs.20,000/- towards deficiency of service and mental agony caused to the Complainant along with Rs.5,000/-.   Accordingly Point Nos. 2 and 3 are answered.

In the result the Complaint is allowed in part. The 1^st and 2^nd Opposite Parties are jointly and severally directed to pay a sum of Rs.3,23,499/- (Rupees Three Lakh Twenty Three Thousand Four Hundred and Ninety Nine Only) towards Hospitalisation expenses covered under Insurance Policy No.0131012820P101191111, valid  from 13.05.2020 to 12.05.2021 and to pay a sum of Rs.20,000/- (Rupees Twenty Thousand Only) towards deficiency of service and mental agony caused to the Complainant along with Rs.5,000/-(Rupees Five Thousand Only) towards cost of the litigation to the Complainant within 8 weeks from the date of the receipt of this order.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 12^th of April 2023.

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT

 List of documents filed on the side of the Complainant:-

 

Ex.A1	13.05.2020	Policy No: 0131012820P101191111 Family Medicare Policy 2014
Ex.A2	08.07.2020	Discharge Summary sheet by Narayana Hospital, Purasawalkam
Ex.A3		Discharge Summary sheet by Apollo Hospitals Pvt Ltd and Hospital receipts
Ex.A4	16.07.2020	Payment Made towards the Hospital bill for the difference amount post approval of partial cashless claim
Ex.A5	04.09.2020	Reimbursement claim preferred with TPA
Ex.A6	12.12.2020	Email sent by the insurance agent in regards to seeking explanation on deficiency in claims
Ex.A7	20.03.2021	Complaint letter sent to the Office of The Insurance Ombudsman. State of Tamil Nadu and Puducherry
Ex.A8	02.09.2021	Banking Ombudsman Award No: IO/CHN/A/HI/0118/2021-2022
Ex.A9		Lab Reports from various Diagnostic centers
Ex.A10		Policy terms and conditions
Ex.A11	29.11.2021	Pre complaint Notice under Consumer Act issued to the Opposite Party
Ex.A12	02.12.2021	Specific power of Attorney
Ex.A13		ID Proof of the Complainant and Power Agent

 

List of documents filed on the side of the Opposite Parties:-

-NIL-

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT